The Surgeon's Meant-To-Be Bride

by Amy Andrews

  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. No wonder Gill had been a little surprised by the divorce papers that morning. Talk about giving him mixed signals! She’d been away for a year and had completely caved after being back in the team for one day and had slept with him. And every day since practically, apart from the time she’d been sick.

  She had to stop leaning on him. She’d managed for a year without him but had just fallen back into old habits this last two months. No. Gill would go home to be with his grandfather and she would see to her own condition if that was what was required.

  Kelly accompanied the patient from the medical building. Theire came also, talking quietly to the young man.

  ‘This guy is the sixth passenger from that car accident. 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.’

  ‘Kehr’s sign?’ asked Gill, knowing that when blood from an injured spleen irritated the subdiaphragmatic nerve root, referred pain was felt in the left shoulder tip.

  Kelly nodded. ‘There’s 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.’

  ‘Pain relief?’ asked Gill, as he switched on the handheld 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?’

  Kelly laughed. ‘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 didn’t want to. 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 said, turning to him, her eyes sparkling with ferocity above her mask. ‘You are a stupid man. To think I wasted my affections on you a few years ago.’

  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 verbal stop sign.

  ‘You love her, don’t you?’ Katya 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.’

  ‘Stupid man,’ said Katya, flicking off the tap with her elbow and flapping her arms up and down 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 as soon as Gill had gowned and gloved and joined them at the table.

  He prepped the area, swabbing it generously with Betadine, streaks of the brown liquid running down the patient’s flanks, and then draped the abdomen, leaving the patient’s stomach exposed.

  With a final nod from Joan he accepted the scalpel from Katya and put knife to skin. The spleen resided in the left upper quadrant, under the diaphragm and lateral to the stomach. It was protected in part by the ribs but despite this it was prone to blunt trauma.

  He made a classic incision, a vertical one about twenty centimetres long, over the spleen area. He cauterised the bleeding points as he went, entering the peritoneal cavity and retracting the skin and muscle layers.

  There was blood, a lot of blood. He couldn’t see anything. ‘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 looking up, as he continued to operate.

  ‘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 shot. There was too much blood to hope to salvage it and no 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 sequestration or storing functions, but other areas of the body could take over the spleen’s role easily.

  Gill worked methodically to tie off the spleen’s blood supply and ligamental attachment. Everything had to be ligated so the organ was no longer fixed to the peritoneum before he could remove it. He had to take special care that he didn’t interfere with any of the nearby pancreas’s blood supply as he went. In fact, he had to be very careful of the pancreas altogether, given its close proximity.

  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 cauterised 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.

  He plonked it in the kidney dish Katya held out for him and removed the sponges he had packed into the abdomen to soak up some of the blood. He could hear Harriet and Katya doing a count and realised he was back again 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 and Harriet, who was nearest, answered. She nodded as she watched Gill degown.

  ‘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 cla
ssical 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 and talent built up over years, and pure art to watch.

  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, all else but what the two of them were doing would cease to 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 at her, 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, and noted 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 from 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 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. 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 or the condyles had been completely blown to smithereens. The sharp splintered edges of the femoral shaft were exposed. An X-ray had revealed no fracture further up the femur.

  The missing limb had been completely blown to pieces by the look of the remaining leg and, even if it had been rescued and had been in good enough condition, there wasn’t the time and it wasn’t the place for lengthy limb salvage operations requiring delicate microsurgery.

  Gill looked at the mangled 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 stage down the track. And evacuate him 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 that a prosthetic device could be fitted to.

  The first thing Gill had to do was decide on the level of amputation. Most surgeons incised about fifteen centimetres above the knee joint but each case was individual and traumatic amputation often required a higher amputation level to allow for viable skin and muscle coverage of the bone.

  Gill made his transverse incision about twenty centimetres. It was well up from the mangled tissue and jagged bone edge and Gill estimated there would be enough healthy skin to cover the stump. The tourniquet provided a perfectly bloodless field, enabling Gill to keep going without having to use diathermy on any bleeding points.

  He was aware only of the leg and Harriet’s presence beside him. She wasn’t humming as she usually did, but Gill couldn’t think of a better person to be in the zone with. She passed him up instruments as if she’d been born to it. The pain obviously wasn’t affecting her ability to assist him and he drew comfort from that.

  Harriet made a supreme effort to concentrate on the operation. Gill was proceeding through the muscle layers, dividing the nerves as he went so the cut ends would retract below the end of the remaining bone. This was important to help with the phantom limb pains suffered by most amputees.

