by Andrews, Amy
minutes,’ said Kelly. ‘He can go on that, along with the two
abdos Ben’s done. Can Gill call Megan and let her know?’
‘Sure,’ Harriet confirmed.
‘OK, thanks. Now, I’ve got a middle-aged male with circumferential full-thickness burns to the upper arms. He has
cyanosis and impaired capillary refill of his hands, with increasingly weaker radial pulses. He’s going to need bilateral escharotomies to return his peripheral circulation. His upper chest also has full-thickness burns but they’re not circumferential.’
Harriet winced. ‘How’d he manage that?’
‘In a car that was fired on. It crashed and burned, to coin
a phrase. Four others from the same accident are dead, a sixth
is arriving soon.’
‘Okay.’
‘Burns guy also has a deep thigh laceration that’ll need a
good scrub. Ask Gill if he can clean and suture it while you have him under.’
‘Will do.’
‘I’ve organised evac to a specialised burns unit within the hour.’
‘Slave-driver,’ Harriet teased. ‘Send it over, I’ll let the team know.’
The already intubated patient arrived within five minutes
of the conversation and within ten minutes Gill was ready to put knife to skin. It wasn’t an operation that required a lot of materials. In fact, escharotomies were often performed in ERs and at bed sides with nothing but a scalpel blade.
But when you had the use of a theatre and a skilled surgeon, you used them.
Gill inspected what had been opened for him. Some drapes, a scalpel and some sponges. Also a basic suture pack for the thigh wound and a small metal bowl full of aqueous chlorhexidine so the wound could be thoroughly cleaned. The whole procedure shouldn’t take longer than twenty minutes.
He glanced up to see Harriet standing well back and to the side and smiled beneath his mask. Her dislike of burns was legendary. Not that he could blame her. Cutting into dead flesh wasn’t exactly his cup of tea either. But it wasn’t like he and Siobhan should need anything more and, if so, then Katya, who was quite interested in burns due to her younger sister having suffered extensive burns as a baby, could do the honours.
Starting on the left arm, Gill made an incision through the
eschar, into the deeper, viable subcutaneous tissues. It started at the armpit and followed a mid-lateral line down the length of the full-thickness burn and finished just beyond the demarcation line between burnt and viable tissue.
The incision gaped but surprisingly didn’t bleed very much and Gill inserted some sponges to absorb the small ooze and then quickly diathermied a few vessels. He noted the hand pink up immediately and was pleased that such a simple intervention could mean the difference between saving or losing an arm.
He repeated the process on the other limb, with the same result, and was thankful that the man’s chest burns didn’t encircle his chest wall, as escharotomies were often required in those situations, too. The tight eschar and swelling tissues beneath could prevent adequate chest movement, hindering breathing.
Of course, this man still had a long way to go yet. He would require extensive debriding of the dead tissue and grafting and many, many blood transfusions. The next weeks would require very specialised management.
Siobhan dressed the burns while Gill helped himself to the suture tray and worked on the gaping thigh wound caused by some sort of sharp projectile during impact. He was lucky that no major vessels had been cut.
The wound was oozing but it was only a slow trickle as he attacked the deep wound with the soapy chlorhexidine, a yawn escaping behind his mask. It wasn’t that late, they’d only been operating for a few hours, but lengthy surgery the night before and then Harriet’s early morning wake-up call were beginning to have an effect.
He scrubbed away at the pink tissue, refusing to let his
mind go back to this morning any further. That would only lead to thoughts of the divorce and it was done whether he liked it or not. Still, he glanced at Harriet hanging back by the wall and couldn’t quite believe he was never going to be in an operating room with her again.
Even during their separation he’d always known she’d come
back, but this time when they said goodbye, it was forever.
Finally satisfied that he’d removed all dirt and foreign matter such as vegetation or gravel from the wound he chose a suture from the selection Siobhan had set out for him and began to sew the laceration together in layers.
