"Can we start?" Paul demanded. He shifted his weight. He knew he couldn't begin yet, but he wanted to communicate his impatience and displeasure. They shouldn't have called him until all was ready. His time was too valuable for him to be standing idly while Carl messed around with all his toys.

Continuing to ignore Paul's peevishness, Carl concentrated on testing Kristin's level of consciousness. Satisfied she'd reached an appropriate state, he injected the muscle relaxant mivacurium, which he preferred over several others for its rapid spontaneous recovery time. When the mivacurium had taken effect, he skillfully slipped in an endotracheal tube to ensure control of Kristin's airway. Then he sat down, attached the anesthesia machine, and motioned to Paul that everything was set.

"It's about time," Paul mumbled. He and Sheila quickly draped the patient for laparoscopy. The target was the right ovary.

Carl settled back after making the appropriate entries into the anesthesia record. His role at that point was to watch his monitors while maintaining anesthesia by carefully titrating the patient's state of consciousness with a continuous propofol infusion.

Paul moved quickly, with Sheila anticipating his every move. Along with Constance Bartolo, the scrub nurse, and Marjorie Hickam, the circulator, the team worked with metronomic efficiency. At this point there was no conversation.

Paul's first goal was to introduce the trocar of the insufflation unit to fill the patient's abdominal cavity with gas. It was the creation of a gas-filled space that made the laparoscopic surgery possible. Sheila helped by grabbing two bites of skin alongside Kristin's belly button with towel clips and pulling up on the relaxed abdominal wall. Meanwhile, Paul made a small incision at the umbilicus and then proceeded to push in the nearly foot-long Veress insufflation needle. In his experienced hands two distinct pops could be felt as the needle passed into the abdominal cavity. While holding the needle firmly at its serrated collar, Paul activated the insufflation unit. Instantly, carbon dioxide gas began to flow into Kristin's abdominal cavity at a rate of a liter of gas per minute.

As they waited for the appropriate amount of gas to enter, disaster struck. Carl was preoccupied, watching his cardiovascular and respiratory monitors for telltale signs of the increasing intra-abdominal pressure, and failed to see two seemingly innocuous events: namely a fluttering of Kristin's eyelids and a slight flexion of her left leg. Had Carl or anyone else noticed these movements they would have sensed that Kristin's level of anesthesia was becoming light. She was still unconscious but close to waking, and the discomfort of the increasing pressure in her belly was serving to rouse her.

Suddenly Kristin moaned and sat up. She didn't get all the way up; Carl reacted by reflex, grabbing her rising shoulders and forcing her back down. But it was too late. Her rising off the table forced the Veress needle in Paul's hand to plunge deeper into her belly, where it penetrated a large intra-abdominal vein. Before Paul could stop the insufflation unit, a large bolus of the gas entered Kristin's vascular system.

"Oh my God!" Carl cried as he heard in his earpiece the beginnings of the ominous telltale mill-wheel murmur as the gas reached her heart; a threshing sound like the agitation cycle of a washing machine. "We've got a gas embolism," he yelled. "Get her on her left side!"

Paul yanked out the bloody needle and tossed it to the side, where it clanked against the tile floor. He helped Carl roll Kristin over in a vain attempt to keep the gas isolated in the right side of her heart. Paul then leaned on her to keep her in position. Although still unconscious, she fought back.

Meanwhile, Carl rushed to insert, as aseptically as possible, a catheter into Kristin's jugular vein. Kristin resisted and struggled against the weight on top of her. Inserting the catheter was like trying to hit a moving target. Carl thought about increasing the propofol or giving her more mivacurium, but was reluctant to take the time. At last he succeeded with the catheterization, but when he drew back on the plunger of the syringe all he got was a bloody froth. He did it again with the same result. He shook his head in dismay, but before he could say anything Kristin briefly stiffened, then convulsed. Her body was racked by a full-blown grand mal seizure.

Frantically Carl dealt with this new problem while he battled the sinking feeling in his own gut. He knew all too well that anesthesiology was a profession marked by numbing, repetitive routine occasionally shattered by episodes of pure terror, and this was as bad as it got: a major complication with a young, healthy person undergoing a purely elective procedure.

Both Paul and Sheila had stepped back with their sterile, gloved hands clasped in front of their gowned chests. Along with the two nurses, they watched as Carl struggled to terminate Kristin's seizure. When it was over, and Kristin was again on her back motionless, no one spoke. The only sound other than the muted noise of a radio coming through the closed door to the sterilizer room was the anesthesia machine breathing for the patient.

"What's the verdict?" Paul said finally. His voice was emotionless, and it echoed in the tiled space.

Carl breathed out like a balloon deflating. Reluctantly he reached forward with two index fingers and pulled back Kristin's eyelids. Both pupils were widely dilated and did not react to the brightness of the overhead light. He took his own penlight from his pocket and shined the beam into Kristin's eyes. There was no reaction whatsoever.

"It doesn't look good," Carl croaked. His throat was dry. He'd never had such a complication.

"Meaning?" Paul demanded.

Carl swallowed with difficulty. "Meaning my guess would be that she's stroked out. I mean, a minute ago she was light, now she's gorked out. She's not even breathing on her own."

Paul's head bobbed up and down perceptively as he pondered this information. Then he snapped off his gloves, tossed them on the floor, and undid his mask, which he allowed to fall forward onto his chest. He looked at Sheila. "Why don't you continue with the procedure? At least you'll get some practice. And do both sides."

"Really?" Sheila questioned.

"No sense being wasteful," Paul said.

"What are you going to do?" Sheila asked.

"I'm going to find Kurt Hermann and have a chat," Paul said as he untied and pulled off his gown. "As unfortunate as this incident is, it's not as if we haven't anticipated such a disaster, and at least we've planned for it."

"Are you going to inform Spencer Wingate?" Sheila asked. Dr. Wingate was the founder and titular head of the clinic.

"That I don't know," Paul said. "It depends. I prefer to hold off and see how events play out. What do you know about Kristin Overmeyer's arrival today?"

"She came in her own car," Sheila said. "It's out in the parking lot."

"She came alone?"

"No. As we advised her, she brought a friend," Sheila said. "Her name is Rebecca Corey. She's out in the main waiting area."

As Paul started for the door his eyes locked onto Carl's.

"I'm sorry," Carl said.

Paul hesitated for a moment. He felt like telling the anesthesiologist what he thought of him, but changed his mind. Paul wanted to keep a cool head, and getting into a conversation with Carl at that point would have gotten him all worked up. It had been enough that Carl had kept him waiting for so long.

Without even bothering to change out of his surgical scrubs, Paul snatched a long white doctor's coat from the room that served as the surgical lounge. He pulled the coat on as he descended the metal stairs in the stairwell. Passing the first floor, he exited out onto the lawn, which was showing the first signs of spring. With the coat clutched around himself against the blustery early April New England wind, he hurried down toward the clinic's stone gatehouse. He found the chief of security behind his scarred and worn desk, hunched over his department's schedule for the month of May.