“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?”
“What am I seeing?” Lynn asked in a hesitant voice. It was all she could do to keep from recoiling and running from the room.
“Notice that when I rotate the head, the eyes move in the opposite direction.” Charles rotated Carl’s head again.
It was now easy for Lynn to see that Carl’s eyes did rotate as Charles had described, blankly staring upward as his head went to the side.
“It’s a vestibulo-ocular reflex,” Charles said in a didactic-medical monotone that was all too familiar to Lynn. “It means that the brain stem and the involved cranial nerves are operating as they should. If the patient is malingering, acting as if unconscious, something you will see on occasion in the ER, the eyes move in the direction of the rotation. If the brain stem is not functioning, then the eyes don’t move at all. Rather dramatic, wouldn’t you say? I could also show you the same phenomena using caloric stimulation, meaning putting cold water into his ears. Would you like to see that as well?”
“This is quite enough,” Lynn said. She pulled her hand back, allowing Carl’s eyelids to close slowly. She had to get away. To where, she didn’t know. As a member of the hospital community and soon to be a doctor, she felt a responsibility in Carl’s disaster above and beyond her recommending Dr. Weaver and the Mason-Dixon Medical Center.
“I have all the paraphernalia available,” Charles said. “It will only take a second to get it. It’s no imposition whatsoever.”
“Thank you,” Lynn said, backing up from the bed. “I appreciate your taking the time to show me what you have, but I have to go. I’m sorry.??
?
“That’s quite all right,” Charles said. He stared at Lynn and furrowed his brows. It was obvious he was confused about her behavior. “If any of the other members of your preceptor group would care to see this classic doll’s eye movement, I’d be happy to show it to them.”
“Thank you,” Lynn said. “I’ll let the others know.”
Lynn fled out of the ICU. Once in the hall, she stopped and took a few deep breaths. It was somehow comforting to be back in the usual commotion of the hospital with patients, nurses, and orderlies passing her. Her heart was still racing. There was nothing she could do to help Carl, and her first thought was that she had to find Michael. She needed an anchor, someone to hold on to during this storm of uncertainty and emotion.
5.
Monday, April 6, 12:25 P.M.
Lynn found Michael in the cafeteria. She had first gone back to check the coffee shop, but he and the others had left. She thought about texting him but had no idea what to say. Instead she wanted just to find him. Maybe she wouldn’t even say anything for a time.
Considering the hour, she had decided the cafeteria was the best bet, as the food was considerably cheaper there than at the coffee shop, and Michael rarely missed a meal. As usual the room was crowded with its usual lunchtime rush. It had taken her a moment but she managed to locate him in the food line. She felt lucky he was by himself. The other members of the earlier coffee-shop group were nowhere to be seen. She was glad about that. She wanted to talk only to Michael.
“Hey, Lynn. How’s Carl doing?” he asked when he turned to look who had tapped him on his shoulder.
“I need to talk,” Lynn said, her voice faltering. “Privately.”
“Okay, no problem,” Michael said. Knowing her as well as he did, he immediately sensed her brittle emotional state. He eyed her. “You okay?”
“That remains to be seen,” Lynn said. There was an audible catch in her voice.
“How about grabbing some lunch and hanging with me?”
“I’m not hungry at the moment.”
“Do you mind if I eat while we talk?”
“Of course not!”
“Then let me settle up for these vittles. Then we can sit over there in left field by the far wall. I see a couple of free tables.”
Lynn glanced in the direction and nodded. The cafeteria was as good as anyplace else in the hospital for a talk with Michael. The hubbub might actually help her keep her emotions in check.
Although Lynn wasn’t hungry, she was thirsty, and she got herself some water before sitting at one of the free tables they had seen from the steam-table line. The area was farthest away from the windows, which looked out onto a sumptuously landscaped interior garden. A number of tables in the garden were the most popular, and were the first to fill up when the weather was as good as it was. Lynn could see quite a few of her classmates outside.
As she sat waiting for Michael to pay, she watched him in the checkout line. He was a commanding presence and stood out from the similarly white-coated medical students. The main reason was a combination of his size and the fact that he was black. In Lynn’s class there were only three African American males along with five females of color, making up only 6 percent of the class despite the school’s active recruitment efforts. Michael was a muscular man with a thick neck who Lynn learned had played football at the University of Florida and who had had a shot at playing professionally had he not set his heart on becoming a doctor. Lynn knew that the career choice was a debt he owed to his mother. His features were broad, his skin a dark mahogany, and his hair was relatively long and worn in what Lynn had come to know was a lock-twist. Initially she thought they were short dreadlocks but now she was the wiser.
Back on the second day of medical school when Lynn had first spoken with Michael when paired with him for the anatomy lab, she had been mildly intimidated. Not only was he a sizable man, but he seemed to her to have an animus toward her right out of the gate. From their first words he complained about her attitude, so she did the same. During the initial days they merely tolerated each other, and both had to make an effort just to get along well enough to work together.
