Doing Harm (11 page)

Oh, God, please no. Please no. Oh God. Oh God.

My hands begin to shake so badly I can barely hold the instruments—which doesn’t seem to matter too much at this point since I can’t see the instruments anyway with all the blood in the way. I grab the camera from Luis and jerk it around, hoping to find a clear spot, but see nothing.

The bleeding, where’s the bleeding coming from?

The steady, rhythmic beep of the cardiac monitor speeds up, jolted out of its earlier, complacent cadence by Mrs. Samuelson’s heart, which has started beating faster in response to the blood now squirting ferociously into her abdomen.

“Anesthesia? I’m having some trouble here.” I try to sound calm. I know I don’t.

In response to the increased tempo of the cardiac monitor, Susan has already tossed her textbook aside and is standing up, her body tensed, perfectly motionless except for her eyes, which dart between her cardiac monitors and the video screen.

“I’m having a little trouble. We’ve got some bleeding. Pretty brisk. Probably from the IVC, maybe something else, too. I can’t tell where for sure. I think we’re having some serious volume loss here.”

Serious volume loss
is euphemistic surgeon talk for
bleeding like a stuck pig.

“Please call your attending now!” I call, still focused on the unchanged red image on the video screen, all the while sweeping the camera around with my left hand and futilely moving the sucker back and forth with my right. “And make sure she’s got an active type and cross!”

Susan starts working furiously, simultaneously grabbing the telephone with one hand and one of the patient’s IV lines with the other.

I try one more feeble pass with the sucker, groping this way and that, hoping that I’ll get lucky, that I’ll find the source of the bleeding, that everything will turn out okay, willing with every neuron in my brain for the blood to go away but at the same time knowing that there’s not a chance on God’s green earth that it will.

Nothing happens, of course. The absolute redness of the screen doesn’t change one iota. Presumably, Mrs. Samuelson’s blood continues to gush from the big hole I’m sure I’ve made in the biggest vein in her body and there’s nothing I can do about it.

She’s bleeding to death right before my eyes.

Raw, primal panic slams over me with the force of a sledgehammer. I freeze, staring at the video monitor in disbelief, paralyzed by what’s happening, still holding the camera and sucker but doing nothing.

The blood, inscrutable and indifferent, stares back. I suddenly wish I were somewhere, anywhere but here. I feel as if I’ve plunged over my head into a frigid, roiling, black ocean, and I’m completely disoriented and don’t know which way to swim to get to the surface.

All I want to do at this moment is drop everything and run home and hide in a closet and hope all this crap just goes away and everything goes back to the way it was before the bleeding started.

Shit, shit, shit. It’s all my fault.

“Steve!” Luis is frantically tugging at the sleeve of my gown.

My fault.

“Holy shit, Steve!” Luis screams.

My fault, my fault, my fault.

“Do something! Let’s convert! Holy shit!” He’s practically yanking my arm off now in an attempt to get my attention.

Convert.

“Convert!”

Convert?

Right. Convert.

I’ve got to convert.

Right now.

Luis has managed to pull me back into reality, to jerk me to the surface of that dark ocean, by reminding me that the only option we have at this point is to pull out all of our laparoscopic instruments and make as big an incision as possible in Mrs. Samuelson’s side so we can stick our hands inside her body and control the bleeding the old-fashioned way. To convert as quickly as we can from a minimally invasive surgical procedure to a maximally invasive one.

It’s the only shot we have at saving her life.

“Call Dr. Lassiter. Now—911!” I yell to no one in particular over Zeppelin, which is still playing in the background. “Give me a scalpel. We’re going to convert. And turn off that goddamn music!”

I quickly open all the laparoscopic valves to let the carbon dioxide out of Mrs. Samuelson’s belly. It escapes with an angry hiss, and her abdomen deflates like a popped balloon.

Luis and I start ripping the sterile sheets off so we can make a bigger incision in the skin. But the adhesive strips that hold the sheets to her body cling to our gloves and quickly become tangled like pieces of Scotch tape that stick to your fingers when you’re trying to break them off from the dispensing role. Luis and I curse and fumble, losing precious seconds and even more precious blood, as we try to peel them off our gloves.

