Shane is halfway through adjusting the IV drip when the patient's fingers suddenly twitch, not the normal post-anesthetic tremors, but something jerky and wrong.

"Dr. Ahlstrom?" Kimberly, your scrub nurse's voice pitches higher as the monitors start their shrill protest, the oxygen saturation numbers plummeting while the endotracheal tube remains stubbornly in place.

Outside the OR window, Medford's usual drizzle blurs the parking lot lights into smears of yellow, but right now, the only thing out of focus is why a routine gallbladder surgery that just turned into a code blue.

"Check the tube placement again!" Shane barks, glove snapping against the laryngoscope handle as he repositions the patient's head. The tube's still seated, but the waveform's gone flat.

"Bronchospasm or laryngospasm?" Kimberly is already reaching for the emergency drugs, her wrist trembling slightly as she preps the epinephrine.

Shane's fingers press against the patient's rigid neck. No air movement. "Laryngospasm. Suction, now." The sound of mucus rattling in the tube confirms it. The patient's jaw locks tighter, cords standing out in their neck like guitar strings.

Kimberly slaps the suction catheter into his palm, her voice steadying as she counts out loud, "Ninety seconds since last breath."

Shane works fast. Clear the airway, reposition, but the vocal cords remain clamped shut. The heart monitor stutters into bradycardia.

"Push point-two epi, IV push, now." His own pulse thrums in his ears as Kimberly obeys. The syringe plunger depresses, medication vanishing into the IV line.

The monitors scream on: flatlined. Shane's hands move before his brain processes it, thumb finding the xiphoid process, fingers interlacing for compressions.

"Starting CPR. Kimberly, call for backup." The first compression cracks cartilage. Thirty down. Two breaths via ambu-bag. The patient's chest doesn't rise.

"Tube's obstructed," Shane mutters, ripping the ET tube free. He grabs a fresh laryngoscope, fingers slick with sweat. The glottis is a tight white slit. "It's still locked. Give me point-five succinylcholine."

Kimberly hesitates, realizing the possible consequences. "That'll paralyze him completely..."

"We're losing him!" Shane snarls, watching the heart line tremble into asystole. He tears the vial from her hand himself and spikes it into the IV port.

The drug hits the bloodstream like a chemical sledgehammer. The patient's rigid throat muscles finally slacken beneath his fingers.

"Tube's in," Shane gasps as the fresh ET tube slides past the now-flaccid cords. Kimberly squeezes the ambu-bag twice.

The chest rises this time. The monitor beeps once, twice, then resumes its jagged rhythm as sinus rhythm flickers back to life.

"Pulse is back," Kimberly exhales, her shoulders sagging as she checks the carotid. "But his sats are still in the toilet." She adjusts the oxygen flowmeter with a click.

Shane wipes his forehead with the back of his sleeve, leaving a streak of sweat across the fabric.

"Get an ABG. I want to know if we're dealing with hypoxia-induced acidosis too." The metallic scent of blood and antiseptic hangs thick in the air.

Kimberly nods, already drawing the syringe. "What could've triggered this? No history of reactive airways..." Her gloved hand presses gauze against the puncture site.

Shane's eyes flick to the anesthesia machine, checking the vaporizer settings. "Could've been secretions irritating the cords, or maybe the propofol dose was light."

He adjusts the ventilator's FiO2 up to 100%, watching the pulse ox climb to 88% with agonizing slowness.

Kimberly hands him the arterial blood gas syringe, its contents dark as venous blood. "PaO2's 48. Base deficit of nine. This isn't just hypoxia, he's in metabolic freefall." The ABG analyzer spits out numbers that make Shane's gut tighten.

"Switch to sodium bicarb drip," Shane orders, peeling back the patient's eyelid. The pupil reacts sluggishly.

"And get neurology on standby." The ventilator cycles with a hiss, its bellows lifting in perfect rhythm, mocking the chaos beneath.

Kimberly's fingers dance across the phone keypad, but she pauses mid-dial. "BP's dropping again... 80 over 40." The cuff reinflates with a mechanical wheeze.

"Push another epi bolus," Shane snaps, his own adrenaline making the words come out sharper than intended.

He watches the arterial line waveform: a weak, thready scribble where there should be clean peaks. The bicarb bag gurgles as it empties into the IV.

"Vasopressor drip next," Shane mutters, hands flying to adjust the norepinephrine infusion rate. His fingers still slick with sweat slip on the dial but he catches himself before overshooting the dose.

Kimberly's eyes dart between monitors and meds, her voice dropping to a whisper as she preps the next syringe. "This isn't just laryngospasm anymore. Something else is wrong..."

Kimberly adjusts the norepinephrine drip, her fingers tightening around the IV line. "His lactate was six on the last gas. Feels like we're chasing our tails." The monitor alarms again. ST-segment elevation creeping across the EKG like poison ivy.

Shane grabs the ultrasound probe, gel smearing across the patient's chest. The screen flickers to life. Right ventricle dilated, septum bowing. "Pulmonary embolism!" The words taste like copper in his mouth.

Kimberly's breath catches. "No thrombolytics with recent surgery..."

"Call IR," Shane barks, scanning the ultrasound again. The clot's massive... right heart strain worsening with each compression. "We need thrombectomy now." The patient's lips tinge blue despite 100% FiO2.

Kimberly's already on the phone, barking coordinates to Interventional Radiology upstairs. "ETA seven minutes," she reports, slamming the receiver down. "BP's 70s systolic..."

Shane's hands tighten around the ultrasound probe. The right ventricle quivers like overstretched taffy. "We don't have seven minutes."

