Coma

From the record Susan could see that Nancy Greenly had been moved from the OR into the recovery room at 8:51. A Block Ade square-wave nerve stimulator had been used to test the function of Nancy’s peripheral nerves. It had been originally suspected that she had been unable to metabolize the additional dose of succinylcholine. But the nerve function had been detected in both ulnar nerves, meaning that the problem was most likely central, in the brain.

Over the following hour Nancy Greenly had been given Narcan 4 mg to rule out an idiosyncratic hypersusceptibility to her pre-op narcotic.

There had been no response. At 9:15 she had been given neostigmine 2.5

mg to see if the block on her nerves and hence her paralysis was due to a curarelike competitive block despite the result of the nerve stimulator test. Nancy Greenly had also been given two units of fresh frozen plasma with documented cholinesterase activity to try to eliminate any succinylcholine that might have still remained. Both these measures resulted in some mild twitching of a few muscles but no real response.

The anesthesia record ended with the terse statement in Dr. Billing’s handwriting: “Delayed return of consciousness post anesthesia; cause unknown.”

Susan next turned to the operative report dictated by Dr. Major.

DATE: February 14, 1976

PRE OP DIAGNOSIS: Dysfunctional uterine bleeding POST OP DIAGNOSIS: Same

SURGEON: Dr. Major

ANESTHESIA: General endotracheal using halothane ESTIMATED BLOOD LOSS: 500 cc

COMPLICATIONS: Prolonged return to consciousness after the termination of anesthesia

PROCEDURE: After appropriate pre-op medication (Demerol and Phenergan) the patient was brought to the operating room and attached to the cardiac monitor. She was smoothly inducted under general anesthesia utilizing an endotracheal tube. The perineum was propped and draped in the usual fashion. A bimanual examination was carried out revealing normal ovaries, adnexa and an antero-flexed uterus. A #4

Pederson speculum was inserted into the vagina and secured. Blood clots were sucked from the vaginal vault. The cervix was inspected and appeared normal. The uterus was sounded to 5 cm with a Simpson sound.

Cervical dilation was carried out with ease and minimal trauma. Cervical dilators #1 through #4 were passed with ease. A #3 Sime curette was passed and the endometrium was curetted. A specimen was sent to the laboratory. Bleeding was minimal at the termination of the procedure.

The speculum was removed. At that point it became apparent that the patient was making a slow recovery from anesthesia.

Susan rested her weary right hand by letting it dangle by her side. She had a habit of writing by holding a pencil or pen so tightly that blood flow was restricted. The blood tingled as it returned to her fingertips. Before going back to work, she took several sips of her coffee.

The pathology report described the endometrial scrapings as proliferative in character. The diagnosis was then listed as an ovulatory uterine bleeding with a proliferative endometrium. No clue there.

Next Susan turned to the most interesting page: the initial neurology consult, signed by a Dr. Carol Harvey. Without knowing the meaning of most of what she wrote, Susan copied the consult note as well as she could. The handwriting was atrocious.

HISTORY: The patient is a twenty-three-year-old, white female admitted to the hospital with a problem of (illegible phrase). Past medical history of self and family negative for significant neurological disorders.

Patient’s pre-op workup (illegible phrase). Surgery itself uneventful and immediate result diagnostic and most likely curative of the presenting complaint. However, during surgery some minor problems with the blood pressure were noted, and after surgery there was noted a prolonged unconsciousness and apparent paralysis. Overdose of succinylcholine and/or halothane ruled out. (Entire sentence totally illegible.) EXAMINATION: Patient in deep coma unresponsive to spoken word, light touch or deep pain. Patient appears to be paralyzed although trace deep tendon reflexes elicited from both biceps and quadriceps symmetrically. Muscle tone decreased but not totally flaccid.

Pendulousness increased. No tremor.

Cranial nerves: (illegible phrase) ... pupils dilated and unresponsive.

Absent corneal reflex.

Square-Wave Nerve Stimulator: Persistent although decreased function of the peripheral nerves.

Cerebral Spinal Fluid (CSF): Atraumatic puncture, clear fluid, opening pressure 125 mm of water.

EEG: Flat wave in all leads.

IMPRESSION: (illegible sentence), (illegible phrase) ... with no localizing signs ... (illegible phrase) ... coma due to diffuse cerebral edema is the primary diagnosis. The possibility of a cerebral vascular accident or stroke cannot be ruled out without cerebral angiography. An idiosyncratic response to any of the agents used for anesthesia remains a possibility although I believe ... (illegible phrase).