Trauma (3 page)

Think, dammit! Think!

As if Dr. Metcalf were whispering in her ear, Carrie got the germ of an idea. She recalled a case from back in her internship year. A seventy-year-old woman undergoing a craniotomy for an anaplastic meningioma lost blood pressure during surgery and at the same time developed significant skin hemorrhages.

The body normally regulates blood flow by clotting to heal breaks on blood vessel walls, and after the bleeding stops it dissolves those clots to allow for regular blood flow. But some conditions cause the same clotting factors to become overactive, leading to excessive bleeding, as in the case of that seventy-year-old woman. Carrie recalled the outcome grimly.

Could it be DIC—disseminated intravascular coagulation—causing Beth's bleeding? A tissue factor associated with the tumor could be triggering the cascade of proteins and enzymes that regulate clotting. It was a rare complication of meningiomas, but it did happen, especially if the tumors were highly vascular like Beth's.

“Vitals?” Carrie asked again.

“Stable, Carrie.”

Victims of DIC often suffered effects of vascular clotting throughout the body. Once the clotting factors were all used up, patients began to bleed, and bleed profusely—the skin, the GI tract, the kidneys and urinary system. DIC could be sudden and catastrophic.

“Get me a pro time/INR, APTT, CBC with platelet count, and fibrin split products,” Carrie ordered. “Saline, please. Rosemary, keep up her fluids.”

In a perfect world, Carrie would get a hematology consult pronto, but at such a late hour, nobody would be available. Valerie entered the lab test orders into the OR computer.

“Blood pressure is down a bit to one hundred systolic,” Rosemary said.

Carrie continued to control the bleeding at the tumor site as best she could. Now she was in the waiting game. Nobody spoke. Carrie asked Valerie to shut off the music, and the only sounds in the OR were the persistent noises of the monitors and the rhythmic breathing of the ventilator.

Fifteen minutes later Beth's labs came back. Carrie was sponging away a fresh ooze of blood as Valerie read the results off the OR computer.

“Pro time and APTT markedly elevated,” Valerie said. “Platelets down to five thousand. Crit down to twenty-two percent—about half normal. Fibrin split products positive.”

No doubt about it,
Carrie thought,
this is DIC
. Beth had been typed and crossed prior to surgery. Carrie ordered FFP, fresh frozen plasma, and a transfusion of packed red blood cells.

“Carrie,” Saleem said, his voice steeped in worry, “I'm seeing hemorrhagic lesions all over Beth's arms.”

Carrie stopped sponging to examine Beth's extremities. Sure enough, blood was pooling underneath the skin, forming ugly bruises marred by bumpy raised patches that looked like charcoaled burn marks. Carrie bit her lip as she cleared beads of perspiration from her brow with the back of her hand.

On paper, she had made no missteps. There was no way for her to have predicted this rare complication of a meningioma surgery. It was just the nature of how the tissue itself could react and explode in the tightly regulated, complex coagulation homeostasis process. One small tip of the scale could have been enough to send the entire well-balanced system into complete disarray. The reduced hematocrit meant that Beth was bleeding internally as well—within her GI and urinary tracts, perhaps elsewhere. Sure enough, the indwelling Foley collecting bag was filling with blood-tinged urine.

“Give me two liters of normal saline.”

At this point, the FFP and PRBC were ready for transfusion.

“BP down to ninety over sixty. Pulse one twenty,” Rosemary announced.

Carrie took in the information, but she remained calm.

I'm not going to let you die.

At one o'clock in the morning, Carrie had another decision to make. Should she treat Beth with heparin, too? The drug could dramatically worsen the bleeding because it was a blood thinner, but on the other hand, Carrie remembered from her rotation on the medical service that heparin could help by preventing the clotting that caused the consumption of coagulation factors. In some DIC cases, a blood thinner could actually promote clotting. It was a crapshoot. Carrie had been right to give Beth a traditional treatment thus far, but her condition was again deteriorating, and rapidly.

“I want a heparin infusion, now.”

The words left Carrie's mouth before she realized she'd spoken them. Though her team was masked and gowned, Carrie had no trouble seeing the astonished looks on everyone's faces. Saleem hesitated, but Carrie barked the order again, and this time he jumped. Everyone held a collective breath as the drug was administered intravenously. Carrie kept a careful watch over the wound and continued to sponge away the bleeding. To her eye, the blood flow seemed to have lessened.