He rips open the crash cart's bottom drawer, fingers closing around a bag of alteplase. "Forget protocol. Push twenty milligrams thrombolytic IV push. Now!"

Kimberly's eyes widen. "Shane..."

"Do it!" Shane snatches the syringe, spikes the vial, and draws up the dose himself. The amber liquid swirls as he hands it to her. "Push slow. Watch for reperfusion arrhythmias."

Kimberly's fingers tremble as she depresses the plunger, the thrombolytic vanishing into the IV line. The EKG stutters. Ventricular tachycardia flickering to life. Shane reaches for the defibrillator pads. "Charging to 200. Clear!"

The shock jolts the patient's body off the table. The monitor flatlines for three agonizing seconds before a weak pulse reappears.

Shane's gaze darts to the ultrasound screen. Right ventricle contracting weakly now, but contracting. "Clot's breaking up. Get me another ABG."

Kimberly draws blood swiftly, her voice tight. "If he hemorrhages from the surgical site..."

"Pressure bandage the abdomen," Shane interrupts, watching the ultrasound screen as the right ventricle's motion improves fractionally.

"Get two units of FFP ready." The ABG analyzer whirrs, spitting out fresh numbers. PaO2 climbing to 62, lactate down to 4.8. Not good, but better.

Kimberly presses fresh gauze against the surgical incision, her knuckles white. "BP’s stabilizing, it's 90 systolic now. IR team’s two minutes out."

Shane doesn’t take his eyes off the ultrasound. The right ventricle’s motion is sluggish, but the septum no longer bows. "Keep the norepinephrine drip running. And get me a central line kit. We’re drowning him in fluids." His voice is hoarse, adrenaline ebbing into exhaustion.

Kimberly tears open the sterile pack, her gloves snapping against her wrists. "You think he threw the clot from dehydration?" She threads the guidewire with practiced ease, even as her shoulders tense. "His pre-op labs were clean."

Shane palpates the jugular, his fingers finding the pulse beneath clammy skin. "Could've been the positioning during surgery. Or maybe he's got some undiagnosed hypercoagulable disorder."

The needle slides in, dark blood swirling into the syringe. The ultrasound screen shows the wire curling perfectly into the SVC.

"Got it," Kimberly murmurs, threading the catheter over the wire. The monitor chirps: BP stabilizing at 95 systolic.

Shane presses a gloved thumb against the incision site as Kimberly secures the line. "Run another gas in ten. If his lactate keeps dropping..." The OR doors burst open.

"Interventional Radiology," announces a tall resident wheeling a portable angiogram machine. His eyes flick to the ultrasound screen. His eyes widen with recognition. "That's a right heart under siege."

Kimberly steps back, making room. "Clot's breaking up with thrombolytics, but we need definitive..."

The IR resident nods sharply, already prepping the groin for femoral access. "Got a pigtail catheter ready for mechanical thrombectomy. Status on bleeding risk?" His gloved hands move with urgent precision as he palpates the femoral pulse.

"Gallbladder bed might ooze," Shane warns, stepping back to give the team space. "We've got FFP hanging and pressure on the incision." The ventilator cycles with a hiss, the patient's oxygen saturation now hovering at 91%.

The IR resident nods, inserting the guidewire smoothly. "We'll go gentle on the heparin flush." The screen flickers to life, revealing fragmented clot strands swirling in the pulmonary arteries like ghostly seaweed.

"Dang, this is ugly, but at least it's moving." His fingers twist the catheter controls, deploying the mechanical thrombectomy device with a soft click.

Kimberly leans in, watching the screen as fragmented clots get sucked into the catheter. "That's more like it." The pulse oximeter chirps: 94% now.

Shane exhales sharply, rolling his stiff shoulders. "Pressure holding?" His voice rasps from the adrenaline crash.

Kimberly checks the surgical dressing. "No fresh bleeding. His urine output's picking up too. Looks like our patient is stabilizing nicely."

The IR resident grunts as he maneuvers the catheter deeper into the pulmonary artery. "Got another big fragment here... almost... there."

The screen flashes as the clot vanishes into the device. "That's the last of the major occlusions. Circulation should improve now."

He glances at the EKG, where the ST segments are slowly returning to baseline.

Kimberly wipes her forehead with the back of her sleeve. "Should we wake him? Or keep him sedated for now?"

Shane shakes his head, watching the patient's pupils contract under his penlight. "Not yet. With that much thrombolytic on board, we need to watch for delayed hemorrhage."

The ventilator cycles again, its rhythmic hiss now reassuring rather than ominous. Kimberly nods, adjusting the norepinephrine drip down slightly as the BP stabilizes at 100 systolic.

"We should run a thrombophilia panel," she murmurs, glancing at the IR resident. "You see many clots like this in otherwise healthy patients?"

The resident peels off his gloves with a snap. "Not unless they’ve been sitting on a transatlantic flight." He nods toward the lab slips. "Run a D-dimer too. That might tell us if there’s more lurking."

Shane rubs his temples, the fluorescent lights suddenly too bright. "Kimberly, can you..." His pager blares before he finishes, the display flashing ICU STAT.

Kimberly grabs it before he can move. "I've got this. You're shaking like a leaf." She turns to the IR resident. "Keep his heparin drip at 300 units per hour. And watch his abdominal dressing, last thing we need is a delayed bleed."

The ICU call turns out to be another crashing patient. Septic shock from a perforated ulcer. Shane's hands steady as he gloves up again, the familiar crisis rhythm overriding his exhaustion.

"Page hematology for a hypercoag workup on our PE," he throws over his shoulder at Kimberly. "And check his protein C levels."

THE END