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Monday, April 6, 12:40
P.M.

A
s they ascended in the elevator, Michael glanced at Lynn. She was watching the floor indicator above the door. Her eyes were red and watery. The elevator was crowded, putting a lid on any conversation about their mission. For Michael there was a strange, uncomfortable sense of déjà vu, and he hoped any similarities to the events he was thinking about would be minimal.

When the doors opened on the sixth floor, Michael and Lynn were not the only people to get off. Lynn grabbed Michael’s arm to hold him back as the other passengers proceeded toward their respective destinations, most going to the central desk. The place was as busy as it had been earlier.

“We have to have a plan here,” Lynn said, lowering her voice so as not to be heard. Several people were standing nearby, waiting for a down elevator. “I got away with going into the ICU earlier because the resident assumed I was on a neurology rotation. You are not going to get away with that. They’re going to remember you because
you stand out. How do you plan on handling this? You know we medical students are not welcome in the ICU unless we have an official reason.”

“I’m counting on not having a problem, provided we don’t act hesitant or indecisive.”

“What is it you want to do, exactly?”

“Mainly I just want to look at the chart. But we’re not just going directly to the desk and grab the chart without checking out the patient. That’s not cool. It’s not the way it’s done. You know what I’m saying? Do you remember where Carl is? That would be a help. We don’t want to draw attention to ourselves by acting lost.”

“He’s in cubicle number eight, I believe, but I could be wrong. My mind’s in turmoil.”

“All right, here’s the plan. We head directly into cubicle eight. Provided it’s the right address, we check out Carl’s current status. If it’s not, we find him, fast! You okay with that? You don’t have to do anything. Just hang. I’ll do something appropriate to make it look official.”

“All right,” Lynn agreed, although she wasn’t entirely sure her emotions wouldn’t take over.

“Let’s do it!” Michael said with conviction.

With Michael half a step ahead and moving at a quick pace, they passed the busy sixth-floor central desk and headed for the ICU. At the door Michael hesitated for a split second to glance at Lynn, arching his eyebrow. Lynn assumed he was questioning her mental state, so she nodded. She was as ready as she was going to be.

Michael pushed through the heavy door. Inside was a different world. Gone were the noise of the lunch carts, the babble of voices, and the sense of commotion. In its place were the muted electronic sounds of the monitoring and the to-and-fro cycle of a couple of ventilators. Otherwise a heavy stillness reigned. The patients were all completely immobile.

As he had said, Michael made a beeline for cubicle 8. Lynn’s memory had served her well. Carl was in the bed and momentarily alone. The half dozen nurses and an equal number of aides on duty were occupied with other patients.

Michael went to Carl’s right, and Lynn to his left. Carl appeared to be sleeping as he had before, save for the jerking of his free leg. Again Lynn had to suppress the almost irresistible urge to reach out and shake him awake. For the briefest moment she felt a twinge of anger, as if Carl were doing this on purpose.

“Deceptively peaceful,” Michael said.

Lynn nodded. Tears again threatened. She tried to think objectively about what might be going on in Carl’s brain. She watched as Michael took out his penlight. After raising both of Carl’s upper lids, he shined the light alternately in each eye. “Pupils are equal and maybe sluggish, but both react. Nothing to ‘fatmouth’ about, but it is something. At least the brain stem is still working.”

Lynn nodded again but didn’t speak. As a defense mechanism she thought about the doll’s eye movement that the neurology resident had shown her, and its implications.

“Vital signs are normal,” Michael said.

Lynn followed his gaze up to the monitor. Everything was as it had been earlier, including the oxygen saturation, at 97 percent.

“All right,” Michael said, lowering his voice and looking across at Lynn. “So far, so good.” The busy nurses seemed indifferent to their presence. “Let’s mosey over to the central desk. And try to relax, girl! You look like you are about to rob a bank.”

Lynn didn’t bother to answer. She tolerated his mildly disrespectful language just as he allowed her to call him “boy” on occasion. It was only when they were certain no one else was listening that they used such slang. It was another sign of their closeness and shared understanding of discrimination.

