As soon as Mannerheim had finished removing brain tissue, Ranade slowed the ventilation of the patient. He wanted to let Lisa's blood pressure rise a little while Mannerheim inspected the cavity for any bleeding. After a careful check Mannerheim was satisfied the operative site was dry. Taking a needle holder he began to close the dura, the tough covering over the brain. At that point, Ranade began carefully to lighten Lisa's anesthesia. When the case was over he wanted to be able to remove the tube in Lisa's trachea without her coughing, or straining. This required a delicate orchestration of all the drugs he'd been using. It was imperative that Lisa's blood pressure not go up.
The dural closure went swiftly and with a deft rotation of his wrist, Mannerheim placed the last interrupted stitch. Lisa's brain was again covered, although the dura dipped down and was darker where Lisa's temporal lobe had been. Mannerheim cocked his head as he admired his handiwork, then stepping back, he snapped off his rubber gloves. The sound echoed in the room.
"All right," said Mannerheim, "close her up. But let's not make it your life's work."
Motioning for the two Japanese doctors to come with him, Mannerheim left the room.
Newman took Mannerheim's position at Lisa's head. "Okay, Lowry," said Newman, echoing his boss, "let's see if you can help me rather than hinder me."
After dropping the bone flap into place like the top of a Halloween pumpkin and tying the sutures, Newman was ready to close. With a pair of rugged tooth forceps, he grabbed hold of the edge of Lisa Marino's wound and partially everted it. Then he plunged the needle deep into the skin of the scalp, making sure he picked up pericranium, and brought the needle out in the wound. Detaching the needle holder from its original position on the shank of the needle, he used the instrument to grab the needle tip, bringing the suture out into the wound; With essentially the same technique, he put the silk through the other side of the wound, trailing the suture off into Dr. Lowry's waiting hand so he could tie the stitch. They repeated this procedure until the wound was closed with black sutures, giving the impression of a large zipper on the side of Lisa's head.
During this part of the procedure, Dr. Ranade was still ventilating Lisa by compressing a breath bag. As soon as the last stitch was to be placed, he planned to give Lisa one hundred percent oxygen and reverse the remaining muscle paralyzer her body hadn't metabolized. On schedule his hand again compressed the breathing bag, but this time his experienced fingers detected a subtle change from the previous compression. Over the last few minutes Lisa had begun to make initial efforts to breathe on her own. Those efforts had provided a certain resistance to ventilating her. That resistance had been gone on the last compression. Watching the breathing bag and listening with his esophageal stethoscope, Ranade determined that Lisa had suddenly stopped trying to breathe. He checked the peripheral nerve stimulator. It told him the muscle paralyzer was wearing off on schedule. But why wasn't she breathing? Ranade's pulse increased. For him anesthesia was like standing on a secure but narrow ledge on the side of a precipice.
Quickly, Ranade determined Lisa's blood pressure. It had risen to 150 over 90. During the operation it had been stable at 105 over 60. Something was wrong!
"Hold up," he said to Dr. Newman, his eyes darting to the cardiac monitor. The beats were regular but slowing with longer pauses between the spikes.
"What's wrong?" asked Dr. Newman, sensing the anxiety in Dr. Ranade's voice.
"I don't know." Dr. Ranade checked Lisa's venous pressure while preparing to inject a drug called nitroprusside to bring down her blood pressure. Up to this point Dr. Ranade believed the variation in Lisa's vital signs was a reflection of her brain responding to the insult of surgery. But now he began to fear hemorrhage! Lisa could be bleeding and the pressure in her head could be going up. That would explain the sequence of signs. He took the blood pressure again. It had risen to 170 over 100. Immediately he injected the nitroprusside. As he did so, he felt that unpleasant sinking feeling in his abdomen associated with terror.
"She might be hemorrhaging," he said, bending down to lift Lisa's eyelids. What he saw was what he'd feared. The pupils were dilating. "I'm sure she's hemorrhaging," he yelled.
The two residents stared at each other over the patient. Their thoughts were the same. "Mannerheim's going to be furious," said Dr. Newman. "We better call him. Go ahead," he said to Nancy Donovan. "Tell him it's an emergency."
Nancy Donovan dashed over to the intercom and called out to the front desk.
"Should we open her back up?" asked Dr. Lowry.
"I don't know," said Newman nervously. "If she's hemorrhaging inside her brain it would be better to get an emergency CAT scan. If she's bleeding into the operative site, then we have to open her up."
"Blood pressure still rising," said Dr. Ranade with disbelief as he watched his gauge. He prepared to give her more medication to bring the blood pressure down.
The two residents remained motionless.
"Blood pressure still rising," shouted Dr. Ranade. "Do something, for Christ sake!"
"Scissors," barked Dr. Newman. They were slapped into his hand and he cut the sutures he'd just finished placing. The wound spontaneously gaped open as he got to the end of the incision. As he pulled the scalp flap back, the section of skull they'd removed for the craniotomy pushed up at them. It seemed to be pulsating.
"Let me have the four units of blood that's on call," shouted Dr. Ranade.
Dr. Newman cut the two hitch sutures holding the bone flap in place. The piece of bone fell to the side before Dr. Newman picked it up. The dura was bulging out with an ominous dark shadow.
The OR door burst open and Dr. Mannerheim came flying in, his scrub shirt was unbuttoned save for the bottom two.
"What the hell's going on?" he shouted. Then he caught sight of the pulsating and bulging dura. "Jesus Christ! Gloves! Let me have gloves!"
Nancy Donovan started to open a new pair of gloves, but Mannerheim snatched them away from her and pulled them on without scrubbing.
As soon as a few sutures were cut, the dura burst open, and bright red blood squirted out over Mannerheim's chest. It soaked him as he blindly cut the rest of the sutures. He knew he had to find the source of the bleeding.
"Sucker," yelled Mannerheim. With a rude sound, the machine began to draw off the blood. Immediately it became apparent that the brain had shifted or swelled because Mannerheim quickly encountered the brain itself.
"The blood pressure is falling," said Ranade.
Mannerheim yelled for a brain retractor to help him try to see the base of the operative site, but blood welled up the moment he took the sucker away.
"Blood pressure…" said Dr. Ranade, pausing. "Blood pressure unobtainable."
The sound of the cardiac monitor, which had been so constant during the operation, slowed to a painful pulse, then stopped.
"Cardiac arrest!" shouted Dr. Ranade.
The residents whipped up the heavy surgical drapes, exposing Lisa's body and covering her head. Newman climbed up on the stool next to the OR table and began cardiac resuscitation by compressing Lisa's sternum. Dr. Ranade, having obtained the blood, hung it up. He'd opened all his IV lines, running fluid into Lisa as fast as possible.
"Stop," yelled Mannerheim, who'd stepped back from the OR table when Dr. Ranade had shouted cardiac arrest. With a feeling of utter frustration, Mannerheim threw the brain retractor to the floor.
He stood there for a moment, his arms at his sides with blood and bits of brain dripping from his fingers. "No more! It's no use," he said finally. "Obviously some major artery gave way. It must have been from the God-damned patient pushing in those electrodes. Probably transected an artery and put it into spasm, which was camouflaged by the seizure. When the spasm relaxed it blew. There's no way you can resuscitate this patient."