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Tuesday, April 7, 6:33
A.M.

M
ichael pulled his medical student white coat over his scrubs. When he emerged from the men’s locker room, he didn’t want to hang out in the surgical lounge for fear of getting into a conversation with someone who might feel obligated to ask what the hell Michael, as a fourth-year medical student, was doing in scrubs. Instead he went out into the hall by the elevator to wait. He didn’t have to wait long.

“Of all people, I bumped into infamous Dr. Sandra Wykoff,” Lynn said in a forced whisper when she appeared. As usual, there were other people waiting for an elevator. “She was changing right next to me.”

“And who might Dr. Wykoff be?” Michael asked, his voice rising for effect.

“Oh, come on!” Lynn complained irritably. “She was Carl’s fucking anesthesiologist, who was responsible for what happened. How could you forget?”

“I’m trying to make a point, my dear. You don’t know that she
was responsible. That’s the kind of comment that is going to get you in a whole shitload of trouble.”

“Technically you’re right,” Lynn snapped. “But she was in charge when whatever happened happened. There’s no denying that. If she didn’t cause it, she could have stopped it or prevented it.”

“You don’t know that, girl. I’m telling you straight. You are going to crash and burn.”

The elevator doors opened. The car was full. Lynn and Michael and several others had to squeeze on as people reluctantly made room. The two students didn’t try to talk as the elevator rose, stopping on each floor. Once they got out on the sixth floor they walked slowly and let the other people who had gotten out pass by. Most were nurses and nursing assistants who were coming in for the morning shift.

“Wykoff’s first case for today was canceled,” Lynn said when she was sure no one would overhear. “She agreed to talk to me, provided her second case doesn’t get moved up.”

“I better come along just to keep you in line,” Michael said. “You are on a self-destructive roll.”

“Do you really want to come along?” Lynn said with a touch of disdain. “I thought you weren’t going to help.”

“Like I said. Somebody’s got to protect you from yourself and make sure you cut this woman some slack, you know what I’m saying?”

As they got closer to the neuro ICU, Lynn’s pulse began to rise and her anxiety ratcheted upward. If there had been a change in Carl’s status, she would not have heard one way or the other, as she wasn’t in the immediate family loop. Although she expected little change, she knew there was a slight chance that he could be better or worse. Unfortunately, with a provisional diagnosis of extensive brain necrosis, his chances of improvement were mighty slim, which left the downside much more probable.

Outside the double doors, Lynn hesitated out of worry about
what she was going to confront. Michael sensed her reluctance. “You want me to go in and see what’s up?” he suggested. “Then I could fill you in.”

“No,” Lynn said. “I want to go in and see him. I’ll be all right.”

As Lynn and Michael had hoped, the nurses were busy at rounds. As the door closed behind the medical students, they could see that the nursing team going off-shift and the team coming on were all congregated in bay number 5, going over a new arrival. For the moment all the other patients, including Carl, were on their own.

At the central desk, the ward clerk, Peter Marshall, was already on duty, watching over the monitor feeds. His day had already begun, even though technically it wasn’t supposed to begin until seven. Lynn remembered that had never bothered Peter. He always arrived early to get a jump on the day.

A female attending physician was also at the desk, busy at work with a number of charts stacked in front of her and one open. Lynn and Michael could tell from her long white professorial coat that she was an attending, and not a resident. They didn’t recognize her.

The medical students went directly to cubicle 8, with Lynn lagging slightly behind, afraid of what she was going to see. Carl wasn’t sitting up having breakfast, but he wasn’t dead, either. He looked as serene as he had the day before, with his eyes closed, as if asleep. He was still in the exact same supine position, with the CPM flexing and extending his operated leg. His IV was running as it had been, but it had been repositioned as a central venous line and now went into his neck.

“Looks generally about the same as yesterday,” Michael commented. Lynn nodded, restraining herself from reaching out to touch Carl’s face. She noticed that his beard had darkened, and as her eyes traveled down his body, she observed that both arms were now relaxed. Apparently the decorticate posturing was gone. Whether that was a good sign or not, Lynn had no idea. The myoclonic jerks of his free leg had also stopped.

