The effect of the succinylcholine was seen almost immediately. At first there were minute fasciculations of the muscles of the face, then the abdomen. As the bloodstream sped the drug throughout the body, the motor and end plates of the muscles became depolarized, and total paralysis of the skeletal muscles occurred. Smooth muscles, like the heart, were unaffected, and the beep from the monitor continued without a waver.
Nancy’s tongue was paralyzed and it fell back, blocking her airway. But that didn’t matter. The muscles of the thorax and abdomen were paralyzed as well, and any attempt at breathing ceased. Although chemically different from the curare of the Amazon savages, the drug had the same effect, and Nancy would have died in five minutes. But at this point nothing was wrong. Dr. Billing was in total control. The effect was expected and desirable. Outwardly calm, inwardly very tense, Dr. Billing put down the breathing mask and reached for the laryngoscope, step number 22 on his list With the tip of the blade, he pulled the tongue forward and maneuvered past the white epiglottis, while he visualized the entrance to the trachea. The vocal cords were ajar, paralyzed with the rest of the skeletal muscles.
Swiftly Dr. Billing squirted some topical anesthetic into the trachea, followed by the endotracheal tube. The laryngoscope made a characteristic metallic snap as Dr. Billing folded the blade onto the handle. With the help of a small syringe, he inflated the cuff on the endotracheal tube, providing a seal. Quickly he attached the tip of the rubber hose, without the face mask, to the open end of the endotracheal tube. As he compressed the ventilating bag, Nancy’s chest rose in a symmetrical fashion. Dr. Billing listened to Nancy’s chest with his stethoscope and was pleased. The entubation had been as characteristically smooth as expected. He was in total control of the patient’s respiratory state. He adjusted his flow meters and set the combination of halothane, nitrous oxide, and oxygen he wanted. A few pieces of tape secured the endotracheal tube. A twist of the finger adjusted the I.V. rate. Dr. Billing’s own heart began to slow down. He never showed it, but he always got very tense during the entubation procedure. With the patient paralyzed one has to work fast, and do it right.
With a nod, Dr. Billing indicated that Gloria, D’Mateo could begin the prep of Nancy’s shaved perineum. Meanwhile Dr. Billing began to make himself comfortable for the case. His job was now reduced to close observation of the patient’s vital signs: heart rate and rhythm, blood pressure, and temperature. As long as the patient was paralyzed, he had to compress the ventilating bag, to breathe the patient The succinylcholine would wear off in eight to ten minutes; then the patient could breathe herself, and the anesthesiologist could relax. Nancy’s blood pressure stayed at 105/70. The pulse had steadily fallen from the anxiety state prior to anesthesia to a comfortable seventy-two beats per minute. Dr. Billing was happy, and he looked forward to a coffee break in about forty minutes.
The case went smoothly. Dr. Major did his bimanual examination and asked for some more relaxation. This meant that Nancy’s blood had detoxified the succinylcholine given during the entubation. Dr. Billing was happy to give another 2 cc. He dutifully recorded this in his anesthesia record. The result was immediate, and Dr. Major thanked Dr. Billing and informed the crew that the ovaries felt like little smooth, normal plums. He always said that when he felt normal ovaries. The dilation of the cervix went without a hitch. Nancy had a normally antero-flexed uterus, and the curve on the dilators was a perfect match. A few blood clots were sucked out from the vaginal vault with the suction machine. Dr. Major carefully curetted the inside of the uterus, noting the consistency of the endometrial tissue. As Dr. Major passed the second curette, Dr. Billing noted a slight change in the rhythm of the cardiac monitor. He watched the electronic blip trace across the oscilloscope screen. The pulse fell to about sixty. Instinctively he inflated the blood pressure cuff and listened intently for the familiar far-away deep sound of the blood surging through the collapsed artery. As the air pressure drained off more, he heard the rebound sound indicating the diastolic pressure. The blood pressure was 90/60. This was not terribly low, but it puzzled his analytical brain. Could Nancy be getting some vagal feedback from her uterus, he wondered. He doubted it, but just the same be took the stethoscope from his ears.
“Dr. Major, could you hold on for just a minute? The blood pressure has sagged a little. How much blood loss do you estimate?”
“Couldn’t be more than 500 cc,” said Dr. Major, looking up from between Nancy’s legs.
“That’s funny,” said Dr. Billing, replacing the stethoscope in his ears. He inflated the cuff again. Blood pressure was 90/58. He looked at the monitor: pulse sixty.
“What’s the pressure?” asked Dr. Major.
“Ninety over sixty, with a pulse of sixty,” said Dr. Billing, taking the stethoscope from his ears and rechecking the flow valves on the anesthesia machine.
“What the hell’s wrong with that, for Christ’s sake?” snapped Dr. Major, showing some early surgical irritation.
“Nothing,” agreed Dr. Billing, “but it’s a change. She had been so steady.”
“Well, her color is fantastic. Down here, she’s as red as a cherry,” said Dr. Major, laughing at his own joke. No one else laughed.
Dr. Billing looked at the clock. It was 7:48. “OK, go ahead. I’ll tell you if she changes any more,” said Dr. Billing, while giving the breathing bag a healthy squeeze to inflate Nancy’s lungs maximally. Something was bothering Dr. Billing; something was keying-off his sixth sense, activating his adrenals and pushing up his own heart rate. He watched the breathing bag sag and remain still. He compressed it again, mentally recording the degree of resistance afforded by Nancy’s bronchial tubes and lungs. She was very easy to breathe. He watched the bag again. No motion, no respiratory effect on Nancy’s part, despite the fact that the second dose of the succinylcholine should have been metabolized by then.
The blood pressure came up slightly, then went down again: 80/58. The monotonous beep of the monitor skipped once. Dr. Billing’s eyes shot to the oscilloscope screen. The rhythm picked up again.
“I’ll be finished here in five minutes,” said Dr. Major for Dr. Billing’s benefit With a sense of relief, Dr. Billing reached over and turned down both the nitrous oxide and the halothane flow, while turning up the oxygen. He wanted to lighten Nancy’s level of anesthesia. The blood pressure came up to 90/60, and Dr. Billing felt a little better. He even allowed himself the luxury of running the back of his hand across his forehead to scatter the beads of perspiration that had appeared as evidence of his increasing anxiety. He glanced at the soda-lime CO2 absorber. It appeared normal. Time was 7:56. With his right hand he reached up and lifted Nancy’s eyelids. They moved with no resistance and the pupils were maximally dilated. The fear returned to Dr. Billing in a rush. Something was wrong… something was very wrong.
1
Monday, February 23, 7:15 A.M.
Several small flakes of snow danced down Longwood Avenue in the half-light of February 23, 1976. The temperature was a crisp twenty degrees and the delicate crystalline structures fluttering earthward were intact even after striking the pavement. The sun was obscured by a low cover of thick gray clouds which shrouded the waking city. More and more clouds were swept in by the sea breeze, enveloping the tops of the taller buildings in a mist, making it become paradoxically darker as dawn spread its frail fingers over Boston. It was not supposed to snow, yet a few flakes had crystallized over Cohasset and had blown all the way into the city. The few that reached Longwood Avenue and were blown right on Avenue Louis Pasteur were the survivors until a sudden down-draft slammed them against a third-story window of the medical school dorm. They would have slid off had it not been for the layer of greasy Boston grime on the pane. Instead they stuck there while the glass slowly transmitted the heat from within, and their delicate bodies dissolved and mingled with the dirt.