Still not out of the woods. Not even close.

All Carrie and her team could do now was contain the bleeding, keep administering fluids, and pray the decision to use heparin was the right course of action.

At four o'clock in the morning, Beth finally seemed to be stabilizing. Her blood pressure had risen to 110/65. By that point, everyone in the OR was utterly exhausted, with Carrie in the worst shape of all. This was her patient—on her watch! Carrie's feet had swollen to the size of water balloons and her back strained against the tug of eight grueling hours spent standing.

Carrie ordered another set of labs. This time, while the FSP was still elevated, the PT and APTT were definitely showing signs of improvement. The bleeding looked better, too.

Valerie appeared stunned, as did Saleem.

“Carrie, whatever in the world inspired you to give this poor darling heparin?” Valerie asked.

Carrie was breathing as though she had just finished a sprint-distance tri. “Just a thought I had, I guess.”

At five forty-five in the morning, Beth Stillwell was handed off from surgical to the medical and hematology teams in the ICU. Her DIC was still a problem and she would need much more intensive work to stabilize her, but the major bleeding seemed to be contained. Fifteen minutes later, Valerie and Beth were changing out of their bloodstained surgical scrubs in the women's locker room.

“She's going to make it because of you, because of what you did in there,” Valerie said, brushing tears from her eyes.

Carrie had never seen Valerie cry before, and the sight set a lump in her throat. “But what's the quality of her survival going to be?” Carrie answered. “She bled a lot.”

“Carrie Bryant, don't be so hard on yourself. If it had been any other doc in there, they wouldn't have ordered the heparin and we'd be having a very different conversation right now.”

“Maybe.”

Valerie turned fierce. “Don't you maybe me, Dr. Bryant! You diagnosed DIC quick as you did, and correctly at that. Then treating her with heparin? Girl, in my humble opinion, you are a hero here. Real and true, and I want to give you a hug.”

Valerie opened her arms and Carrie fell into her embrace. The moment she did, the tears broke and would not stop for more than a minute. It had been such a long night.
I made a promise.…

Carrie broke away from Valerie, but could not get the faces of Beth's young daughters out of her mind. She took a moment to regain her composure, then checked the time on her phone. It was six fifteen in the morning. She was due back in the OR for the astrocytoma surgery with Dr. Metcalf in forty-five minutes.

“I've got to go break the news to Beth's sister,” Carrie said, her chest filling with a heavy sadness.

The conversation would be briefer than the family deserved, but she'd page Dr. Michelson and make sure he could be there for follow-up questions. At this point, Carrie only had time to take a quick shower and wolf down a peanut-butter-and-jelly sandwich with a black coffee chaser outside the OR.

That was all the time she ever seemed to have.

 

CHAPTER 3

Carrie arrived to scrub fifteen minutes late, expecting to see Dr. Stanley Metcalf already gowned and glowering. Next to medical incompetence, Dr. Metcalf despised tardiness most of all. She was surprised and more than a little relieved to discover he had yet to show up for Leon Dixon's brain surgery.

In addition to making sure the circulating and scrub nurses were at their stations and ready to go, it was Carrie's responsibility to get the patient prepped, properly positioned, and draped correctly. The only part of the pre-op routine Carrie did not oversee belonged to Dr.Lucas Fellows, the anesthesiologist, who would take care of getting the patient anesthetized and intubated. Surgeons and anesthesiologists did not always play nicely in the same sandbox, each guarding their turf with vigor.

Still, when it came time to put scalpel to skin, Dr. Metcalf was the general in charge. Most surgeons with a reputation like his came with a plus-sized ego. The man could be bombastic, often arrogant, always meticulous, and so demanding of his assistants that a healthy dose of fear was advisable for any underling assigned to him.

Despite his intimidating reputation, the advantages of working with Dr. Metcalf were undeniable. He offered the best opportunity for growth and learning, and for that alone, Carrie was grateful to be his foot soldier. But having incurred Dr. Metcalf's wrath once before, Carrie was glad to have a few extra minutes to set up the OR.

