In Coma, Robin Cook, a trained medical doctor turned writer, describes the carefully controlled chaos of a major urban teaching hos pital. He takes us all over the hospital—from the dingy basement to the lofty Grand Rounds—putting the American transplant industry under a microscope. The novel's central theme reveals the controversy surrounding our search to define brain death and the way transplant organs are procured and disseminated. In his author's note Cook says he intends to entertain, but Coma is definitely not science fiction. His belief, which contradicts the U.S. transplant industry's official stance, is that scarce organs are pirated and sold to the highest bidder every day. At the time he wrote Coma in 1977, he also saw as unacceptable the definition of brain death, which, as noted earlier, is contrasted with cardiac death. What medical organizations such as the American Medical Association and various transplant organizations are trying to do is to improve legislation to effect a greater number of donors by offering financial and moralistic incentives, by educating the public on the need for donor organs, and by dispelling myths and misconceptions. The significant problem remains of legally obtaining the donor's and the family's timely permission to harvest organs. The revised Uniform Anatomical Gift Act, promulgated in 1987, increased donor awareness but has not solved the problem of providing enough transplant organs.
The way Cook describes the hospital hierarchy is important to weaving Coma's sinister plot. The viewpoint is mostly third-year medical student Susan Wheeler's. She has left her intensive book learning and just started her clinical surgical rotation, going on the ward with patients for the first time. She and four others are on the bottom professional rung. Doing scut work—and often learning from the more competent nurses—they do not have much credibility and power. They do not have much confidence, either, often feeling like imposters. Small accomplishments, like successfully inserting an IV needle into a vein, cause euphoria. One student faints at his first operation, not an uncommon happening. The bright and beautiful Susan Wheeler feels panicked, like the rest: "What if someone expected her to make some life-death decision to go along with her white coat and her impotent stethoscope in her pocket." The medical students' superiors are the residents (first-year residents are often called interns). Wheeler's immediate supervisor is intermediate surgical resident Mark Bellows, who is responsible for her learning and for her actions. George Chandler is the chief surgical resident, a job Mark Bellows competes for. Bellows does not want to make waves when the spirited Susan Wheeler tells him of a horrific hospital conspiracy to turn healthy patients into profitable organ donors. Her investigation shows a high incidence of prolonged coma resulting from anesthetic complications in surgery. But, one by one, as she naively approaches her superiors for help, they try to quash her efforts. The hospital's lower and upper worlds collide, as conspiratorial terror develops and her life is threatened.
As would be expected, Cook also describes the antagonism existing between medicine and disease. Surgeons, especially, are seen as the conquering warriors. Other relationships—because the book was written in 1977—have changed somewhat. For instance, Susan Wheeler describes the "paradoxical loneliness" of being the only woman on her rotation, among all-male superiors: "[S]he felt she was entering a male club; she was an outsider forced to adapt, to compromise." In the patriarchal system of men's rule and sexism toward women, a woman responding with competitive and aggressive action is labeled "a castrating bitch"; however, if taking a more passive, compliant stance, she is told she cannot compete. Susan's hard investigative data and strong intuitive feelings on the coma incidents are met with patronizing behavior toward the beautiful medical student. Now, however, with more women entering medical school than men, the system Susan entered is changing. But the hospital hierarchy Cook describes is still in effect today. He also gives enough technical medical descriptions of operations and details of diseases and autopsies to satisfy premed students. Realistic accounts of the intricacies of applying anesthesia and of the drama of performing surgeries add to the growing terror. Dated accounts of computerized medical research will make today's students appreciate what is currently available.
Interwoven into the high tension of a covert hospital conspiracy, Cook portrays the problem of drug-addicted doctors, dehumanization in the medical field, and the doctor-patient relationship. A hoard of narcotic drugs is found in an attending surgeon's hospital locker once assigned to Mark Bellows. The hospital wants the investigation kept internal and private, a conspiracy of silence. The story relates to the medical profession's continual efforts to deal with stressed-out doctors whose narcotic licenses make it too easy to self-medicate. Now programs help with recovery to return valuable medical professionals to their professions. Also as shown in Coma, doctors' dehumanizing patients leads to errors in their medical judgment. Often sick patients cannot easily describe symptoms to their doctors, and when their doctors cannot bridge this lack of communication, the patients suffer the consequences, which leads to medical mistakes. In 1999 the National Institute of Medicine estimated that deaths from medical mistakes exceeded 44,000 (about the same as motor vehicle accident deaths). In other words, it is "like a jet crash every day of the year" (Neergaard).
The very worse kind of medical mistakes, Dr. David Hilfiker believes, involves "a failure of will," which happens even though "a doctor knows the right thing to do but doesn't do it because he is distracted, or pressured, or exhausted" (Hilfiker, 376). Cook portrays members of the medical staff as having profit motivation and as treating each coma patient as the object it has become, "like a part of a complicated game, like the relationships between the football and the teams at play. The football was important only as an object to advance the position and advantage of one of the teams." Cook's conspiratorial and cynical doctors detach from any human connection with their coma victims, avarice and greed being chief motivators. In fact, generations of doctors were taught to have "detached concern" and not to get too close to a patient; but now having empathy is linked with communication for better doctoring. An unnatural distance also creates a level of dissatisfaction in the doctor-patient relationship and eventual physician burnout. Susan Wheeler's human connection with her two coma patients, in particular, and her attention to detail sustained her investigation all throughout Coma. To borrow from legendary humanist doctor Sir William Osler, with patients as texts, the best teaching during clinical rounds is done by the patients, themselves.
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