The circular central desk was usually dominated by the duo of
the head nurse, Gwen Murphy, and the very capable long-term clerk, Peter Marshall, who had been around so long he felt proprietary. From their neurology rotation Michael and Lynn remembered both of them as efficient and professional and very helpful. At the moment only Peter was present. As usual, like all ward clerks, he was on the phone, but he raised his eyebrows questioningly as he gave them a once-over. At the moment Gwen was apparently occupied elsewhere.

Under the lip of the surrounding countertop were flat-screen monitors displaying the readouts of the vital signs of each patient. Lynn’s eyes went directly to 8. Everything was normal. On top of the countertop was a rotating chart rack.

“Hey, dude,” Michael said to Peter as a greeting, evoking a roll of the eyes on Peter’s part. Not giving him a chance to respond, Michael turned his attention to the chart rack, which he gave a deliberate spin. He stopped it so the slot for cubicle 8 was facing him. Without the slightest hesitation Michael withdrew the chart, grabbed a couple of chairs, and pulled them off to the side. He motioned to Lynn to take one, and he sat in the other. He opened the chart and rapidly leafed through to the anesthesia record.

As Michael was doing this, Lynn watched Peter out of the corner of her eye. As Michael had anticipated, he seemed to ignore them, at least until he finished his current phone conversation. Then he said, “Hey, can I help you guys?”

“We were told to check out the anesthesia record on Vandermeer,” Michael said. “And we got it right here. Thanks! Take a look, Lynn!”

Michael positioned the chart so that Lynn could see. There was a handwritten note by the anesthesiologist, Dr. Sandra Wykoff, as well as the three-page printed version done by the anesthesia machine. They read the handwritten note, which was thankfully easy to read in contrast to a lot of notes that they had had to read by doctors in hospital charts over the last couple of years:

Healthy 29 year old Caucasian male in excellent health scheduled for anterior cruciate repair of right knee under general anesthesia. Anesthesia machine function checked both manually and automatically. Some pre-op anxiety. Pre-op medication Midazolam 10mg IM at 7:17 am with good result. Patient relaxed. Intravenous catheter placed without difficulty. Breathed 100% oxygen with face mask beginning at 7:22 am. Induction with 125mg Propofol IV at 7:28 am. 100% oxygen given by face mask before laryngeal mask airway LMA 4 placed and inflated with no problems. Isoflurane, nitrous oxide, and oxygen began at 7:35 am. Eyes taped shut. Vital signs normal and stable. ECG normal. Oxygen saturation stable at 99–100%. Spontaneous respiration with normal volume and rate. Operation commenced with placement of tourniquet on right leg. No changes in vital signs, ECG, and oxygen saturation. Fifty minutes into the case at 8:28 am as requested surgeon communicates he is within forty minutes of completion. At 8:38 am isoflurane shut off. Nitrous oxide and oxygen continued. At 8:39 am low-oxygen alarm sounds as oxygen saturation falls precipitously from 98% to 92%. At same moment ECG shows tenting of T waves. Oxygen flow increased. Oxygen saturation rapidly climbs back to 97% at 8:42 am. Low-oxygen alarm shuts off. ST waves on ECG return to normal. Nitrous oxide flow reduced at 8:44 and ventilation assist started. At 8:50 am decorticate leg hyperextension with both lower extremities noted by the surgeon and pupils noted to be dilated with sluggish reaction to light. Nitrous oxide stopped at 8:52 am and pure oxygen maintained. Ventilation assist turned off at 8:58 am as patient’s breathing returned to normal volume and rate. Surgeon removes tourniquet and completes the case at 9:05 am. Patient fails to wake up. Chief of anesthesia, Dr. Benton Rhodes, called in on the case. Under his direction Flumazenil given in 0.2mg increments X 3 with no observable result. At 9:33 am patient taken to PACU while continuing to
breathe 100% oxygen. Emergency neurology consult called. Vital signs, ECG, and oxygen saturation remain normal and stable.

Sandra Wykoff, MD.

Michael and Lynn finished at almost the same moment and looked up at each other. “I don’t know much about anesthesia,” Lynn said. “We only had that one lecture about the basics in our surgery rotation. I’m going to have to do some research to understand it all.”

“But the important point is that there was some documented hypoxia,” Michael said. “The O
2
level fell for a couple of minutes, and the ECG changed.”

