who’d had the complication after surgery that morning and that Joel needed anaesthetic information urgently.
Allegra remembered the case well. Gaile Donovan was a forty-eight-year-old woman with ovarian cancer that had invaded the pelvic wall and sigmoid colon. Harry had helped the gynaecologist with the pelvic exploration. The gynaecologist had been keen to get the tumour out but after five litres of blood loss, the normally calm-under-pressure Harry had broken out in a sweat trying to control the bleeding and had insisted they pull the plug before the patient expired on the table. They had packed the pelvis and temporarily closed the abdomen, with the intention of a second-look laparotomy the next day.
When Allegra arrived in HDU, she could hear Harry and Joel discussing the plan of action.
‘The patient’s BP has hit the floor, Harry,’ Joel said. ‘She’s obviously bleeding again—you have no choice but to operate again now.’
‘It was a nightmare the first time around,’ Harry said. ‘I think an angiogram and embolisation would be a better choice for controlling the bleeding.’
‘Listen, Harry,’ Joel said. ‘She’s pouring blood and wouldn’t survive the trip to X-Ray, let alone a couple of hours on the X-ray table, having films done. The blood loss has got to be stopped or at least slowed a hell of a lot first. Maybe embolisation, then.’
‘Damn it! I wish I’d never become involved in this case,’ Harry grumbled. ‘I could see it was trouble as soon as we opened.’
‘Use the theatre here,’ Joel suggested. ‘It’s on site, it’s staffed and it’s got angiography capability. Why don’t you talk to Radiology now so they come in and set up in case you want to do on-table embolisation?’ He turned as he saw Allegra, his expression visibly hardening. ‘I thought Tony called for the anaesthetist on duty.’
‘I’m the one he called, but if you’d prefer someone else, fine—go ahead,’ she said with a flash of her green eyes.
He shifted his mouth in what was clearly reluctant resignation and turned back to Harry. ‘Dr Tallis can anaesthetise for you. I’ve got to get a new central line in quickly to catch up with volume.’
‘Right.’ Harry nodded in agreement and with a quick grimace in Allegra’s direction headed towards Radiology and the ICTU theatre.
Once Harry had left, Joel turned to fill Allegra in on the patient’s condition. ‘Mrs Donovan’s MAP’s 50, pulse 160, sats 80—not good. I’ve got a norad infusion up and fresh blood pouring in, but she needs surgical control of the bleeding. I’m replacing your central line from this morning—it seems to be kinked or compressed somewhere and I just can’t get enough volume through it. Harry’s using the theatre here.’
Allegra had to force aside her personal issues with him to maintain professional calm. ‘I’ll head down now and set up. Will you bring her down?’
‘Yes, in about ten minutes. How much blood altogether did she have in Theatre this morning? I haven’t had time to familiarise myself with the anaesthetic charts here—it would take me ten minutes to add it all up.’
‘Yes, they are confusing. Fifteen units of packed cells and four units of whole blood. She also had four packs of albumin volume expander and three fresh-frozen plasmas. How many have you crossed-matched now?’
‘Twenty packed cells—that’s the current hospital supply of B at the moment. Red Cross are bleeding call-ins tonight to replenish supplies,’ he answered.
‘Good. I’d better get going,’ Allegra said, and left the unit.
Joel turned back to the patient, his brow tightening with tension as he called on all his intensive care skills to work to salvage the rapidly developing disaster in front of him.
Gaile Donovan had two young teenage daughters and a loving husband waiting anxiously in the waiting room for news of their loved one’s condition. Gaile’s cancer diagnosis had been bad enough, but to suffer this complication during surgery added an element of potential tragedy that would be very hard to announce to the family if things didn’t go well.
With the help of Danielle and the nursing staff, he replaced Allegra’s previously inserted central line over a guide-wire and ensured it was running rapidly.
‘Danielle, increase the noradrenaline infusion to three now, please, to help maintain blood pressure. I’m starting a vasopressin infusion to reduce venous pressure in the pelvis,’ Joel instructed.
‘Dr Addison, she’s bleeding from every puncture site,’ Danielle observed with growing alarm.
Despite massive transfusion, it was clear to Joel that coagulopathy was developing, and his inner tension went up another notch. Gaile’s young daughters’ faces swam before his eyes and his stomach clenched uncomfortably at the thought of having to face them with the worst news in the world.
‘Unless we get this blood loss stopped now, no amount of intensive care is going to help her,’ he said. Turning to the nurse at his side, he instructed, ‘Get me four packs of FFP and I’ll call the blood bank myself to retrieve ten packs of platelets.’
The ICTU nurse left to retrieve the packs of fresh-frozen plasma, which were stored in the ICTU blood fridge, as Joel reached for the nearest telephone.
A few minutes later a courier came in with the thawed platelets and Joel stabilised the patient to the point where she could be transferred to the operating theatre for a further attempt at pelvic packing and possible embolisation.
In Theatre, Allegra had set up the anesthetic machine, arterial line and monitoring equipment, and Harry and the scrub team were already scrubbed and waiting.
‘She’s extremely unstable, Dr Tallis—I’m just keeping up with fluids and she’s coagulopathic. She’s on norad at three and a vasopressin infusion. I’ve got FFP and platelets running and we’re onto unit ten of fresh B blood, with ten left to go. Blood bank is scouring for more,’ Joel said as the patient was transferred to the operating table.
Allegra gave him a worried look. ‘I’ve really got my hands full here. Once we open up, her BP is going to hit the floor again.’
‘I know that. I’ll stay here and help with fluid and coag management while you manage the anesthesia,’ he offered.
‘That’s a first,’ Harry said, as the scrub nurse handed him scissors to open the previous incision. ‘You don’t often see an intensivist in Theatre.’
‘That’s the whole point of this new unit,’ Joel said, as he assisted Allegra to attach the arterial line and monitor. ‘Overlap of skills to break down the rigid barriers between specialties.’
While Allegra concentrated on anesthesia, Joel juggled fluid input, coagulation factors, consultation with the haematologists and blood bank, and provided general support to Allegra during the procedure. After rapid prepping and draping of the abdomen, Harry opened the previous incision to be greeted by welling up of venous blood from the pelvis.
‘Her blood pressure’s 60, Dr Addison,’ Allegra said with concern, as she pumped in blood through two lines.
‘Harry, we’re not winning up this end. Can you control anything down there?’ Joel asked over the drapes.
‘I’m doing my best,
