19

One slow deliberate stroke, as though drawing a straight line with a pencil, Silas drew the scalpel from just below the sternum down the centre of the abdomen as far as the pubis, an incision of more than six inches. Once through the skin, he proceeded to cut further into the flesh, stopping frequently to take the diathermy probe from Mel as each bleeding point required to be cauterised. Each time it emitted a short sizzling sound and the slight smell of hot flesh as the probe gripped and burnt the tiny tissue ends. Through the rectus sheath, he continued cutting until he reached the layer of the peritoneum.

“Two clips please,” ordered Silas without looking up.

Mel placed the handles of the forceps, one at a time, firmly into his opened hand. She watched as he attached each instrument to the layer of peritoneum in order to lift it.

“Knife.”

She returned the scalpel to his hand.

“Now I’m going to make a small incision here to start with to allow the air to get in. This will allow the abdominal organs to drop down. Then I’ll extend it. You need to be ready with the sucker.” He explained the procedure, as if speaking into the wound, eyes firmly fixed upon the increasingly cavernous opening.

As the sharp curved blade sliced through the visceral sheath of the peritoneum, just like the puncture of a water bed, it released the internal pressure. A copious clot, like a spongy glutinous mass, shining under the fierce bright lights, rose up on its bed of free fluid as though it were boiling. The release of its confinement allowed the eruption of its hidden contents to rush from its depths. Liver-like clots obscured the scene, evidence of the long slow seepage that was sapping Charlie’s strength and life.

“Suction! Quickly!” yelled Silas, his hand already extended to receive the apparatus. Thrusting the hissing tube into the cavity, it gurgled and spluttered as it vacuumed away what seemed to Mel copious amounts of the liquid blood.

“Receiver!”

Pulling clots the size of golf balls out of the opened wound, he flung them into the metal dish, continuing to use the sucker, which now dragged the dark thick blood down the length of its tubing into a plastic receiving canister. As the canister filled, Mel called to Danny to bring over a replacement.

Danny, who had fidgeted and carefully moved unobtrusively around the confined theatre space, to gain the best possible view of the proceedings, now stood like a statue. The unexpected drama unfolding before his eyes, drained the colour from his face, his eyes wide and staring, mouth opened as fear transfixed him to the spot.

“Danny! Somebody! Get me another bottle! I need it now!” Mel’s shout left Danny unmoved.

Maddie left the door she was guarding like a greyhound from a trap. Grabbing a replacement canister from a box in the corner of the room, she delivered the item almost at a run. Mel talked the novice through the procedure of stopping, disconnection and re-connecting the new bottle and, after a few minutes delay, once again the sucker tube gurgled and rattled as it withdrew yet more blood from the patient.

Silas perspired heavily. Droplets of water ran down his forehead unchecked. Unable to wipe away the moisture whilst enveloped in sterile gown and glasses, he could only blink repeatedly, trying to relieve the smarting in his eyes and maintain reasonable visibility. Lack of air-conditioning in the veterinary theatre and with no facility for rapid air exchange, the temperature within the confines of his attire rose. The discomfort was exacerbated by the tension.

Mel was quick to recognise his difficulty. “Maddie,” she called, deciding to waste no more time on her official helper Danny, who remained in a catatonic state. Instead she turned to the woman who at least appeared to have temporarily abandoned her role as prison guard. “Use one of those paper towels over there to mop his brow, please. Whatever you do, don’t touch his gown or the green drapes,” she added the warning.

Obediently Maddie carried out her instructions, reaching on tip-toe beside Silas to remove the persistent perspiration. Silas, who turned slightly towards her to accommodate the wiping of his forehead, turned back immediately to the matter in hand, without acknowledgement.

As the bloody scene was at last cleared of almost a litre of blood, Silas began to pull aside the small bowel and omentum, at last exposing a view of the top of the spleen. A fibroelastic capsule encased the purple organ, resembling a soft aubergine, which now oozed a new persistent leakage of blood.

