“You’re practically home free,” Noah said. “It looks good. All you have to do is suture up the bed to prevent adhesions, make sure there are no bleeders, then pull out the instruments.”
Mark set to work. Some inexperienced surgeons had trouble with coordination when looking at a monitor at eye level as their hands manipulated the instruments below, inside the patient’s body. Mark wasn’t one of these. Noah had never had any problem, either, which he attributed to his playing computer games where the play was carried out by manipulating a computer mouse off to the side while looking straight ahead at a monitor. This realization had given him some satisfaction that gaming hadn’t been as worthless as his mother had complained.
Once the gallbladder bed had been closed, Noah encouraged Mark to irrigate the area with saline and then suck up the fluid. It was the best way to look for any tiny leaking blood vessels that could cause big trouble after the surgery. A few moments later, when Mark was done with this last suturing chore, everything looked perfect. The case was essentially done.
“We are going to be withdrawing the instruments,” Noah said to the nurse anesthetist so she could begin lightening up on the anesthesia. Surgery was a team sport, and it was important to keep everyone informed.
At that moment, the PA system suddenly sprang to life. Everyone started and momentarily froze with their attention focused. Announcements over the inconspicuous speakers rarely occurred, but when they did, it meant something critical was happening. It was Janet Spaulding, and her voice was urgent: “We have an apparent malignant hyperthermia in room number ten. I repeat, we have a malignant hyperthermia in room number ten. The MH cart and all available personnel are needed immediately in room number ten.”
Although the anesthetist, the scrub nurse, the circulating nurse, and Mark immediately regained their composure and went back to work on the case at hand, Noah felt differently. Despite being involved in an ongoing operation and therefore not expected to respond, he desperately wanted to do so: Ava was the anesthesiologist assigned to room 10 for an emergency appendectomy on a twelve-year-old boy named Philip Harrison. Noah was aware of this because it had been up to him, as per usual, to assign a resident assistant for the surgeon, Dr. Kevin Nakano.
“Mark!” Noah said sharply. “Do you feel confident to close the incision sites on this case?”
“I suppose,” Mark said, a bit taken aback.
“It’s not hard,” Noah snapped. “But you must close the fascia, particularly at the incision in the umbilicus. We don’t want her to get a belly-button hernia. Understand?”
“Got it,” Mark said.
“I want to get down to room number ten in case I’m needed,” Noah said, as he stepped back from the operating table, snapping off his surgical gloves in the process. He nodded to the nurse anesthetist to make sure she knew he was leaving before the case had ended.
As he went through the OR room door, Noah struggled out of his surgical gown. He left it and the used gloves next to the scrub sink and started running down the hall toward room 10. What was propelling him with such urgency wasn’t necessarily the patient’s well-being but rather Ava’s. He had never seen a case of malignant hyperthermia, known as MH, but he knew a significant amount about the condition, a rare but life-threatening problem usually triggered by exposure to certain drugs used for general anesthesia. The body’s muscular machinery went into uncontrolled overdrive, potentially leading to organ failure and death.
What was worrying Noah was the possibility that Ava could be facing yet another anesthesia catastrophe so soon after experiencing two others that already had undermined her self-esteem and had her questioning her competence. Noah wanted to be present for moral support, if nothing else. Although he’d never seen a case of malignant hyperthermia personally, he’d participated on numerous occasions in practice sessions spearheaded by the Anesthesia Department for dealing with the critical emergency.
Noah burst into OR 10 and found himself in the middle of chaos. There were twenty people in the room along with the malignant hyperthermia cart, which contained all the potentially needed drugs and hardware to deal with the emergency. About half the people grouped around the patient were anesthesia residents; the rest were nurses, except for two surgical residents. Off to the side was the cardiac crash cart in case it was needed.
The frantic activity was centered on preparing the major treatment modality, a drug called dantrolene. Since the drug was unstable in solution, it had to be prepared on the spot just prior to use. While that was in process, other people were preparing a cooling blanket. Ice was brought in and put in a basin, into which bottles of IV fluid were placed. As suggested by the name of the condition, one of its critical hallmarks was a dangerous rise in body temperature that had to be controlled or, in irreverent resident parlance, the brain would be “fried.”
Dr. Kevin Nakano was standing off to the side with his sterile hands clasped over his sterile surgical gown. His eyes had the terrified look of someone who wanted desperately to do something but didn’t quite know what. The situation had been commandeered by the MH team. A sterile towel had been placed over the tiny incision site that Dr. Nakano had been in the process of closing when all hell broke loose. The appendix had already been removed.
Noah made his way through the crowd to the head of the table. Ava stood, her stool pushed to the side, tending to the anesthesia machine, which was ventilating the patient with 100 percent oxygen. Even so, the patient’s oxygen saturation was low, as evidenced by the oximeter alarm and the patient’s color, a mottled blue.
Noah and Ava exchanged a quick but knowing glance. He could tell immediately that she was beside herself with concern but in control, like a competent pilot in an emergency. Noah looked at the ECG and could see the boy’s heart was racing.
“What’s his temperature?” Noah asked over the tumult of voices in the room.
“One-oh-six and climbing,” Ava said. She shook her head. From her eyes alone Noah could sense she knew she was in the middle of a true emergency and was heartsick over the possible consequences. “He’s only twelve years old,” she managed.
“Scary!” Noah said. He was going to say more, but he was nudged aside by the most senior anesthesia resident who’d responded to the call, Dr. Allan Martin, the designated leader of the assembled MH group.
“Here’s the first hundred milligrams of dantrolene,” Allan said to Ava.
“Thank God!” Ava said, taking the medication and immediately attaching it to the IV line. “But I’m going to want three more doses prepared.”
“It is in process,” Allan assured her.
Noah watched as other members of the team properly positioned the cooling blanket for the now completely rigid boy. All his muscles were in tight contraction. It was as if he were made of wood.
The circulating nurse approached Ava from the other side and handed her a piece of paper.
“Allan,” Ava called. “The potassium is going up. I’m going to give glucose and insulin.”
Allan responded with a thumbs-up.
Noah managed to move back to Ava. After she had given the insulin, she had a moment of comparative calm.
“What was the first sign of trouble?” Noah asked.
“A sudden unexpected rise in end-tidal carbon dioxide,” Ava said. She was staring at the temperature readout.
“Oh,” Noah responded. He had expected something more dramatic and not quite so esoteric. “That was all?”