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“Thanks, but no,” Carl said. “I’m a little late, which I hope means I’m not going to be sitting around.” It was clear he was agitated.

“Hey, man,” Frank said, “you got to relax! It’s no big deal. I had my tonsils out when I was ten. It was a piece of cake. I remember
being told to count backward from fifty. I got to about forty-six and the next thing I knew I was being awakened, and it was all done.”

“I have a bad feeling about this,” Carl said. He turned to look at Frank.

“Shit, man, why are you going to go and say something stupid like that? Be positive! Look, you got to get it done, and you got to get it done now so, come next December, you’re good to go for the next basketball season. We need you healthy.”

Carl didn’t respond. There was a line of cars backed up under the porte cochere. People were getting out with overnight bags. Carl guessed they, too, were arriving for surgery. He wished he could take it all in stride as it appeared others were doing. He glanced at his cell phone. It was now almost five after seven. He had meant to arrive exactly on time so there would be no sitting around.

“I’ll get out here,” Carl said suddenly, opening the passenger-side door as he spoke. He climbed out.

“I’ll have you at the door in thirty seconds,” Frank said.

“I don’t think so. It will be faster if I walk.” Carl slammed the car door and opened the trunk. He lifted the backpack containing his essentials and slung it over his shoulder. “Don’t forget about the cat!”

“No worries,” Frank said as he, too, alighted from the car. He came around and gave Carl a quick hug. Carl didn’t respond, just looked him in the eye when his friend stepped back. But when Frank raised a fist, Carl followed suit. Their knuckles touched in a fist bump. “Later, dude!” Frank added. “You’re going to be fine.”

Carl nodded, turned, and negotiated the small tangle of cars waiting to get closer to the front door to disgorge their passengers. As he entered the hospital he remembered reading Dante’s description of hell in civilization class at Duke.

A pink-smocked volunteer directed him down the hall to surgical admitting. Carl gave his name to one of the clerks seated behind a chest-high counter.

“You’re late,” the woman said with a mildly accusatory tone of voice. She had an uncanny visual resemblance to Carl’s sixth-grade teacher, Miss Gillespie. The association made him feel as if he were going back to an earlier stage in his life when he truly wasn’t in control of his fate. Carl had been an irrepressible twelve-year-old and had clashed with Miss Gillespie. The clerk picked up a packet of paperwork that was on the desk in front of her and handed it to Carl. “Take a seat! A nurse will be with you shortly.”

Although similarly as bossy as the clerk, the nurse was significantly more congenial. She smiled when she asked Carl to follow her back to a curtained-off area where there was a gurney made up with fresh sheets and a pillow. Draped across it was the infamous hospital johnny. After checking his picture ID and asking his name and birth date, she put a name tag on his wrist. Once that was done, she told him to put his valuables in a zippered canvas bag that was also on the gurney, take off his clothes, put on the johnny, and lie down. From the inside, she pulled the curtain around to allow privacy. She watched as Carl picked up the johnny and tried to figure out how it was supposed to be worn.

“The opening should be in the back,” the nurse said, as if that were going to solve Carl’s confusion. “I’ll be back shortly when you are done.” She then disappeared through the curtain. It was apparent she was in a hurry.

Carl did as he was told but had trouble with the johnny, particularly in terms of figuring out how to secure it. One tie was at the neck, the other at the waist, which made no sense. He did the best he could. No sooner had he gotten onto the gurney and pulled the sheet up around his torso than the nurse was outside the curtain, calling to ask if he was finished.

Back inside the curtain, the nurse then went through a litany of questions: Did you eat anything this morning? Do you have any allergies? Do you have any drug intolerance? Do you have any removable dentures? Do you smoke? Have you ever had anesthesia? Have
you had any aspirin in the last twenty-four hours? It went on and and on, with Carl dutifully answering
no
over and over until she queried how he felt.

“What do you mean?” Carl asked. He was taken aback. It was an unexpected question. “I feel nervous. Is that what you are asking?”

The nurse laughed. “No, no, no! I mean do you feel well right now and did you feel normal during the night. What I’m trying to ask is whether or not you feel like you might be coming down with something. Have you had any chills? Do you feel like you have a fever? Anything like that?”

