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Monday, April 6, 11:05
A.M.

L
ynn was in a hurry. It was a way to avoid thinking. Without bothering to change back to her street clothes, she went directly to the main elevators, where a number of people were waiting. To avoid the possibility of getting into a conversation, she avoided any eye contact, keeping her attention glued to the floor indicators above the elevator doors. Nervously she continuously pressed the up button. None of the cars appeared to be moving up or down.

“That’s not going to get the elevator here any faster,” a woman said. Lynn closed her eyes, hoping that by not responding she would be spared having to try to be pleasant while her mind was in turmoil. There was nothing about Carl being in the neuro ICU that could be good news, and it was difficult not to imagine the worst.

“You are a fourth-year med student, if I’m not mistaken,” the voice said, undeterred by Lynn’s silence.

Reluctantly Lynn turned to face the woman. As soon as she did, she recognized her as one of the surgical attendings. She was
wearing a long white lab coat over scrubs. Lynn assumed she was between cases and heading up to the surgery floor to check on a patient.

Lynn tried to smile in an attempt to be sociable. Her pulse was throbbing in her temples. She wondered if her face was red or pale. It had to be one extreme or the other, as she was experiencing an adrenaline rush. She was aware she was hyperventilating. She nodded. “I am,” she said distractedly. What the hell could be holding up the elevators? Still none had moved from the various floors where they had been when she first hit the button.

“Lynn Peirce,” the surgeon said, bending forward and reading Lynn’s ID hanging from a lanyard around her neck. “Actually, I remember you from your third-year surgery rotation. I’m Dr. Patricia Scott.”

“I remember you for sure,” Lynn managed. “Your lectures were terrific, especially your slides.” Lynn forced another half smile at the tall, elegant woman before returning her attention to the elevator floor indicator. She hoped her anxiousness wasn’t too apparent. She didn’t want to explain herself.

“Thank you. You must have been paying attention. I remember you did extremely well. I understand you got your residency notification a couple of weeks ago. Considering how well you did in your surgery rotation, I hope you gave surgery some consideration.”

“Orthopedics, actually,” Lynn said.

“Indeed! That’s terrific. We need more women in all the surgical fields, particularly orthopedics, where we are not very well represented. Where will you be going for your training?”

“I’m staying here,” Lynn said.

“Wonderful,” Dr. Scott said sincerely. “That’s super. I’ll look forward to having you scrub with me during your first year of general surgery.”

“I’m sure I will enjoy that, Dr. Scott,” Lynn said, hoping she
didn’t appear as preoccupied and stressed as she felt. Finally one of the elevators that had seemingly been parked on the first floor began to ascend.

“You can call me Patricia now that you will be part of the house staff. And, for the record, my office is always open if you need any advice. It wasn’t that long ago I went through the training gauntlet, and unfortunately surgery is still anachronistically considered by some to be a men’s club.”

“I appreciate your thoughtfulness,” Lynn said.

The elevator’s doors opened. The car was jam-packed. Dr. Scott gestured for Lynn to precede her, and both had to literally squeeze in to allow the doors to close. Lynn was briefly tempted to ask Dr. Scott what it meant for a patient to go to the neuro ICU directly from the PACU, but she didn’t. The trouble was, she could guess. It had to have been some kind of anesthesia problem or disaster. Yet she still maintained a certain amount of hope it could have been something less worrisome. Could a nerve in Carl’s leg have been damaged with the bone drill? As bad as that might be, it was better than other possibilities she was trying to avoid imagining.

By the time they got up to the sixth floor, where neurology and neurosurgery were located, the elevator had emptied considerably. Lynn thanked Patricia Scott before getting off. She walked quickly. She knew where the neuro ICU was located. She’d been there on a few occasions during her neurology rotation and again during her stint on neurosurgery.

Most visitors to the floor were expected to check in at the main nurses’ station. But Lynn decided on the spur of the moment to act the same way she had down in the PACU: as if she belonged. Without hesitation she pushed into the ICU directly.

