Pittsburgh
The chief is late.
Something like forty minutes ago I paged her so we could round on our gentleman in the unit, and she told me that it would take about ten minutes to finish some dictations, after which she’d be right over.
“Narf! Ciao, boss,” I said as I hung up the phone. I suggested to the medical student that she do something productive like spin around in tight little circles while we waited.
So now it’s forty minutes later, and the stud is even more dizzy than usual. Her pager goes off.
“Hey! Somebody is paging me!”
“Reckon so. Why don’t you answer it?”
Inspiration hits her like a ray of sunlight. “I think I’ll answer it,” she proclaims. After a short conversation that I can’t make heads or tails of, she tells me, “That was the hospital operator. She said the chief is in the o/r. I have to go to conference. See you later...”
“Hang on a sec. Do you suppose she might need some help there?”
“Wow. I don’t know, I didn’t ask.”
“Doesn’t it strike you as somewhat unusual that the chief might go to the trouble to have the hospital operator page you just to give you an update on her whereabouts? I mean, especially after she blew us off for rounds?”
She thinks about it. “Um - not really. Do you think she might really need some help?”
“Well golly, I sure do. What do you think?”
“I think I have to go to conference. Could you check in the o/r and see if she needs some
help?"
The circular conversation is beginning to make me dizzy.
“You damn betcha I’m gonna check.”
“Okay. Could one of you guys page me in an hour and tell me where you are?”
“No. You page. Don’t page the chief - page me, okay? I’ll give you careful instructions on how to find us.”
“Okay. Bye-bye.”
My head is still aching from the exchange as I walk into the o/r.
There’s a lady on the table being prepped and draped, and anesthesia is running around like crazy. The chief sees me and utters briefly, “G/I bleed.”
“I’m there.”
I turn about smartly and walk out to begin the ritual handwashing. There are pressure infusers in the room, and blood is hanging in three of them pouring into the patient very, very rapidly. That’s bad. And instead of the usual laconic and droll wit I usually expect from anesthesia, there’s six people who are well and truly hustling. That’s worse.
I think about the whole picture as I’m massaging chlorhexidine into my skin, and then
I abort my scrub at two and a half minutes and walk back in to dry off my hands and gown up.
“This lady was life-flighted in from an outlying hospital,” the chief tells me. There are eight rather noisy conversations going on in the room all at once, but somehow I manage to hear every word she says even though she’s speaking quietly. “They were going to percutaneously drain her infected gallbladder to let it cool off before doing definitive surgery, but apparently they lacerated her liver. She had a pressure of forty downstairs in the e/r. Knife, please!”
She makes a long deep incision right down to the fascia with her scalpel. The usual practice is to use the knife only to breach skin and then to travel down through subcutaneous tissue and fat with the electrocautery blade. This nifty electrical marvel cooks bleeding vessels shut as it divides them, and also makes it rather difficult to accidentally incise fascia, or more importantly the relatively fragile bowel which can lie directly underneath it. If you unintentionally cut bowel, you end up contaminating the abdominal cavity with poop and all of the nasty little bacteria which work symbiotically with your body to produce it. The fact that she has chosen to disregard this nicety of surgical etiquette indicates that she’s in a very big hurry indeed.
So with a couple of incredibly deep, deft slices, she exposes gleaming fascia. It’s a sick blue in color, and it bulges ominously from the incision. “Got your suckers ready Grim?” she asks.
“Hit me, Reaper.”
She lifts the tissue with long forceps and makes a two centimeter nick in it with the knife blade. Immediately a fountain of blood erupts a good seven inches into the air. The attending pokes two of his fingers into the hole and lifts the tissue away from bowel. The chief follows him down with the knife, parting tissue and opening up the patient’s belly in one clean slice from just below sternum to just below navel.
I have two suction catheters in the wound, and the scrub nurse is holding a third. They’re all going full-tilt, but blood splashes out all over the floor anyhow.
This, once again, is bad.
By way of comparison, surgeons often perform relatively major abdominal procedures with a total blood loss of two or three hundred ml’s, or perhaps half a beer-bottle’s worth. Such a loss is trivial, reflected only by a slight drop in a couple of lab values. Clinically, it is impossible to detect. Generally speaking, however, the patient’s blood starts off in confines of his or her vessels rather than filling up the entire abdominal cavity, as is the case with this unfortunate soul.
