by Amy Andrews
Gill hoped as he concentrated on his scrub that he located the blood with his first burr hole. He was more than aware that the patient might not have an extradural at all, although he’d bet his last cent on it. They were embarking on a fishing expedition inside someone’s head and once he started he’d have to make several attempts to either find it or satisfy himself that there was nothing to be found.
Gill had done many of these procedures over the years and was more than conscious of the fact that the object of this type of emergency surgery was to decompress the head and then get the patient out to specialised help. Drill a hole, evacuate the blood, stitch him up and fly him out. Not drill as many holes as he could and fluff around till he found something.
The other possibility was that he’d find a subdural haematoma—blood underneath the dural covering. Gill sincerely hoped not. It wasn’t that he couldn’t handle it, it was just a little longer, a little more complicated, a little more potentially serious for the patient.
‘Mannitol’s finished,’ said Helmut to Gill, as Gill entered the theatre with wet arms held up in front of him. Good, that should deal with any cerebral oedema caused by the pressure of the blood clot on the surrounding tissues. Now, to find it…
Harriet and Helmut positioned the patient on the table as Gill gowned and gloved. They propped a doughnut headrest beneath the young man’s head and a sandbag beneath his left shoulder to help keep his head averted to the right. Harriet heard the buzz of hair clippers and watched as Helmut shaved half the patient’s head, noting the boggy swelling above the temple and a slight graze where the assault had occurred.
‘Remind me to never let you cut my hair,’ murmured Harriet, and Helmut winked at her.
‘Ready, Joan?’ asked Gill.
‘You may proceed,’ she chirped in a fake high-society accent and then laughed self-deprecatingly.
Gill prepped the shaved area with Betadine and Harriet hit the play button on the CD player. Ella was on, Joan was happy and, apart from the now constant niggle in her side, Harriet cruised happily into circulating mode.
This was the part she really enjoyed about her job. Watching Gill operate. Seeing his brow pucker in concentration, his long fingers accept instruments with practised ease, his quick mind and skilled hands anticipating and adapting.
She loved standing beside him and watching him up close but sometimes she almost preferred watching him from a distance. She could observe without the sheer force of his physical presence blurring her senses. He was at home in his scrubs and with his hands inside someone’s body. This was his environment. Watching him was like watching an artist paint or a songwriter compose lyrics—it was pure poetry in motion.
Gill made a vertical incision about three centimetres long over the swollen fracture site. It was no lower than the cheekbone to avoid cutting the facial nerve, and one finger’s-breadth in front of the tragus of the ear. He separated the temporalis muscle and incised the periosteum, inserting a self-retaining retractor and cauterising a couple of bleeding blood vessels.
He could now see the white skull bone. ‘Drill,’ he said, and Katya passed it to him.
The drill was a manual device, which looked almost exactly like a standard hand-operated wood drill. They used much more modern expensive pneumatic drills in large operating theatres but the old-fashioned drill still did the job. He slowly cranked the handle round and round to make a hole through the bone, careful not to use too much pressure and accidentally plunge through into the brain.
He felt an irregular wobbling and pulled back, knowing that he had perforated through the two to three millimetres of temporal bone. The hole was too small to tell if there was any extradural blood. ‘Conical burr, please.’ Gill needed to enlarge the hole to be sure.
‘There she blows,’ he said, as the haematoma became evident. He relaxed a little. Finding the bleed straight away was a relief. He hadn’t wanted to drill any more holes but wouldn’t have been able to avoid it had the first one been negative. He would have had to keep going, making more holes until either he’d found it or he could be reasonably certain there wasn’t a bleed to be found.
‘Ronguer, please.’ Gill used the heavy bone-cutting scissors to nibble away a little extra bone and expose more of the haematoma. Katya passed him a syringe and he gently washed out the rather large blood clot and cauterised the bleeding point.
‘OK, let’s get this kid out of here,’ said Gill as he prepared to close.
Harriet blinked as a rush of faintness washed over her. She leaned back against the wall and watched as Gill expertly brought the muscle and skin layers together again, using staples for the external incision. She wasn’t humming along to Ella as she usually did, though. In fact, she was forcing herself to concentrate on what he was doing and ignore the sudden surge of nausea that was trying to outdo the cyst pain for her attention.
‘Pupils are equal and reacting,’ said Joan, flashing a penlight in her patient’s eyes. ‘Well done, Guillaume. Good save. I’ve given him some broad-spectrum antibiotic cover,’ she said.
