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After I assured him I would be ready when he got to the medical center, and we disconnected, I stared out the window, feeling particularly lonely and worrying that Bob’s state of mind was going to cause problems for us over the long haul. We had to use Mason-Dixon Medical Center, as it was the only area hospital in our insurance network. The problem is, when Bob gets started on something like this, involving a major lawsuit, he is like a dog with a bone. I can’t imagine why Middleton Healthcare Hospitals would see more blood-protein abnormalities than other hospitals. It doesn’t make sense. Does Bob think they are drumming up business? I can’t
imagine that could be true! But his aggressiveness about the hospital gives me a bad feeling, especially since the doctors and nurses really did help me when I was in need on Friday night. What if the boys need hospitalization in the near future? Could Bob jeopardize that? What I do know, and know better than anybody else, is when Bob says he is going to sue somebody, it happens. I suppose I can hope that once I am home I can calm him down, and we all get back to normal.

Monday, April 6, 6:30
A.M.

S
pring in Charleston, South Carolina, is a resplendent affair, and by the beginning of April, it is always well under way. The azaleas, camellias, hyacinths, early-blooming magnolias, and forsythias, as if competing for attention, all contribute to the riot of color and fragrance. And on this particular day, as the sun prepared to rise, there was the promise that it would be glorious for almost everyone in this scenic, historic town. Everyone, that is, except for Carl Vandermeer, a successful young lawyer who had grown up in nearby West Ashley.

Most mornings, regardless of the time of the year but particularly in the springtime, Carl would be part of a sizable group of joggers who ran along the Battery, which was located at the southern tip of Charleston’s peninsula. The Battery fronted that portion of the expansive Charleston Harbor formed by the confluence of the Cooper and the Ashley Rivers. Lined with restored nineteenth-century mansions and boasting a public garden, the Battery was one of the city’s most attractive and popular locales.

Like most of his fellow runners, Carl lived in the immediate and
charming residential neighborhood known to the locals as SOB, the acronym for “South of Broad.” Broad Street was a thoroughfare that ran east to west across the Charleston peninsula between the two rivers.

The reason Carl was not jogging this beautiful spring morning was the same reason he had not been jogging for the previous month. He had torn the anterior cruciate ligament in his right knee during the final basketball game of the past season. He and a half dozen other athletically inclined lawyers had formed a team to play in a city league.

Carl had always been into sports through high school and Duke University, where he played Division 1 lacrosse with considerable renown. Having made it a point to keep himself in shape even during law school, he thought of himself as generally immune to injury, especially since he was only twenty-nine years old. Throughout his athletic career he had never suffered more than a couple of sprained ankles.

So the knee injury had come as an unwelcome surprise. One minute he was perfectly fine, having played the entire first half of the game and scoring eighteen points in the process. With the ball in his possession, he had faked the fellow guarding him to the left and then went to the right, to drive to the basket. He never made it. The next thing he knew, he was sprawled on the floor, unsure of what had happened. Embarrassed, he got right to his feet. There was some discomfort in his right knee, but it wasn’t bad. He took a few steps to walk it out and immediately collapsed a second time. That was when he knew it was serious.

A visit to Dr. Gordon Weaver, an orthopedic surgeon, had confirmed the diagnosis to be a torn anterior cruciate ligament. Even Carl, a complete medical novice by choice, had been able to see it on the MRI. The bad news was that he’d have to have surgery if he wanted to play any kind of sports. Dr. Weaver said the best
operation involved diverting a portion of his own patellar tendon up through his joint. The only good news was that his health plan would cover the whole deal, including the rehab. His bosses at the law firm where he worked were not thrilled about the necessary downtime, but missing work was not what bothered Carl. What bothered Carl was that he had a particularly strong distaste for anything having to do with medicine and needles. He had been known to pass out from merely having blood drawn, and he didn’t even like the smell of rubbing alcohol because of its associations. He had never been hospitalized, but he had visited friends who had been, and the experience had freaked him out, so going into the hospital that morning for surgery was going to be a challenge, to say the very least.

The irony of his embarrassing and secret medical phobia was that his steady girlfriend for the last two years, Lynn Peirce, was a fourth-year medical student. She often made him light-headed with her stories of her daily experiences at the Mason-Dixon Medical Center, where Carl was scheduled to have his surgery in a few hours. She had been the one who had recommended Dr. Weaver and had explained in agonizing detail exactly how Carl’s knee was going to be repaired.

