Trauma

CHAPTER 2

Carrie had met Beth again in the preoperative area, this time accompanied by Rosemary, a certified registered nurse anesthetist. While Carrie had never worked with Rosemary before, watching her insert the IV into Beth’s arm made Carrie confident in the CRNA’s ability. Rosemary gave Beth a light dose of midazolam, which decreased anxiety and would mercifully bring about amnesia. Some things were best not remembered, brain surgery among them.

Once in the OR, Rosemary got Beth connected to the monitors that tracked vitals. She delivered a dose of propofol to induce general anesthesia, followed by a push of succinylcholine to bring on temporary muscle paralysis. From that moment on, the endotracheal tube would do all the breathing for Beth.

Dr. Saleem Badami, originally from Bangalore, India, and a highly regarded intern, was to assist with the operation. This was really a one-person show, so Dr. Badami was there primarily to monitor Beth’s neurological status during surgery.

The circulating nurse had painstakingly prepared the necessary equipment, including the Midas Rex drill, which Carrie would use to penetrate the skull and turn the flap. Last on the team was Valerie, a scrub nurse born in Haiti. A longtime vet of BCH, Valerie was one of the best scrub nurses on staff. As usual, Valerie looked in total command of her craft as she prepped her station for the upcoming operation. It was Valerie who had introduced Carrie to the joys of listening to jazz while operating, and over the years the two had grown close.

If there was one drawback to working with Valerie, it was her unwavering commitment to finding Carrie a date. Beneath her surgical cap and scrubs, Carrie had luxurious brown hair down to her shoulders, almond-shaped brown eyes, enviably high cheekbones, and a body toned and muscled from hours of training. All that, combined with her intellect and outgoing personality, and Dr. Carrie Bryant was somebody’s total package. Despite Carrie’s repeated assurances that she was happily single, Valerie never failed to bring a list of eligible bachelors to surgery.

“His name is James, and he’s some hotshot at a biotech startup in Cambridge. My mother knows his family.”

“Thanks for the suggestion,” Carrie said, checking over the equipment, “but today the only man I’m interested in is John Coltrane. Let’s fire up the music, please.”

Carrie waited for the first notes from “Out of this World,” the first cut from Coltrane (Deluxe Edition), to play before she picked up the scalpel and positioned it for the initial cut. The little stomach jitter that had been kicking around was gone. The first solo flight had to happen to everyone at some point, and today was her day.

You’ve got this, Doc. You trained hard.

Any and all distractions faded. Lingering thoughts of her ex-boyfriend, Valerie’s biotech guy, and tomorrow’s surgery with Dr. Metcalf were just ghosts in her consciousness. Her focus was intense. She loved being in the zone; this level of concentration was a rush like no other. Prior to surgery, Carrie had managed sundry pro forma tasks, those checklist items requiring no thought or decision. Following standard procedure, she had used Mayfield pins to secure Beth’s head in three fixation points.

It was time to operate.

Carrie made the first scalp incision, expertly cutting the shape of a large semicircle over the crown of Beth’s shaved and immobilized skull. She paused to examine her work. It was a fine first cut, and Carrie was pleased with the results. The skin flap was certainly large enough.

The growth was sitting underneath the skull, originating from the meninges, the membrane that covers the brain. It was directly adjacent to the superior sagittal sinus, the major venous channel coursing between the brain’s hemispheres. From what Carrie had seen in the MRI, the sinus appeared to be open. This was one of her chief concerns going in. If the tumor were adhering to the sinus, Carrie could do only a partial resection, which would mean Beth would need additional treatment, such as radiation therapy or another surgery.

Why did you make that promise?

It was probably seeing Beth’s kids, especially little six-year-old Emily with her sweet toothy smile, that had clouded Carrie’s better judgment. If the tumor were free from the sinus, the only treatment Beth would need would be careful follow-up to ensure no recurrence, and perhaps an anticonvulsant medication to reduce the risks of residual seizures.