“But not much. The O
2
only fell to ninety-two percent briefly and then went back up to ninety-seven percent. That is not a huge fall and probably about what people experience getting off the plane in Aspen, Colorado. And it was only for three minutes.” Lynn pointed to where it was noted in the handwritten summary.

“Then how come the ECG showed the T wave changes?”

Lynn shrugged. “I don’t know enough to even guess.”

“Let’s check out the machine-generated record.”

Michael turned to the relevant page of the three-page anesthesia record. What they were interested in was the intra-operative portion. Both knew that the modern anesthesia machine was computer driven and kept track of all the variables in real time, including what was portrayed on the monitor. At the end it printed it all out in graphic form. Everything that had happened was recorded, including gases, drugs, fluids used, and all the monitoring parameters.

“And what are you people doing?” a voice questioned. It was not antagonistic but definitely authoritative.

Both Lynn and Michael looked up. Looming over them was Gwen Murphy, the head nurse. She was a stout, ample woman with flame-red hair and rosy cheeks.

Without skipping a beat, Michael said, “We have been sent by
anesthesia to check out this case of delayed emergence from anesthesia.”

Gwen eyed Lynn for a moment, then nodded as if buying Michael’s explanation. “The patient is scheduled for an MRI this afternoon.” Without elaboration she turned around and went back to her post in front of all the monitors.

Lynn leaned over to Michael and whispered: “How did you come up with that?” She was impressed. Knowing that what they were doing was more than merely frowned upon by the authorities, Gwen’s sudden appearance and challenge had scared her. She knew she would have tripped over her words had she tried to say anything. So she had been glad Michael had spoken up. She and all the other medical students had been warned they were not permitted to look at charts or electronic medical records, EMRs, unless specifically authorized, most specifically including those of friends or even family members. Patient confidentiality was taken quite seriously by the administration, and looking at records under false pretenses was a serious and punishable offense.

“Practice, I guess,” Michael said. “Did you notice she didn’t look at me?”

“Now that you mention it, I guess I do. I can tell you; she definitely stared at me. I thought it was because I was feeling so guilty that it showed.”

“I don’t think so,” Michael said. “I believe her not looking at me is that unconscious discrimination at work that I’ve mentioned to you. Senior staff, both doctors and nurses, often don’t look at me. But it is okay. I’m used to it. And sometimes it helps, like letting us get away with what we’re doing right now.”

“I’m sorry,” Lynn said.

“Hey, it’s not your fault. And it doesn’t bother me anymore. Anyway, let’s get back to why we’re here.”

Without another word, the two students turned their attention
back to the printed anesthesia record. Both could plainly see where the oxygen saturation suddenly fell to 92 percent. Running their eyes down to the associated ECG recording of the heart, they could appreciate the changes that coincided.

“Is that a hypoxic change on the ECG?” Michael asked.

“I believe so,” Lynn said. “I’ll need to find out for sure. I certainly have my work cut out for me.”

“What do you mean?”

“Just what I said. I’m going to figure out why this happened.”

“I’ve seen a case just like this before.”

Lynn looked up at Michael. She was surprised. “Really! When?”

Without answering, Michael looked over at Gwen and Peter. Both were occupied. Taking advantage of the situation, Michael pulled out his smartphone. After quickly turning off both the sound and the flash, he took a photo of the anesthesia record. In the next instant the phone disappeared.

“Jesus!” Lynn croaked in a forced whisper. “Why did you risk that?” Nervously she glanced back at Gwen and Peter. She was relieved to see that Gwen was involved in a conversation with another one of the ICU nurses, and Peter was on the phone busily taking dictation.

“We may need it,” Michael said cryptically. “Are you finished with the chart?”

“I’d like to read the neurology consult, even though I already have a pretty good idea what it says.”

“Let’s do it and hightail it out of here. Then I’ll tell you about the other case.”

Monday, April 6, 12:55
P.M.

A
s soon as the heavy ICU door closed behind them, Lynn peppered Michael with questions about the supposedly similar case, wanting to know exactly how similar it had been.

“It was exactly the same,” Michael said as they walked along the crowded sixth-floor hallway, skirting lunch carts.

“Was it a delayed emergence from anesthesia?”

“Absolutely. I’m telling you, it was just the same.”

“When was it?”

“About three months back, when we were on pediatrics.”