It also had been at Lynn’s insistence that he request that his operation be Dr. Weaver’s first case on a Monday morning. The rationale, she explained, was that everyone would be fresh and on the ball, meaning there would be less chance for mistakes or scheduling problems. Carl knew that Lynn meant well with all this, but her comments only made him even more nervous.

Lynn had offered to spend the night as she had on Saturday night to make sure Carl followed his pre-op orders and got to the hospital on time, but Carl had begged off. He was afraid she might end up innocently saying something that would make him even more worried than he already was. But he didn’t tell her that. He
said he thought he’d sleep better alone and reassured her that he would follow his pre-op instructions to the letter. She had accepted gracefully and said that she’d come visit him in his hospital room as soon as he came back from the PACU, or post-anesthesia care unit.

Carl had never mentioned his medical phobia to Lynn for fear that she, at a minimum, would laugh at him. Nor did he let on how anxious he felt about his upcoming surgery. To preserve his ego, there were some things better left unsaid.

Carl let the alarm ring unabated for a time out of fear of falling back asleep. He’d slept poorly and had had trouble getting to sleep the night before. His instructions from Dr. Weaver’s nurse were to have nothing by mouth after midnight except water and to take a good, hot shower with antimicrobial soap when he got up with particular attention paid to his right leg. He was supposed to arrive at the hospital no later than seven, which was going to be a rush, since it was already six-thirty. He wanted it to be a rush, thinking he’d have less chance to think, but here he was, not even out of bed and already anxious.

As if sensing his distress, Pep, his nimble eight-year-old Burmese cat, awoke at the foot of the bed and came up to rub her wet nose against Carl’s stubbled chin.

“Thank you, girl,” Carl said, tossing back the covers and making a beeline to the bathroom. Pep tagged along as always. Carl had saved the cat at the end of his undergraduate senior year at Duke when one of his classmates was going to abandon her at the pound after graduation in the hope that it would be adopted. Carl couldn’t abide by the plan, considering it a possible death sentence. He took the cat home for the summer, became hopelessly enamored with her, and ended up taking her along to law school. Frank Giordano, a close friend and fellow basketball-playing lawyer, who would be arriving shortly to drive Carl to the hospital, had volunteered to take care of the cat by coming to Carl’s house and making sure it had
food and water until Carl’s homecoming in three days. Everything was in order, or so Carl thought.

•   •   •

A
s Carl Vandermeer eased into a hot shower, Dr. Sandra Wykoff leaped out of her BMW X3. She was in a hurry not because she was late but because she was enamored with her work. Unlike Carl Vandermeer, she loved medicine so much that she had not taken a real vacation in the three years she’d been on staff at the Mason-Dixon Medical Center. She was a board-certified anesthesiologist who had trained across town at the older Medical University of South Carolina. She was thirty-five years old, a workaholic, and relatively recently divorced after a short marriage to a surgeon.

From her reserved parking spot on the first floor of the parking garage, she avoided the elevator and took the stairs. It was only one flight, and she liked the exercise. The state-of-the-art operating rooms of the medical center, which was built just after the millennium, were on the second floor. In the surgical lounge she gazed up at the monitor displaying the image of the operating room’s white board. She was assigned to OR 12 for four cases, the first being a right anterior cruciate repair with a patellar allograph by Gordon Weaver under general anesthesia. She was pleased. She particularly liked Gordon Weaver. Like most of the orthopedic guys, he was a gregarious fellow who enjoyed his work. Most importantly, from Sandra’s perspective, he didn’t dawdle and was vocal if there was more blood loss than expected. To her, such communication was important, but not every surgeon was as cooperative. Like all anesthesiologists, she knew that she was the one responsible for the patient’s well-being during an operation, not the surgeon, and she appreciated being informed if anything occurred with the surgery that was out of the ordinary.

Using her tablet PC, Sandra typed in the patient’s name, Carl
Vandermeer, along with his hospital number and her PIN to access his nascent EMR, electronic medical record. She wanted to look at his pre-op history. A moment later she knew what she was dealing with: a healthy twenty-nine-year-old male with no drug allergies and no previous anesthesia. In fact there had been no previous hospitalizations for any reason whatsoever. It was going to be an easy, straightforward case.

