Coma

Doctor Norman Goodman had been on the staff at the Memorial for eight years and held a joint appointment at the medical school. He had a lab on the fourth floor of the Hilman Building with a large population of monkeys. His interests involved developing newer concepts of anesthesia by selectively controlling various brain areas. He felt that eventually drugs were going to be specific enough so that just the reticular formation itself would be altered, thereby reducing the amount of drugs necessary to control anesthesia. In fact, only a few weeks earlier he and his laboratory assistant, Dr. Clark Nelson, had stumbled onto a butyrophenone derivative which had slowed the electrical activity only in the reticular formation of a monkey. With great discipline he had kept himself from becoming overly encouraged at such an early time, especially when the results had been from a single animal. But then the results had become reproducible. So far he had tested eight monkeys and all had responded the same.

Dr. Norman Goodman would have preferred to give up all activities and devote twenty-four hours a day to his new discovery. He was eager to advance to more sophisticated experiments with his drug, especially a trial on a human. Dr. Nelson, if anything, was even more eager and optimistic. It had been with difficulty that Dr. Goodman had talked Dr.

Nelson out of trying a small subpharmacological dose on himself.

But Dr. Goodman knew that true science rested on a foundation of painstaking methodology. One had to proceed slowly, objectively.

Premature trials, claims, or disclosure could be disastrous for all concerned. Accordingly Dr. Goodman had to rein in his excitement and maintain his normal schedule and commitments unless he was willing to divulge his discovery; and that he was unwilling to do as yet. So on Monday morning he had to “pass gas,” as they called it in the vernacular

... devote time to clinical anesthesia.

“Damn,” said Dr. Goodman straightening up. “Mary, I forgot to bring down an endotracheal tube. Would you run back to the anesthesia room and bring me a number eight.”

“Coming up,” said Mary Abruzzi, disappearing through the OR door. Dr.

Goodman sorted out the gas line connectors and plugged into the nitrous oxide and oxygen sources on the wall.

Sean Berman was Dr. Goodman’s fourth and final case for February 23, 1976. Already that day he had smoothly anesthetized three patients. A two-hundred-and-sixty-seven-pound flatulent female with gallstones had been the only potential problem. Dr. Goodman had feared that the enormous bulk of fatty tissue would have absorbed such large quantities of the anesthetic agent that termination of the anesthesia would have been very difficult. But that had not proved to be the case. Despite the fact that the case had been prolonged the patient had awakened very quickly and extubation had been carried out almost immediately after the final skin suture had been tied.

The other two cases that morning had been very routine: a vein stripping and a hemorrhoid. The final case for Dr. Goodman, Berman, was to be a meniscectomy of the right knee and Dr. Goodman expected to be in his lab by 1:15 at the latest. Every Monday morning Dr. Goodman thanked his lucky stars that he had had enough foresight to have continued his research proclivities. He found clinical anesthesia a bore; it was too easy, too routine, and frightfully dull.

The only way he kept his sanity those Monday mornings, he’d tell his neighbor, was to vary his technique to provide food for his brain, to force him to think rather than just sit there and daydream. If there were no contraindications, he liked balanced anesthesia the best, meaning he did not have to give the patient some gargantuan dose of any one agent, but rather he balanced the needs by a number of different agents. Neurolept anesthesia was his favorite because in certain respects it was a crude precursor to the types of anesthetic agents he was looking for.

Mary Abruzzi returned with the endotracheal tube.

“Mary, you’re a doll,” said Dr. Goodman, checking off his preparations. “I think we’re ready. How about bringing the patient down?”

“My pleasure. I’m not going to get lunch until we finish this case.” Mary Abruzzi left for the second time.

Since Berman did not offer any contraindications, Goodman decided to use neurolept-anesthesia. He knew Spallek didn’t care. Most orthopedic surgeons didn’t care. “Just get them down enough so I can put on the Goddamn tourniquet, that’s all I care about” was the usual orthopedic response to the query about which anesthetic agent they might prefer.

Neurolept anesthesia was a balanced technique. The patient was given a potent neurolept, or tranquilizing agent, and a potent analgesic, or painkiller. Both agents provided easily arousable sleep as a side effect.