Excerpts

Spring in Charleston, South Carolina, is a resplendent affair, and by the beginning of April, it is always well underway. As if competing for attention, the azaleas, the camellias, the hyacinths, the early blooming magnolias, and the forsythias all contribute their 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 day for most everyone in this scenic, historic town. Everyone, that is, except 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 that 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 River. Lined with period mansions and boasting a public garden, the Battery was one of the most attractive and popular locales of the city. Like most of the other runners, Carl lived in the surrounding and charming residential neighborhood called SOB to the locals as the acronym for 'South of Broad Street.' Broad Street was a thoroughfare that ran east-west across the Charlestown 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 his 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 scored 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 how he had gotten there. 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 for the second time. That was when he knew it was serious.           A visit to Dr. Gordon Weaver, an orthopedic surgeon, had confirmed the diagnosis as 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 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 down time, but missing work was not what bothered Carl. What bothered Carl was that he had a particularly strong distaste for having anything to do with medicine and needles. He had been known to pass out merely having blood drawn and 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 lightheaded 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. It had been she who had recommended Dr. Weaver and had explained in agonizing detail on exactly how his knee was going to be repaired. It also had been Lynn's insistence that he request to have his operation be Dr. Weaver's first case on a Monday morning, saying that everyone was fresh and there was less chance for mistakes. Carl knew that Lynn meant well through all this, but her comments only made him even more nervous. Lynn had offered to spend the night as she had 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 nervous 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 and 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 was about his up-coming surgery. For ego preservation, there were some things that were better left unsaid.           Carl let the alarm ring unabated for a time for fear of falling back asleep. He'd slept poorly and had trouble getting to sleep the night before. His instructions from Dr. Weaver's nurse were not to eat after midnight except water and take a good, hot shower with antimicrobial soap when he got up, paying particular attention 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 into 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 the feline at the pound after graduation with hopes it would be adopted. Carl couldn't abide by the plan, thinking it a possible death sentence. He took the cat home for the summer, got hopelessly enamored and ended up taking it to law school with him. Frank Giordano, a close friend and fellow basketball-playing lawyer, who was going to 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. *           As Carl Vandermeer eased into a hot shower, Dr. Sandra Wykoff leapt out of her BMW X3.She was in a hurry because she loved her work. In contrast to Carl Vandermeer, she loved medicine so much she had not taken a real vacation in the three years she'd been on staff of 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 eschewed the elevator and took the stairs. It was only one flight, and she liked 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 OR12 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 were more blood loss than expected. To her, such communication was important, but not every surgeon was as cooperative. Like all anesthesiologists, she knew that it was she who was responsible for the patient's well-being during an operation, not the surgeon, and she appreciated being informed if anything out of the ordinary occurred.           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 EHR, electronic health 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, straight forward case, or so she thought.           After changing into her scrubs, she made her way into the OR proper, passing the OR desk commanded by the extraordinarily competent OR supervisor, Geraldine Montgomery. Continuing on, she passed the entrance to the PACU on her right, which used to be called the recovery room. The preoperative 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 inevitably busy Monday schedule. As a generally friendly although private person, Sandra greeted anyone who caught her eye, but she didn't stop to talk 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 that 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.           Entering OR twelve, Sandra greeted Claire Beauregard, the assigned circulating nurse, who was already busy setting up for the case. But there was no conversation. Sandra made a beeline to her trusted mechanical partner with which she was going to be spending most of the day. It bristled with varying colored 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 a hundred 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 required checklist used in a modern aircraft before takeoff to make certain all systems function properly. But Sandra did not turn the machine on 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 one hundred percent certain everything was in order. She liked to physically touch and operate all the valves. It made her 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 the machine on. 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, heart function, or low oxygen levels in the blood. Sandra was pleased. When there was something 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 after she'd gone down to the department to ask a simple service related question. He gave her the creeps particularly after he called her at home 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. Sandra then began checking her supplies and pharmaceuticals with equal diligence. She liked to touch everything she might need so she knew where it was. If there was an emergency she didn't want to search for anything. She wanted everything at her fingertips. *           "Want 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.           "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 backwards 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 time his arrival 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 his 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 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 was 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 paper work 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 siFyodorrly 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 provide 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 was 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 again 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 naïve. "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 1 to 10!" "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 knee cap.  "We want to be sure to operate on the correct 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. *           "Dr. 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 am.           "I'll be ready," Jennifer said. As Sandra walked back down the central corridor, she checked Carl's EHR 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 they were 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. She had a syringe with the proper dose according to Carl's weight in the pocket of her scrubs. 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. Working with him was going to be a pleasure she thought. "Good morning Mr. Vandermeer," Sandra said, "I'm Doctor 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 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 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 made by the admitting nurse 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 mid-sentence, again reminding Sandra why she was so fond of the midazolam. It would only be much later that Sandra would question the dose she had given in the process of questioning 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 over 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 she was now beginning, and then long segments of relative boredom requiring dedicated effort to stay focused. Whenever she thought about it, the metaphor 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 midflight auto-pilot and have little to do other than scan 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 non-flammable, 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, EKG, 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 EKG 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 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 what anesthesia really was: 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. 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 like it always was, yet it provided her a shot of euphoria of a job well done and a patient well served. "Everything okay?" Doctor Weaver questioned. He was eager to begin. Sandra gave a thumb's-up as she manually checked Carl's blood pressure yet again. She then helped Clair 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 mid-flight. 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 only spoke up 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 keep her 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 honed 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 EKG. 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 for fear the possible artifact had been real kept her glued to her seat, watching the patient monitor closely. It was mesmerizing as the tracings raced across the screen, particularly the EKG 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 was approaching. 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. Her eyes shot to the monitor. The oxygen had suddenly gone from nearly 100% down to 92%. 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% and already heading upward. But why did it drop? Sandra didn't have the foggiest notion. That was when she noticed the EKG 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 hyper-extending. 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 shinned in a beam of light into the 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 hyper-extension 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!  Excerpted from Host by Robin Cook All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.