Coma

by Robin Cook

  “Susan, I’ve already told you that succinylcholine would not work in the OR, not with the surgeon and the anesthesiologist right there. Besides you cannot give succinylcholine by gas . . . at least, I’ve never heard of it. Maybe you could, but anyway, they’d just keep respiring the patient until it was gone; there wouldn’t be any hypoxia.”

  Susan took another slow sip from the bourbon.

  “What you’re saying is that the hypoxia in the OR has to occur without the color of the blood changing so the surgeon stays nice and happy. How could that be done? . . . You’d have to block the use of oxygen by the brain somehow . . . maybe at the cellular level . . . or block the release of oxygen to the brain cells. It seems to me there is a drug that can block oxygen utilization, but I can’t think of it offhand. If the valve on the oxygen line were significant, it would have to be a drug that comes in a gas form. But there’s another way to do it. You could use a drug that blocks the uptake of oxygen on the hemoglobin and yet still keeps the color. . . . Mark, I’ve got it!” Susan sat bolt upright, her eyes wide open, her mouth forming a half-smile.

  “Sure you do, Susan; sure you do,” soothed Mark sarcastically.

  “Carbon monoxide! Carefully bled-in carbon monoxide, by way of the T-valve, titrated to cause just the right amount of hypoxia. The blood color would stay the same. In fact it would get even brighter red, cherry red. Even a very small amount would cause the oxygen to be displaced from the hemoglobin. The brain is starved of oxygen and—coma. In the OR everything has seemed absolutely normal. Then the patient’s brain dies; there is not a trace of the cause.”

  There was a silence as the two people looked at each other. Susan expectantly, Bellows with tired resignation.

  “You want me to say something? OK, it’s possible. Ridiculous but possible. I mean it’s theoretically possible for the OR cases to be caused by carbon monoxide. It’s an awful idea, maybe it’s even ingenious, but at any rate, it’s possible. The trouble is there are still twenty-five percent of the coma victims who didn’t even get close to the OR.”

  “They’re the easy ones to explain. That was never hard. It was the OR cases that were hard. It was also hard for me to break away from the idea in the diagnosis of disease in medicine that one should search for single causes. But in this case we’re not dealing with a disease. The cases on the medical floors were given sublethal doses of succinylcholine. Something like that happened in a V.A. hospital in the Midwest, and even in New Jersey.”

  “Susan, you can hypothesize until you’re blue in the face,” said Bellows with a tinge of anger growing out of frustration. “What you’re suggesting is some fantastic organized plan—a criminal plan—with the sole purpose of making people comatose. Well, let me tell you this: you haven’t given an ounce of effort to the biggest question: the question of why. Why, Susan? Why? I mean, you’re spinning your mental wheels at ninety miles per hour, taking all sorts of risks with your career, and mine, I might add, to come up with a potentially plausible although fantastic explanation for what is a series of unconnected, unfortunate incidences. But at the same time, you’ve conveniently forgotten to ask why. Susan, there would have to be motive, for Christ’s sake. It’s ridiculous. I’m sorry, but it is ridiculous. And besides, I’ve got to go to sleep. Some of us work, you know. . . . And there isn’t one bit of solid evidence. A valve on the oxygen line! God, Susan, that’s pretty weak. I mean you’ve got to come to your senses. I can’t take any more of this. Really. I’m finished. I’m a surgical resident, not a part-time Sherlock Holmes.”

  Bellows got up and finished his bourbon in one long drink.

  Susan watched him intently, her paranoia awakening once again. Bellows was no longer on her side. Why indeed? The criminal aspect of the matter was horribly apparent to her at that point.

  “What makes you so sure,” continued Bellows, “that all this has anything to do with Nancy Greenly or Berman? Susan, I think you’re jumping to conclusions. There’s an easier explanation for this character who seems so interested in getting hold of you.”

  “I’m waiting.” Susan was angry now.

  “The guy was probably looking for some action and you . . .”

  “Screw you, Bellows!” Susan went livid.

