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In the induction phase, Sandra was now in her most attentive mode. With an eagle eye on all the monitors she continued to use the black breathing mask to allow Carl to breathe pure oxygen. In the background she was vaguely aware of Dr. Weaver coming into the room and putting on his sterile gown and gloves. After approximately five minutes, Sandra put the breathing mask aside and picked up the appropriately sized LMA. In a practiced fashion she inserted the triangular, inflatable tip into Carl’s mouth and pushed it into place with her middle finger. Quickly she inflated the tube’s cuff and attached the tube from the anesthesia machine. The immediate detection of carbon dioxide by the anesthesia machine in the exhaled gas suggested the LMA was properly seated. But to be sure, Sandra listened to breath sounds with her stethoscope. Satisfied, she taped the LMA tube to Carl’s cheek so that it could not be moved. She then dialed in the proper levels of isoflurane, nitrous oxide, and oxygen. The nitrous oxide had some anesthetic properties but not enough to be used on its own. What it did do was lessen the amount of isoflurane needed, which was helpful, because the
isoflurane did have some mild irritant effects on breathing passageways. She then taped Carl’s eyes shut after putting in a bit of antibiotic ointment to protect his corneas from drying.

Sandra watched the anesthesia machine with its readout of all the vital signs. Everything was in order. The takeoff had been smooth. Metaphorically they were nearing cruising altitude and soon the seat belt sign could go off. Sandra’s pulse, which had jumped considerably during the induction of anesthesia, dropped back to normal. It had been a tense few minutes, as it always was, yet it provided her a shot of euphoria of a job well done and a patient well served.

“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!

Monday, April 6, 9:20
A.M.

L
ynn 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.

What had made Lynn laugh so suddenly was an off-color joke about an angel who had traded in her harp for an upright organ. It had been told by Ronald Metzner, the jokester of the class, who had a phenomenal memory for jokes. What caught Lynn by surprise was that, although she usually didn’t find his jokes funny, somehow this one touched a nerve without her knowing exactly why, and only later would she realize it was because of suppressed tension she was trying to ignore.

Apologizing again to her companions for what she thought was a major faux pas, Lynn picked up her coffee cup and saucer to wipe off the table. She noticed that Ronald had a big, contented smile on his face, obviously pleased with the effect he had had on her and on the group as a whole.

The six medical students, four women and two men, appropriately dressed in their white coats, were hyped up and goofing off. For them, the almost four years of work, doubt, discovery, and challenge were all but over. Just over two weeks previously they had gotten the results of the National Residency Matching Program, so their uncertainty was behind them. They all knew where they were going for the next and, perhaps, most important part of their professional training.

For the final couple of months before graduation the group and
several dozen other fourth-year students on the same rotation were supposedly getting their introduction to ophthalmology; ear, nose, and throat; and dermatology. But the rotation was not as organized or as important as had been the case in other, more basic disciplines, such as third-year internal medicine and surgery. They also had no real patient responsibilities, at least not yet. So far there had only been what they considered rather poorly planned and uninspiring lectures and demonstrations in the three specialties. That morning they had decided to skip the lecture to enjoy their sense of accomplishment. Truth be known, they were essentially in a cruise mode until getting their diplomas.

“I never knew you were interested in orthopedics,” Karen Washington said to Lynn after the group had recovered. Karen’s tone had a slightly captious tinge that only Lynn could detect. Just before the angel joke, Lynn had revealed her residency plans, which she hadn’t shared until that moment, and it had come as a surprise for Karen. She and Lynn were both from Atlanta and had known each other from high school and their undergraduate college days at Duke. They had been close friends during high school and their college freshman year, but when they both had decided on medicine as a career, competitiveness had interfered. But it wasn’t the only thing that came between them. Financial problems with Lynn’s family during sophomore year at college had impacted every aspect of her life, including her relationship with Karen, whose family was particularly well off.

Although Lynn and Karen ended up at the same medical school, their close friendship had never truly revived, as Karen’s keen competiveness continued. Instead Lynn had gravitated toward a close, platonic connection with Michael Pender. At one point during the first year of medical school Karen had confided to Lynn that she would have understood better if it had involved romance. Lynn’s response was that she was the one who was most surprised to have
such a close, nonromantic friendship with a male, although Lynn’s boyfriend, Carl Vandermeer, had come in at a close second. Lynn had confided to Karen that Carl initially had a lot of trouble accepting the situation.

It had all started innocently enough and was based on the alphabetical proximity of their surnames, Peirce and Pender. As a consequence, from day one Lynn and Michael had been thrown together for everything that required medical students to pair up, mostly for labs and physical diagnosis. Although never romantic, they became a real team, somewhat like a brother and sister, making sure they had the same rotations, covering for each other, and studying together to the partial and unintended exclusion of others. The result was that Lynn and Michael had been saddled with the nickname “the twins.”

“Really? Orthopedics?” Karen continued, with disbelief. “It caught me totally by surprise, as much or more so than if you had told me you were going into urology. I always thought you were sure to become one of those brainy internal-medicine people.”

“I don’t know why it should have been a surprise,” Lynn responded, sensing a bit of the old hurt feelings on Karen’s part. “You of all people know that I was always a jock in high school and college, especially with my interest in lacrosse. Sports have always been a part of my persona. But what sealed the deal was doing orthopedics as my elective this fall. It surprised me how much I liked it. To me it is happy medicine, at least for the most part. That’s appealing.”

