“What’s the biggest risk of operating with this position?” Alex asked Steve Stein as they opened the bone flap for a craniotomy. Alex had the patient positioned on his left side, the table incline placing the feet a few inches lower than the head.
“Blood loss?”
Alex made the “wrong answer” buzzer sound. “Nope. Try again.” Then to Chuck, “Bone wax.” Quickly, with the piece of bone detached from the skull and safely wrapped in a saline-soaked sterile towel, Alex began pushing wax into the marrow space of the skull edges. “Why am I using bone wax?” The sterile wax would seal the space, making it airtight.
Steve moved the sucker closer to where Alex worked, clearing away the oozing blood. “To stop bleeding.”
Alex packed the last spot, then used a wet cotton sponge to wipe the remaining wax off his gloves. “True, but what else? Why not simply cauterize the space?”
“Don’t know. Because cautery doesn’t work well with bone?”
Alex placed the unused glob of wax back on the overhead tray. “We want to prevent air from being sucked into the venous system. Doesn’t have to be much at any one time, but over time it can add up.” He looked to Chuck. “Irrigation.”
Chuck placed a blue rubber ball with a short nozzle in Alex’s hand. He used this to squirt sterile saline over the exposed dura and bone edges, washing away residual bone dust and blood before proceeding to the next stage of the opening. “Same goes for when we open the dura. We have a major venous sinus running along here,” he said, pointing along the midline of the brain surface. “We need to be extremely careful to keep from getting an air embolism. That, Doctor Stein, is our most serious concern right now. And what’s the name of this sinus we’re trying to avoid?”
“Superior saggital sinus.”
“Exactly.”
A few minutes later, Alex stopped Stein as he carefully cut open a three-sided flap of dura hinged along the sinus. “Hold on. You’re close to the edge of the sinus now. It’s not safe to cut any closer. Let me take it from here.” Alex stepped over to the wall-mounted X-ray box for a closer look at the CT scans to gauge the sinus width. He heard Stein ask for a pair of surgical scissors and started to turn to tell him again to stop, when, to his horror, blood gushed from the wound. Stein froze.
“Shit!” Alex shouldered Stein aside. “Lap pad, soaked!”
Chuck rammed the sodden cotton into his hand. Alex pushed it against the dura, hoping to stop the hemorrhage and prevent the sinus from sucking air. “What the hell did you do?”
“I … wanted a bit more exposure. Just a snip.”
“I said stop. What didn’t you understand about that one fucking word?” Alex immediately regretted his tone. “Sorry.”
His mind started racing. His gentle pressure on the lap pad was keeping the bleeding minimized but not controlled. He paused to collect his thoughts. It was crucial to glimpse the damage so he could decide the best way to repair it. “Bob, we have a major problem here.”
“I can see that,” Cole replied, peering over the sterile drapes.
Alex began thinking out loud, talking to no one in particular. “We need to look at the damage. Steve, how much did you cut?”
“Jeez, I don’t know. I put the tips of the Metzenbaum in and snipped … Wasn’t much, couldn’t been more than a couple millimeters.”
Bullshit. From the ooze seeping around the lap pad, Stein had clearly entered the sinus in the upper right-hand corner of the craniotomy. The question now was how much had been opened. Regardless of how much pressure he applied—and he couldn’t apply much because he was pressing against brain—the bleeding continued, forcing him to do something quickly to control it before the patient bled too much.
“Okay, I’m going to pull back the corner to get a look. Steve, I want you ready with a large-bore Sachs sucker.”
He waited for Chuck and Steve to change to a larger sucker, capable of handling the amount of bleeding.
“Ready?”
Steve put the sucker tip into place next to where Alex would pull back the lap pad.
“Have another soggy lap pad ready, Chuck. Okay, here I go.” He tossed the soaked pad blindly behind him then reached for a replacement. Blood gushed at him with such force he couldn’t see the origin. “Fuck!” He pressed the fresh pad into place.
“Bob, we’ve got some serious trouble here.” He fought to keep gut-wrenching fear from his voice. If he showed the slightest panic, everyone would panic.
“What do we do?” Stein asked.
“Shhh! Let me think!”
Basics. Always default to basics. Knowing there were fundamental rules, surgical principles to follow, gave him a sliver of hope. Don’t deviate from the basic rudiments. Control bleeding and maintain an airway. He ran a mental checklist of the things he needed. “Bob, how much blood we have on hand?”
“Two units.”
“Run out a couple red tops for four more immediate units, then have them set up another four for standby … just in case. We’re getting some major blood loss here.”
“I’m drawing them as you speak,” Cole said.
“And turn off the music.”
In the next instant all you could hear were the monitors and mechanicals. Alex bet everyone could probably hear his heart hammering his sternum.
Blood’s taken care of, airway’s under control. What next?
“Bob. Raise and level the table.”
“Silence!” Alex cut Stein off again but this time didn’t bother to worry about his tone. Several seconds ticked past as he thought and rethought his limited options. He was sweating profusely as drops slithered down his chest.
“Okay, here’s the deal,” he explained to no one in particular. “We’re in the sinus. That much is clear. The question is how much is cut and how can we control it.” All of this was rhetorical, he knew, but it felt better to talk through it out loud. “I need a visual to know that.”
“Chuck, load up a big wad of Surgicel plus a wad of thrombin-soaked Gelfoam.” Both were agents used to help blood clot. “When you have those ready, let me know and I’ll try to take another look. Steve, be ready with two Sachs suckers down here. Soon as I pull the lap pad, get in and clear out as much of the field as possible.” He wished for more experienced hands to help him but couldn’t afford the time to muster another assistant into the room. He flashed on Reynolds’s advice of having seniors with him. Too late for that.
