Do no harm, p.25
Do No Harm, page 25
‘We’re going to put you under now, okay? Rest assured that we are here to help you, and nothing more. When you wake up you will be safe at home, feeling much stronger than you do now. Sound good?’
He nods nervously behind his oxygen mask, but I can still see that look of distrust in his eyes. He looks around, searching for someone.
‘I think he wants you.’
Mr Shabbar steps forward and leans over the patient, taking his hand. While they whisper to each other under their breaths in prayer, I think over the next steps in my head: as soon as the patient is sedated, Dr Burke will fit the breathing tube and Margot will get to work draping the patient ready to be cut, and I will head to the foot of the bed to dissect the bypass veins myself.
I look to Margot. If she’s scared, she is good at concealing it, and I’m glad I have her on side. I need her extra pair of eyes, her strength. For as soon as I make the first cut, there is no going back. The patient must live, or we all die. Zack would never be found. From now until daybreak, all of their lives depend on me.
When Faheem steps away, I nod towards Dr Burke and watch as he injects the anaesthesia into the IV, and step towards the patient.
‘Count down from ten for me.’
‘Ten…’ he rasps behind his mask. ‘Nine…’
Before he can reach eight, his eyes roll and his lids flicker shut.
No going back now.
I move to the end of the table with my pulse thumping in my neck, and lift up the surgical drapes to expose the patient’s legs to begin harvesting the veins. My heart drops at what I see.
Large, swollen calves. Fat, purple feet where blood is trapped beneath the skin. I see Margot tense up in the corner of my eye. We both know what this means. I can almost hear her, taunting me from inside her head.
I told you we shouldn’t be going in blind.
46
Anna
Wednesday, 10 April 2019, 01:10
‘How long have his legs been like this?’ I ask.
I try to sound as flippant as I can. The moment I show Faheem weakness, or even the slightest lack of knowledge, his distrust of me will spike. I can’t afford to have him trust me any less, especially not this early in the procedure; I haven’t even cut into the patient yet. If I’m going to get through this surgery without a hitch, I need him calm.
‘About four months,’ he says, from the corner of the room.
‘And has he experienced a dry cough?’
I watch as Faheem thinks back. ‘Yes. Often.’
‘And is the shortness of breath worse when he lies down?’
‘Yes… Why are you asking me these questions?’
‘Just continuing my assessment,’ I lie. ‘Nothing to worry about. Margot, scalpel.’
I take the blade and make the first cut, and begin preparing to dissect veins for the coronary bypasses.
The symptoms Mr Shabbar confirmed suggest that the patient not only has blocked coronary arteries, but constrictive pericarditis: the sac that should be protecting his heart is inflamed. Instead of keeping his heart from harm, the pericardium is choking the life out of it.
The only treatment is to remove it; hell, it’s the only way I’ll be able do the procedure that we are actually here to perform. But the two procedures need to be tackled in completely different ways. To bypass the coronary arteries, I need to transfer blood circulation to the heart–lung machine, but to remove the pericardium, I need the heart to beat on its own and keep its blood supply going. If the pericardium causes bleeding, I need to know about it before I sew him up; being on the heart–lung machine takes that opportunity away. On another patient, I might perform the coronary artery bypasses off-pump and while the heart is still beating, but it comes with more risks, and this patient’s heart is far too weak. If it is put under any more strain there is a high chance it will give up on me.
I should have been more thorough in my assessment when I met the patient. If I had, I might have seen this coming. But I was so eager to get out of there.
I dissect the last of the veins and silently form my plan.
I’ll delay using the heart–lung machine and perform the pericardiectomy, then switch to the machine and complete the bypasses. When it’s all done, we will restore heart function and wait for as long as we can for any signs of bleeding from the pericardiectomy. That’s if we have time to spare at the end of the procedure; if there aren’t any other surprises in store.
After I have closed up the incisions on the patient’s legs, Margot takes the dissected veins and I move to the top of the operating table towards the chest.
