I
"Dean!"
Dean looked up from rinsing off his hands to see Chuck bearing down on him, which was almost never a portent of anything delightful. "Yeah?" he asked carefully as he tore off a paper towel to dry his hands.
"How are you at BKAs?" the charge nurse asked.
"A BKA?" Dean whistled. "Why are we doing it here? Those usually go to St. Luke's."
"It is at St. Luke's." Chuck shrugged. "Cage is doing it, and wants Novak there for the anastomosis. And Novak wants you. You're on the books to tech for St. Luke's, right? You take call there?"
"Yeah." Dean wrinkled his brow to remember if he had his badge for St. Luke's in his bag. "When is it?"
Chuck consulted his watch. "In about two hours. You up for it?"
Dean balled up the paper towel and tossed it into the trash bin. "I can't go disappointing Dr. Novak, now can I?"
II
Though it took getting lost three times in the twisting corridors of the hospital, fighting with the scrub dispensing machine that wouldn't recognize his badge, and visiting two locker rooms to find an empty place to stow his bag, Dean finally tied on a mask and stepped into the orthopedic operating room at St. Luke's.
There was a very different feeling to being in St Luke's Hospital as opposed to Summit Outpatient Surgery Center. Though owned by the same medical group, money tended to be funneled into St Luke's rather than Summit, and it showed: Summit was slightly behind the curve of technology and needed a thorough retrofitting, whereas St. Luke's had recently enjoyed a complete remodel of its surgery wing, and it still gleamed with new stainless steel and unscuffed pale blue linoleum.
Dean's eyes automatically sought out the back table as he slipped through the doors, and noted approvingly that there were two – one for the amputation, one for the anastomosis – and that the table he deemed as his had been opened, but not set up.
"You Novak's scrub?" the masked and gowned tech at the amputation table asked.
"Yeah. Dean Winchester. I'd shake your hand, but I should probably wait until I'm scrubbed in."
The other tech's eyes showed that he was politely smiling at Dean's jest. "Leo Fitz. Good to meet you. Those should be your gown and gloves – Novak told me what size you wore."
"Did he?" Dean asked, startled. "Didn't think he paid that much attention."
Leo blinked. "You're his tech, aren't you?"
"I guess? I've only known the guy for –" Dean counted in his head. "– about eight weeks or so." He shook his head. "Whatever. When are we starting?"
"You've got time," Leo said wryly. "You don't even need to scrub in until Novak starts his thing, which won't be for at least two hours or so. Pull up a stool and enjoy the show."
Dean did just that, settling into a corner by the autoclave and enjoying watching the bustle of someone else's room for once. The patient was wheeled in on a gurney – also newer than the fare at Summit – and settled onto the table as the tech deftly arranged his instrumentation. Dean would never admit how impressed he was; he was fairly certain he'd need two tables to himself if he had that many instrument pans, but Leo was obviously skilled enough to make do with just the one. He watched Leo's movements intently, privately taking notes, and didn't notice that Dr. Novak was in the room until he spoke.
"He's awfully rigid."
At the sound of Dr. Novak's voice, Dean's attention shifted abruptly to the surgeon, who was helping position the now-sleeping patient on the table. Even behind his mask, Dean could tell that Dr. Novak was frowning.
"I noticed that," the anesthesiologist said in a troubled tone. "Jaw's clenched pretty tightly, too."
At that, Dean could see Dr. Novak's shoulders tense as the surgeon froze. "What's the capnometry?" he asked sharply as the anesthesia machine began a discordant beep. "Did you use sux to intubate?"
"Yeah, I –" The anesthesiologist's eyes went wide as he looked down at the patient. "Shit."
"Shit is right," Dr. Novak said grimly. "You want me to get a line in so we can get ABG's to confirm, or go right to Dantrolene?"
"What?" the anesthesiologist asked helplessly. Dr. Novak's eyes narrowed; Dean looked at the anesthesiologist and when he saw how young the eyes were above the mask, recognized the problem immediately.