The sudden massive loss of blood caused frantic activity at the top end of the table. A flustered Clive attempted to both continue rhythmically squeezing the reservoir bag supplying oxygen to Charlie, at the same time exchanging the now empty bag of intravenous fluid with a full one. This he managed to single-handedly achieve by tucking the oxygen bag beneath his right armpit, maintaining the pumping action with his arm, and using his teeth to tear open the outer plastic covering of the new fluid bag.

Clive’s expression portrayed a desperation bordering on panic. Crushing the new fluid bag with his hands, he forced the liquid into Charlie’s vein in an attempt to maintain the sudden drop in his blood pressure.

“You okay there, Clive?” Mel asked in alarm.

Silas paused to peer at his colleague, piercing dark eyes perturbed by the distraction.

“Blood pressure” hissed Clive. “Seventy-five over thirty. Suddenly dropped. Can’t sustain him like this. You’ll have to close up and get out, Silas. Stop the operation!”

“I can’t; not yet at least,” defied Silas. “I’ve identified the spleen now. Just let me get it out.” He dismissed Clive’s dilemma, returning his attention to the open wound with renewed commitment.

“He needs more fluids. He needs blood!” wailed Clive.

“Let me do that,” intervened Maddie, who gestured towards the green re-breath bag. “I can do that while you see to the rest. I’ve seen how you do it” she urged, reaching towards the bag.

“What can I do to help?” the timid voice of Danny joined in. At last emerging from his panic-stricken trance, he at last appeared to have recognised that his lack of participation was hardly contributing to the efforts being made to save the life of his father.

“I need another pack of swabs, Danny. There are a few packs on the bottom of my trolley. Can you open one and tip them onto my tray the way I showed you. Mel saw his lips tighten as he drove himself reluctantly to become involved.

“Roberts artery forceps.” Silas held out his hand expectantly as Mel scanned the row of implements.

“Which one is it?”

“That one, next to your clips. Quickly, I need it now.”

Swiftly she selected a scissor-like instrument. It had the ability to crush, rather than cut, with a graduated ratchet at the base of the handles used to hold the clamp in the closed position. She pressed the handles firmly into his hand and watched as Silas attached the forceps to the splenic artery beneath the spleen.

“Another!” He clamped again.

“Scissors!” He proceeded to cut between the two forceps, severing the artery supplying the organ. Mel watched fascinated as next he clamped and cut the splenic vein, repeating the procedure and leaving all four forceps attached. Requesting again the scissors, he began cutting away at the pedicles holding the flaccid organ in place, finally lifting the spleen like a prize free of the body and placing it with satisfaction into the metal receiver, held in readiness by Mel.

“Suction.”

Still a light stream of blood gurgled its way up the tubing and into the second, almost full canister.

Meeting his eyes across the operating table, Mel saw that the dark eyes had softened and more gently this time he asked for vicryl thread with which to tie off the clamped vessels before removing the forceps and returning them to Mel to replace on her trolley.

Silas glanced again towards Clive, who was still absorbed in his own responsibilities. Maddie continued to bag the patient, frowning with concentration as she endeavoured to maintain a steady slow rhythm of respiration, as near as she could to a dozen per minute.

“Clive,” he interrupted the anaesthetist. “I need to wash out the wound with saline. It’ll be cold. We’ve no means of warming it. That okay?”

“Just get on with it and be as quick as you can. He’s really poorly,” he complained.

It took several minutes to syringe and suck out the saline and few remaining small clots, after which Silas checked the severed vessels, examined the liver for lacerations and adjacent bowels. A silicone drain, its distal end embedded deep into the wound was held in position at skin level with silk sutures. This completed, he began the process of closing all the incised layers, finally suturing the skin and covering the neat line of the incision with an adhesive dressing.

Mel felt elated. The operation was completed and Charlie had survived. Her role as the scrub nurse had gone better than she could possibly have hoped. As she replaced the bloody instruments into the tray and covered them with a green drape, she looked at each of the participants within the theatre. Silas dragged off the sterile drapes from Charlie and threw them onto the floor. After checking the viability of the wound drain, he stripped off his gloves with a flourish and discarded them in similar fashion. Clive, having regained control of the re-breath bag, continued to pump oxygen into the non-breathing recipient, anxiety still imprinted in his furrowed brow. Maddie, standing at his side, rolled her head round on her shoulders, relieving the tension in her upper body from maintaining a fixed position for over half an hour. She seemed more relaxed and in no hurry to regain her former position next to Dennis, still guarding the outer door. Danny passed from Silas to Mel, untying the gown tapes, a suppressed grin advertising the relief he obviously felt.