‘Dr Burke,’ I say calmly, conscious that Faheem is hanging off my every word. ‘We’ll be delaying bypass initially.’
‘Why?’ Faheem interjects. ‘You said you could do this—’
‘I can. But I have to deal with another issue first, which needs to be dealt with while the heart is beating on its own.’
‘What do you mean, another issue?’ he asks, standing to attention.
‘Swollen legs, dry cough, breathing issues exacerbated when lying down… these are symptoms of constrictive pericarditis. The sac around his heart that is there to protect it has thickened and hardened, making the heart struggle to do its job. It’s not a problem, it just changes our plans slightly.’
I request the scalpel from Margot and turn to Mr Shabbar.
‘You may wish to turn away for this bit.’
With the blade poised in my hand, a sense of control comes over me. I slowly run the scalpel along the skin until his flesh and muscle peel away and the white of his breastbone is exposed. I hand the scalpel back to Margot, who passes me the oscillating saw in return.
Faheem flinches as I power the saw. I move the blade up and down through the bone until the pressure gives and the rib cage cracks open, all the while fearing the level of disease I will find beneath. I pass the saw to Margot and take up the retractors to open the chest.
‘What are the risks of this other procedure?’ Faheem asks.
This is the first time I have had a patient’s guardian in the theatre with me, and I can’t say I like it. I fit the metal teeth of the retractors between the crack in the bone, and talk as I go.
‘Well, there is an increased risk of infection, potential heart displacement—’
‘Then you mustn’t do it.’
‘The alternative is that the patient dies,’ I reply flatly. ‘Would you like me to save his life?’
Mr Shabbar looks back at me, his cheeks reddening with anger.
‘Of course.’
‘Then you need to let me do my job. Outside of this room, you can treat me however you like, but in here, during this surgery – you follow my lead. Otherwise the patient will die. Is that clear?’
We stare at each other across the room. A flush of heat prickles across my back from the scrutiny, but I hold his gaze. I can feel Dr Burke squirming from the tension, sense Margot holding her breath. Finally, he nods. I sigh silently behind my mask.
‘Thank you.’
I take hold of the retractor and shift the ribcage apart, and slowly reveal the organ beating away inside the chest cavity. Usually Margot and I would jump straight in, tools poised. But instead we stand on either side of the table and stare silently into the chest, before sharing a brief, terrified look.
This is quite possibly the most severe case of constrictive pericarditis I have ever seen.
47
Margot
Wednesday, 10 April 2019, 02:10
‘Slower,’ Dr Jones orders, placing a gloved finger on mine where it is poised along the tweezers. ‘Even if you think you’re going too lightly – go lighter. These heart walls are extremely friable.’
Friable is putting it lightly. The pericardium hasn’t only constricted around the heart, it has calcified, essentially supergluing itself to the surface of the muscle. It will be impossible to remove it all without tearing the heart to shreds.
‘Dr Jones, I’m going as lightly as I can, but—’
‘No buts,’ she replies harshly. ‘Just get it done.’
… but it is so difficult to do this while the heart is still beating.
Every time I peel a strip of it away, I have to follow the rhythmic movements of the heart so I don’t accidentally stab it with my tool. If I pull away too fast or tug too hard, I could tear the whole thing open. But the patient’s heartbeat is irregular due to all of the strain it is under, making its rhythm difficult to predict. The patient may be in his forties, but his heart might as well belong to an eighty-year-old chain smoker.
I check the clock: it’s quarter past two in the morning. My head is pounding with stress. We have been performing the pericardiectomy for forty-five minutes, and we are only half done; we haven’t even got to the blocked coronary arteries yet. If we aren’t out of here before six, we might as well be sitting ducks, waiting for someone to walk inside and catch us in the act.
Shabbar and his men are watching us from the corner of the room. He has his sights set firmly on Dr Jones, looking from her hands to her eyes, and back again. If he does look away, it is to assess me, or Dr Burke sat shaking in the corner.