The neuro ICU appeared superficially similar to the PACU in terms of its prominent high-tech equipment, but here patients stayed much longer, sometimes weeks, even months on occasion. There were separate cubicles defined by glass walls, and not all the patients
were sporting bandages. There was also less frantic activity from constant arrival and departure. Instead, a kind of heavy silence reigned, broken only by the distant beeping of monitors and the rhythms of the ventilators. A central circular desk was positioned to afford a view into each of the sixteen individual bays. All were occupied. At least half had nurses in direct attendance.

As Lynn glanced around the room she saw that each cubicle had an ID slot with the patient’s name printed in bold letters. Almost at once she zeroed in on
VANDERMEER
, cubicle 8. Slowly she advanced. Carl was supine. She could not see his face. As she had expected, there was a CPM apparatus constantly flexing and extending his operated leg. Seeing it gave her a modicum of premature hope that everything was as it should be, but it didn’t last long.

Two people were in attendance. An ICU nurse was on Carl’s right, checking the blood pressure by hand, even though there was a BP readout on the monitor. On Carl’s left was a resident physician dressed all in white. He was using a penlight and shining it alternately into each of Carl’s eyes. It didn’t take Lynn long to recognize that Carl was unconscious. She could also see that he was evidencing some low-amplitude myoclonic jerks with his free leg. His free arm and wrist were flexed across his body. The other arm with the IV was secured to the bed rail.

Coming up to the foot of the bed, Lynn looked at the monitor. Blood pressure was normal. The same with pulse and the ECG, as far as she could tell, but she was no expert with ECGs. She could see that oxygen saturation was down a little but still reasonable at more than 97 percent. Carl seemed to be breathing normally. She forced herself to glance at his face, which she could now plainly see. His color wasn’t bad, maybe a little pale. The worst part was that it was definitely Carl and not someone else.

As the resident straightened up he noticed Lynn. Slipping his penlight into his jacket pocket, he asked, “Are you from radiology?” Then without waiting for an answer, he added, “We are going to
need an MRI or a CT scan ASAP.” Lynn could read his name tag: Dr. Charles Stuart, neurology. He was a slight man with thinning hair, small features, and rimless glasses.

“I’m not from radiology,” Lynn managed. Seeing Carl unconscious and possibly seizing was almost too much to bear. “I’m a medical student,” she added. She reached out and grasped the railing at the foot of the bed to steady herself. As she had in the PACU, she felt suddenly light-headed. A hospital was a place of tragedy as well as hope, but this was turning out to be all tragedy. “What is going on?” she asked as casually as she could.

“It’s not looking good,” Charles said. “It seems that we are dealing with a delayed return to consciousness after reportedly uneventful anesthesia for a routine ACL repair. So far it is a mystery as to why.”

“So he hasn’t awakened?” Lynn asked, not knowing what else to say, yet feeling as if she had to say something to warrant standing there.

“That’s the long and short of it,” Charles said flippantly. Lynn didn’t fault him. She’d come to learn that it was one of the ways house officers shielded themselves from the reality of human tragedy, which they were forced to face on a daily basis. Another way was to become consumed by academic detail, which he then evidenced by saying, “He’s completely unresponsive to spoken word and normal touch, except for a slight corneal reflex. On the positive side, he has retained some pupillary response to light. Seems that the brain stem is working, but with his decorticate posturing and flexion response to deep pain, it doesn’t look good for his cortex. It must have been a global insult, and we feel it was most likely hypoxic in origin, despite what the anesthesiology report suggests. It can’t have been embolic, as his deep tendon reflexes are not only preserved but also symmetrical. The problem is that he has a Glasgow Coma Scale sum of only five. As you probably know, that’s nothing to write home about.”

Lynn nodded. The reality was that she had little understanding of anything the neurology resident was talking about except the concept of an insult to Carl’s brain from hypoxia, meaning lack of oxygen. Neurology had been a short rotation and more applied neuro-anatomy than clinical.

“How could there be hypoxic damage if, as you say, the anesthesia was uneventful?” Lynn asked, more by medical-student reflex than anything else. Medical students were expected to ask questions.

“Your guess is as good as mine,” the resident said, reverting back to flippancy. “I’m afraid that’s going to be the million-dollar question.”