“I get it,” Carl said, feeling embarrassingly naive. “Unfortunately I feel fine health-wise, so there’s no excuse not to go forward with all this. To be honest I’m just anxious.”

The nurse looked up from her tablet, where she had been recording all of Carl’s responses. “How anxious do you feel?”

“How anxious should I feel?”

“Some people find the hospital stressful. We who work here don’t because being here is an everyday event. You tell me, say on a scale of one to ten.”

“Maybe eight! To be honest, I’m really nervous. I don’t like needles or any other medical paraphernalia.”

“Have you ever had a hypotensive episode in a medical setting?”

“You’ll have to translate that into English.”

“Like fainting?”

“I’m afraid so. Twice. Once having my blood drawn for some tests in the college infirmary, and once trying to give blood in college.”

“I’m going to note this in your record. If you’d like, I’m sure they will give you something to calm you down.”

“That would be nice,” Carl said, and he meant it.

The nurse took Carl’s blood pressure and pulse, which she remarked were normal. She then had a conversation with Carl about which knee was to be operated on, and when Carl pointed to his right knee, she made an X with a permanent marker on Carl’s thigh,
four inches above his right kneecap. “We want to be sure not to operate on the wrong knee,” she said.

“Me too,” Carl responded with alarm. “Has that ever happened?”

“I’m afraid so,” the nurse said. “Not here, but it has happened.”

Holy fuck
, Carl thought. Now he had something else to worry about. As nervous as he felt, he wondered if he had been wrong in discouraging Lynn from coming by to at least say hello before the procedure. Maybe he needed an ombudsman.

•   •   •

D
r. Wykoff, the patient is in the CSPC,” Claire said, coming back into OR 12, referring to the center for surgical patient care, an extra-long name for the patient holding area.

“How about Dr. Weaver?” Sandra responded.

“He’s changing. We’re good to go.”

“Perfect,” Sandra said. She stood and picked up her computer tablet. “How are you doing, Jennifer?” Jennifer Donovan was the scrub nurse, who was already gowned, gloved, and setting out the sterilized instruments. It was 7:21
A.M.

“I’ll be ready,” Jennifer said.

As Sandra walked back down the central corridor, she checked Carl’s EMR and noticed the admitting nurse’s entries. There were no red flags for trouble. The only thing she picked up on was that the patient was unusually anxious and had a history of several hypotensive episodes in the past associated with drawing blood. In Sandra’s experience she’d come across a number of men with such a phobia, but it had never been a problem. People rarely fainted when lying down. As far as she was concerned, anxiety was par for the course. That’s why she liked midazolam, or Versed, so much. It worked like a charm, relaxing even the most skittish patients. In the pocket of her scrubs she had a syringe with the proper dose, according to Carl’s weight.

She found Carl Vandermeer in one of the pre-op bays of the
CSPC. She couldn’t help but notice that he was a handsome man with dark, thick hair and startlingly wide-open blue eyes. Except for his apparent anxiety, he was the picture of health. The thought went through her mind that working with him was going to be a pleasure.

“Good morning, Mr. Vandermeer,” Sandra said. “I’m Dr. Wykoff, I will be your anesthesiologist.”

“I want to be asleep!” Carl stated with as much authority as he could muster under the circumstances. “I went over this with Dr. Weaver, and he promised me that I would be asleep. I don’t want an epidural.”

“No problem,” Sandra said. “We’re all prepared. I understand you are a little anxious.”

Carl gave a short, mirthless laugh. “I think that is an understatement.”

“We can help you, but it does require me to give you an injection. I know you don’t like needles, but are you okay with getting one? It will help, I guarantee.”

“To be truthful, I’m not excited about it. Where will you give it?”

“Your arm will be fine.”

Steeling himself, Carl dutifully exposed his left arm and looked away to avoid seeing the syringe. After a quick swipe with an antiseptic wipe, Sandra gave the injection.

Carl turned back. “That was easy. Are you finished already?”

“All done! Now I want to go over with you the material the admitting nurse recorded.”

Rapidly Sandra asked the same questions about Carl not having had anything to eat since midnight, about allergies, about drug intolerance, about medical problems, about previous anesthesia, about removable dentures, on and on. By the time Sandra got to the end, Carl’s attitude had completely changed, thanks to the midazolam. Not only was he no longer anxious, he was now finding the whole situation entertaining.