Gill thanked her as he placed the last staple, pulling his gloves and gown off, looking for Harriet and catching a glimpse of her as she slipped out through the doors. He didn’t realise he did that until now. Until she wasn’t there. Looked at her for that smile in her eyes that said, You did good, you’re my hero. Even after a year’s separation she had still given him that look post-op. He’d got back into the habit of expecting it and realised he was going to have to get out of the habit all over again.
Harriet pulled the lid down on the toilet and sat on it with wobbly legs. She wiped her mouth with the back of her hand, the acrid taste of vomit in her mouth causing her to shudder. She held her side and felt a tear slide out from behind her closed lids.
She felt awful. The night stretched ahead of her, a long dark highway. All she wanted to do was take a painkiller and go to bed for a week. Bloody ovary! Between this one and her non-existent other one, she’d had enough of her female bits and pieces. She pulled off some toilet paper, blew her nose and wiped her eyes. Only eight hours to go.
CHAPTER SIXTEEN
2200 HOURS
ACTUALLY, Harriet felt better after her quick trip to the loo. The pain was still there but the nausea had settled, and brushing her teeth and a quick splash of water on her face had revived her considerably. She’d only been gone for ten minutes so she doubted whether they’d missed her.
‘Here you are,’ said Gill, rounding the corner and nearly running straight into her.
‘Here I am,’ she said, injecting a note of cheer into her voice as she untangled herself from the confines of his arms and kept going.
‘How are you feeling? Are you OK? You look a little pale. I looked for you but you’d gone.’
Harriet shrugged off his staying hand on her shoulder, refusing to look into his beautiful grey eyes. She had a night of surgery to get through and if she admitted feeling unwell he would demand she withdraw. Although the thought of it sounded like perfect bliss, she couldn’t let the team down.
It was their last day. She’d already had two days out at the beginning of their rotation due to illness when they’d had to operate one person down. They were on the homeward stretch—she would cope with the pain and when it was all over she could skive off.
‘Harriet,’ he said, grabbing her arm again, and was pleased when she stopped trying to walk away. ‘It’s bad, isn’t it?’
She sighed, still refusing to look at him. If she did that right at this moment, when she was feeling so vulnerable, she was going to cry. ‘It’s fine,’ she dismissed.
He turned her around and lifted her chin so she had no choice but to look at him. ‘Talk to me,’ he said softly.
She sighed again. ‘It’s sore.’
‘Worse than when you had it drained that time?’
She shook her head, remembering that time vividly. Gill had taken her to the emergency department of the nearest London hospital, doubled up with pai
n. They’d done an ultrasound and found the large ovarian cyst, and a gynaecologist had done an ultrasonic-guided needle aspiration and sucked off forty mils of serous-looking fluid.
The instant pain relief had been wonderful but short-lived as he’d decided to check out the state of her other ovary and had had to deliver the news about her unusual anatomy. It had been a double whammy on a particularly awful day.
Gill had been great, so wonderful and sympathetic for a while, but as the full implications had dawned on Harriet and her biological clock had roared to life, that’s when the arguments had begun.
‘No! Absolutely not. It’s just a constant ache, more annoying than anything.’ She decided not to tell him about the vomiting. ‘I’ll take a couple of more painkillers. That really knocked it on the head last time.’ She turned to go again.
‘I really am sorry, you know. About the tube…the whole baby thing. I swear to you, Harry, if I wanted a baby, I would want one with you.’
Harriet stopped in her tracks. She turned to look at him and saw his genuine sentiment written all over his gorgeous face.
‘I know, Gill. I know.’ And she turned on her heel and headed back to the theatre to help clean up. What was the point in leaving things bitter and twisted? She knew he meant it. She knew he was genuinely sorry about the way things had turned out between them. Her side ached with each footfall and her heart ached with each glimpse, each memory, each breath. Ached for all they could have been.
‘You OK?’ Katya asked, as Harriet entered the theatre, followed closely by Gill. ‘You look pale.’
Harriet rolled her eyes and forced a smile onto her face. ‘Looks like I’m going to need to top up my tan when I get home. All this indoors stuff isn’t good for you.’
Gill had an instant flash of Harriet sun-baking naked and was glad the phone rang to distract him.
‘How did the burr holes go?’ asked Kelly.
‘Good catch. Large extradural. He’s in HDU. He needs evac.’
‘I’ve got a chopper landing in approximately thirty minutes,’ said Kelly. ‘He can go on that, along with the two abdos Ben’s done.’