"Should I take over?" Dr. Novak asked, tone urgent but still somehow kind.
The anesthesiologist nodded. "And I'll page the charge."
"You do that." Dr. Novak strode over to the intercom in the corner, closing the gap quickly. "What's the code?"
"We don't have one," the circulating nurse said as she stripped the heated blankets and warmers from the patient's body, leaving his skin bare to the chill air of the operating room. "It's just 'MH.'"
"MH, operating room seven," Dr. Novak said into the intercom, his voice steely with forced calm. "MH, operating room seven." He repeated it once more and then flicked the intercom off, turning to Dean. "Dean. Do you know where the ice machine is?"
Stunned by the rapidity of events, Dean could only nod.
"We need ice. Lots of it. Take a cart and some basins – Luc, your patient's in MH crisis," Dr. Novak said, interrupting himself as Dr. Cage burst into the room.
"Shit," Dr. Cage said.
"That's the general consensus," Dr. Novak said, the last words Dean heard as he finally recalled how to command his legs and raced for a cart and basins.
The intercom call had been picked up by the hospital switchboard; the announcement was now being broadcast through the entire surgery wing by a coolly calm female voice. Dean had to steer around three people who were jogging toward room seven, one of them wheeling an unwieldy blue cart that Dean knew had to be the malignant hyperthermia rapid response cart.
The ice machine was new and efficient, but still seemed to take hours to fill the first basin. Dean could see more personnel heading with purposeful haste toward the room, and he swallowed, his heart racing. He'd heard of malignant hyperthermia, of course – any surgical pharmacology course at least touched on it – but it was tremendously rare. One of the anesthesia drugs was making the patient's muscles contract uncontrollably, making the body temperature spike dangerously and releasing muscle cells into the bloodstream and urine. Back in the room, they probably had thirty minutes to push the drugs that would counteract it, and they needed ice to lower the body temperature before it got more dangerous.
Frustrated with the rate at which ice was being dispensed and knowing it was gravely needed, he set another basin below the funnel, jammed the handle of the cart against the panel that activated the dispenser, and strode quickly back to the room, carrying the first basin by hand.
He'd barely made it into the room before the basin was snatched from him; he had time to glimpse Dr. Novak very grimly placing a line in the patient's left arm before he ducked out again to pace back down the hall to the ice machine.
The second basin filled, Dean watched as the machine filled two more before the light indicating the machine was empty flicked on. Four basins would have to suffice, for now. Dean hurriedly wheeled the cart back to the room and shoved open the doors with his back, dragging the cart behind him.
No fewer than four people were shaking bottles of yellow fluid, reconstituting the drug that was the only thing that could counteract malignant hyperthermia. The contents of the first basin Dean had brought had already been emptied into plastic bags that now rested atop the patient's bare skin; someone was already filling more bags to replace the first ones as they melted. The charge anesthesiologist had taken the CRNA's place at the head of the bed, clearly having difficulties keeping the patient's airway open and viable as his muscles seized. Dr. Novak, moving with that same flat calm Dean had seen before, was holding his hand out for syringes of the reconstituted drug. "Dantrolene!" he barked, snapping his fingers. "Come on!"
Hearing the command in Dr. Novak's voice made Dean's response automatic. He stepped up to the blue cart and grabbed a bottle of the yellow powder with one hand and began drawing up sterile water in a syringe with another. "How much are we pushing?" he asked in a low voice of the nurse next to him.
"At least two thousand cc's," the nurse replied shortly. "Get mixing."
There were thirty-six bottles. Dean's grasp of mental arithmetic was abysmal, but he was fairly certain that they'd be using every one. He grabbed another.
"Pushing the second sixty cc's now," Dr. Novak announced as he pushed the plunger of a syringe.
"Glucose," the charge anesthesiologist said in a sharp tone to the CRNA. "And bicarb. Has the lab come back with the ABGs yet?"
