Coma

The case went smoothly. Dr. Major did his bimanual examination and asked for some more relaxation. This meant that Nancy’s blood had detoxified the succinylcholine given during the entubation. Dr. Billing was happy to give another 2 cc. He dutifully recorded this in his anesthesia record. The result was immediate, and Dr. Major thanked Dr. Billing and informed the crew that the ovaries felt like little smooth, normal plums.

He always said that when he felt normal ovaries. The dilation of the cervix went without a hitch. Nancy had a normally antero-flexed uterus, and the curve on the dilators was a perfect match. A few blood clots were sucked out from the vaginal vault with the suction machine. Dr.

Major carefully curetted the inside of the uterus, noting the consistency of the endometrial tissue. As Dr. Major passed the second curette, Dr.

Billing noted a slight change in the rhythm of the cardiac monitor. He watched the electronic blip trace across the oscilloscope screen. The pulse fell to about sixty. Instinctively he inflated the blood pressure cuff and listened intently for the familiar far-away deep sound of the blood surging through the collapsed artery. As the air pressure drained off more, he heard the rebound sound indicating the diastolic pressure.

The blood pressure was 90/60. This was not terribly low, but it puzzled his analytical brain. Could Nancy be getting some vagal feedback from her uterus, he wondered. He doubted it, but just the same be took the stethoscope from his ears.

“Dr. Major, could you hold on for just a minute? The blood pressure has sagged a little. How much blood loss do you estimate?”

“Couldn’t be more than 500 cc,” said Dr. Major, looking up from between Nancy’s legs.

“That’s funny,” said Dr. Billing, replacing the stethoscope in his ears. He inflated the cuff again. Blood pressure was 90/58. He looked at the monitor: pulse sixty.

“What’s the pressure?” asked Dr. Major.

“Ninety over sixty, with a pulse of sixty,” said Dr. Billing, taking the stethoscope from his ears and rechecking the flow valves on the anesthesia machine.

“What the hell’s wrong with that, for Christ’s sake?” snapped Dr. Major, showing some early surgical irritation.

“Nothing,” agreed Dr. Billing, “but it’s a change. She had been so steady.”

“Well, her color is fantastic. Down here, she’s as red as a cherry,” said Dr. Major, laughing at his own joke. No one else laughed.

Dr. Billing looked at the clock. It was 7:48. “OK, go ahead. I’ll tell you if she changes any more,” said Dr. Billing, while giving the breathing bag a healthy squeeze to inflate Nancy’s lungs maximally. Something was bothering Dr. Billing; something was keying-off his sixth sense, activating his adrenals and pushing up his own heart rate. He watched the breathing bag sag and remain still. He compressed it again, mentally recording the degree of resistance afforded by Nancy’s bronchial tubes and lungs. She was very easy to breathe. He watched the bag again. No motion, no respiratory effect on Nancy’s part, despite the fact that the second dose of the succinylcholine should have been metabolized by then.

The blood pressure came up slightly, then went down again: 80/58. The monotonous beep of the monitor skipped once. Dr. Billing’s eyes shot to the oscilloscope screen. The rhythm picked up again.

“I’ll be finished here in five minutes,” said Dr. Major for Dr. Billing’s benefit With a sense of relief, Dr. Billing reached over and turned down both the nitrous oxide and the halo-thane flow, while turning up the oxygen. He wanted to lighten Nancy’s level of anesthesia. The blood pressure came up to 90/60, and Dr. Billing felt a little better. He even allowed himself the luxury of running the back of his hand across his forehead to scatter the beads of perspiration that had appeared as evidence of his increasing anxiety. He glanced at the soda-lime CO2

absorber. It appeared normal. Time was 7:56. With his right hand he reached up and lifted Nancy’s eyelids. They moved with no resistance and the pupils were maximally dilated. The fear returned to Dr. Billing in a rush. Something was wrong ... something was very wrong.

Monday, February 23, 7:15 A.M.