In order to look as if he were on a legitimate mission, Michael took out his penlight and tried Carl’s pupillary reflexes. While he was busy, Lynn glanced up at the monitor. She didn’t want to look into Carl’s unseeing eyes again, as doing so had unnerved her the day before. She saw that the blood pressure was normal as was the oxygen saturation. The ECG looked normal to her as well. It was then that she spotted the temperature graph. Carl had a fever of 103 degrees, and it had been as high as 105! She knew that wasn’t good news.

“Pupillary reflexes are better than yesterday,” Michael said, straightening up. “I wonder if that is a good sign.”

“His temperature is elevated,” Lynn said with concern, pointing up to the monitor.

“So it is,” Michael said after taking a look. “That can’t be good.”

“It’s not,” Lynn said. “Pneumonia is a big threat to people in a coma. I learned that last night.”

“You got that right. Sounds like you learned a lot in one night.”

“It is amazing what you can get done if you don’t eat or sleep.”

“Then let’s get you down to the cafeteria before you flatline.”

“Let’s check the chart first. I want to see the results of the MRI he was supposed to have had.”

Leaving Carl’s cubicle, the duo walked directly toward the central desk. As they traversed the room, Lynn made momentary eye contact with Gwen Murphy, who had moved on to cubicle 6, along with all the other nurses. Fortunately Murphy’s expression didn’t change. For Lynn, being an interloper was a nerve-racking experience. She was impressed that Michael seemed to be taking it in stride.

At the circular desk, Michael smiled at Peter, who smiled back. The clerk was on the phone with Clinical Chemistry, trying to get the latest lab values before they were even in the computer. The attending physician didn’t look up from her work. The stack of charts was still in front of her.

As he had done the previous day, Michael went directly to the circular chart rack and gave it a decisive spin. He stopped it at the slot for cubicle eight. There was no chart.

Tapping Peter’s shoulder, Michael silently mouthed, “Vandermeer,” and motioned toward the chart rack. Without interrupting his phone conversation, Peter pointed to the attending physician. Michael understood. The attending had Vandermeer’s chart, a new, potentially problematic complication.

With a shrug, Michael started toward the attending, only to have Lynn grab the sleeve of his white coat and restrain him.

“What are you going to say?” Lynn questioned in a whisper.

Michael shrugged again. “I’m going to wing it, as usual.”

“You can’t use the anesthesia ruse because she might be from anesthesia.”

“You are so right,” Michael said with a nod.

“Hold on,” Lynn said. She stepped over to Peter and scribbled on the notepad in front of the clerk:
Who’s the attending, and what department is she from
?

Without interrupting his conversation, Peter scribbled:
Dr. Siri Erikson, hematology.

Lynn mouthed a “Thank you” to Peter and then took the note back to Michael.

“Hematology?” Michael questioned, still in a whisper. “What does that mean? Carl’s got a blood problem?”

“Who’s to know?” Lynn said. “I hope not. Maybe there is some association with the fever.”

“I would think a fever in a comatose patient would call for an infectious disease consult, not one from hematology.”

“I agree. Anyway, let’s see how friendly she is toward medical students.”

Both Lynn and Michael were well aware that some medical attendings savored the teaching role whereas others saw it as a burden and acted accordingly.

“The good news is that she’s not from anesthesia,” Michael said, “so our cover is okay if it comes to that.”

“You do the talking,” Lynn said. “You’re better at deception than I.”

“I’m going to pretend I didn’t hear that, girl.”

“That’s fine, boy!” Lynn responded.

Michael approached the hematologist. He cleared his throat to announce himself. “Excuse me, Dr. Erikson.”

The woman looked up from her work. She was attractive, somewhat heavyset mature woman in her late forties or early fifties. Consistent with her family name, she looked Scandinavian, with blond hair and a pale complexion. Her eyes were a clear cerulean blue. “Yes,” she said.

“My partner and I were wondering if we could take a quick look at Vandermeer’s chart if you are not using it at the moment.”

Dr. Erikson turned to the stack of charts in front of her and fished out Carl’s. She handed it up to Michael but maintained a hold on it. “I’m not finished with it,” she said. “So I need it back.”

“Of course,” Michael said. “We’ll just be a moment.”

“I assume you are medical students,” Dr. Erikson said, glancing briefly at Lynn. She had yet to let go of the chart. “What is your association with the case?”