Dean focused all his attention on grabbing another bottle, injecting it with the water, shaking the bottle until all the powder had dissolved, and then drawing up every drop of the drug into the syringe before passing it off. In the strange, unreal flow of time under pressure, it seemed to take long minutes before the fluid in the bottle had fully dissolved the freeze-dried drug, and even longer to draw up all sixty cc's into the syringe. Behind him, Dr. Novak kept up a steady chant of how many cc's he had pushed into the patient's IV; at the edge of his focus he could hear other numbers and vital signs being reported in identical tones of forced calm, edged with adrenaline and fear.
Dean went to grab another bottle to find them all gone. Thrown forcefully out of his focused cycle, he looked blearily at the clock, and was astonished to see that hardly twenty minutes had passed. If he'd had to go by his aching, tense muscles, he'd have bet on at least an hour.
"Thirty-fifth syringe," Dr. Novak announced, his voice beginning to flag slightly. "How are numbers looking?"
"Still hyperkalemic," the anesthesiologist replied, "but coming down. Body temp is hovering around normal. I think we can move him to ICU."
Dr. Novak nodded, and Dean could see that the surgeon looked suddenly weary. "Last syringe at ten thirty-three." As soon as the syringe was emptied he tossed it to the ground. "Someone get me a stool."
Dean was moving before anyone else in the room seemed to hear his request. Dr. Novak sank onto the stool gratefully, reaching up to tear his mask from his face, hands shaking. With a heavy sigh of relief, he looked up at Dr. Cage. "Luc, it's your patient. Do me a favor and take over now."
"Right." Dr. Cage shook his head in astonishment. "They teach surgeons that much about MH in school now?"
"Hospital I was at had three or four MH drills a year," Dr. Novak replied. "Most people know what needs to be done, they just need someone telling them to do it."
"Still." Dr. Cage laid a hand on Dr. Novak's shoulder. "That was incredible. Thanks, Cas."
Dr. Novak dismissed the praise with a wave of his hand, but Dean could see the surgeon sitting up a little straighter. He caught Dean's eye and offered him a tired smile. "Hey, at least I can save one patient, right?"
III
The clock on the wall was not suspended in time today, though as Dean shifted in his seat and glanced at it he would be willing to swear that it was moving more slowly than conventional clocks.
"Is Dr. Novak going to be joining us?" The lawyer's gravelly voice was like old, scarred leather.
"We were busy at St. Luke's earlier," Dean answered absently. "Give him a few minutes to get down here."
The lawyer sighed and checked his watch in an exaggerated gesture before leaning back in his seat. Dean busied himself with looking out the window at the cloudy late October sky, letting Ellen and Bobby's conversation fade into soft edges of sound.
The door opened and Dean had to stop himself from whipping his head around to watch Dr. Novak stride in. As Dean had suspected, he was once again wearing a suit – this one a dark charcoal grey against a crisp white shirt, the tie a shifting molten silver that caught the light. Dean briefly wondered how many suits the surgeon owned.
"Sorry," Dr. Novak said, slipping into an empty seat. "I had a patient."
"Not to worry," the lawyer said expansively. "Patients have to come first."
Dr. Novak peered at the lawyer, brows knitting. "I was under the impression that this meeting would be with Infection Control."
"Victor's ill," the lawyer replied shortly. "And despite the uplifting results of his investigation, the family is suing anyway. Good afternoon, gentlemen and lady. As most of you already know, the name is Fergus Crowley, from Legal. I'll be present at any further gatherings surrounding this incident."
"Goody," Dean murmured under his breath. Crowley shot him a pointed look before continuing.
"I'm advising the surgery center not to settle," he said bluntly, opening a folder in front of him. "Which means each of you are likely to be asked to appear in court for testimony, reiterating what you said during the investigation."
"I'm sorry," Dr. Novak interrupted, "but why aren't we settling? The patient died."