Still, she'd have to hurry.

Thinking of Beth, Carrie finished scrubbing in a daze. Breaking bad news was a part of the job, but that did not make the task any easier. Beth's sister, Amanda, had been told the surgery should not take longer than three hours, so she knew something had gone terribly wrong before Carrie set foot inside the waiting room.

“I'm sorry, but I have some bad news.” Carrie had been taught to use that phrase, but still, there were few words a doctor despised saying more than those.

I'm sorry …

Valerie had accompanied Carrie into the cramped conference room where she had taken Amanda to consult with her in private. Because of Carrie's back-to-back surgeries, Valerie offered to hold the conference with Dr. Michelson instead, but Carrie believed the privilege of caring for sick people came with the added burden of being the messenger.

“Is she going to live?” Amanda had asked after Carrie finished.

Amanda was a sweet-faced woman, five years younger than Beth, and the strain in her kind eyes put a lump in Carrie's throat.

“We're doing everything possible to make sure that she does,” Carrie said.

Amanda bit at her lower lip, but could not hold back the rush of tears in her eyes. In response, Carrie reached across the table and clutched the young woman's trembling hand.

“I'm so sorry, Amanda, we're doing everything we can. Please know that. I'm deeply sorry for what's happened here.”

A single nod sent Valerie off to get Amanda some water. Carrie did her best to answer Amanda's many questions, though she suspected the young woman would retain little of it. Carrie spoke frankly but compassionately, and promised to follow up with the hematology team looking after Beth as soon as she could.

In the OR, prepping for the next patient, Carrie struggled to push Amanda's tears, Beth's three children, and the complexity of Beth's case out of her mind. A man with a serious brain tumor was waiting for her in the OR, and he deserved her undivided attention.

Margaret, the circulating nurse, was on her first day at BCH, so she was shy and quiet as she assisted Carrie with her surgical gown and gloves. It was just as well. Carrie's guilt and exhaustion left her in no mood for small talk.

Scrubbed and gowned, Carrie entered the OR and headed straight to the viewbox. The films weren't there. She looked around and saw that X-ray had delivered them, but Margaret hadn't put them up, probably because she was new and nervous.

Though the task was the new nurse's, it was easier for Carrie to do it herself. Carrie grumbled under her breath as she removed the MRI image from the protective envelope.

Dammit!

The moment her gloved hand came in contact with the film, Carrie realized her mistake. She had broken scrub by touching a nonsterile object with her sterilized gloved hand. She'd have to go through the sterilization procedures all over again. It would mean being even more rushed during prep than she already was. Dr. Metcalf could arrive at any second, and if he did not see everything in pristine order, ready to drill, there would be serious fireworks.

For now, it was back to Leon's film.

Carrie had given him only a cursory examination previously, but she remembered that Leon had exhibited cognitive and behavioral problems, some muscular control issues, memory problems, and difficulty controlling his temper.

Carrie tossed the film up on the viewbox, a film she had seen only once before, briefly, in Dr. Nugent's office. That felt like a lifetime ago. Based on visual characteristics, the brain tumor was probably an astrocytoma, the most common form of tumor, but pathology would have to confirm. From what Carrie could see, the mass was not characteristic of a systemic cancer, something that had metastasized to the brain. Good news for Leon. Still, she doubted it was a totally unsuspected abscess, something that surgery plus a prolonged course of antibiotics could essentially cure. Dr. Nugent had said something similar during his brief consult.

Regardless, it didn't do any good to speculate. They would sample the tissue, get the pathology report, and go from there.

Carrie saw that the mass was located deep in the temporal lobe. It looked angry, with a good deal of edema. Leon would most likely need additional surgery to debulk the tumor, followed by radiation and chemotherapy treatments. He might get a few more quality years before the tumor came back to take it all away.

Carrie's dry eyes ached from lack of sleep. At least this case would not be difficult for Dr. Metcalf, who had probably done a thousand of these procedures. She'd be home sometime after noon and asleep a few minutes after that. Assuming, of course, that Dr. Metcalf actually made it to surgery. Carrie had never worked a case before where he'd been so late, and she was beginning to wonder if he had the wrong date on his schedule. In an administrative behemoth like BCH, stranger things had happened.