Lynn was about to ask how Michael had known about the case when she looked ahead. Coming toward them was Dr. Gordon Weaver and, most alarmingly, Markus and Leanne Vandermeer, Carl’s parents.

Like a scared rabbit, Lynn froze. They had not yet seen her, as they were far enough away and there was enough commotion in the corridor between them to create a significant distraction. For a second Lynn thought about turning and running in the opposite direction. Having yet to come to terms with her own raw emotions by
any stretch of the imagination, she didn’t know how she would respond should there be any criticism or blame. There was little doubt in her mind that they would be as devastated as she was.

Sensing Lynn’s reaction, and recognizing the parents, Michael firmly grabbed her arm. “Play it cool, sister,” he whispered.

“I’m not sure I’m ready to deal with this,” Lynn croaked. She tried to pull out of Michael’s grasp, but he held on.

“Hang!” Michael said definitively. “You can handle it, and it’s better to get it over with here in the hospital.”

Her pulse racing, Lynn watched them approach. The first to recognize her was Leanne. She was a slight woman wearing a gray, conservative suit, looking like the elementary school teacher she was. When she caught sight of Lynn, her drawn face revived from grief to concerned sympathy. Without the slightest hesitation she came directly at Lynn and enveloped her in a sustained embrace. Lynn was pleasantly surprised. Previously Leanne had never given her more than a slight kiss on the cheek.

“How are you managing, my dear?” Leanne asked, still holding on to Lynn’s arms after the lengthy hug. She was a good six inches shorter than Lynn and had to look up into her face. “Now, I want you to promise me you are going to take this bump in the road in stride. He’ll be waking up soon. Trust me! Everything is going to work out just fine. I’m sure of it. I know how busy you are. Patients are depending on you. You have to take care of yourself and get back to your work.”

Lynn glanced at Michael for support. Thanks to Carl’s descriptions, she was aware Leanne was controlling, but this seemed beyond the pale. The woman was telling her how to respond to the disaster.

“I’m so sorry for you this mild complication had to occur,” Leanne said. “But it will be over soon. I’m certain.”

“I’m sorry, too,” Lynn said. Leanne’s apparent denial of the reality of Carl’s condition was such a surprise that it made it easier for
Lynn to control her emotions. Lynn had feared censure and blame but was experiencing empathy. She was both relieved and thankful.

“You must be just devastated,” Leanne continued. “Have you seen him?”

Lynn nodded, hesitant to admit she had in front of Dr. Weaver, who she thought might recognize her having done so as a violation of hospital rules, but Dr. Weaver, obviously having his own problems, didn’t respond.

“How does he seem?” Leanne asked. Her expression of concern morphed back to grief.

“Very calm,” Lynn said. “He looks like he’s asleep.”

Leanne let Lynn go, and Markus gave her a second hug. Carl’s father was a sizable man like his son but heavier boned. His face was lined and always tan. He was an inveterate golfer who loved his bourbon. In contrast to his wife, he looked thoroughly shell-shocked and chose not to speak.

“Has there been any change?” Leanne asked when Markus let her go.

“I’m afraid not,” Lynn said. She gestured to Michael. “You remember Michael Pender, of course.”

“Yes, of course,” Leanne said, briefly acknowledging Michael but immediately turning back to Lynn. “We are going to make sure that the best doctors are involved in Carl’s care. I’m sure there will be a change for the better very soon.”

“I hope so,” Lynn said, nodding her head. She looked at Dr. Weaver, who was still dressed in scrubs. He didn’t meet her gaze and encouraged the older Vandermeers to move on toward the neuro ICU, saying there was only a small window of opportunity for their visit.

After promises to get together, the Vandermeer parents continued down the hall. Lynn and Michael headed in the opposite direction toward the elevators.

“Now, that wasn’t half-bad,” Michael said.

“They were very generous,” Lynn admitted. Quickly her mind reverted to what they had been talking about before catching sight of the Vandermeers. “What were the details of that similar case you mentioned, and how did you hear about it?”

“It was an African American female in her late twenties or early thirties, generally about the same age as Carl. She was operated on with general anesthesia after being shot in both knees. She didn’t wake up. There was an episode of hypoxia just like with Carl, and that was it.”

“She was operated on here at Mason-Dixon Medical Center?”

“Yes. I’m telling you, the case was a mirror image.”