It was done quickly and the phone rang again just as Gill was removing his mask. He strode over and plucked the receiver off the wall. ‘Are you done?’ asked Kelly, not bothering with pleasantries.
‘Just.’
‘Suspected splenic rupture incoming,’ she said. ‘He needs a laparotomy, stat.’
‘What’s Ben doing?’
‘Just started an amputation.’ Kelly replied.
‘Okay.’ He pulled off his gown. ‘Send it over.’
CHAPTER SEVENTEEN - 2300 HOURS
Sometimes this job was crazy and the team found themselves rushing one patient out to Megan in HDU and preparing for another. They heard a helicopter land as their patient arrived and knew Megan and the others would be grateful to soon have four fewer patients.
Harriet wondered how many more helicopters would land and take off tonight before theirs arrived in the morning. She pushed herself to do her job, despite her tummy feeling more and more like a helicopter had landed inside it and was tearing it to shreds with its blades. The painkillers she had taken before the burns case didn’t seem to be having much effect this time.
She decided to pass on scrubbing for this op, even though it was her turn. Katya didn’t mind and Harriet promised she’d scrub in next, even though she doubted she’d feel like doing it then either, unless she had a miraculous recovery.
Her normal treatment for cyst pain was to take paracetamol
and rest as much as possible. The pain usually only lasted a day or two and was generally fairly bearable. She could manage it just fine without it interfering too much with her day-to-day life or work. It was a nuisance more than anything. But this was shaping up to be almost as bad as the time she’d had to have it drained.
Great! She didn’t want to have to spend her stopover in London having fluid sucked out of her abdomen. Not a great way
to start her new life. And Gill wouldn’t be with her either... just as well he was heading straight home or she didn’t know if she’d be brave enough to go through the procedure alone.
And then what would he think? She was supposed to be ending it, making a clean break. Something she’d already failed when she’d slept with him again so soon after her return to the team.
And every day since, apart from the time she’d been sick.
No wonder Gill had been a little surprised by the divorce papers that morning. Talk about giving him mixed signals! She had to stop leaning on him. She’d managed for a year without him and she’d manage again.
Gill would go home to be with his grandfather and she would see to her own condition if needed and that was that.
Kelly arrived with the patient from the medical building a short time later. Theire came as well, talking quietly to the young man.
‘This guy is the sixth passenger from that car accident,” she said to Gill. ‘He jumped clear of the vehicle before it crashed and exploded, but landed heavily on his left side. He’s complaining of abdo pain and has rebound tenderness in his left upper quadrant.’
Gill nodded as he smiled at his patient. ‘Kehr’s sign?’ He knew that when blood from an injured spleen irritated the subdiaphragmatic nerve root, referred pain was felt in the left shoulder tip.
‘Yep. Also free fluid in the abdomen on ultrasound. He’s hypotensive and tachycardic. He’s had two units of colloid and that’s his second unit of blood hanging.’
‘What pain relief has he had?’ asked Gill, as he switched on the han
dheld ultrasound machine and located the free fluid Kelly had been talking about.
‘He’s had some morphine. Theire has explained what you’re going to do.’
‘OK, thanks, Kel. Don’t suppose it’s slowing down?’
‘In your dreams, Guillaume,’ she threw over her shoulder as she and Theire exited the theatre.
Gill went to scrub and was surprised when Katya joined him.
‘I thought it was Harry’s turn,’ he said, as he soaped up his hands.
‘She’s going to scrub in next.’
Gill hesitated behind his mask as he asked the next question. ‘Is she all right, Katya?’ He had heard her confiding in Katya earlier on — maybe Harriet had told the Russian nurse more about her pain.
‘Nothing a baby wouldn’t fix,’ she said, not bothering to even look at him.
Gill’s hands stilled momentarily, before recommencing the scrub. Not really what he’d meant. ‘Katya,’ he said, a warning in his voice.