Surgeons were not, in Carrie’s opinion, like normal people. They were more like clutch shooters who took the ball with three seconds left and the basketball game on the line. Difficult times seemed to bring out the best in their cool. Sure, Carrie had sweated for just a bit at the start of the operation, but that was normal. Good, even. She was young, inexperienced, and it was smart for her to be cautious. Things could head south in a flash, but Carrie was not overly concerned. By the fourth year of residency, any surgeon who would cower in a decisive moment had been culled from the herd.

Carrie set to work placing the Raney clips around the margins of the retracted tissue to hold the scalp in place. The slim blue clips were atraumatic, designed to minimize injury and limit both bleeding and tissue damage.

Thirty minutes into surgery.

It took another fifteen minutes for Carrie to set all the clips in place. Now it was time for her to drill. Carrie held the high-speed stylus in her steady right hand and made four expertly placed burr holes on either side of the parasagittal sinus.

“Change the drill, please,” Carrie said.

The circulating nurse handed Carrie a different high-speed pneumatic drill, and she used that one to cut through the skull between the burr holes. Carrie took in a breath as she lifted the bone flap over the dura. She carefully handed the bone flap to Valerie for safekeeping until she was ready to reconstitute the skull after removing the tumor.

Valerie, being Valerie, anticipated Carrie wanting bone wax to control bleeding from the exposed skull margins.

You’ve got a great team here, Carrie thought.

Pausing, Carrie examined the dura, a thick membrane that is the outermost of the three layers of the meninges surrounding the brain, for any signs of damage. Using her gloved fingers, she carefully palpated the hard, solid tumor beneath. She judged the location of the growth to be perfect for resection, and then used cotton pledgets to tamp down the margins of the exposed dura.

Carrie was exceedingly careful with the pledgets, because too much traction on the dura might cause tugging on critical veins over the surface of the brain, which could result in bleeding. When the pledgets were properly positioned, Carrie was ready for her next incision, keeping in mind that she would cut one centimeter away from the tumor.

One centimeter. Exact. Precise.

Done. After her perfect cut, Carrie used the coagulator and Gelfoam sponges judiciously to control hemostasis and limit bleeding. And there it was, the tumor, sitting on the top of the brain, pressing down on the cortex that controlled Beth Stillwell’s leg and bladder. It was not too big, but it sure was ugly, and more vascular in appearance than she had expected from the MRI image. Thank goodness it was not adherent to the sinus! Carrie could resect it cleanly. Still, the vascular supply was far more complex than she had predicted.

“James is a heck of a lot better-looking than that nasty thing,” Valerie said.

Carrie laughed lightly.

The time was 10:30 P.M. Beth had been in surgery for two and a half hours, a little bit longer than Carrie had anticipated, but not unusually long.

“Vitals?” Carrie asked.

“Looking fine,” Rosemary said.

One hour and I’ll be done, Carrie estimated.

Working with care, Carrie removed the tumor, along with the adherent patch of excised dura, which would be sent off to pathology for a frozen section. It did not appear malignant by gross inspection. She would want to be sure the margins were clean and there was no evidence of malignancy elsewhere. At this point, Carrie figured she could get to the on-call room by midnight and grab five or so hours of sleep before she needed to be back in the OR by seven o’clock the next morning for surgery with Dr. Metcalf.

Ah, the glorious life of a doctor. Her dad, an internist at Mass General, had warned Carrie about the rigors of residency, but his description paled in comparison with the real thing.

Carrie paused to examine her work once more. Something was beginning to bother her. The margins of the craniotomy looked to be oozing blood, much more than usual.

“More Gelfoam and four-by-fours.” Carrie’s voice sounded calm, but had a noticeable edge.

Valerie complied with speed. As Carrie dabbed away the bleeding, her whole body heated up beneath her surgical scrubs.

“Vitals?”

“Blood pressure stable at one hundred over seventy, normal sinus at ninety.”

What the heck is happening?

Carrie did everything she could to stanch the bleeding, but the oozing persisted. She started to worry.

Why isn’t Beth’s blood clotting?

Her pre-op labs had showed a normal coagulation profile. She should not be having this problem during surgery. What is going on? Where is the bleeding coming from?

From the beginning of her residency, Carrie had been taught to think on her feet, but her mind was drawing blanks.

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.