The attending places a large abdominal retractor at the margins of the wound and opens it up wide. When I finally have enough blood sucked away to permit them to see what they’re doing, he reaches over the liver with a single finger and touches it just there. Instantly the outpouring of new blood decreases dramatically. He pulls his finger away for a moment, exposing a little pulsatile jet. The finger slides back into place.
“Looks like they managed to transsect a hepatic artery with their catheter,” he remarks, “I wonder what the chances against that are? Wow. What incredibly bad luck.”
The scrub nurse chooses that moment to hand me a tool I’ve been lusting after all month. It’s an instrument about the diameter and length of a good fountain-pen on the end of a long cable barely thinner than the instrument itself. The circulating nurse slides the floor switch under my right foot. I look down quickly to make sure I know where it is, and am utterly appalled at what I see: the floor is covered with blood. My sneakers are splattered, and my scrub pants are soaked.
I mash the switch and point the thing at a clean white sponge. Nothing happens. I reluctantly pass it to the chief, who points it at the liver surface, directly adjacent to the attending’s finger. “Okay,” she says, and he shifts his finger as I simultaneously step on the switch again. Liver tissue a centimeter away from the thing’s tip instantly turns a deep charred brown. She waves the wand around a little bit, and the brown area becomes wider and deeper. Blood continues to squirt through the charcoal.
“Damn. So much for that.” She hands it back to me. This is the argon cautery wand, and it can pretty much turn the surface of any solid organ to char instantly. As best I can figure, argon gas sprays out the tip, while an electrode within generates an enormous electrical potential.
There’s a fat conductive pad glued to the patient somewhere to complete the circuit, so current travels through the gas, turning it to plasma. Hot stuff.
The surgical axiom in this case is, “charcoal doesn’t bleed.” Anyhow, it doesn’t work this time. Instead, The chief places a couple of fat sutures through liver tissue, and pulls them tight, squooshing the bleeding vessel shut somewhere within.
While she’s working, I point the argon cautery at a bloody sponge, hit the switch again, and watch as blood turns to carbon. The cotton beneath is untouched. Miraculous. I suspect it has something to do with the conductivity of whatever the plasma arc is playing across, but I don’t really know. Regardless, I can’t quite work up the courage to point the thing at my bloody gloved finger, though I’m sorely tempted. Difficult to believe though it might be, I’m somehow able to resist the compelling lure of incredible stupidity, at least this time around.
The chief finishes stitching the liver. The bleeding stops except for some persistent oozing from the entry and exit points of the stitch.
This is bad. Oozing usually stops within twenty or thirty seconds, but in this case it just goes on and on. I look at the blood on the surgical drape. There is a thin pool in a depression, and I stir at it with a finger while the chief and the attending examine the rest of the liver. Usually, it would very rapidly become thick and clotted. Though I stir and stir, the blood remains as thin as chicken broth.
“Um - I know you guys gave platelets and frozen plasma, but I think we might need some more,” I say to the anesthesia team. “She’s not clotting at all. I mean, not even a little bit.” I look up over the drape at their monitors. “Is that temperature for real? Is her core temp really thirty-two cee?”
Thirty-two celcius is about 89.6 farenheit. Double-plus ungood.
The answer floats back to me, “yes.”
The attending catches my eyes briefly. I’ve sat with him a lunch a couple of times, and had some really nifty conversation. Still, he knows damned well that I’m not a surgeon. They all know that I’m not a surgeon, and hence generally assume (incorrectly) that I’m not terribly interested in surgery. I am an outsider, and therefore am expected to remain relatively silent during a case. I can get away with making very quiet wisecracks to the chief, but I speak to the attendings only when spoken to, and never give orders that could affect intra-operative management. He is curious, I suspect, to see how I’ll bury myself.
“She’s - ah - not really going to clot at all if she’s that cold. The coagulation cascade just won’t work at that temperature. We really need to - um - well, warm her up and get more clotting factors into her, okay?”
The attending says nothing, and
turns his eyes back to the work at hand.
Commentary runs through the back of my mind: He goes up for the shot - wait, it’s on
the rim - Yes! It’s good! Amazing!
They have now exposed the gallbladder. It is without question one of the most remarkable things I have ever seen during a surgical procedure. Folks’ gallbladders are usually about the size of a fat man’s thumb. This one is more like one of those huge oblate salted bread sticks that you get in pseudo-posh Italian restaurants. It is bigger than a generous bratwurst, and great vast parts of it are dead and gangrenous. It has to come out, ‘cause it’s gonna pop soon, dumping three or four hundred ml’s of infected goop into the patient’s belly.