They arrived at the elevators. Lynn tugged on Michael’s coat to get him to stop. She didn’t want to talk about a case on a crowded elevator, but she wanted to hear more. “Well, how did you hear about it?”

“My mamma called me from Beaufort to tell me a distant relation was having a major complication after surgery here. She asked me to look into it, so I did.”

“What was the woman’s name?”

“Ashanti Davis.”

“What kind of relation was she to you?”

“Very distant and only by marriage. Cousin of the brother of an in-law on my mother’s side of the family or something obscure like that. I knew her a little in high school because we went to the same regional school, but she was ahead of me and never finished, and we ran in different circles.”

“Shot in the knees? Was that the result of some sort of gang war?”

“Someone had a serious beef with her—that much is clear.”

“What’s happened to her?”

“She permanently gorked out after the operation. Within days they moved her over to the Shapiro Institute.”

“That’s awful,” Lynn said. “And is she still there?”

“As far as I know. I don’t think anybody visits or asks. Nobody in her family wants to pay the kind of bread they get for room and board, if you know what I’m saying. She wasn’t very popular in her family, to put it mildly, even in her surviving immediate family. In high school she was considered a slut with a penchant for dating all the aspiring gang members. I kept my distance. She even got one of my cousins shot dead, so her getting shot wasn’t all that unexpected considering the people she ran with. She was a bad apple.”

“What an awful story,” Lynn said. “Before getting shot, was she generally healthy, like Carl?”

“As far as I know.”

Lynn shook her head. The fact that there were two healthy people at Mason-Dixon who within months of each other did not wake up from anesthesia was more than disturbing; it was downright frightening. And it was terrifying to think of Carl being transferred over to the Shapiro. After the brief visit, she and her medical-student colleagues equated it to being shipped off to Hades.

“I would love to have a look at Ashanti’s hospital record,” Lynn said.

“Whoa!” Michael said, leaning away from Lynn as if she might be contagious. “That’s the kind of thing that could get you kicked out of medical school. Carl’s chart is different, as it is an active case, with all sorts of people having access. With Ashanti, it would be a totally different ball game. You’d have to use the EMR, and you would be caught right away.”

“I wouldn’t do it myself,” Lynn said, thinking about who might be willing to get such a record for her. Earlier Dr. Scott had offered to help her, saying her office was always open. And Lynn thought about the anesthesiologist who had taken care of Carl. Maybe she would be interested, provided she wasn’t the one who administered the anesthesia to Ashanti.

“I do have a photo of her intra-operative anesthesia record
someplace,” Michael said. “I took it in the neuro ICU the same way I just took Carl’s.”

“Really?” Lynn said with surprise. “Where is it? Could you find it?”

“I’ll have to look. As I recall, it’s either on my PC or on a flash drive that’s got to be someplace in my room.” As full-time scholarship students, both Michael and Lynn were expected to live in the dorm, a separate building on the medical center’s expansive campus. Most of the other fourth-year students had moved out to private apartments. Lynn had not minded remaining since it was convenient when on call to sleep in her own bed rather than in the on-call room. Besides, she had been staying at Carl’s most weekends.

“You’ll look?”

“Of course I’ll look. But not now, if that’s what you’re thinking.” Michael glanced at his watch. “We’re already late for the ophthalmology lecture. We better get our asses over to the clinic building.”

“I’m not going to the lecture,” Lynn said in a tone that did not brook argument. “There’s no way I could sit still for an hour in my state of mind. I’m fried.”

“What are you going to do?”

“I’m going to ride my bike down to Carl’s house and try to chill.” Lynn said. “I need to read up on anesthetic complications, particularly delayed emergence, and I can do it using his PC. I’ll feel closer to him there. I might even pray a little. I’m that desperate.”

Michael looked askance at Lynn. Religion had been a frequent topic of discussion for them, especially during their third year, when they were on pediatrics, and more recently during their advanced pediatric elective. Having to deal with suffering children with cancer had made them feel there could not be a God, at least not a loving, caring God that might be swayed by prayer.

“I know,” Lynn said, anticipating what Michael was thinking. “It
goes against what I said during all those late-night talks of ours, yet seeing Carl in the state he is in makes me want to cover all the bases.”

Michael nodded. He thought he understood. This episode had cast his friend emotionally adrift.