  “Now she gets mad. Goddamn it, Susan, you take this whole affair as some sort of complicated game. I don’t want to argue with you.”

  “Every time I tell you about some aggressive behavior from Harris to this fucker who tried to kill me, all you can come up with is some Goddamn sexist explanation.”

  “Sex exists, my child. You’d better learn to face that.”

  “I think it’s more your problem. You male doctors never do seem to grow up. I guess it’s too much fun being an adolescent.” Susan got up and put her coat back on.

  “Where are you going at this hour?” said Bellows with an authoritarian air.

  “I have a feeling I’m safer on the street than here in this apartment.”

  “You’re not going out now,” said Bellows with determination.

  “Ah, now the male chauvinist is displaying his true colors. The great protector! Bull crap. The egoist says I’m not going. Just watch.”

  Susan left quickly, slamming the door.

  Indecision kept Bellows immobile and silent as he watched the door. He was silent because he knew that she was right in a lot of ways. He was immobile because he really wanted to be rid of the whole mess. “Carbon monoxide, holy shit.” He walked back into his bedroom and got into bed once more. Looking at the clock, he realized morning was going to arrive very, very quickly.

  D’Ambrosio began to panic. He had never liked confined spaces and the walls of the freezer began to move in on him. He began to breathe faster, gulping for air, and then he thought he might be going to suffocate. And the cold. The deathly cold wormed its way through his heavy Chicago overcoat, and despite constant motion, his feet and hands had gone numb.

  But by far the most disturbing aspect of the whole miserable affair was the bodies and the acrid odor of formaldehyde. D’Ambrosio had seen a lot of grisly scenes in his life and had been through some gruesome experiences, but nothing could compare with being in the freezer with the stiffs. At first he had tried not to look at them, but involuntarily and out of mounting fear, his eyes had been drawn to the faces. After some time it had begun to look as if they were all smiling. Then they were laughing and even moving when he didn’t watch them carefully. He emptied the clip in his pistol by blasting away at one particularly sneering corpse whom he imagined he recognized.

  Finally D’Ambrosio retreated to the corner so he could keep the whole group in view. Slowly he sank into a sitting position. He couldn’t feel his knees any longer.

  Thursday

  February 26

  10:41 A.M.

  The path dipped down to the left, through a thicket of gnarled oak trees standing in a bed of twisted briars. The branches of the trees arched over the pathway, enclosing it like a tunnel and precluding a view for more than a few feet. Susan was running and she dared not look behind her. Safety was ahead; she could make it. But the pathway narrowed and the branches clutched at her, hindering her. The briars caught in her clothing. She desperately tried to force her way through. She could see some lights ahead. Safety. But the harder she pulled, the more entangled she got, as if she were in a giant spiderweb. With her hands, she tried to free her feet. But then her arms became hopelessly entangled. There were only minutes left. She had to get free. Then she heard a car horn and one arm came free. The horn repeated itself and she opened her arms. She was in room 731 at the Boston Motor Lodge.

  Susan sat up in the bed, looking around the room. It had been a dream, a recurrent dream which she hadn’t had in years. With wakefulness came relief, and she sank back, pulling the covers up around herself. The auto horn which had awakened her sounded for the third time. There were some muffled shouts, then silence.

  Susan looked around the room. Tasteless American. Two large beds with a neu
tral flower-print spread. The rug was a heavy shag, a shade of spring green. The near wall was papered with a repeating floral design in green. The far wall was a pale yellow. There was a picture over the bed, a tawdry reproduction, portraying an idyllic barnyard scene with a few ducks and sheep. The furniture too was cheap, but there was an impressive, twenty-eight-inch color TV set—the indispensable solace of motel life. Aesthetics had low priority at the Boston Motor Lodge.