At that point, Sandra started her IV. Carl couldn’t have cared less and watched her preparations with a sense of detachment. It helped that she was extremely confident and competent with the procedure. She always made a point to start her own so she could trust it. She used an indwelling catheter rather than a simple IV. Carl never stopped talking through the process, particularly about his girlfriend, Lynn Peirce, who he said was a fourth-year medical student and the best-looking woman in her class. Sandra diplomatically let the issue drop.

A few minutes later Dr. Gordon Weaver appeared to have a few words with Carl, including which knee they were going to work on. He checked that the X that the admitting nurse had made with the permanent marker was on the proper thigh.

“You people are really hung up on which knee,” Carl joked.

“You better believe it, my friend,” Dr. Weaver said.

With Sandra guiding in the front and Dr. Weaver pushing from the back, they wheeled Carl down and into OR 12, stopping alongside the operating table directly under the operating room light. Somewhere en route Carl had drifted off into light sleep in midsentence, again reminding Sandra why she was so fond of the midazolam. Only much later would Sandra question the dose she had given in the process of reviewing everything she had done. Sandra, Dr. Weaver, and Claire Beauregard moved Carl over onto the operating table with practiced efficiency.

When Dr. Weaver went out to scrub, Sandra pulled the anesthesia machine close to Carl’s head. This was the part of the case that she liked the best. She was center stage and about to prove once again the validity of the science of pharmacology. Anesthesia was a specialty marked by extreme attention to detail; periods of intensive activity, like what she was now beginning; and then long segments of relative boredom, which required dedicated effort to stay focused. Whenever she thought about it, the analogy of being a pilot
came to mind. At the moment she was about to take off. After that had been accomplished she would be in the equivalent of midflight autopilot and have little to do besides scanning the monitor and the gauges. It wouldn’t be until the landing that she’d again be called upon for intense activity and attention to detail.

Since there were no specific contraindications to any of the current anesthetic agents, she planned on using isoflurane, supplemented with nitrous oxide and oxygen. She had used the combination in thousands of cases and felt comfortable with it. There was no need for any paralyzing drugs because a knee operation didn’t require any muscular relaxation like with an abdominal operation, and she wasn’t going to use an endotracheal tube. Instead she would use what was known as a laryngeal mask airway, or LMA. Sandra was a stickler for detail in all aspects of her life but most specifically for anesthesia, and had never had a major complication.

Like all anesthetists who are specially trained nurses and anesthesiologists who are specially trained doctors, Sandra knew that the ideal anesthetic gas should be nonflammable, should be soluble in fat to facilitate going into the brain, but not too soluble in blood so that it could be reversed quickly, should have as little as possible toxicity to various organs, and should not be an irritant to breathing passageways. She also knew that no current anesthetic agent perfectly fulfilled all these criteria. Yet the combination she intended to use with Carl came close.

The first thing that Sandra did was to set up all the patient monitoring so that she would have a constant readout of Carl’s pulse, ECG, blood oxygen saturation, body temperature, and blood pressure, both systolic and diastolic. The anesthesia machine would monitor the rest of the levels that needed to be watched, such as oxygen and carbon dioxide levels in inspired and expired gases and ventilation supply variables.

As Sandra positioned the monitors, particularly the ECG leads
and the blood pressure cuff, Carl became conscious. There was no anxiety on his part. He even joked that with everyone wearing masks it was like being at a Halloween party.

“I’m going to give you some oxygen,” Sandra said as she gently placed the black breathing mask over Carl’s nose and mouth. “Then I will be putting you asleep.” Patients liked that comfortable metaphor rather than what Sandra knew anesthesia really to be: essentially being poisoned under controlled and reversible circumstances.

Carl didn’t complain and closed his eyes.

At that point Sandra injected the propofol, a fabulous drug in her estimation that was unfortunately made infamous by the Michael Jackson tragedy. Knowing what propofol did to arterial blood pressure, ventilation drive, and cerebral hemodynamics, Sandra would never give the drug to someone without appropriate physiologic monitors and a primed and ready anesthesia machine.