"Because," Crowley said slowly, "I can get the case dismissed on the grounds of contributory negligence. Nobody owes anyone any money, nobody's license gets tarnished." He pulled a sheaf of paper from the folder and began passing it around. "The results of the investigation. The hospital is responsible for nothing. Your patient died of stupidity, Dr. Novak."
"Excuse me?" the surgeon asked, the edge of his voice sharp.
"You'll see on page seven," Crowley said, flipping his own packet open, "that she visited the Urgent Care facility two weeks before her death, complaining of pain and fever at the groin incision. Only at the groin incision." He looked up pointedly. "From your testimony, the instrument in question was dropped afteryou had finished with the groin incision, and that the incision was in fact closed and dressed before the instrument returned to the field. Am I correct?"
"Yes," Dean said.
"The Urgent Care nurse prescribed her antibiotics and instructed her to make an appointment to return to you, Dr. Novak." Crowley smiled thinly. "Much like her appointment with you was never scheduled, she never picked up her antibiotics from the pharmacy."
"Why?" Dr. Novak asked.
"That much wasn't a part of the investigation," Crowley replied mildly. "You may also be interested to know that of all the instructions on the post-operative wound care sheet she received, she acted counter to every single one." He held up a hand and began raising fingers as he droned off a list. "She removed her dressings that evening to take a bath. She did not replace them. She bathed daily, in hot water, with the wound exposed. She did not spend a few days off her feet, and in fact continued to go on her daily walks."
"That makes no sense," Dr. Novak interrupted. "I went over everything with her and with her granddaughter after the procedure."
Crowley blinked. "And her granddaughter?" he asked sharply.
"Yes," Dr. Novak responded, still puzzled. "Mrs. Wilson was slightly senile. Her granddaughter was her unofficial caregiver. She said that she was living with her grandmother until she could find an assisted living facility she approved of."
"I see," Crowley said slowly. He returned his eyes to the paper before him. "At any rate. The investigation shows very clearly that the hospital holds no liability for the severity of the infection. Nevertheless, Miss Ava Wilson, as I mentioned earlier, is still intending to sue for misfeasance."
With a jolt that made Dean catch his breath, a small thought took root in his mind. "The granddaughter is the only family?"
"Miss Wilson is the only surviving family member, yes," Crowley replied.
Dean licked his lips. "Mr. Crowley. Who exactly is going to benefit from this lawsuit, if we were to lose?"
The look that Crowley directed at Dean was one of puzzled arrogance. "Miss Wilson, of course."
Dr. Novak cleared his throat, his eyes thoroughly troubled. "As I recall," he said slowly, "Ava is a medical assistant. She ought to know better about the care of surgical wounds. And she would also be the one to pick up anything from the pharmacy for her grandmother, who doesn't drive."
Crowley's face was studiously blank. "Dr. Novak," he said slowly, "I believe I understand what you are driving at."
"Good," Dr. Novak said bluntly. "Because there's no way I'm going to come out and say it."
Clearing his throat, Crowley was the very image of restraint and aplomb, spoiled only by the eagerness behind his eyes. "I believe we are finished here," he said, nodding to Bobby and Ellen. "Unless you have anything to add."
Mutely, they shook their heads.
Crowley nodded. "Dr. Novak," he said softly as Bobby and Ellen rose from their chairs, "are you prepared for the police to become involved?"
IV
The tap on his shoulder nearly made Dean jump as he spun, fingers still buttoning the front of his shirt. A strange lurch in his chest made him swallow as he met Dr. Novak's eyes.
"I'm buying this time," Dr. Novak said in a strained voice.
Dean glanced around the locker room to ensure it was empty. "Drinks?" he clarified with mild disbelief.
Dr. Novak nodded. "The MH crisis earlier today, we may have just uncovered a murder charge. And we could be implicated." He raked a hand through his hair, mussing it slightly. "If you need a drink half as much as I do, we won't even bother pouring it into glasses first."