Lynn had never considered herself racist, but over time Michael had made her see that she had been to an extent, and that racism was unfortunately alive and well in America. Michael for his part learned from her that he was so accustomed to having to deal with patronizing attitudes that he often evoked it. He also came to learn from her that despite fifty-plus years of feminism, misogyny and gender discrimination had not disappeared. Both came to understand that with racism and gender issues, one had to be a member of the oppressed to really appreciate the subtleties and the not-so-subtleties of discrimination that had so influenced their respective lives. Throughout her life, Lynn always felt she had to do a bit better than the men with whom she was competing whereas Michael always felt he had to do much better than everybody.
As Lynn and Michael came to understand they were kindred spirits, they began to appreciate each other’s idiosyncrasies apart from race and gender, stemming from their different backgrounds: Lynn, from a middle-class Atlanta upbringing, with two siblings who ultimately fell on hard times; and Michael, from a single-parent household from the South Carolina Low Country, with five siblings who had had to struggle to keep a roof over their heads and food on the table. They also became aware of their similarities besides their being extremely motivated hard workers who strived for excellence. Both had defied stereotypes and had responded to STEM programs in their schooling, meaning science, technology, engineering, and math. Both early on liked computer gaming and had an interest and facility in coding. Both had aced college. In medical school both were on full scholarships, which was the main reason they were at Mason-Dixon University. Both of them had been accepted at all the medical schools to which they had applied, but Mason-Dixon had had the best offer financially. Finally, although Lynn had been close to her father, she also knew what it was like not to have one.
As Michael approached, Lynn felt thankful for their relationship and grateful to the school for having paired them up. She had never had a male friend like Michael, and valued their relationship, as he had truly expanded her life in so many ways. And now, if the neurology resident was right in his prognosis of Carl’s condition, she was going to need Michael’s support more than ever.
“Okay, whassup?” Michael said, affecting nonchalance while sliding his tray onto the table. He settled his solid two-hundred-pound frame onto the chair, which squeaked in protest. He picked up his sandwich and took a healthy bite.
For a minute Lynn was unable to speak. She wasn’t one to cry often, possibly because of a reaction to the stereotype, and she didn’t want to cry now. She felt torn. She wanted Michael’s support to avoid the sense of isolation that she was already feeling from the shock of this unfolding calamity, yet she worried that telling Michael about what had happened would make it more real. As a medical student, she knew enough about the psychology of the grief reaction to know that she was still solidly in the early denial stage.
Michael did not press her. He chewed his sandwich and took another bite, seemingly ignoring her. He was content to wait. He knew her well enough to be concerned. Something significant was in the wind, and it had to do with Carl and his surgery.
Lynn took a drink of water and then closed her eyes tightly. When she opened them she let the facts flow out, explaining about Carl’s apparent anesthesia disaster and how she had gone up to the neuro ICU and talked with the neurology resident. She concluded by saying that Carl’s Glasgow score was only five and that the neurology resident said the prognosis was dismal.
Michael put his sandwich down and pushed his plate away as if he had lost his appetite. “That’s a low Glasgow score.”
Lynn stared at her friend. There were lots of times that he amazed her, and this was an example. She had never heard of a Glasgow score, and Mich
ael apparently had, despite the fact that they both had taken the same neurology rotation during their third year. He had a facility to remember facts no matter how obscure. “How do you know about the Glasgow score? I don’t think I have ever heard of it.”
“Let’s just say I had reason. It is a way to evaluate people in a coma. What was the neurology resident’s name?”
“Charles Stuart, I think. I don’t know for sure. My mind isn’t working at full speed.”
“I don’t think we had him for any part of our neurology rotation.”
“I know for sure we didn’t. I had never seen him before.”
“What else did he say besides the Glasgow score and that the prognosis was not good?”
“He said that he expected to see extensive laminar necrosis on the MRI when they do it.”
“I don’t know what laminar necrosis is.”
“I don’t, either, but it is not hard to guess.”
Michael nodded. “Did you talk to anyone else, like the surgeon or the anesthesiologist?”
“I haven’t spoken to anyone. I wanted to talk to you first.”
“Did you look at the anesthesia record?”
“No. All I did was see if it was Carl, and it is. He’s in a freaking coma, for Chrissake! And I was the one who recommended the doctor and encouraged him to get his fucking knee fixed here at Mason-Dixon.”
Michael reached out and enveloped Lynn’s comparatively narrow wrist with his large hand. His grip was firm. “Listen, sister,” he began. When they were alone together they jokingly called each other sister and bro, a bit of Black argot that Michael had instigated as a sign of their platonic intimacy and comfort with each other. As a further sign of their closeness, he also treated her to basketball metaphors he’d used with his buddies in high school. “I can tell you right off the top, you are not responsible for whatever happened during today’s game. You weren’t a player. No fucking way!”