“Want me to bust out Fullager?” the circulator asked, referring to the chief resident. “He’s just next door.”
“Thanks, but we don’t have time.” He glanced up and saw Chuck pouring thrombin into a stainless steel bowl, soaking big squares of Gelfoam. Two big wads of Surgicel, a silver mesh, were balled up and ready to go. “Tell me when you’re ready.”
“Thirty seconds.”
Alex checked his own breathing, forcing himself to take slow, measured breaths instead of hyperventilating as he’d been doing. He mentally orchestrated the exact moves he needed to make once he pulled away the sponge. “Speed kills,” he muttered, an old axiom learned from Baxter. Be careful.
“Ready when you are,” Chuck said.
“Okay, listen up everyone. This is the plan. I’m going to pull back the corner of this lap pad while Steve sucks. I figure we have maybe three seconds to look. Chuck, have the Gelfoam ready first.” He held up his bayonet forceps so Chuck could load the tips with the foam. “I’m going to stuff this into the corner, then pack it in place with the Surgicel. Steve, have a cottonoid ready to follow. Soon as I put the Surgicel in place, stuff that cottonoid directly on top of all of it. Then a fresh lap pad.” The old pad was already leaking way too much blood. “Okay, we set?”
Chuck, Stein, and Cole said they were.
“On the count of three. One, two, three.”
Alex threw the blood-soaked pad off to his left, landing with a sodden plop on the floor, while Stein sucked at the torrent of blood filling the field. “Suck!”
Stein couldn’t begin to keep up with the hemorrhage.
“Shit! Gelfoam.”
He quickly stuffed the foam into the approximate location, then repacked the field in the order he’d described, holding just enough pressure to keep the blood from seeping around the pack.
“What now?” Cole asked.
Good question.
“Can’t see the bleeding site well enough. I want to try one more look, but not until I’ve held pressure on it for five minutes by the clock.” He hoped the thrombin-soaked Gelfoam might slow the hemorrhage by that time. “Start the clock. I don’t want us short-changing the time. Bob, raise his head just a bit.”
“Why do that?” Stein asked. “Doesn’t that increase your risk of air embolism?”
Alex nodded. “Yes it does, but so far we haven’t been able to see a goddamn thing. I’m hoping to improve enough venous return to slow the bleeding and see the cut. If we have any chance at all of getting the patient out of here, we have to control the bleeding. Forget about going after the tumor at this point.”
The room remained deathly silent. Everyone realized Alex wasn’t being melodramatic.
“Everyone know what to do?” Alex asked even though he knew they did. “Okay then, on the count of three. One, two, three.”
Hands flew. Alex glimpsed the cut sinus. He held out his hand. “Backhanded dural silk. Quickly!” He intended to stitch in a Gelfoam patch, another trick learned from Baxter. If he could just get the stitch in—
“We’re getting air,” Cole said with urgency.
“Lap pad.”
Alex packed the opening as Cole leveled the operating table.
“She just arrested,” Cole said.
The pit of Alex’s stomach dropped out. The complication just gained more momentum than they could likely handle, and in that instant he knew the patient was doomed.
“Get the overhead out,” Alex shouted, kicking off the brake and pushing the heavy table away from the patient just as Chuck jumped off. The sterile field vanished as he dragged drapes over it, but at this point sterility was the least of their concerns. Alex stayed at the patient’s head, holding the blood-soaked pad on the wound in an attempt to staunch more bleeding, which he later realized was fruitless because the heart was no longer beating.
With the respirator on full assist, Cole started pumping the chest, the monitors screaming at the flat-line EKG. “Get another anesthesiologist in here!” Cole yelled to the paralyzed, wide-eyed circulator.
She bolted from the room.
“Your call,” Cole said to Alex.
Alex used the bloodied sleeve of his surgical gown to blot away tears. He tried to swallow, but the constriction in his throat kept him from doing that. Cole, the other two anesthesiologists, Chuck, Steve, and the circulator waited in the mess surrounding the operating table: syringes, sponges, debris strewn over the floor. He tried to swallow again and wet his mouth with saliva.
“Okay.” He glanced at the wall clock. “The official time of death is nine twenty-seven,” he said in a weak, cracking voice.
He stripped off his gloves, balled up his gown, and threw the wad into the linen hamper. “I’ll go tell the parents.” The patient was a twenty-one-year-old single woman.
Cole came up to him and rested a reassuring hand on his shoulder. “I’ll go with you.”
Alex felt a flood of relief for having his support. Telling the family was going to be difficult enough. Doing it alone, unbearable.
“You don’t have to, you know.”
“I know, but I should be there with you.”
“Thank you.”
Alex knocked twice on the door before pushing it open. The mother and father sat side by side in the small room. Styrofoam cups littered the chipped table to the right, and the air smelled of coffee. The mother looked up, saw Alex, and smiled. “That was quick.”
Alex entered the room, his mind now completely blank, having lost the words so carefully prepared during the trip there. A flash went through the father’s eyes. He knew what was coming.
“I’m afraid I have bad news,” Alex said, moving to the mother. “Your daughter had a serious complication and her heart stopped. We couldn’t get it started again.” She studied his eyes, processing the unfathomable information as her husband wrapped his arm around her shoulders, hugging her to himself. “I’m so very sorry,” Alex said as she began to cry. Alex knelt in front of her and took her hands in his. “I’m so very sorry.”