Host by Robin Cook Page B

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 tobreathe 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 byanesthesia 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