Dr Burke looks utterly terrified, staring ahead blindly and tapping his foot nervously on the lino floor. I catch his eye and give him a wink over the top of my mask to try and tell him we will be okay, and he smiles briefly before falling back into his shocked, almost catatonic state.
It’s a lie, of course – I have no idea if we will get through this. Even if we do save this man’s life, we still might each receive a bullet to the back of the head. I imagine the sound of the gunshot, the thud my body would make as it hit the ground.
My breaths get shallower, and shallower.
Don’t think of that, I scold. Stop panicking – just breathe.
Dr Jones is inevitably tense. While usually she holds herself with relaxed ease, tonight she is working with a stifling rigidity, her muscles frozen into place with fear and angst. Her mask is barely moving due to the pace and depth of her breaths.
‘Margot,’ she says. Her eyes dart up to meet mine in a flash and I jolt. ‘Focus.’
My cheeks flush and I look back down to the heart.
I have been knowingly avoiding certain pieces of the pericardium, but all of the easier pieces have been removed. I zone in on an area that is reaching around the side of the upper-right atrium, and poise my tweezers.
Slowly, I remind myself, as I assess the rhythm of the patient’s heartbeat, and pinch the strip between the tips. Just as I begin to peel it away, the heart beats out of sync and pulls away from my hold, the wall of the right atrium tearing open as it goes. Dark blood immediately gushes out and into the chest cavity. The heart-rate monitor screams.
‘What did you do?’ Dr Jones scolds.
‘It wasn’t my fault! There was a palpitation and then—’
‘Save your excuses and give me suction, now.’
I put down the tweezers and take up the suction, aiming the nozzle over the blood filling the chest and blocking the view of the tear, as Dr Jones picks up her needle driver and suture. Just as she is about to hook the needle into the heart wall, we both freeze to the faint yet deafening click of a bullet entering the chamber of a gun.
I look up. Faheem is stood behind Dr Jones, his gun pointed directly at the back of her head. Dr Burke is whimpering. I peer over Dr Jones’ shoulder to see another of the men aiming a gun between his eyes.
The third gunman is behind me.
‘If he dies, you die, Dr Jones,’ Faheem says. ‘You all do.’
My stomach drops. Tears instantly fill my eyes. The heart-rate machine gets louder. Screeching into my ears until I can’t think straight.
I don’t want to die.
I stare into Dr Jones’ terrified eyes, stray tears slipping down my cheeks as I watch her process the fear. Faheem prods the barrel of the gun into the back of her head.
‘Come on!’
She whimpers as it touches her, and clenches her eyes shut, her lips moving behind her mask as she thinks aloud. Slowly, her breaths calm, and her body stops shaking. When she opens her eyes, I see how focused they have become.
‘Burke,’ she orders. ‘Stats.’
I hear him scramble at his station.
‘B-b-b-blood pressure dropping fast.’
‘Push nitroprusside and up the blockers. Push his BP down as low as it’ll go, and get ready to administer a transfusion or jump on bypass if I need you to. And Margot, for the love of God, suction.’
I look down. The patient’s chest has filled with blood, sloshing and bubbling where the heart is beating erratically. I thrust the nozzle into the pool and suck it away, as Dr Jones hooks the needle into the heart wall and begins to suture the tear together against the heart’s beating.
‘Blood volume falling,’ Dr Burke calls.
‘Start a transfusion,’ she orders. ‘Give him everything we have.’
The nozzle of the gun grazes the back of my head and the shock of it makes me burst into tears.
I don’t want to die. I don’t want my baby to die.
‘Margot,’ Dr Jones shouts. ‘Look at me.’
I open my eyes, and blink back the tears between whimpers.
‘Don’t think of the gun,’ she says. ‘Think of the patient. I can’t do this without you. Now focus.’