‘I’ll ring Megan and let her know to prepare the patients,’ said Gill.
‘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. His upper chest also has full-thickness burns but they’re not circumferential.’
Full thickness meant all of the epidermal and dermal layers of skin had been destroyed and the subcutaneous tissues damaged. ‘What’s his percentage?’
‘I’ve estimated about thirty per cent.’
‘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.’
‘Someone’s a good shot,’ he commented.
‘Burns guy also has a deep thigh laceration that’ll need a good scrub. Be a sweetie and suture it while you have him under. Reckon you can have it done before the chopper lands? I’ve organised evac to a specialised burns unit.’
‘Slave-driver,’ he teased. ‘Send it over. What’s Ben doing at the moment?’
‘Another shrapnel to the gut.’
The already intubated patient arrived within five minutes of the conversation and the team was ready for him. 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 bedsides with nothing but a scalpel blade. But when you had the use of a theatre and a skilled surgeon, you used them.
Harriet had opened up some drapes, a scalpel and some sponges. For the thigh wound she’d given Siobhan a basic suturing pack and had poured some aqueous chlorhexidine into the metal bowl so the wound could be thoroughly cleaned. The whole procedure shouldn’t take longer than twenty minutes.
She turned her back on the patient to start Ella up. She suppressed the shudder she felt at seeing the charred skin. Burns was one injury she found difficult to stomach. Even in the early stages and from behind a mask, they had a smell about them that was very distinctive.
Given the delicate state of her stomach, Harriet decided the further away she stayed, the better. Siobhan shouldn’t need anything more opened, and if she did then Katya, who was quite interested in burns due to her younger sister having suffered extensive burns as a baby, could do the honours.
Gill saw Harriet standing back and to the side and smiled beneath his mask. Her dislike of burns was legendary. Not that he could blame her. It wasn’t exactly his cup of tea either. He could think of other things he’d rather be doing than cutting into dead flesh, but just having her near, humming to Ella, helped take his mind off what had to be done.
Gill knew he had to make the escharotomy incision through the tight eschar, or dead tissue caused by the burn, into the fat layer below to relieve the pressure of the rapidly swelling tissue beneath. Otherwise the swelling would continue and, with no way to escape, further constrict the blood supply of the arms, compromising the circulation and viability of the limb.
He started on the left arm and 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.
Gill inserted some sponges to absorb the small ooze and then quickly diathermied a few vessels. He noted the hand pinking up and was pleased that such a small, 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, and escharotomies were needed to relieve the constriction.
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 indeed.
Gill moved out of the way so Siobhan could fill the escharotomy incision with SSD cream and dress the burns while he dealt with the thigh laceration. Once the patient arrived at a specialised facility they would have their own way to dress the gaping wounds, but MedSurg standard practice was to fill the incisions with the white meringue-like cream, plaster the rest of the burns with the same stuff, cover the escharotomies with a non-adhesive dressing and then bandage them in place.
Gill helped himself to the suture tray and worked on the gaping thigh wound. The man must have lost an argument with something reasonably sharp in the accident. He was lucky that no major vessels had been cut. The wound was oozing but it was a slow trickle. Gill noted Joan and Helmut checking a bag of blood—the first of many for this patient.
A yawn escaped behind his mask as he attacked the deep wound with the soapy chlorhexedine. 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 the divorce. It was done. 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, he knew it was for keeps.
Gill completed the compound scrub of the wound, satisfied that he’d removed all dirt and foreign matter such as vegetation, gravel and grass. He chose a suture from the selection Siobhan had set out for him and began to sew the laceratio
n together again in layers.
The phone rang just as he was putting the last skin sutures in place. Harriet answered.
‘Are you done?’ asked Kelly, not bothering with pleasantries.
‘Just about,’ said Harriet.
‘Suspected splenic rupture,’ said Kelly. ‘He needs a laparotomy, stat.’
Harriet placed her hand over the mouthpiece. ‘Spleen,’ she said, responding to Gill’s raised eyebrows.
‘What’s Ben doing?’
‘Did you hear that?’ asked Harriet, talking into the phone.
‘Just started an amputation,’ Kelly replied.
Harriet shook her head at Gill.
‘Fifteen minutes,’ he said, pulling off his gown. ‘Tell her to 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 the 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 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 any effect this time.
So she decided to pass on scrubbing this time, even though it was her turn. Katya didn’t mind and Harriet promised she’d scrub for the next op, 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 a 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.