  But the place was safe. After leaving Bellows’s apartment in the wee hours of the morning, Susan had wanted only to find someplace where she could sleep in peace. She had noticed the gaudy motel sign from Cambridge Street on a number of occasions. The sign was awful, certainly not something to beckon the weary. Nonetheless, the room had provided the haven she needed. She had checked in as Laurie Simpson and had waited in the lobby for a good quarter of an hour before going up to the room. When the man at the desk looked at her strangely, she gave him an extra five dollars and told him to call her if anybody inquired about her. She said she was worried about a jealous lover. The desk clerk had winked at her, grateful both for the five dollars and the confidence she extended to him. Susan knew that he accepted the story without question; it was part of the male vanity.

  Having taken these precautions, and after moving the desk in front of the door, Susan had allowed herself to fall asleep. She had not slept soundly, as her terminal dream demonstrated, but she felt reasonably refreshed.

  She remembered the strong words with Bellows the night before and debated about calling him. She regretted the exchange, feeling that it had been totally unnecessary. She also remembered her feelings of paranoia and felt embarrassed.

  Yet she remembered her hyper state of mind and felt that her reactions were understandable. She was surprised that Bellows had not been more tolerant. But of course he wanted to be a surgeon, and she had to recognize that his career aspirations made it difficult if not impossible for him to view the situation with an open mind. Still, she regretted the split, if for no other reason than the fact that Bellows had played an effective devil’s advocate to her ideas. After all, he was correct that Susan had no idea of motive, and if some large organization was involved, then there must be one.

  Maybe the coma victims were the targets of some gangland vendetta? Susan dismissed the idea instantly, remembering Berman and even Nancy Greenly. No, that couldn’t be. Maybe extortion was involved; perhaps the families hadn’t paid off and—wham! But that seemed unlikely. It would be too hard to keep the coma business secret. It would be easier to kill people outright, outside the hospital. There had to be some reason for these comas happening in the hospital. There must be some pattern for each victim, some common denominator.

  As Susan mused, she lifted the phone onto the bed. She dialed the medical school and asked for the dean’s office.

  “Is this Dr. Chapman’s secretary? . . . This is Susan Wheeler . . . that’s right, the infamous Susan Wheeler. Look, I’d like to leave a message for Dr. Chapman. There’s no need to bother him. I was supposed to start a surgery rotation at the V.A. today, but I’ve spent a terrible night and I’ve got some abdominal cramps that won’t quit. I’ll be better by tomorrow morning, I’m sure, and I’ll call if I’m not. Would you please see that Dr. Chapman is informed of this, and the Department of Surgery at the V.A.? Thanks.”

  Susan replaced the receiver. The time was quarter to ten. She dialed the Memorial and asked for Dr. Stark’s office.

  “This is Miss Susan Wheeler calling. I’d like to speak to Dr. Stark.”

  “Oh, yes, Miss Wheeler. Dr. Stark expected your call at nine. He’ll be with you shortly. He was worried when you didn’t call.”

  Susan waited, twisting the cord to the phone between her thumb and index finger.

  “Susan?” Dr. Stark’s voice was concerned. “I’m very glad to hear from you. After what you described happening to you yesterday afternoon, I became concerned when you didn’t call. Are you all right?”

  Susan hesitated, wondering if she should use the same cover with Stark as she used for Chapman. Stark might have dealings with Chapman. She decided she’d best be consistent.

  “I have some abdominal cramps which have kept me in bed. Otherwise I’m fine.”

  “The rest will do you good. As for your requests: I have some good news and some bad news. What do you want first?”

  “I’ll take the bad.”

  “I’ve talked with Oren, then Harris, and finally Nelson about getting you reinstated here at the Memorial, but I’m afraid they are adamant. Obviously they don’t run the Surgery Department, but we do depend on cooperation around here and, to be truthful, I was not overly insistent. If they had wavered, I would have been more forceful. But they didn’t. You certainly stirred the fire, young lady!”

  “I see. . . .” Susan was not surprised.

  “Besides, if you came back here, I think it would be hard for you to overcome your reputation. It would follow you. It’s best to let things cool off.”

  “I suppose. . . .”

  “The V.A. program is a popular affiliated program and you’ll get to do more surgery there than you would here.”