The chief and the attending dissect the distended monstrosity away from liver-bed, and hand it off the surgical field in a stainless-steel basin which is barely large enough to contain it. More oozing. Lots and lots of oozing. They try the argon cautery again. It helps somewhat, but blood continues to flow through carbonized liver tissue. They pack sponges into the space, and go on to place a tube in the duct which once led from the now missing-gallbladder, so the liver can continue to drain bile.
Eventually they decide that there is simply no way to control the bleeding other than to leave sponges in place to physically compress tissue and staunch the flow of blood.
This is also unusual. Surgeons tend to have morbid fear of leaving things like surgical sponges inside of patients, ‘cause they invariably prevent normal wound healing, and often become infected. It’s not a problem this time though, mainly because they really have no other options, but also because they know they’re going to have to go back in a few days and take another look around anyhow.
At some point during all of this, the circulating nurse tells me that my pager has gone off, and that she has the medical student on the line. I cleverly stashed the cursed thing on a shelf in the o/r next to three or four others before I scrubbed, against the possibility that I might get a call from the floors about a patient there.
“Please give her my compliments, and tell her that the team would be happy to have her join us in the o/r.”
A few minutes later she walks in, asks a couple of questions, then goes off to sit in a corner and poke through stuff in one of the supply cabinets.
Meanwhile, the chief and the attending have placed the bowels and other loose organs back into the patient’s abdominal cavity. They attempt to approximate the edges of the wound, only to discover that there’s no way that it’s going to close as they would like. The abdominal contents have become grossly edematous during the course of the procedure, and have swelled to such an extent that everything simply won’t fit. No one is terribly surprised by this, especially in light of the profoundly pathologic state of her clotting system and the massive insult she has suffered. The question now is what to use as a temporary patch.
“You could maybe slice open a sterile one-liter saline bag, and you know, sew it in place over the incision,” I suggest.
The chief and the attending look at me as if I’m insane.
“No, really - I read about it once in this great short story about a trauma involving a motorcycle,” I tell them.
“Whatever,” the chief says. “Could we have a large gore-tex patch please?”
Ah. Gore-tex. The same stuff that makes your expensive ski-jacket warm and cuddly is also used in various and assorted surgical procedures. In this case, she is handed an 15x25 centimeter section of the stuff that is roughly three millimeters thick. She trims the corners off of it and begins to sew it into place at the deep margin of the incision.
The student suddenly walks up to the table and says, “Hey! What are you guys doing?”
No one answers.
“What is that thing?”
“Pssst - c’mere,” I say, as quietly as I can. She leans forward. “No, no - sneak around behind me - you’ll contaminate the field there,” I say.
I’m just south of Maryann on the patient’s right. The student comes around further south, so she’s off on my right-hand side. “Listen,” I say quietly, so neither the chief nor the attending can hear, “you can’t ask questions right now --”
“But I wanted to know --” she says clearly, above all the noise in the o/r.
“Shh. I said listen okay? Don’t talk. Don’t explain. Just listen for a minute. Nod your head if you understand. Don’t say anything. Just nod.”
She nods. I’m almost down at the patient’s feet as I’m talking to her, trying to make sure I can still see well enough to deliver suction if it’s needed.
“You can’t ask questions now,” I start again, as quietly as I can.
“But --”
I shake my head. “Listen. Please. You can’t ask questions. You’ve been sitting in the corner for the past twenty or thirty minutes. You have to pay attention to what’s going on if you want to be able to ask questions. You and me, see - we’re lucky. We have a very nice chief and an incredibly indulgent attending. Most of the rooms you could go into, well - someone would probably rip off your head and shit down your neck for this. If you want to be allowed to ask questions, you need to grab a couple of stepping stools and stand behind me or Maryann, and do your best to follow what’s going on. Then if you have questions, you can ask them really quietly, as long as you’re sure no-one’s doing something particularly difficult at the moment. You can almost always ask the intern, ‘cause we usually don’t do anything more important than work suction or retract anyhow. The moral of this story is that you have to pay attention, okay?”
Neither Maryann nor the attending has heard a single word of what I’ve said. I’ve been incredibly goddamned quiet while speaking to her.