‘Guillaume.’ She half turned in his direction, her eyes sparkling with ferocity above her mask. ‘You are a stupid man.’
Gill smiled and bit the side of his cheek to stop himself
from laughing. He should have known that Katya-the-blunt
wouldn’t have paid any heed to the tone of his voice.
‘You love her, don’t you?’ she demanded.
‘Of course.’
‘Then give her what she wants. That’s what you do when
you’re in love. You make the other person happy.’
‘She doesn’t want that, Katya. I offered this morning. She wants me to want a baby.’
‘Like I said. Stupid man.’ Katya flicked off the tap with her elbow and flapped her arms in and out to shake off the excess water. ‘What’s not to want?’
She disappeared quickly and Gill, who was stuck with a mental image of Harriet holding Gillian as he washed off his soapy arms, couldn’t answer her question.
He followed her into the theatre and noticed that Ella was already playing. Their patient was anaesthetised and Joan indicated she was ready. Gill gowned and gloved and moved to the table where he prepped the operative area, swabbing it generously with Betadine, streaks of the brown liquid running down the patient’s flanks.
Next he draped the abdomen, leaving the patient’s stomach exposed and, with a final nod from Joan, he accepted the scalpel from Katya and put knife to skin.
He made a classic incision about twenty centimetres long, over the spleen area, cauterising the bleeding points as he went. Entering the peritoneal cavity, he retracted the skin and muscle layers.
There was blood, a lot of blood.
He couldn’t see a thing. ‘Suction,’ he said to Katya, who put the sucker head into the pool of blood, half filling the litre suction bottle.
‘How’s he doing?’ he asked Joan, without taking his eyes off the operative site.
‘A little hypotensive still.’
‘There’s a hell of a lot of blood here. You may want to rapidly infuse some O-neg.’
Gill approached the spleen from the underside to fasten the splenic artery, fully expecting the dark purple, bean-shaped organ to fulfil the grade five criteria — totally screwed. There was too much blood to hope to salvage it and zero place in field
surgery to attempt it anyway.
This young man needed the haemorrhaging organ removed pronto so his blood loss could be stemmed. Luckily it was a bit like the appendix — not vital to life. Sure, it had important immune and storage functions, but other areas of the body could take over the spleen’s role if required.
Gill worked methodically to tie off the spleen’s blood supply and ligaments so the organ was no longer fixed to the peritoneum. He was aware all the time of the nearby pancreas and careful not to interfere with any of its blood supply.
He shut himself off to everybody and everything except the odd update from Joan and Ella Fitzgerald singing...He forgot about his grandfather and the divorce and Peter and Harriet and that this was their last day. All he could see was moist, bloody tissues, all he could feel were slippery, warm body parts and all he could smell was burning flesh as he zapped anything that bled.
And in thirty minutes he’d removed the spleen.
‘Good God, it looks like someone’s put it in a blender,’ said Helmut, as Gill held it up for everyone to see.
Plonking it in the kidney dish Katya held out for him, he removed the sponges he had packed into the abdomen to soak up some of the blood while Harriet and Katya did the count. He realised then he was back from the zone he’d been in. He was conscious of things again, noises and activity beyond his immediate space.
He took the opportunity, now that the patient’s bleeding
was under control and his observations had stabilised, to do a
quick exploration of nearby organs. The pancreas, diaphragm and stomach were all examined and found to be intact. Gill explored a little further, checking also on the nearby kidneys.
Satisfied that everything looked good, Gill lavaged the abdomen and closed the muscle and skin layers. The phone rang as Gill was pulling the drapes off the patient and Harriet, who was nearest, answered. He saw her nod a couple of times before putting the phone down.
‘Above-knee amputation. Incendiary device,’ said Harriet.
‘Bring it on,’ he said.
CHAPTER EIGHTEEN - 2400 HOURS
Twenty minutes later they were operating again. Harriet was
scrubbed in with Gill. She hadn’t really wanted to. The pain in her side was getting quite bad but at least with something to do she might be able to keep her mind off the constant throb.