  “That may be true, but as for teaching, it’s far inferior to the Memorial.”

  “But on your other request about the Jefferson Institute, I had some luck. I managed to speak to the director, and I told him about your special interest in intensive care. I also told him you were particularly interested in visiting his hospital. Well, he has obligingly agreed to allow you to come, if you come after the busiest part of the day, sometime after five. But there are some conditions. You must go alone, since only you will be permitted inside.”

  “Of course.”

  “And since I have really extended myself and have gone off channels, so to speak, I would prefer that you don’t mention your visit to anyone. I must admit, Susan, that I really had to make an effort to get you invited. I’m telling you this not because I want you to feel indebted or anything, but rather as partial atonement for my not getting you reinstated here at the Memorial. The director of the institute told me categorically that he would not allow any others to visit with you. They do allow group visits when they have time to supervise them. It’s a rather special place, as I believe you’ll see. It would be somewhat embarrassing if you wanted to bring someone else. So you must go alone. You can understand that, I presume.”

  “Of course.”

  “Well, then, let me know what you think of the facility. I haven’t been there myself yet.”

  “Thank you very much, Dr. Stark. Oh, there’s one other thing. . . .” Susan considered telling Stark about the second experience with D’Ambrosio. She decided against it, because he had wanted Susan to go to the police yesterday; now he’d be insistent. Susan did not want the police, not yet. If it were some large organization behind the whole affair, it was naive to think they didn’t have a contingency plan to allow for police probes.

  “I’m not sure,” continued Susan, “if it’s significant, but I found a valve on the oxygen line into room No. 8 in the OR. It’s near to the main chase.”

  “Near the what?”

  “The main chase where all the piping in the hospital courses from floor to floor.”

  “Susan, you’re pretty remarkable. How did you find out about that?”

  “I went up into the ceiling space and traced the gas lines to the ORs.”

  “Ceiling space!” Stark’s voice rose in irritation. “Susan, that’s carrying this affair a bit too far. I cannot condone your climbing around in the ceiling spaces over the operating rooms.”

  Susan waited for the ax to fall as it had with McLeary or Harris. Instead there was a pause. Stark broke it. “Anyway, you say you found a valve in the oxygen line to room No. 8.” His voice was almost back to normal.

  “That’s right,” said Susan cautiously.

  “Well, I think I know what that’s for. I’m chairman of the OR Committee, as you might have guessed. That valve is probably th
e bleed valve for getting rid of air bubbles when the system is charged up. But one way or another, I’ll have someone check it and make certain. By the way, what is the name of the patient you wanted to see at the Jefferson Institute?”

  “Sean Berman.”

  “Oh yes, I remember the case. It was just the other day. One of Spallek’s. A meniscus case, as I recall. Tragedy . . . the man was about thirty. A real shame. Well, good luck. Tell me, are you off to the V.A. today?”

  “No, my stomach condition will keep me in bed, at least for the morning. I’m quite sure I’ll be able to get back to work tomorrow, though.”

  “I hope so, Susan, for your sake.”

  “Thank you for your time, Dr. Stark.”

  “Not at all, Susan.”

  The line disconnected and Susan hung up.

  The soiled gloves fell into the wastebasket beside the sponge rack. On the rack was a group of blood-stained sponges hanging like dirty clothes on a line. A nurse passed behind Bellows and undid the string at the neck of his operating gown. Bellows tossed it into the hamper by the door and left.

  It had been an uncomplicated gastrectomy, a procedure Bellows usually liked to perform. But on this particular morning Bellows’s mind had been somewhere else and the double-layer closure of the stomach pouch and the small bowel had been tedious rather than enjoyable. Bellows could not stop thinking about Susan. His thoughts ran the gamut from tender concern, accompanied by remorse for the words that had driven Susan away the night before, to self-righteous pleasure in the comments he had felt justified in making. He had already gone too far, gambled too much, and it was quite apparent that Susan had no intentions of easing up on her idiotic drive in the direction of career suicide.