SPARTANBURG, S.C. — Nick Dixon’s knee surgery was scheduled to be over by lunchtime, but the 18-year-old couldn’t wait to share the good news with his mother. A standout football player with multiple Division II college scholarship offers, Dixon had quietly committed to play at Wingate University the previous night.

“Okay, we’ll talk about it later,” Terri Littlejohn told her son on the way to Ambulatory Surgery Center of Spartanburg on Jan. 11. He had torn the meniscus and ACL in his left knee less than a month earlier, and Dixon was eager to get the outpatient procedure over with as soon as possible. The recovery can take up to nine months, and with Dixon’s college decision made, he didn’t want to be sidelined for the upcoming season.

At around 7 a.m., Littlejohn prayed with Dixon for a successful surgery.

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“I kissed him on the forehead and said, ‘I love you, and I’ll see you when you come out,’ ” she recalled recently.

Between 8:15 and 8:30 a.m., within 45 minutes of Dixon entering the operating room, he started to exhibit symptoms of malignant hyperthermia, a condition passed down through families that triggers a fast rise in body temperature and severe muscle contractions in response to certain drugs used as part of general anesthesia.

At 11:19 a.m., around the time Dixon’s surgery was originally scheduled to end, he was moved to Spartanburg Medical Center. Littlejohn was ushered from the waiting room to see him, still unaware that anything had gone wrong. At that point, he was in cardiac arrest.

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“The last thing I remember is I reached out to him,” Littlejohn said. “Something just came over me. I think I knew then that my baby was gone. They said I passed out.”

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Dixon was pronounced dead four hours later. He would have been on Wingate’s campus by now, practicing with his new teammates in preparation for the season opener against Johnson C. Smith on Sept. 5. Instead, his family is left replaying the events of Jan. 11 in painstaking detail and asking how one of the most common sports surgeries — there are about 100,000 ACL reconstructions a year in the United States — turned tragic.

Death during an ACL reconstruction is so rare that Timothy Hewett, former director of the Orthopedic Biomechanics Laboratory at the Mayo Clinic, said such instances aren’t even tracked. “There are probably less than a handful of cases … ever,” he said in a text message.

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Dixon’s family knew him as a homebody, occasionally suckering Littlejohn into letting him stay home from school on the days she had off from work so they could clean the car together and shop for groceries. He was the family “clown,” Littlejohn said, and even as he was being prepped for his knee surgery that Friday morning, Dixon was making his mother laugh in the waiting room with texts about having to get his leg shaved. He loved playing video games and texting his longtime girlfriend at all hours of the night. The couple had planned to attend Wingate together.

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Littlejohn said she has always hated football — even the Super Bowl — but she asked for every Friday night off this past year so she could go to Dixon’s games. That’s how she realized how good her boy really was, reveling in hearing others in the stands yell for the coach to put him in at linebacker or defensive end or running back. At 6 feet and 245 pounds, Dixon was appreciatively called “Big Nick” or “Beast” or “Freight Train.”

“I’d be like, ‘Yeah, Freight Train is mine,’ ” Littlejohn said.

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Littlejohn urged her son against playing basketball because she worried he would get injured, but he suffered the knee injury in the second half of South Carolina’s premier high school football all-star game, the Shrine Bowl. During practices that week, Dixon’s stepfather, Tim Littlejohn, remarked about the players Dixon would be going up against, “Those are some big jokers.” Dixon agreed, adding: “I’ll hit them, though. I ain’t scared of them.”

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“No, you ain't ever been scared of nothing,” Tim responded.

Tim had rearranged his work schedule Jan. 11 to be home by noon so he could help tend to Dixon after his surgery. He instead met Terri at Spartanburg Medical Center, where a large contingent from Spartanburg High also had gathered. A basketball game for that night was canceled at the news of Dixon’s death.

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The Littlejohns, claiming medical negligence, filed a wrongful death lawsuit against the attending nurse anesthetist and anesthesiologist, in addition to the medical group they both work for, Anesthesiology Consultants of the Upstate, and the Ambulatory Surgery Center of Spartanburg. Representation for each party declined to comment because it’s an active matter.

According to an affidavit provided by Dixon family attorney Blake Smith, Robert Sikorski, the medical director of trauma anesthesiology at the Johns Hopkins University School of Medicine, reviewed Dixon’s medical records and determined that “to a reasonable degree of certainty, Nicholas Dixon died as a direct result of gross negligent care.”

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Malignant hyperthermia occurs in one in 5,000 to 50,000 instances in which people are given anesthetic gases. It’s hard to know exactly how common it is because many people with an increased risk of the condition are never exposed to the drugs that trigger a reaction. Treatment involves Dantrolene, medication that remedies the extreme muscle tightness and cramping associated with malignant hyperthermia. Sikorski stated in his affidavit that the physicians were delayed in recognizing Dixon’s malignant hyperthermia and subsequently failed “to rapidly administer” Dantrolene as well as repeat it “in an ongoing manner” and “to administer the proper repeat dosage” according to the malignant hyperthermia protocol.

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“We just hope this raises awareness because we don’t want this to happen to anyone else,” Terri said.

Dixon was buried in his white Spartanburg High football jersey, and his jersey number, 7, has been retired by the Vikings. He had worn No. 38 his first three years on the team, and though Tim and Terri tried to talk him out of switching — college recruiters already knew him as No. 38, they argued — Dixon insisted. It represented the seven children of the household, and it was supposed to be lucky.

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“A lot of stuff we found out afterward,” Terri said. “We didn’t know that he was reading Bible scriptures with friends, and a lot of his friends have sent me text messages where he was motivating them — younger kids and his teammates. They were like brothers, and it’s like Nick was, I guess, the leader. … I didn’t know he was doing that stuff.”

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The family visited Dixon’s grave on Valentine’s Day, and Terri purchased a red heart balloon for each person to hold at the cemetery. She double-checked that she brought all of them with her, so she was surprised when one was mysteriously floating in her bedroom later that day. It’s still there and hasn’t gone flat yet, and every time it bobs from one end of the room to another, the Littlejohns see it as Dixon’s way of communicating with them. Timothy said he often talks to it when he’s getting ready for work in the morning.

Dixon shared a bedroom with 11-year-old brother Shane, and in the month after Dixon’s death, Shane couldn’t sleep in there. He eventually asked Terri to cover one wall with photos of Dixon so it would feel like he was looking over Shane. He wants to play football, too, at the same positions as Dixon.

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“I’m scared for him to play, but I know he loves it,” Terri said. “I won’t miss a game, and I’ll be there for him. And I just pray. We’re going to get Shane some kneepads and some cushion and some extra armor to keep them knees and stuff together.

“You’re nervous and you think about it, but you got to let him live.”

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