After changing into her scrubs, she made her way into the OR proper, passing the OR desk commandeered by the extraordinarily competent OR supervisor, Geraldine Montgomery. On her right she passed the entrance to the PACU, which used to be called more simply the recovery room. The pre-operative holding area was on the left. There was a lot of frenetic activity in both rooms. A bevy of nurses and orderlies were preparing for the soon-to-begin and inevitably busy Monday-morning schedule.

As a generally friendly although private person, Sandra greeted anyone who caught her eye, but she didn’t stop to chat or even slow down. She was on her usual early-morning mission. She was eager to check out the anesthesia machine she would be using for the day, something all anesthesiologists and nurse anesthetists were required to do. The difference was that Sandra was more conscientious than most and couldn’t wait to start.

Sandra worshipped the newer anesthesia machine, which was essentially computer driven. In fact it was the expanding role that the computer played in anesthesia that had attracted her to the specialty in the first place. As her father’s daughter, Sandra was also attracted to most everything mechanical. Her father, Steven Wykoff, was an automotive engineer brought to Spartanburg, South Carolina, from Detroit, Michigan, by BMW in 1993. The fact that computers were destined to become more and more involved in medicine was the reason she went to medical school. It was during her third-year surgery rotation that she was introduced to anesthesia, and she was
captivated from the start. The specialty was a perfect blend of physiology, pharmacology, computers, and mechanical devices, all of which suited Sandra just fine.

Entering OR 12, Sandra greeted Claire Beauregard, the assigned circulating nurse, who was already busy setting up for the case. But there was no conversation. Sandra stepped over to her trusted mechanical partner, with which she was going to spend most of the day. It bristled with varicolored cylinders of gas, multiple monitors, meters, gauges, and valves. The machine, like all the equipment in the relatively new hospital complex, was a state-of-the-art computer-controlled model. It was number 37 out of nearly 100 total. The number was on a sticker on the machine’s side, which also included its service history.

From Sandra’s perspective the apparatus in front of her was a marvel of engineering. Among its many features was an automatic checklist function that satisfied what the FDA required before use, akin in many respects to the checklist required in a modern aircraft before takeoff to make certain all systems functioned properly. But Sandra did not turn on the machine immediately to initiate the automatic checklist. She liked to check the machine the old-fashioned way, particularly the high-pressure and the low-pressure systems, just to be 100 percent certain everything was in order. She liked to physically touch and operate all the valves. Her hands-on inspection made her feel much more confident than relying on a computer-controlled algorithm.

Satisfied with what she found, Sandra rolled over the stool that would be her perch for the day, sat down, and pulled herself directly up to the anesthesia machine’s front. Only then did she turn on the machine. Spellbound as usual, her eyes stayed glued to the monitor as the apparatus went through its own automated checklist, which included most of what she had already done. A few minutes later the machine indicated all was in order, including the alarms for trouble,
such as changes in the patient’s blood pressure and heart function or low oxygen levels in the blood.

Sandra was pleased. When something was amiss, even a minor thing, she was obliged to contact the Clinical Engineering Department, which serviced the anesthesia machines. She found the technicians to be a weird bunch. Those she had had interaction with were all expat Russians with varying fluency in English, most of whom seemed like the teenage computer nerds of her youth. She particularly did not like Misha Zotov, who had sought her out in the hospital cafeteria to engage her in conversation the day after she’d gone down to the department to ask a simple service-related question. He gave her the creeps, even more so by calling her at home a few days later to ask her to have a drink with him. How he’d gotten her unlisted number she had no idea. Her response was to fib and say she was in a committed relationship.

With the anesthesia machine ready to go, Sandra then began checking her supplies and pharmaceuticals with equal diligence. She liked to touch everything she might need so she would know where it was. If there was an emergency, she didn’t want to search for anything. She wanted everything at her fingertips.

•   •   •

W
ant me to park and come in with you?” Frank Giordano asked Carl as he turned into the Mason-Dixon Medical Center a few minutes after seven. They had been driving in silence. Initially Frank had tried to make conversation as they started northward up King Street, but Carl wasn’t holding up his side. Frank guessed that Carl was stressed out about his upcoming surgery, especially after Carl admitted he was as nervous as hell before they had started out.