“Everything okay?” Dr. Weaver questioned. He was eager to begin.
Sandra gave a thumbs-up as she manually checked Carl’s blood pressure yet again. She then helped Claire put up the anesthesia screen, which would be covered with sterile drapes to isolate the patient’s head from the sterile operative field. After the screen was in place she sat back down. She was now in midflight.
As he worked during the course of the operation, Dr. Weaver kept up a mostly one-sided conversation with everyone in the room. He talked about what he was doing technically as he fashioned the patellar graft, he talked about his kids, and he talked about his weekend house on Folly Island.
Sandra listened with half an ear, as she imagined the scrub nurse and circulating nurse did as well. Sandra spoke up only once when there was a break in Dr. Weaver’s monologue. She took the opportunity to ask how long he thought he’d be.
The surgeon straightened up, paused briefly, and assessed his progress. “I’d guess another forty minutes or so. It’s all going smoothly. Everything okay up there with you?”
“Everything is fine,” Sandra said. She glanced down at her notes. The machine did the anesthesia report in contrast to the old days, but she kept her own record for her own use and to remain focused. Another forty minutes would put the total time for the procedure at just a little more than an hour and a half, meaning Dr. Weaver was acting true to form. There were other orthopedic guys who would take nearly double his time.
Sandra moved a bit to keep her circulation going and stretched out her legs. She had the option of having someone come and relieve her for a few minutes if she so desired, but she rarely took advantage of the opportunity and wouldn’t now, even though everything was going perfectly smoothly.
Sandra heard the sound of the drill start, meaning Dr. Weaver was creating a pathway through bone into which he would thread the patellar allograph. Knowing that the periosteum was richly enervated with pain fibers, Sandra looked up at the integrated patient monitor screen to see if there were any observable changes to suggest Carl’s level of anesthesia wasn’t what it should be. All the tracings were exactly as they had been throughout the case. She homed in on the heart rate. It was at seventy-two, without the slightest change. But as she was watching, the screen did something she had never seen it do before. It seemed to blink, as if for a split second it had lost its feed.
A bit concerned about this blip, Sandra leaned closer to get a better look as her own pulse ratcheted upward. The idea of losing all the monitors in the middle of the case was not a happy thought. Holding her breath, she watched to see if there was another episode. A few seconds went by and then a few minutes. There wasn’t another blink.
After five minutes she began to relax, especially since the tracings on the monitor all stayed completely normal, including the ECG. Whatever it had been clearly hadn’t happened again. The only change, and she wasn’t even sure there had been a change, was that all the tracings appeared very slightly higher on the screen than they had been, as if there had been a slight baseline or calibration change. But that couldn’t have happened, because she hadn’t changed anything.
Sandra shook her head as if to loosen imagined cobwebs. Maybe she did need a break. Yet her fear that the possible artifact had been real kept her glued to her seat and watching the patient monitor closely. It was mesmerizing as the tracings raced across the screen, particularly the ECG, with its rapid, repetitive, staccato up-and-down movements.
After about ten minutes Dr. Weaver got Sandra’s attention by telling her that he was within twenty minutes from closing the skin. That meant that her second most busy time had arrived. She shut off the isoflurane but maintained the nitrous oxide and oxygen. The second she did so, disaster struck! The blood oxygen alarm went off, making Sandra jump.
Sandra’s eyes shot to the monitor. The oxygen had suddenly gone from nearly 100 percent down to 92 percent. That wasn’t terrible, but it was a change, as it had been pegged at maximum during the whole case. It was also encouraging that it was now at 93 percent and already heading upward. But why did it drop? Sandra didn’t have the foggiest notion. That was when she noticed the ECG had changed, too. At the same moment the oxygen level had fallen, there was sudden tenting of the T wave, suggesting endocardial ischemia, meaning lack of adequate oxygen to the heart. That was not good. But how could it be? How the hell could the heart be lacking oxygen when the blood level hadn’t changed but an instant earlier and not by much? This was nuts!
Sandra forced herself to be calm by sheer force of will. She had to think. Something was wrong, that was clear. But what? Quickly she upped the oxygen percentage, cutting back on the nitrous oxide. That was when she noticed the tidal volume was seemingly falling, meaning Carl wasn’t taking as deep breaths as he had been. Immediately Sandra dialed in ventilation assist. She wanted to push in more oxygen to get the low-oxygen alarm to turn off.
“Hey!” Dr. Weaver yelled out with alarm. “Both his legs are hyperextending. Is he seizing? What the hell is going on?”
“Oh, God, no!” Sandra cried out silently. She leaped up, snatching a penlight in the process. Pulling off the tape holding Carl’s eyelids closed, she shined a beam of light into his pupils. What she saw terrified her. Both pupils were widely dilated and only sluggishly reactive! She felt a sudden weakness in her legs, requiring her to momentarily support herself by grabbing the edge of the operating table. Her fear was that the hyperextension of the legs was something called decorticate rigidity, suggesting that the cortex of the brain, the most sensitive part, was not getting the oxygen it needed. When the cerebral cortex of the brain is deprived of oxygen, the millions of brain cells don’t merely malfunction like the heart — they die!
2
Monday, April 6, 9:20 A.M.
Lynn Peirce and the friends she was sitting with burst out laughing. Unfortunately for her, she had just taken a sip of coffee and ended up spraying a small arc of it onto the table in front of her. She was mortified and couldn’t quite believe what she had done. “I’m so sorry,” she managed while wiping her lips with a napkin. Michael Pender, positioned directly opposite her, leaped back, overreacting for dramatic effect, knocking over his chair in the process. Everyone laughed even harder, to the point where they garnered disapproving looks from people nearby.
Lynn and Michael were sitting with four other fourth-year medical students in the popular ground-floor coffee shop of the Mason-Dixon University Medical Center. It was an 800-bed hospital, run by Middleton Healthcare, which owned and operated a total of thirty-two hospitals sprinkled throughout the southeastern corner of the United States. The students were crowded around a four-top table, having pulled over a couple of extra chairs for a celebratory coffee break. The floor-to-ceiling sliding glass windows directly next to them were pushed open, allowing warm air from outside to permeate the room, and affording an unobstructed view over the meticulously landscaped hospital grounds.
The hospital was situated in the northeastern corner of Charleston, South Carolina, with a bit of the “Holy City” visible over a row of magnolias that lined the street. It was called the Holy City because of all the churches, and even from the hospital coffee shop, a number of steeples could be seen jutting up from among the historic homes. It was a gorgeous morning, like most Charleston spring mornings, filled with sunshine, flowers, and the sounds of songbirds.