Coma

“Go to it,” said Bellows to Reid as he stepped back from the bed. Reid immediately recommenced his cardiac massage. Cartwright nodded, indicating that there was a strong femoral pulse. “Stark is going to be pissed when he hears about this,” continued Bellows, eyeing the monitor,

“especially right after his lecture on vigilance in these cases. Shit, I really don’t deserve this kind of headache. If she croaks, my ass is grass.”

Susan had trouble comprehending that Bellows had actually said what he did. Once again she was faced with the fact that Bellows and probably the entire crew were not thinking of Nancy Greenly as a person. The patient seemed more like the part of a complicated game, like the relationship between the football and the teams at play. The football was important only as an object to advance the position and advantage of one of the teams. Nancy Greenly had become a technical challenge, a game to be played. The final, ultimate result had become less important than the day-to-day plays and moves and ripostes.

Susan felt a strong surge of ambivalence toward clinical medicine. Her nascent female sensitivities seemed to be a handicap within the mechanistic and tactically oriented atmosphere. She silently longed for the old familiar lecture hall and its abstractions. Reality was too bitter, too cold, too detached.

And yet there was something fascinating and academically satisfying seeing the application of the basic scientific knowledge she had acquired.

From physiology experiments with animal hearts, she comprehended the disorganization that the fibrillating heart within Nancy Greenly represented. If only the whole mass could be depolarized to stop all electrical activity, then the intrinsic rhythm could possibly begin again.

Susan strained to watch as Bellows placed the defibrillating paddles on Nancy Greenly’s exposed chest. One of the paddles was held directly over the sternum, the other was placed against the left lateral chest, slightly distorting the left breast with its pale nipple.

“Everyone away from the bed!” ordered Bellows. His right thumb made contact and a powerful electric charge spread through Nancy Greenly’s chest, arcing from one paddle to the other. Her body jerked upward; her arms flopped across her chest with her hands twisting inward. The electronic blip disappeared from the screen, then it returned. It traced a relatively normal pattern.

“She’s got a good pulse,” said Cartwright.

Reid held up on the external massage. The rate held steady for several minutes. Then a premature ventricular contraction appeared. The rate was again steady for several minutes followed by three premature ventricular contractions in a row.

“V tach,” said Shergood confidently. “The heart is still very easily excitable. There has to be something very basic wrong here.”

“If you know what it is, don’t keep it from us,” said Bellows. “Meanwhile let’s have some lidocaine, 50 cc.”

One of the nurses drew up the lidocaine and handed it to Bellows.

Bellows injected it into the I.V. line. Susan moved so that she could see the monitor screen more clearly.

Despite the lidocaine, the rhythm rapidly deteriorated to senseless fibrillation once more. Bellows swore, Reid started massage, and the nurse recharged the defibrillator.

“What the hell is going on here?” queried Bellows, motioning for another amp of bicarbonate to be given. He didn’t expect an answer; he was posing a purely rhetorical question.

Another dose of epinephrine given I.V., followed by a second defibrillation attempt, returned the rate to a semblance of normal. But premature contractions returned, despite additional lidocaine.

“This has to be the same problem that they had in the OR,” said Bellows, watching the premature contractions increase in frequency until the rhythm dissolved into fibrillation. “You’re up again, Reid ole boy. Let’s go, team.”

By 1:15 Nancy Greenly had been defibrillated twenty-one times. After each shock a relatively normal rhythm would return only to disintegrate into fibrillation after a short duration. At 1:16 the ICU phone rang. It was answered by the ward clerk, who took the information. It was the lab calling with the stat electrolyte values. Everything was normal except the potassium level. It was very low, only 2.8 milliequivalents per liter.

The ward clerk handed the results to one of the nurses, who showed them to Bellows.

“My God! 2.8. How in Christ’s name did that happen? At least we have an answer. OK, let’s get some potassium in her. Put 80 milliequivalents into that I.V. bottle and speed it up to 200 cc per hour.”

Nancy Greenly responded to this command by immediately lapsing back into fibrillation for the twenty-second time. Reid started compression while Bellows readied the paddles. The potassium was added to the I.V.