And she had promised Katya.
It was going to be a long procedure, probably close to ninety minutes barring complications, and would require all her concentration to anticipate Gill’s requirements and keep the operation flowing smoothly. She loved that most about her job. The dynamics of an experienced surgeon and the assistant.
Watching people who had been operating together for a long time was like watching prima ballerinas dance Swan Lake or a
concert pianist playing classical music. Every move was choreographed perfectly. It was fluid and graceful. One hand meeting the other at just the exact moment to accept an instrument without any interruption to the flow of the proceedings.
It was a special skill built over years. It was...art.
The pain in her side was making it difficult for her to concentrate. She needed to get into the zone that Gill always entered the second he picked up a scalpel. Because if she didn’t stay one step ahead of him and he had to wait for something, it would pull him right out of his bubble. And that made him frown and even though he was too polite to say anything, she would know she had let him down and professionally she had never let him down.
Never.
Sure, in the beginning there had been an awkwardness to their technique, as there always was with a new partnership. It hadn’t been as smooth and the flow had been stilted. Rigid, mechanical even. But she had always managed to anticipate his
requirements and the flow soon followed.
Harriet took a deep breath, forcing herself to relax. If she could get outside her body and into her head then, just like Gill, nothing else but what the two of them were doing would exist.
Including the wretched pain!
Gill heard Harriet’s indrawn breath, quite loud in their close confines. He turned to her and raised his eyebrows, still worried about her abdominal pain. He felt slightly reassured by her quick wink but he noted the fine sheen of sweat on her brow with concern. It wasn’t an uncommon sight, given the hot theatre lights directly above their heads, but it was unusual before the op had even got under way.
‘I’m good to go,’ said Joan.
‘Tourniquet on at 0010,’ said Helmut, noting it down on the anaesthetic sheet.
The leg’s major blood vessels had been crudely ligated in the field as a temporary measure to prevent the patient fro
m exsanguinating through his open wound. It was Gill’s job to fix the mess and to do that he needed a bloodless field and haemostatic control of the leg.
A tourniquet was used for this purpose. It could be left on for a maximum of two hours but it was important that it be released a little about every ten minutes to reperfuse starved tissues and prevent ischaemia, possibly necrosis from tissue hypoxia.
The normal rule of thumb was ten minutes on, ten minutes off and it was Helmut’s job to control, monitor and document the
inflation and deflation of the tourniquet.
Gill looked down at the prepped, mangled right leg. It had been traumatically amputated just above the knee joint, necessitating a transfemoral or above-knee amputation. The flesh was shredded. The distal extremity of the femur had been completely blown to smithereens exposing the sharp splintered edges of the femoral shaft.
The missing part of the limb had apparently been completely blown to pieces by the explosion but, even if it had been rescued and been in good enough condition, there wasn’t the time and this theatre wasn’t the place for lengthy limb salvage operations requiring delicate microsurgery.
Gill examined the remains of the leg, thinking it looked like some gruesome prop dreamed up by a special effects department. War injuries necessitating amputation were very different to nice clean civilian jobs, the majority of which were performed electively for vascular problems.
In combat wounds the initial trauma usually involved a high-energy impact, completely shattering bone and severely damaging soft tissue. The nature of these wounds required a staged-management approach and were left open until the soft tissue had recovered and stabilised.
They were also exceedingly dirty and attempting to close the wound too early could result in failure and infection, requiring a higher level of amputation.
Gill’s immediate job was to get the bleeding under control and prepare the muscles, nerves and bone for closure at some future stage. And evacuate to the nearest specialist facility.
These centres were equipped to deal with traumatic war injuries. Through aggressive wound care and physio, they would optimise recovery of the injured tissues and eventually close the skin, fashioning a stump to which a prosthetic device could be fitted.
