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?”
“That was just the first sign of trouble,” Ava said, staring at the temperature readout as if trying to make it go south by sheer force of will. “Then I noticed his jaw clenching. That was when I knew what was happening and called the alarm. By the time the MH team got here he was completely rigid. It came on really, really fast. I’m afraid it’s a severe case, which doesn’t make any sense. There’s no family history. I even asked the mother pre-op.”
“I’m sorry,” Noah said, not knowing what else to say. He could feel her anguish.
“The temperature is not responding to the first dose of dantrolene,” Ava said.
“Is that bad?” Noah asked.
“Of course it’s bad,” Ava said, as if angry. “It’s climbed to above one-oh-seven.”
Ava called over to Allan, asking for the next dose of dantrolene, but before it could be given the cardiac alarm went off. Twelve-year-old Philip Harrison’s heart went into fibrillation.
The team responded appropriately, since the cardiac crash cart was already in the room. The patient was successfully defibrillated, and a relatively normal heartbeat returned. The second dose of dantrolene was given. More tricks were also tried to get the patient’s temperature to reverse its relentless rise. It was at that point that Dr. Adam Stevens, the same cardiac surgeon who had helped Noah on the Bruce Vincent case, came into the room to see what was happening. He had just finished a case of his own. He saw Noah and made his way over to him.
“What’s happening?” Dr. Stevens asked.
Noah gave the surgeon a quick rundown, saying that it was not looking good for the boy. “The temperature is now over one-oh-eight, despite everything that’s being done,” Noah added with growing alarm.
“I don’t like that mottled blue cyanosis,” Dr. Stevens said. “That’s a super-bad sign, suggesting disseminated intravascular coagulation.”
“More dantrolene,” Ava desperately called out to Allan. “The temperature is still rising.”
“There’s only one way to bring the temperature down,” Dr. Stevens said. “Put him on the pump and run the blood through an ice bath. That will do it. Of course, we’re not sure if his brain hasn’t already called it quits. We could do an EEG, but by the time we do that, it most likely would be too late.”
“You’re willing to put him on bypass?” Noah questioned. After the Vincent catastrophe, Noah was less willing to contemplate such heroics, especially after what Dr. Mason had said to him about it being Noah’s actions that had killed the hospital parking czar.
“If you’ll help, I’ll do it,” Dr. Stevens said.
In record time, with both Noah and Dr. Nakano assisting Dr. Stevens, Philip Harrison was put on cardiac bypass. Unfortunately, his temperature had reached 113 before the cooling could be instigated. As the final coup de grace when the temperature had been brought down into the normal range, the heart would not start, agonizingly similar to the situation with Bruce Vincent. All the effort turned out to be in vain.
“Well, we gave it our best,” Dr. Stevens said an hour later. He was speaking to the entire group in the operating room. No one had left.
Everyone felt dispirited, having given their all, and said little as they filed out of the room. Dr. Stevens departed first, followed by Dr. Nakano. No one spoke.