Top-Notch Men!. Anne Fraser
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it! I wish I’d never become involved in this case,’ Harry grumbled. ‘I could see it was trouble as soon as we opened.’
‘Use the theatre here,’ Joel suggested. ‘It’s on site, it’s staffed and it’s got angiography capability. Why don’t you talk to Radiology now so they come in and set up in case you want to do on-table embolisation?’ He turned as he saw Allegra, his expression visibly hardening. ‘I thought Tony called for the anaesthetist on duty.’
‘I’m the one he called, but if you’d prefer someone else, fine—go ahead,’ she said with a flash of her green eyes.
He shifted his mouth in what was clearly reluctant resignation and turned back to Harry. ‘Dr Tallis can anaesthetise for you. I’ve got to get a new central line in quickly to catch up with volume.’
‘Right.’ Harry nodded in agreement and with a quick grimace in Allegra’s direction headed towards Radiology and the ICTU theatre.
Once Harry had left, Joel turned to fill Allegra in on the patient’s condition. ‘Mrs Donovan’s MAP’s 50, pulse 160, sats 80—not good. I’ve got a norad infusion up and fresh blood pouring in, but she needs surgical control of the bleeding. I’m replacing your central line from this morning—it seems to be kinked or compressed somewhere and I just can’t get enough volume through it. Harry’s using the theatre here.’
Allegra had to force aside her personal issues with him to maintain professional calm. ‘I’ll head down now and set up. Will you bring her down?’
‘Yes, in about ten minutes. How much blood altogether did she have in Theatre this morning? I haven’t had time to familiarise myself with the anaesthetic charts here—it would take me ten minutes to add it all up.’
‘Yes, they are confusing. Fifteen units of packed cells and four units of whole blood. She also had four packs of albumin volume expander and three fresh-frozen plasmas. How many have you crossed-matched now?’
‘Twenty packed cells—that’s the current hospital supply of B at the moment. Red Cross are bleeding call-ins tonight to replenish supplies,’ he answered.
‘Good. I’d better get going,’ Allegra said, and left the unit.
Joel turned back to the patient, his brow tightening with tension as he called on all his intensive care skills to work to salvage the rapidly developing disaster in front of him.
Gaile Donovan had two young teenage daughters and a loving husband waiting anxiously in the waiting room for news of their loved one’s condition. Gaile’s cancer diagnosis had been bad enough, but to suffer this complication during surgery added an element of potential tragedy that would be very hard to announce to the family if things didn’t go well.
With the help of Danielle and the nursing staff, he replaced Allegra’s previously inserted central line over a guide-wire and ensured it was running rapidly.
‘Danielle, increase the noradrenaline infusion to three now, please, to help maintain blood pressure. I’m starting a vasopressin infusion to reduce venous pressure in the pelvis,’ Joel instructed.
‘Dr Addison, she’s bleeding from every puncture site,’ Danielle observed with growing alarm.
Despite massive transfusion, it was clear to Joel that coagulopathy was developing, and his inner tension went up another notch. Gaile’s young daughters’ faces swam before his eyes and his stomach clenched uncomfortably at the thought of having to face them with the worst news in the world.
‘Unless we get this blood loss stopped now, no amount of intensive care is going to help her,’ he said. Turning to the nurse at his side, he instructed, ‘Get me four packs of FFP and I’ll call the blood bank myself to retrieve ten packs of platelets.’
The ICTU nurse left to retrieve the packs of fresh-frozen plasma, which were stored in the ICTU blood fridge, as Joel reached for the nearest telephone.
A few minutes later a courier came in with the thawed platelets and Joel stabilised the patient to the point where she could be transferred to the operating theatre for a further attempt at pelvic packing and possible embolisation.
In Theatre, Allegra had set up the anesthetic machine, arterial line and monitoring equipment, and Harry and the scrub team were already scrubbed and waiting.
‘She’s extremely unstable, Dr Tallis—I’m just keeping up with fluids and she’s coagulopathic. She’s on norad at three and a vasopressin infusion. I’ve got FFP and platelets running and we’re onto unit ten of fresh B blood, with ten left to go. Blood bank is scouring for more,’ Joel said as the patient was transferred to the operating table.
Allegra gave him a worried look. ‘I’ve really got my hands full here. Once we open up, her BP is going to hit the floor again.’
‘I know that. I’ll stay here and help with fluid and coag management while you manage the anesthesia,’ he offered.
‘That’s a first,’ Harry said, as the scrub nurse handed him scissors to open the previous incision. ‘You don’t often see an intensivist in Theatre.’
‘That’s the whole point of this new unit,’ Joel said, as he assisted Allegra to attach the arterial line and monitor. ‘Overlap of skills to break down the rigid barriers between specialties.’
While Allegra concentrated on anesthesia, Joel juggled fluid input, coagulation factors, consultation with the haematologists and blood bank, and provided general support to Allegra during the procedure. After rapid prepping and draping of the abdomen, Harry opened the previous incision to be greeted by welling up of venous blood from the pelvis.
‘Her blood pressure’s 60, Dr Addison,’ Allegra said with concern, as she pumped in blood through two lines.
‘Harry, we’re not winning up this end. Can you control anything down there?’ Joel asked over the drapes.
‘I’m doing my best, guys, but there’s no one bleeding point,’ Harry rasped back, beads of sweat appearing on his brow above his mask.
Harry rapidly removed the old packs and repacked the pelvis, this time using multiple thumbtack-shaped staples to pin down every obvious bleeding vein to the pelvic walls before compressing with packs. In addition he ligated both internal iliac arteries. Although a drastic step, the bleeding finally slowed then stopped with repacking the pelvis.
‘I can see clotting. You must have improved her coag profile significantly,’ Harry said with obvious relief in his eyes as they connected briefly with Joel and Allegra’s.
‘She’s just about used up the entire supply of platelets and FFP. I think she’ll run into ARDS after all of this,’ Joel said.
‘Her ventilation pressures are up, she’s got pulmonary oedema—she’s already in respiratory distress. I appreciate your help in Theatre, Dr Addison, but I’ll be fine in here now. I’m sure you’ve got other concerns in the unit apart from this one patient,’ Allegra said with brisk formality.
Joel gave her an indecipherable look before shifting his gaze towards the surgeon. ‘See you later, Harry. Good luck with the rest of the procedure.’
‘Yeah, thanks, Joel. I think I like this cross-over idea, ICU, anaesthesia and Theatre all in one for this sort of case. I just hope this poor lady makes it. She’s put up one hell of a fight so far.’
‘It’s not over till it’s over,’ Joel said as he shed his theatre overgear and dropped it into the bins as he went. ‘I’ll speak to the relatives if you want me to, and then I’ll do a quick changeover round with Tony Ringer before I leave.’
‘No, don’t worry, Joel, I’ll see them. It’s my responsibility,’ Harry replied.
Joel nodded and left the theatre.
Harry looked at Allegra once Joel had left. ‘I know I’ve said it before, but you two work well as a team,’ he remarked. ‘Are the rumours