The nurse finished checking Carl’s blood pressure and headed back toward the central desk. She glanced briefly at Lynn but didn’t say anything. Lynn moved alongside the bed where the nurse had been, forcing herself to look back down at Carl’s face.

From his expression he appeared to be asleep and totally relaxed, despite the movement of his free leg. It was apparent he hadn’t shaved that morning, which was how he looked most Sundays when the two of them awoke. She associated his appearance with intimacy, which was totally out of place in the current environment and circumstance.

Lynn had to fight the urge to reach out and shake him awake, to talk to him, to yell at him to get him to respond and prove the neurology resident wrong about his not being responsive. What made the situation worse was that Carl’s face looked so achingly normal, just as it had yesterday morning when she had awakened and had watched him for a time as he slept, admiring his handsomely masculine features.

“Are you one of Dr. Marshall’s neurology preceptor group?” Charles asked, watching Lynn from across Carl’s bed. It seemed to Lynn that he was sensing something unprofessional about her behavior.

“Yes,” Lynn responded without elaboration. She had been in
Dr. Marshall’s preceptor group, except it was a year ago. It wasn’t easy for her to be deceptive, but she assumed that she would be kicked out of the ICU if she wasn’t there for official teaching purposes. The hospital was strict about confidentiality issues, and she wasn’t technically family, at least not yet. With effort, she avoided eye contact with Charles for the moment. She could tell the resident was watching her.

Hesitantly Lynn reached out and lightly touched Carl’s cheek with her right hand. His skin felt cool but otherwise normal. She was afraid it would feel rubbery and unreal.

“Have you done an EEG?” Lynn asked, falling back into the protective medical-student persona by asking a question. She was suddenly worried that her touching Carl’s face might have seemed strange to the neurology resident. She didn’t say electroencephalogram because that wasn’t how house staff referred to the test of brain function.

“There was an EEG done on an emergency basis. Unfortunately it showed very low amplitude and slow delta background. I mean it wasn’t completely flat, but it shows diffuse abnormality.”

Lynn raised her eyes, forcing herself to look across at Charles despite her discomfort in doing so. In the most professional tone she could manage to camouflage her roiling emotions she asked: “What’s your guess at the prognosis?”

“With a Glasgow score of only five I’d have to say pretty dismal,” Charles said. “That’s been our experience with comatose patients not involving trauma. My guess is that when we get a brain MRI we are going to see extensive laminar necrosis of the cortex.”

Lynn nodded as if she understood what Charles was saying. She had never heard the term
laminar necrosis
, but she very well knew that necrosis meant death, so extensive laminar necrosis must have meant extensive brain death. With some difficulty she swallowed. She wanted to shout “No, no, no!” But she didn’t. She wanted to run
away but she didn’t. Lynn considered herself a modern woman, aware of current-day female opportunity, and she had “taken the ball and run with it,” acing high school, college, and medical school. Her approach was to work as hard as she could, and when she confronted problems or obstacles, which she most certainly had experienced, her reaction was just to strive that much harder. But here was perhaps one of the biggest challenges of her life. Here the man with whom she had come to believe she might share her life was possibly brain dead, and there was nothing she could do.

“Hey,” Charles said suddenly. “You know what? This is a perfect teaching case to demonstrate doll’s eye movement as a test for brain stem function with comatose patients. Have you ever seen it?”

“No,” Lynn forced herself to say. Nor did she think she wanted to see it with Carl as the subject, since it would only make his status that much more real, but she didn’t think she could refuse without possibly betraying that she was there under false pretenses.

“Then let me show you,” Charles said. “But I need your help. You hold his eyes open while I rotate his head.”

As if touching something forbidden, Lynn used the thumb and the first finger of her left hand to elevate gingerly Carl’s upper lids. She stared down into blankness of his mildly dilated pupils. It gave her an eerie feeling, as if she were violating his personhood. Silently she shouted for him to wake up, to smile, and to talk and say that this whole episode was a sham and a joke. But there was no reaction, just his rhythmical breathing.

“Okay, good,” Charles said. He bent over Carl’s chest and put his hands on either side of his head. He first rotated Carl’s head toward Lynn and then back toward himself. “There, did you see it?”