The cardiac monitor is really going now. Mrs. Samuelson’s heart rate, which had been perking along at a nice, normal 70 beats per minute a moment ago, is up to 180. The individual, discrete beeps that signify each separate heartbeat are beginning to merge into a single, high-pitched, plaintive whine.

That’s a really bad sign.

More ominous still, Mrs. Samuelson’s abdomen is rapidly expanding again, filling up now not with carbon dioxide but with the blood that’s supposed to be pumping through her arteries and veins but is instead now gushing ineffectually into her belly.

What a fucking flail.

“Her pressure’s dropping,” Susan calls out loudly. Too loudly. She sounds even more scared than I feel. “She’s down to 60 systolic.” The anesthesia attending arrives a second later and immediately takes control, forcing fluid and medications into Mrs. Samuelson’s bloodstream to keep her blood pressure up while he calmly calls for emergency blood.

But all that barely registers because Luis and I have finally managed to get the sterile sheets off and expose enough of Mrs. Samuelson’s skin to make a bigger incision. I seize the scalpel from the nurse and, in spite of my hand, which trembles like a leaf in a hurricane, manage to quickly carve a large incision that reaches first across her rib cage, then down her abdomen toward her belly button.

As I slide the blade down the length of her body, the scalpel in my hand and the sight of her skin parting like an opening mouth give me new resolve. I clutch the scalpel like a life preserver, dumping my will into its steel. I’ve got to do something, anything … and this is the only thing I can do.

I slice through Mrs. Samuelson’s flank and abdominal muscles and enter the area immediately surrounding her kidney. A river of blood suddenly gushes up and washes over the sides of the incision and onto the floor like water from an overflowing dam. I’m not wearing the protective, waterproof shoe covers that I’m supposed to slip over my regular street shoes, and I can feel the warm blood spill over my sneakers, soak through my socks, and gather in sticky collections between my toes.

I place my sucker in the middle of the red torrent streaming out of her abdomen, but I might as well be trying to vacuum up a lake with a Dustbuster.

“I need another sucker. Now!”

Somebody thrusts one in my hands. I give it to Luis, and he plunges it into the middle of the blood, and, together, our two suckers make an obscene slurping sound as we try to keep up with the furious current.

But it’s not enough. I still can’t see anything. I move my sucker around with one hand while I reach around inside Mrs. Samuelson’s abdomen with the other, desperately trying to find the anatomic landmarks that will guide me to where I think the bleeding is coming from.

I’ve never seen this happen before. I’m not really sure what to do. Worse yet, her intestines keep getting in the way, coiling through and over my hands like a nest of greased, wriggling snakes, obscuring my view. I try to move them out of the way, but they immediately slip right back through my fingers. It’s like I’m trying to see down to the bottom of a bowl full of red-colored noodle soup using only my fingers.

As I struggle, I start to feel the panic close in around me again. The questions shoot rapid-fire through my brain, but I have no answers.

What do I do? How do I get my bearings? Where do I put my hands? How do I stop the bleeding? How do I keep her from dying right in front of me?

At that moment, Larry rushes in, tying his surgical mask.

“What’s going on?” he rasps. His breath is coming in short, sharp gasps, the same as mine. His eyes widen as he absorbs the bloody scene playing out before him.

Thank God.

“I think we’ve got an IVC injury,” I bark. “I’ve converted, but I can’t find where the hole is. I can’t see anything with all the blood.”

“Goddammit! Gloves, now! Steve, get out of my way!”

In an instant his gown and gloves are on, and he’s at the table shoving me to one side with his muscular frame. He hasn’t bothered to scrub. It’s a significant breach of sterile protocol, but protocol is pretty much out the window at the moment. As I dart around to the other side of the table next to Luis, Lassiter plunges both hands into Mrs. Samuelson’s abdomen up to his elbows.

“Suck!”

Luis and I comply, following Larry’s darting hands with the suckers as he gently but quickly coils up the intestines.

“Towels, rolled! And a big Rich. Now, now, now!”

The scrub nurse hands him several rolled-up towels. He adroitly pushes the intestines to one side, places the towels and a large metal retractor over them, and then thrusts the handle of the retractor into Luis’s hand. I peek inside Mrs. Samuelson. Except for the blood, the path through her body to the IVC and kidney is now clear. The intestines are completely out of the way, held from our path by the towels and the retractor.