Mel discarded her protective attire, abandoned her instrument trolley and anxiously approached Clive who, still working as though oblivious to the fact that the surgical procedure had been concluded, ran his fingers over the boxes of drugs piled on a small tray beside the anaesthetic machine. Post anaesthetic recovery was at least Mel’s expertise but as she studied the unconscious patient before her, her heart began to sink. Charlie was still making no respiratory effort, despite the administration of drugs to reverse the muscle relaxants given earlier. He was still dependent upon the manual supply of oxygen. A blue tinge of cyanosis on his earlobes betrayed poor oxygenation and his blood pressure, although improved, had been written by Clive on the side of the pillow as still only eighty over forty.

“Clive?” she asked quietly.

“He needs blood. He’s been slowly bleeding internally for too long. I can’t do the impossible.”

“I got us some colloid fluids and plasma expanders in one of the yellow bags,” she recalled the selection of solutions stolen the previous night.

“I’ve used them already,” he replied miserably. “All we have left are some dextrose saline and saline bags. About six litres, I think.”

“Then we’ll have to manage with what we have,” said Mel decisively. “Let’s raise his legs for a start.” Gathering up the drapes and gowns that had been discarded on the floor, she proceeded to pack them together into a tight bundle and wedged them under Charlie’s heels. Dissatisfied with the result she looked around for something else with which to increase the height. The theatre offered nothing suitable. “May I look in the stockroom?” she directed her question to Maddie, who nodded, but moved back to her original post by the outer door.

A few minutes later, Mel re-emerged carrying a stout square cardboard box. Placing it beneath the pile of green drapes, she managed, with Danny’s help, to raise Charlie’s legs further, thus improving the blood pressure to his vital organs. Another litre of dextrose saline chased earlier fluids into his veins. Mel relieved Clive of the bagging. Freed of the task, he chose to pace the floor, grinding his fists together, waiting for evidence that Charlie’s blood pressure would rise. Mel paused occasionally from compressing the bag and studied the flexible green plastic balloon. At the third respite, she at last detected the faint fluctuations which showed the early signs of spontaneous breathing. Muscle tone and nerve reflexes slowly improved as Charlie gradually emerged from unconsciousness. His blood pressure too, charted an acceptable one hundred over sixty. Clive nodded, a tight-lipped smile creeping across his face.

“Right then, I’ve done my bit.” Silas confronted Maddie and Dennis at the door. “I need a shower and something to eat.” He spoke with the directness of one not accustomed to a refusal.

“We’ll have to take turns at sitting here with Charlie,” Clive spoke to no-one in particular. “I’ll take the first turn. You go and take a break, Mel.”

Mel looked towards Silas, who threw her a piercing look of ‘I told you so’ across the room before turning back to face the door.

“No, I’ll take the first stint.” Mel spoke firmly. “Recovery is my job. You both go and have something to eat and a rest. I’ll be fine. Any problems and I’ll send for you.” Mel wished she was as confident as she sounded. As the doctors left her alone, she turned to look at the pale and weak patient left in her charge.

Their make-shift theatre now resembled a battle-field, proof in its aftermath of the drama played out during the past hour. Blood splashes and footprints stained the floor, discarded gowns and gloves kicked unceremoniously to the side of the room and a collection of empty drug boxes and wrappings strewn on the floor where they had fallen. The abandoned trolley, covered by one of the green drapes which had been thrown over the soiled instruments, now stood beside the sink.

They had done it. Yes, thought Mel with satisfaction, I think we all did incredibly well. We actually carried out a life-saving operation against all the odds. And despite Silas’s misgivings, I even managed to carry out my role as a scrub nurse without any major disasters.

At that moment, the awful truth dawned. They had all been so absorbed by the enormity of the surgery performed that all three of them had probably missed the best opportunity they would likely get to escape from the clutches of this evil gang.