Like a sea of red ink the blood pooled in the open abdomen. The suction eerily quiet. Not the quiet of a foot stepping on the line, no, this was the deafening silence of tubing so full of blood that there is no room for air to bubble through and resonate.

Thirty minutes earlier there was no hole in the cava, the iPod surfed at Pandora’s whim, and the suction sang along with a reassuringly constant gurgle—a noise, much like the beep of the pulse-oximeter, that fades into the background and is hardly noticed until it is, suddenly, gone.

The liver mass was benign in that its telemeres were of an appropriate length, its mitoses well controlled and ordered. But the right upper quadrant ache it caused was malignant, in that it hurt, a lot.

And so the plan was to remove it. Small incisions, a laparoscope, an ERAS pathway, an early discharge.

Until the long forceps, snaked through the number five port, pulled up on the tissue to improve the camera’s view. The tissue, compliant, came away, but, adherent, it brought with it a surprisingly large portion of caval wall.

Tom was a CA-1 and still thrilled by every detail of the anesthetic.

But now the details blurred. The green beats slowed and widened; the red waves shrunk into a line; the white upstrokes failed to rise. What had been three vibrant, dancing fonts now fell away like the last line from a pen in the hand of a sleeping student.

Shouting from surgeons, screeching alarms, the voice of the nurse calling desperately overhead for Tom’s attending, and drowning it all the silence of the suction.

It was not supposed to happen this way. He had met the man’s family, his wife and two small daughters. He had, with the pride of a still new doctor, reassured them that their husband and father would be fine. Tom believed it was true, but also had a personal stake in maintaining positive thinking. His wife was waiting for biopsy results to come back from a lump she’d found.

Ellen, the patient’s older daughter, outgoing at age five, had shown him how to play the puzzle game on her iPad. Lauren, Ellen’s three-year-old sister, made sure that Tom understood that she is three and a half.

Tom stopped the gurney for his patient and family to kiss, “I’ll bring him back to you in just a few hours, good as new.”

He winked at Ellen. She smiled—a pact sealed, an inviolate oath.

A benign beginning to the case. And then the tear, the blood, the blue skin and the flat lines. The shouting, alarms, the silent suction.

Then, in the time between time, Tom saw the green, red and white lines spill from the monitor to the floor. From there they leapt forward, in parallel, train tracks stretching on and on out of time.

He saw, as if from above, the operating room shrink down to become a train car, one of many sliding inexorably along the tracks. Behind—other cars, the scene from earlier in preop, other pieces of the past bound to the car of the now. Ahead—swirling partial images, half-formed: his patient, a coffin, tears and a rosary.

And then, suddenly, a parallel set of tracks swept in from far off carrying another train and, for a moment, the two trains ran next to one another. Two possibilities, two realities, two versions of a world. So similar and yet different in small, stunning ways.

Tom stared with a desperation fueled by a promise made to two little girls who wouldn’t understand why instead of daddy there were strange men in white coats with excuses.

In that instant he knew, somehow, that he could choose, could change realities, could put them all—his patient, the surgeons, himself—on a different path. The opportunity would only last for the briefest moment. No hesitation. He wrenched sideways with every fiber of his being and felt the entire train jolt, screech, and hop, the tracks exchanged.

Gasping, he watched the tracks he had been on, the abandoned train, diverge and speed away, out of sight, out of possibility.

He was back inside the operating room. But in this alternate reality the green, red and white lines were now back on the monitor, flat no longer. There was no blood. The abdomen was closed except for small laparoscopy ports. The room quiet except for Pandora’s chorus and the background white noise of the suction tubing filled with nothing but air. He felt a rush of exuberance. He had done it. He had, amazingly, changed realities and saved his patient. He wondered briefly if anything else would be different in this alternate world.

Tom saw his patient in the PACU before going home. The patient smiled, pain well controlled, wife and children grateful. Ellen looked up at him from the puzzle game she was playing on her Kindle Fire, wide eyes unblinking, “Thank you for taking care of my daddy.”

The pact complete, the oath upheld.

That night Tom’s wife’s biopsy results came back, a day earlier than expected. Too many mitoses, the telomeres too short, the nodes too involved. Tears, fear, sadness, anger.

And the aching memory of his instinctive choice to jump tracks when he could, to enter an alternative reality to save his patient without knowing what it would mean for his own life. It was a memory drowning in questions. What would the biopsy results have been on the other set of tracks? Could he choose to go back?

And the question that would haunt him, now and always, if he could choose—between a train wreck for his patient, for the little girls, and a derailment for his wife, for his own life—what would he do? What choice would he make, and at what cost?