“Yeah, but --”
“Nevermind. The bottom line is that you’re not allowed to talk to us right now. I’ll try to explain it to you again after the case. Shift. You’re in my way.”
She moves half an inch, then back again, and strikes up a bright and noisy conversation with the scrub nurse. They start playing verbal tit-for-tat, and the nurse is clearly winning.
I say very quietly in the chief's ear, “I tried, you know...”
She looks back at me and shrugs. “Think of it as some kind of bizarre improv theater. Doesn’t matter now anyhow - we’re nearly done.”
She finishes sewing the gore-tex patch into place, then fills the space with bandages and then steps back from the table. The surgery is over.
As I step away from the table, stripping off my fluid-impermeable gown, I look down at my legs. Glah. Gnarly. My scrub pants are soaked with blood. My sneakers, formerly a filthy white, are now a filthy red. Maryann is worse, and the poor attending is even more drenched. His black oxford dress-shoes have an incredible dull-red sheen to them.
“Ooooh. Gross!” I announce to the room. The anesthesia staff grins smugly as they behold us in all our spattered glory. They’re still nice and dry, so they have good reason to be smug.
We get the patient off of the operating table and onto the bed, after carefully untangling miles of monitor cabling, IV lines, oxygen tubing and the like. We wheel the bed out of the o/r, through a convoluted mess of corridor and into a room in the intensive care unit.
Once there, she gets plugged back into the ventilator. During the transfer, we breathed for her with a big old ventilating bag, but now we can get her back on the machine and spare our tiring hands. As is my wont, I dick around with the vent, looking at various parameters to try to assess the patient’s respiratory status. I scroll over to the peak airway pressure window, and my eyes go wide. “Oh, no...” I say quietly. One of the unit nurses looks up at me.
“What? Is something wrong?”
I shake my head.
When we step out of the room for a moment I catch Maryann’s eyes. “She ain’t gonna fly, you know.”
“Well, she’s in pretty sorry shape, yeah --”
“No. Her peak pressures are in the mid-fifties. She has ARDS. We’re done.”
She simply looks at me briefly, and goes back into the room to try to help get everything set up and running. She’s irate at this point because some of the things that we ordered to be at the bedside long before we left the o/r still haven’t arrived.
I follow her back in. “Anything else?”
“No. You might as well leave. I’m back-up for trauma anyway, so I’m gonna be here for a while. Go home.”
“Later, boss. See you tomorrow.”
I walk up the long hallway that leads to the parking garage, feeling vaguely guilty for leaving Maryann there to deal with the patient. After I get home and run through the shower, I actually give serious consideration to the notion of going back in to try to help. Then glowing blue numbers from the ventilator flash through my mind and I abandon the idea. There’s no point.
Instead I wander up to Royal’s place on Mount Washington and help myself to a couple bottles of Guinness. I pour myself a very tiny glass of Chartreuse. It goes wonderfully with the cigarette. Royal is still out of town, so once again the place is all mine.
It’s somewhat hazy, but I can still see the hospital on the other side of downtown and two rivers. One of the LifeFlight helicopters goes in to land, and I wonder what they’re bringing in this time. I can picture our patient’s room in the unit with startling clarity. As it happens, I actually can’t get the image out of my head. I make a call to the ‘tern who’s cross-covering to tell him about a guy who might spike a fever.
With the binoculars, I can see the hospital even more clearly. Lovely. I shift them downwards to the sidewalk across the street that I’m sitting over, and look for panty-lines on the young women who are playing sycophant to young men with muscle-cars that have neon hover-lights. I find several.
Head down to southside and wander into one of my more regular haunts. I nod at the bartender as I walk in, and there’s a draught Guinness waiting for me by the time I make it up to the bar.
“Hey, Marcus - how’s work?” she asks.
“Aw - you know, same old stuff: Curing the Sick, Mending Broken Souls, Making the World a Better Place for All Humanity - all that shit . . . Christ, I’m tired, and I’m on-call tomorrow. Could I have another one please?”
When I see the chief the next morning she tells me, “that lady died, you know.”
“Well, I didn’t, but I’m not surprised. It wasn’t if, it was when. I’m sorry you had to deal with it by yourself.”
We make lightning rounds, and then the chief goes off to round with the trauma service before she goes home. This is my last day on service with the department of surgery. All I have to do is make it through the next twenty-four hours of call, and I’m done. It’s a holiday weekend, so I suspect things will be relatively slow.
My pager goes off. Onwards . . .