“My name is Michael Pender and this is Lynn Peirce. We’ve been asked by anesthesia to follow the case.”

“I see,” Dr. Erikson said. She finally released her hold on the chart. “Is it because it is a case of delayed return to consciousness?”

“You got it,” Michael said. He smiled diplomatically, handed the chart to Lynn, and started to take a step away, hoping to end the conversation, but Dr. Erikson spoke up again: “Is it just Vandermeer you are interested in, or are you following Scarlett Morrison as well?”

“Should we be?” Michael asked.

“Not necessarily. But she is a similar case.”

“You mean she is another case of delayed recovery from
anesthesia?” Michael asked. He shot a glance at Lynn, whose eyes had opened wider, despite her fatigue. She was obviously taken aback.

“Yes, she is,” Dr. Erikson said. “She was a Friday surgery. A very similar case, I’m afraid. I’m surprised someone in anesthesia didn’t tell you.”

“I’m surprised, too,” Michael said. “We certainly should be following her.” He glanced at Lynn, who looked as if someone had just slapped her.

“I’m using the Morrison chart at the moment,” Dr. Erikson said. “When you finish with Vandermeer’s, I’ll give it to you.”

“That’s a deal,” Michael said, grabbing Lynn by the arm and forcibly moving her away, over to a couple of empty chairs. The two of them sat down.

“If it is true there’s another case, this is worse than I thought,” Lynn said in an excited, horrified whisper. “If there was another case last week, then the incidence here at Mason-Dixon Medical Center is three in five thousand, meaning it is not eighty times the average, but one hundred twenty times!”

“Calm down!” Michael insisted, trying to keep his own voice low. He glanced over at Dr. Erikson in hopes she wasn’t paying any attention. Luckily she was again totally absorbed in her work. “Let’s take this one step at a time,” Michael said. “We came here to look at Carl’s chart. Let’s do it and get the hell out!”

Making an effort to follow Michael’s advice, Lynn opened the chart. The last entry was a short note by the neurology resident, Charles Stuart, who had been called during the night when Carl’s fever had spiked. Stuart had ordered an emergency portable chest X-ray, which was read as clear, so no pneumonia. He wrote that the operative site was not red or swollen. He sent away a urine sample for bacteriologic studies and drew blood for a blood count and for blood cultures. He concluded his note with the statement “Fever of unknown origin. Will follow. Consult requested.”

“Maybe Dr. Erikson is the consult,” Lynn said.

“Could be,” Michael said. “But hematology and not infectious disease? It doesn’t compute.”

Quickly Lynn flipped through the chart to get to the results of the studies, in particular the MRI, only to learn that a CT scan had been done as well. Laying the chart flat, she and Michael read the reports. Michael finished first and waited for Lynn to do the same.

“There are a lot of terms that I don’t understand,” Michael said.

“Likewise,” Lynn said. “But it’s pretty clear that it isn’t good news, even if we don’t understand all the details. The summary says the CT scan showed severe diffuse brain edema while the summary of the MRI says that the hyperintense cortical signal indicates extensive laminar necrosis. That’s what Dr. Stuart expected. It all translates to extensive brain death . . .” Lynn trailed off, unable to finish her sentence.

“I’m sorry,” Michael said as sincerely as he could.

“Thank you,” Lynn said. Her voice caught. With such terrible news, she was trying not to cry. She was supposed to be a dispassionate medical student.

“Want to look at anything else in the chart?” Michael asked.

Lynn shook her head. As far as she was concerned, there wasn’t any point. The verdict was in. Whether Carl would regain some level of consciousness or not was uncertain, but even if he did, he was never going to be the person she knew. Best-case scenario was probably his entering a persistent vegetative state, a horrid situation that she had read up on the evening before. He would have brain stem function without input from the higher or cortical areas. It would mean he might have sleep-wake cycles but still would be completely unaware of self and environment and need total care until death. In short, he would endure a dehumanized existence. Inwardly she shuddered, wondering if she could cope.

Michael stood up and gave Lynn’s shoulder a reassuring squeeze. He took Carl’s chart back over to Dr. Erikson, who gave him Scarlett Morrison’s chart. He brought it back to where Lynn was sitting
and placed it in front of her. She was in a trance, staring ahead. “You okay?” he asked.