  She did a quick mental check that everything Gill would need or ask for after this stage was on the tray and within easy reach. Orthopaedic sets were just a big boy’s tool set. The instruments weren’t dissimilar to what you would find in any home toolbox—saws, chisels, hammers, screws, drills and nails.

  Oh, sure, they had more sophisticated names but looked almost exactly the same. Harriet found the bone crunching and sheer force required in a lot of orthopaedic ops unsettling. It was kind of brutal and she guessed you just had to have the Y chromosome to get it.

  The pain had become stabbing now and Harriet felt the hot, sharp jab in her side and shut her eyes briefly. She opened them again, forcing herself to tune it out and concentrate on what Gill was doing. There was a long way to go yet, and she would not let him down.

  The clock ticked by as Gill took care of vessels, ligating them. There was relative silence in the theatre, apart from Ella, and Gill occasionally enquiring about their patient’s condition from Joan.

  Harriet reflected how the in-theatre dynamics were different to their out-of-theatre dynamics. Their team chatted and joked a lot outside Theatre. They were close and revelled in banter. But on the job it very much depended on the type of surgery and the pressure Gill was feeling.

  If Gill felt relaxed enough to be chatty then everyone followed suit. But this sort of surgery by its nature was intense, performed on critical patients, and they all felt the enormity of the responsibility they had to keep the patient alive. They followed Gill’s lead. If he was quiet then they all knew and respected his skill enough to let him work in peace without distraction. If he wanted to joke and chat, that’s what they did.

  The clock was just about to tick over to the next hour when Gill said, ‘Release the tourniquet please, Helmut.’

  The tourniquet deflated slowly and Gill watched the operative site carefully for any bleeders. A couple of little vessels oozed and Gill achieved hemostasis with them quite quickly, not bothering to ask for the tourniquet to be reapplied. The tissues were pinking up now as the blood flowed back to them and Gill didn’t want to compromise the circulation to the amputated limb any longer than he had to.

  Harriet picked up the Gigli saw for the next stage of the operation—cutting the femur. An intense, stabbing pain kicked her hard in the side with breathtaking ferocity and the saw slid from her fingers, dropping with a loud metallic clatter to the floor as she clutched the operating table for support.

  An instrument dropping in Theatre pealed as loudly as a church bell. Everyone started and stopped what they were doing.

  ‘Harry!’ said Gill, turning. ‘Are you OK?’

  ‘Of…course,’ she said weakly, swallowing a wave of nausea. ‘Sorry, it slipped.’

  Gill
kept looking at her, searching her eyes, wishing he could see all her face to see if she really was OK. Harriet had never dropped an instrument in all the time they’d been operating together.

  ‘I am allowed one slip-up in seven years, aren’t I?’ she asked defensively, to his incredulous look. And to buy some time to get her breath back from the suddenness of the fierce pain.

  ‘Siobhan, I’m sorry, can you sterilise the saw again?’

  Siobhan picked it off the floor at her feet and took it outside to run it through the three-minute sterilisation process.

  ‘Are you sure you’re OK?’ asked Gill. ‘Do you want Katya to scrub in?’

  ‘I’m fine,’ Harriet dismissed as the pain returned to a more intense throb. She’d never not seen an op through to the end, and she wasn’t about to start.

  CHAPTER NINETEEN

  0100 HOURS

  THERE was a delay while the saw was being resterilised. Gill was out of the zone now and the silence was a little awkward so he encouraged Helmut to tell them a joke. Helmut was very good at jokes with just the right sense of drama to deliver the punch line well. He also had an endless supply and was just what they needed right at that moment.

  Harriet laughed weakly with everyone else at a one-armed surgeon joke, blinking hard to clear a wave of dizziness that threatened to unbalance her. She opened her eyes and was pleased to see the furniture that had been swimming in front of her eyes was firmly back on the floor.

  Siobhan returned with the newly sterilised instrument, placing it on Harriet’s trolley. Harriet passed it to Gill, without dropping it, and the procedure got back on track. She glanced at the clock on the wall as she shifted from foot to foot in her rubber theatre clogs, trying to work out a stance where the pain was more tolerable.

  Thirty minutes, she thought. Tops. All she had to do was last till the end of this procedure and then she would retire unwell, more casualties or not. She didn’t like letting the team down but this pain was only intensifying, and just getting through this op was going to be hard enough.