Cutting for Stone - Abraham Verghese [213]
“More packs!” Id tried to warn the nurses, but we were still unprepared for the torrent.
I reached in with my hand, displacing a second wave of blood as I grabbed the small bowel. With two hands now, I pulled loops out, fed them onto a towel by the side of the incision. In seconds I had effectively disemboweled the patient.
Deepak appeared across from me, scrubbed and ready. I clasped my hands together, stepped back to cross to the other side of the table, but he shook his head.
“Stay there,” he said. He grabbed a retractor and pulled so I could see under the diaphragm.
I stuffed the lap packs all around the liver. Then I did the same on the left side, in the vicinity of the spleen. With cupped fingers, I scooped out the big clots that remained in the abdominal cavity. I jammed more packs all over the abdomen and into the pelvis, until everything was wedged tight. No blood vessel was pumping that I could see.
We could stop and take a breath.
“Are we catching up on blood?” I asked Ronaldo.
“We never catch up,” he said. When I kept staring at him, he shrugged; he nodded at his dials as if to say things were no worse than when we began—that's what I hoped he had said.
Now I carefully removed the packs, starting with the spots where the bleeder was least likely to be. The pelvis was clean—no gusher there. Off came the pack around the spleen. If the patient's belly was a room, the furniture—the most movable, central structures—had been pulled out so we had a good view to the rear. If there was a bleed from a torn aorta or its branches, then this back wall of the abdomen—the retroperitoneum—would have shown a big ugly swelling, a hematoma. But that was clean, too.
I had a premonition that we would find the bleeder behind the liver. A place full of shadows, hard to see or fix. This was where the inferior vena cava, the largest vein in the body, carried blood back from the lower limbs and trunk, running through and behind the liver on its way to the heart. While coursing through the liver, it picked up the stumpy, taut hepatic veins that drained that organ.
I took the pack away from the liver. Nothing.
I gently pulled the liver forward, to look at its dark side.
An angry gush of blood filled the empty bowl of the abdomen. I hastily pushed the liver back, and the pumping ceased. Things were all right as long as we didn't touch the liver. What was it that Solomon, operating in the bush, had called this? The injury in which the surgeon sees God.
“Okay,” Deepak said, “let's leave it like that.”
“What now?”
“He's oozing from the skin incision and from all the IV sites. His blood isn't clotting.” Deepak had a soft voice, and I had to lean over to hear him. “It's inevitable with this much trauma. We open them up, pour fluids into them, and the body temperature drops … We have diluted the clotting system so it stops working. Let's pack around the liver and get out. Put him in ICU where we can warm him up, give him more fresh frozen plasma and blood. In a couple of hours, if he's alive, if he is more stable, we can come back.”
I sandbagged the liver and fed the small bowel back into the wound. Instead of suturing the skin, we used towel clips to hold the wound edges together.
“The transplant teams will be here to harvest the corneas, heart, lungs, liver, and kidneys from the man he shot,” Deepak said. “This theater is bigger, and I'll let them have it.”
IN THE INTENSIVE CARE UNIT, two hours later, the oozing from the puncture wounds ceased. The cluster of poles and machinery around the bed made it tricky to get near Shane Johnson Jr.—that was his name. His family was in the waiting room, trying to fathom the unfathomable. Fresh frozen plasma, warmed blood, and fluids had given Junior a recordable blood pressure and a respectable temperature. He was alive, but just barely.
“Okay,” Deepak said after reassessing the patient, and looking at the clock. “Let's go take another look.”
This time we were in the smaller operating room. Ronaldo was