At one point a large globule of brain tissue momentarily blocked the opening of the sucker. There was a slight whistling noise, before the piece of tissue whooshed up the tube. “There go the music lessons,” said Mannerheim. It was a common neurosurgical quip, but coming from Mannerheim after all the tension he’d caused, it was funnier than usual. Everyone laughed, even the two Japanese doctors.
As soon as Mannerheim had finished removing brain tissue, Ranade slowed the ventilation of the patient. He wanted to let Lisa’s blood pressure rise a little while Mannerheim inspected the cavity for any bleeding. After a careful check Mannerheim was satisfied the operative site was dry. Taking a needle holder he began to close the dura, the tough covering over the brain. At that point, Ranade began carefully to lighten Lisa’s anesthesia. When the case was over he wanted to be able to remove the tube in Lisa’s trachea without her coughing, or straining. This required a delicate orchestration of all the drugs he’d been using. It was imperative that Lisa’s blood pressure not go up.
The dural closure went swiftly and with a deft rotation of his wrist, Mannerheim placed the last interrupted stitch. Lisa’s brain was again covered, although the dura dipped down and was darker where Lisa’s temporal lobe had been. Mannerheim cocked his head as he admired his handiwork, then stepping back, he snapped off his rubber gloves. The sound echoed in the room.
“All right,” said Mannerheim, “close her up. But let’s not make it your life’s work.”
Motioning for the two Japanese doctors to come with him, Mannerheim left the room.
Newman took Mannerheim’s position at Lisa’s head. “Okay, Lowry,” said Newman, echoing his boss, “let’s see if you can help me rather than hinder me.”
After dropping the bone flap into place like the top of a Halloween pumpkin and tying the sutures, Newman was ready to close. With a pair of rugged tooth forceps, he grabbed hold of the edge of Lisa Marino’s wound and partially everted it. Then he plunged the needle deep into the skin of the scalp, making sure he picked up pericranium, and brought the needle out in the wound. Detaching the needle holder from its original position on the shank of the needle, he used the instrument to grab the needle tip, bringing the suture out into the wound; With essentially the same technique, he put the silk through the other side of the wound, trailing the suture off into Dr. Lowry’s waiting hand so he could tie the stitch. They repeated this procedure until the wound was closed with black sutures, giving the impression of a large zipper on the side of Lisa’s head.
During this part of the procedure, Dr. Ranade was still ventilating Lisa by compressing a breath bag. As soon as the last stitch was to be placed, he planned to give Lisa one hundred percent oxygen and reverse the remaining muscle paralyzer her body hadn’t metabolized. On schedule his hand again compressed the breathing bag, but this time his experienced fingers detected a subtle change from the previous compression. Over the last few minutes Lisa had begun to make initial efforts to breathe on her own. Those efforts had provided a certain resistance to ventilating her. That resistance had been gone on the last compression. Watching the breathing bag and listening with his esophageal stethoscope, Ranade determined that Lisa had suddenly stopped trying to breathe. He checked the peripheral nerve stimulator. It told him the muscle paralyzer was wearing off on schedule. But why wasn’t she breathing? Ranade’s pulse increased. For him anesthesia was like standing on a secure but narrow ledge on the side of a precipice.
Quickly, Ranade determined Lisa’s blood pressure. It had risen to 150 over 90. During the operation it had been stable at 105 over 60. Something was wrong!
“Hold up,” he said to Dr. Newman, his eyes darting to the cardiac monitor. The beats were regular but slowing with longer pauses between the spikes.
“What’s wrong?” asked Dr. Newman, sensing the anxiety in Dr. Ranade’s voice.
“I don’t know.” Dr. Ranade checked Lisa’s venous pressure while preparing to inject a drug called nitroprusside to bring down her blood pressure. Up to this point Dr. Ranade believed the variation in Lisa’s vital signs was a reflection of her brain responding to the insult of surgery. But now he began to fear hemorrhage! Lisa could be bleeding and the pressure in her head could be going up. That would explain the sequence of signs. He took the blood pressure again. It had risen to 170 over 100. Immediately he injected the nitroprusside. As he did so, he felt that unpleasant sinking feeling in his abdomen associated with terror.