and alert IR?’
Joe reached for his neck, then frowned. ‘Stethoscope?’ he said briskly, holding out his hand, and she lifted her stethoscope over her head and handed it to him reluctantly.
‘You’re dead meat if anything happens to it, it was a graduation present from my sister,’ she muttered darkly, and he rolled his eyes, introduced himself to Jim and checked his chest.
‘OK, his chest’s clear so I’ll take him straight to IR—’
‘BP falling. Sixty-five over forty.’
Jim was crashing. He groaned, and Iona took his hand.
‘It’s OK, Jim, we’re here, we’ve got you,’ she said, squeezing his hand for reassurance. But it was cold and lifeless, clammy now as well, and she felt her pulse spike.
‘Right, can we have the REBOA kit, please, we need to do this now,’ Joe said. ‘And get me an arterial kit before we lose the femoral artery.’
He was going to insert a balloon into his aorta in Resus? Her eyes widened. She’d never seen it done, far less assisted, and she felt a moment of panic.
‘I can page Sam,’ Iona said hopefully. Sam, who was an ex-army medic, had done it dozens of times in the field and would know exactly what to do, but Joe Baker wasn’t waiting.
‘No time. Can I have a pair of scissors? The first thing we need to do is cut a chunk out of the pelvic binder to give me access.’
He cut a slit above the femoral artery on Jim’s left leg and removed a V from the fabric with a deft snip of the scissors. ‘First I’m going to secure access to the CFA so we don’t lose it. I’m going in on the left because the fractures are worse on the right, so this is our best chance,’ he explained, searching for the artery with his gloved fingertips, his hands rock steady. ‘OK, Jim, sharp scratch coming,’ he warned as he inserted the needle, but Jim was beyond noticing.
‘Right, we’re in. Someone open the REBOA pack and cover him in the sterile drapes. Just leave the site accessible, please. Iona, you’re assisting, come and scrub.’
She felt her pulse rate go up another notch. The IR was already scrubbing and she followed him, joining him at the sink. ‘Isn’t it dangerous without imaging?’ she asked under her breath as she scrubbed. ‘You can’t see what’s going on in there. Wouldn’t it be safer in the IR suite?’
He skewered her with those mesmerising eyes, and they’d turned to ice. ‘Are you questioning my clinical competence?’
She held the icy stare with difficulty and shook her head. ‘No, no, not at all! I’m questioning mine. I’ve never assisted with one of these—’
‘Well, here’s your chance, because he won’t make it to IR and if we don’t do this now, we’ll lose him, so I suggest you take a deep breath and get on with it, because frankly he doesn’t have time for this and nor do I. What do you know about a Zone III REBOA?’
She searched her brain, her heart hammering. ‘It stands for Resuscitative Endovascular Balloon Occlusion of the Aorta, and it’s a balloon catheter inserted via the common femoral artery to cut off the blood supply from the aorta below the balloon. Zone III occlusion is below the renal and mesenteric vessels, and it stops the bleeding from the damaged arteries in the pelvis, so it’ll keep his heart and brain alive until you can get him into the IR suite or Theatre and stop the bleeding.’
‘Contraindications?’
‘Chest trauma, cardiac tamponade, pneumothorax, haemothorax, pleural effusion, aortic dissection—’
‘OK, we’ve ruled them out, so what are the dangers?’
‘Damage to the femoral artery or aorta, and reperfusion injury from cutting off the blood supply for too long.’
He nodded. ‘Exactly, so time is of the essence. Right, let’s get on with this.’
She swallowed and sucked in a breath and reached for a paper towel as someone helped him into a sterile gown. ‘What do you want me to do?’
‘Get gowned up.’ He crossed to the bed, snapping on gloves as he went. ‘OK, we’re ready. Let’s go.’ Jim was completely covered with the sterile drapes, leaving just the small area with the cannula sticking out uncovered for access. He glanced at the team as he reached for the REBOA trolley and injected a local around the site of the cannula, then flushed it with heparinised saline and inserted a fine guide wire.
‘Someone phone the IR suite and get them on standby for immediate transfer as soon as I’m done,’ he said as he was working. ‘Tell them I’ll be ten minutes. OK, Iona, watch and learn.’
She watched, and she learned how wrong she’d been to doubt him. His hands were steady and confident, sensitive as he removed the cannula from the guide wire and inserted the large bore introducer with great care. ‘This is the tricky bit,’ he said. ‘You don’t want to tear the artery, and the Twelve French makes a damn great hole, so you have to be subtle. OK, that’s good.’ He pulled out the fine wire and threaded the stiff guide wire in to the mark he’d made by holding it up against Jim’s body. Hence the gowns and extensive drapes, she realised, so he could do that without risk of contamination of the wire.
‘Right, it’s in. Can you hold that steady, please, Iona, I don’t want it to move. Keep an eye on the mark on it. Good. X-ray check, please, around T4.’ He watched the screen, then nodded. ‘OK, that’s good. Then I slide the balloon catheter in over it, up to the mark, which is below the end of the guide wire, and then I inflate—like that, until I feel the resistance change,’ he said, squeezing the syringe steadily to fill the balloon with saline.
‘OK, that should be it. X-ray check here, please,’ he said, indicating the level.
His eyes flicked to the clock, then the monitor, then the X-ray screen, and she saw the tension go out of his shoulders. ‘Good. His BP’s picking up. Time sixteen seventeen. Make sure that’s on the notes, please. Right, secure this lot with a grip-lock dressing so nothing moves, and let’s go. The clock’s ticking and we’ve got an hour, max.’
Moments later the doors swished shut behind them, and as the team dispersed Iona stood there amid the litter of the procedure, staring after them in a mixture of bewilderment and awe.
Had all that only taken thirty-one minutes? It had been the longest half-hour of her life, but Joe Baker seemed to have taken it in his stride, not seeming even slightly fazed by it.
Good luck, or good judgement? Maybe a bit of both, but Jim was still alive and she knew if it hadn’t been for Joe they would have lost him.
It wasn’t going so well for James and his team, though, from what she could hear, and definitely not his patient.
Then she heard James sigh heavily. ‘OK, everyone, I’m calling it. Are we all agreed?’ There was a low murmur, followed by silence. ‘Time of death, sixteen twenty-one. Can somebody cover him, please, but leave everything in place for the post mortem. I’ll go and talk to his family.’
Her eyes flicked to James, and he was stripping off his gloves and gown and coming over to her.
She smiled at him sympathetically. ‘Thanks for your support. I’m sorry about your patient.’