“But the surgery,” Karen complained with an exaggerated expression of distaste. “It’s not like what people expect surgery to be. It certainly wasn’t for me. It’s like a bunch of carpenters with hammers and saws, banging in nails and then having X-ray come and see where they went. Whereas ophthalmology! What a difference! That is surgery at its best: precise, bloodless, and you get to sit down
while you operate.” Everyone knew Karen was off to Emory in Atlanta for a residency in ophthalmology.

“To each his own,” Lynn said. She was not going to be baited into a comparison of the two specialties.

“And you are staying here?” Karen asked, with continued incredulity. “Actually, for me that was even more of a shock. I thought you were destined for some Ivy League–affiliated hospital, like Mass General in Boston, considering your rank in class.” Everybody knew that Lynn was very near the top of the class, scholastically. She and Michael were always neck and neck in the ranking: two peas in the pod in more ways than one.

“I’m going to leave both internal medicine and the Ivy League to Michael,” Lynn said, acknowledging her partner’s coup. Michael smiled contentedly at the recognition. Everyone at the table knew that few people got a slot at Mass General and Harvard from Mason-Dixon University School of Medicine, whose stated goal was to supply well-trained physicians for South Carolina and its environs, and not for medical academia. “For me, I’m happy staying right here at Mason-Dixon,” Lynn continued. “And you should talk, Karen. Emory for ophthalmology! Not too shabby.” It was also common knowledge that, academically, Karen was in the top ten of the class as well.

“Everybody knows why Lynn is staying here for her residency,” Ronald said with artificial disdain. “Like the angel, she traded in her harp for Carl Vandermeer’s upright organ!”

There was another burst of laughter, this time at Lynn’s expense, although she too was smiling. She pelted Ronald with a balled-up napkin as he basked in the glory of having again gotten everyone to laugh over the same mildly salacious joke.

“Am I to gather that you and Carl Vandermeer are still going to be an item come graduation?” Karen questioned while struggling to control her laughter. The group’s outburst had again
attracted disapproval from others in the coffee shop. It was, after all, a hospital.

Most of the class had met Carl Vandermeer through Lynn at various social functions over the course of their four years of medical school. It was common knowledge that Lynn and Carl had first met at Duke when Lynn was a sophomore and he a first-year law student. It had also been common knowledge that over the last couple of years they were seeing each other exclusively. What wasn’t known was the long-term seriousness of the relationship. Even Lynn didn’t know for certain. As close as they were, Carl was always evasive on the subject.

“We’ll see what happens,” Lynn said, tossing her long brunette tresses away from her face. She had yet to pull her hair back in a barrette, the way she always wore it in the hospital. What she didn’t say was that she felt rather strongly that it better work out with Carl, because the real reason she hadn’t applied for a training program in Atlanta or Boston was because Carl was committed to his job in Charleston. From her perspective there was no doubt it was a sacrifice. Truth be told, she had expected an engagement and wondered if it would be coming for graduation. In her mind, it would be a wonderful graduation present. As a competitive, modern woman, Lynn didn’t feel she needed love, but, having serendipitously found it with Carl, she wanted it. She also had enough self-awareness to suspect that her eagerness to create her own nuclear family had something to do with losing her father when she was in college. She and her father had been close, and it had been because of his early death that she had decided to become a doctor.

“Any specific plans we should know about?” Karen questioned, needling her friend. When the love affair with Carl had begun back at Duke, Karen had accepted the diminution of Lynn’s friendship much more than these last four years when it had expanded to involve Michael. Karen had never lost a girlfriend to a member of the
opposite sex with no romance involved. She couldn’t help but wonder if there was some element of romance between the two, even if they both denied it.

Lynn responded by holding up both hands, palms toward her. “No ring, no specific plans. Like all of us, I’m going to be very busy next year being a first-year resident. That’s job numero uno.”

“Hey, everybody,” Ronald said, “have you heard the one about the urology transplant surgeon?”

It was now Karen’s turn to throw her napkin at Ronald. “Quit while you’re ahead, my man!” she said. “I even remember that joke, and it ain’t funny because it is based on a pathetic male fantasy.”

“It’s a good thing we are graduating soon,” Michael said. “Ronald is running out of jokes.”

“Oh, shit!” Lynn said, catching sight of her watch. “It’s going to ten already. I have to go!” She scrambled to her feet and gathered her dishes together.

“You’re not going to the ophthalmology lecture and make us all look bad, are you?” Alice Wong, one of the other women, asked.

“Hell no!” Lynn said. “Carl had a little operation this morning, and I want to be available when he gets to his room.”

“Really?” Karen questioned. “You never said anything about him having surgery.”

“It was his decision,” Lynn said. “He didn’t want it to be common knowledge.”

“Catch you later,” Michael said. He fist-bumped with Lynn but didn’t get up. He knew that Carl was to be operated on, but he was the only one who did.

“Give him our best,” Karen called out to Lynn, who was already on her way to drop off her dirty dishes, as the coffee shop was run like a school cafeteria.

Lynn waved over her head in acknowledgment but didn’t turn around. She was in a hurry. She was tense because of Carl, and
feared she might have whiled away too much time having coffee. Knowing how fast Weaver was and knowing that the less time a patient was under anesthesia, the shorter the recovery time, she wouldn’t be surprised if she got there and found Carl already in his room. She hoped that would not be the case.