Tess Gerritsen: The Surgeon

A nurse called out: “I’m barely getting the systolic at fifty!”

Time sprang ahead at a frightening pace.

“Get me a gown and gloves,” said Catherine. “Open the laparotomy tray.”

“What about taking him to the O.R.?” said Littman.

“All rooms are in use. We can’t wait.” Someone tossed her a paper cap. Swiftly she tucked in her shoulder-length red hair and tied on a mask. A scrub nurse was already holding out a sterile surgical gown. Catherine slipped her arms into the sleeves and thrust her hands into gloves. She had no time to scrub, no time to hesitate. She was in charge, and John Doe was crashing on her.

Sterile drapes were whisked onto the patient’s chest and pelvis. She grabbed hemostats from the tray and swiftly clamped the drapes in place, squeezing the steel teeth with a satisfying snap,snap .

“Where’s that blood?” she called out.

“I’m checking with the lab now,” said a nurse.

“Ron, you’re first assist,” Catherine said to Littman. She glanced around the room and focused on a pasty-faced young man standing by the door. His nametag read: Jeremy Barrows, Medical Student . “You,” she said. “You’re second assist!”

Panic flashed in the young man’s eyes. “But — I’m only in my second year. I’m just here to—”

“Can we get another surgical resident in here?”

Littman shook his head. “Everyone’s spread thin. They’ve got a head injury in Trauma One and a code down the hall.”

“Okay.” She looked back at the student. “Barrows, you’re it. Nurse, get him a gown and gloves.”

“What do I have to do? Because I don’t really know—”

“Look, you want to be a doctor? Then glove up !”

He flushed bright red and turned to don a gown. The boy was scared, but in many ways Catherine preferred an anxious student like Barrows to an arrogant one. She’d seen too many patients killed by a doctor’s overconfidence.

A voice crackled on the intercom: “Hello, Trauma Two? This is the lab. I have a hematocrit on John Doe. It’s fifteen.”

He’s bleeding out, thought Catherine. “We need that O neg now!”

“It’s on its way.”

Catherine reached for a scalpel. The weight of the handle, the contour of steel, felt comfortable in her grasp. It was an extension of her own hand, her own flesh. She took a quick breath, inhaling the scent of alcohol and glove talc. Then she pressed the blade to the skin and made her incision, straight down the center of the abdomen.

The scalpel sketched a bright bloody line on the canvas of white skin.

“Get the suction and laparotomy pads ready,” she said. “We’ve got a belly full of blood.”

“BP’s barely palpable at fifty.”

“O neg and fresh frozen plasma’s here! I’m hanging it now.”

“Someone keep an eye on the rhythm. Let me know what it’s doing,” said Catherine.

“Sinus tach. Rate’s up to one-fifty.”

She sliced through the skin and subcutaneous fat, ignoring the bleeding from the abdominal wall. She wasted no time with minor bleeders; the most serious hemorrhage was inside the abdomen, and it had to be stopped. A ruptured spleen or liver was the most likely source.

The peritoneal membrane bulged out, tight with blood.

“It’s about to get messy,” she warned, her blade poised to penetrate. Though she was braced for the gush, that first piercing of the membrane released such an explosive spout she felt a flash of panic. Blood spilled onto the drapes and streamed to the floor. It splattered her gown, its warmth like that of a copper-scented bath soaking through her sleeves. And still it continued to flow out in a satiny river.

She thrust in retractors, widening the wound’s gap and exposing the field. Littman inserted the suction catheter. Blood gurgled into the tubing. A stream of bright red splashed into the glass reservoir.

“More laparotomy pads!” Catherine yelled over the scream of suction. She had stuffed half a dozen of the absorptive pads into the wound and watched as they magically turned red. Within seconds they were saturated. She pulled them out and inserted fresh ones, packing them into all four quadrants.

A nurse said, “I’m seeing PVC’s on the monitor!”

“Shit, I’ve already sucked two liters into the reservoir,” said Littman.

Catherine glanced up and saw that bags of O neg blood and fresh frozen plasma were rapidly dripping into the IV’s. It was like pouring blood into a sieve. In through the veins, out through the wound. They could not keep up. She could not clamp vessels that were submerged in a lake of blood; she could not operate blind.

She pulled out the lap pads, heavy and dripping, and stuffed in more. For a few precious seconds she made out the landmarks. The blood was oozing from the liver, but there was no obvious point of injury. It seemed to be leaking from the entire surface of the organ.

“I’m losing his pressure!” a nurse called out.

“Clamp!” said Catherine, and the instrument was instantly slapped in her hand. “I’m going to try a Pringle maneuver. Barrows, pack in more pads!”

Startled into action, the medical student reached toward the tray and knocked over the stack of laparotomy pads. He watched in horror as they tumbled off.

A nurse ripped open a fresh packet. “They go in the patient, not on the floor,” she snapped. And her gaze met Catherine’s, the same thought mirrored in both women’s eyes.

That one’s going to be a doctor?

“Where do I put them?” Barrows asked.

“Just clear the field. I can’t see with all the blood!”

She gave him a few seconds to sponge the wound; then she reached in and tore apart the lesser omentum. Guiding the clamp from the left side, she identified the hepatic pedicle, through which the liver’s artery and portal vein coursed. It was only a temporary solution, but if she could cut off the blood flow at that point, she might control the hemorrhage. It would buy them precious time to stabilize the pressure, to pump more blood and plasma into his circulation.

She squeezed the clamp shut, closing off the vessels in the pedicle.

To her dismay, the blood continued to ooze out, unabated.

“Are you sure you got the pedicle?” said Littman.

“I know I got it. And I know it’s not coming from the retroperitoneum.”

“Maybe the hepatic vein?”

She grabbed two lap pads from the tray. This next maneuver was a last resort. Placing the lap pads on the liver’s surface, she squeezed the organ between her gloved hands.

“What’s she doing?” asked Barrows.

“Hepatic compression,” said Littman. “Sometimes it can close off the edges of hidden lacerations. Hold off exsanguination.”

Every muscle in her shoulders and arms went taut as she strained to maintain the pressure, to squeeze back the flood.

“It’s still pooling,” said Littman. “This isn’t working.”

She stared into the wound and saw the steady reaccumulation of blood. Where the hell is he bleeding from? she thought. And suddenly noticed there was blood oozing steadily from other sites as well. Not just the liver, but also the abdominal wall, the mesentery. The incised edges of skin.

She glanced at the patient’s left arm, which poked out from beneath the sterile drapes. The gauze dressing over the IV site was soaked with blood.

“I want six units of platelets and fresh frozen plasma STAT,” she ordered. “And start a heparin infusion. Ten thousand units IV bolus, then a thousand units an hour.”

“Heparin?” said Barrows in bewilderment. “But he’s bleeding out—”

“This is DIC,” said Catherine. “He needs anticoagulation.”

Littman was staring at her. “We don’t have the labs yet. How do you know it’s DIC?”