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.