“Now, suck!” Larry shouts. “Suck, goddammit! I can’t see a fucking thing.”

Luis and I do our best to keep up with him, holding our suckers underneath the bubbling, gurgling red pool, as Larry gropes around inside Mrs. Samuelson, his hands shifting this way and that underneath the roiling surface of the bloody pool. After a few moments he pauses and looks up at the ceiling, hands motionless. Over his hands, the surface of the blood shifts, swirls, and gurgles into the tips of the suckers.

“Sponge stick!”

He seizes the sponge stick—which looks like a long, thin pair of pliers gripping a soft white bandage in its jaws—from the nurse’s outstretched hand and carefully positions it with the bandage pointing down below the surface of the blood and the handle sticking up in the air.

“Steve, take this. Push down as hard as you can.” I grab the handle and push with all my might.

“Another sponge stick!” He repeats the gesture, positioning the second sponge stick a hand’s length away from the first.

“Steve!” He shakes the handle of the second sponge stick, my cue to grab it. I hand my sucker over to Luis and comply.

“Harder, Steve! Push harder, goddammit!” I do. The blood is flowing more slowly now. Whatever Larry is doing seems to be working.

“Keep sucking, Luis!”

Slowly now, as our suckers wheeze and cough, the blood begins to clear from the operative field.

It’s working. Whatever Larry’s doing, it’s working. The blood slowly empties from her abdomen like water draining from a bathtub. Her organs—the liver, intestines, kidney—gradually reappear, like islands emerging from a red lake. Normal anatomic landmarks take shape.

“There it is.” Larry’s voice is starting to regain some of its normal equanimity. “There’s a big-ass tear in the IVC, all right. And a partial avulsion of the renal hilum.
Fuck.
The renal artery’s holding on by a fucking thread. We’re going to have to take her entire kidney to get the bleeding under control. Satinksy!”

I peer into Mrs. Samuelson’s belly. The damage is even worse than I had imagined. There’s an ugly, jagged gash in the middle of the IVC, as wide as my pinky and half as long, starting where her adrenal vein used to be and extending down the long axis of her body toward her feet. The renal artery and vein, which take blood to and from the kidney, are partially torn, and the kidney now dangles limply from its blood supply, like a broken tree branch that’s been snapped by a strong windstorm.

As I’d suspected, I’ve ripped the adrenal vein right off the IVC, exactly the kind of mistake Larry had wanted to avoid. I realize now that the tips of the sponge sticks I’m still gripping in my hands are pushing against the IVC on either side of the huge gash, forming pressure points that temporarily impede the blood flow, like feet stepping on a garden hose. I never would have thought of doing that.

Larry takes the Satinsky clamp, an instrument vaguely resembling a backyard barbecue tong with a bent handle, and closes it across the gash in the IVC. He then takes a second clamp and closes it across the ends of the torn renal artery and vein.

The bleeding stops.

Larry’s shoulders stoop a little, and he looks up wearily from the operative field to address Susan and her attending, who continue to work furiously at the anesthesia end of the table. “Okay, Anesthesia, we’ve got control of the bleeding. How’s she looking up there, Carlos?”

The anesthesia attending looks at his monitors and grimly shakes his head. “Not good. We’re looking at maybe a four-liter blood loss, plus or minus, over a very short period of time.” So that means Mrs. Samuelson has lost about 70 percent of all the blood in her body. Thanks to me. “It’s been tough to keep up with that kind of resuscitation requirement. I’m giving her packed red cells as fast as I can, but she’s still tachy and hypotensive. I’m also seeing some diffuse ST elevations. I think she might be having an MI from all that acute volume loss.” In other words, the anesthesiologist is telling us that she’s probably having a heart attack because there’s not enough blood in her arteries to feed her oxygen-starved heart.

Larry sighs heavily and mutters “Goddammit” so softly that only Luis and I can hear him. He then says more loudly, “How about her coags? What about the coags?”

“Coagulation parameters are okay, I think. For now. Her pre-op INR, PT, and PTT were all normal. I’ve got repeat parameters pending, and she’s getting platelets and FFP right now. How is she down there? Oozy at all?”