I blink away the tears and look down at the chest cavity, and suction at the blood. I cry and blink, cry and blink, the scene below coming in and out of focus. I hear Dr Jones say something, but it sounds tinny and far away.
‘Blood volume is low but staying put,’ Burke says in response, as sounds become crisper. ‘Pressure slowly stabilising.’
The excess blood has almost gone, and the tear has been sutured shut. The danger is passing. I sigh behind my mask, feeling the tension ease from my shoulders.
Then the heart monitor starts wailing again.
‘Heart has fallen into A-fib,’ Burke calls.
I stare down at the chest cavity. The heart isn’t beating normally: it’s trembling minutely, too weak to push the blood from one chamber to the other.
‘Margot, paddles.’
I reach around for the defibrillation machine and stare right down the barrel of a gun. I scramble for the buttons with tears in my eyes as the weapon is pressed against my temple.
‘Focus, Margot,’ Dr Jones calls over the noise. ‘Remember – you’re thinking of the patient.’
Thinking of the patient, thinking of the patient…
I repeat her words as I power up the machine and the gun digs deeper into the side of my head. Something hot is burning into my thighs. I grab the paddles and turn, and almost slip as I pass them across to her.
‘Charge to one hundred.’
I turn the dial and wait for the all-clear. The electric current shocks the heart, but there is still no response.
‘Charge to two hundred.’
I turn the dial and watch as Dr Jones’ whole body jolts with the motion, and looks towards the heart-rate monitor. Everyone’s attention is on the screen, watching the lines, longing for a change to the low, ineffective rhythm.
If he dies, you die. You all do.
A tear leaks slowly down my cheek.
The heart jolts back to life.
Every chest in the room deflates with relief, and the guns lower from our heads. The adrenaline seems to seep away the second the gunmen step back, and I feel my body slump with exhaustion.
I look down to where my legs had been burning: my scrubs are soaked through with urine, and I can see it shimmering on the floor. When I slipped while turning to hand over the paddles, I had done so on my own urine that had been silently pooling on the floor. I literally pissed myself in fear.
‘Well done, team,’ Dr Jones says. She sounds authoritative and in control, but her eyes are wired, and I notice the paddles shaking in her grip as she passes them back to me. ‘That’s as far as we can go with the pericardiectomy, but it’s enough for the heart to beat without restraint.’ She blinks furiously and looks up at the clock. ‘We have three and a half hours to bypass these arteries. Burke, have the heart–lung machine ready.’
She looks to me across the chest cavity, and puts out her bloodied, gloved hand. ‘Margot, scalpel.’
I reach for the tool table and pick up the scalpel, as the last of my energy threatens to wane.
The surgery we came here to do hasn’t even begun.
48
Margot
Wednesday, 10 April 2019, 05:00
Dr Jones is just finishing up with the last vein graft when the clock strikes five.
I have never been so exhausted. My head is pounding, and my teeth and tongue are coated in fur. The scrub trousers have dried now, stuck to my thighs like a second skin.
Dr Jones looks tired too. The whites of her eyes are bloodshot, and the dark circles around them have grown deeper as the night’s gone on. But somehow, she has kept us all from breaking. Before I entered this room I hated the woman, but now I feel a level of kinship with her that I can’t deny. She must feel it too, for she has been kinder to me tonight than during any of the other surgeries we have worked together. Trauma bonds even the unlikeliest people together, I guess.
Faheem Shabbar is still alert, watching our every move. The men behind him, however, have started to fidget on their feet where the blood will have pooled in them, the pins and needles encroaching up their calves after standing for so many hours.
Dr Burke looks ten years older than he had when he entered the room. His skin is paler, and the bags under his eyes are puffy and swollen. We meet each other’s eyes, but we are too exhausted to force smiles, and acknowledge each other silently before looking away again.
It will be growing light outside before long. Soon patients will be arriving for admission, and the nurses will be getting ready to do their handovers. We have just under an hour to get the patient sewn up and off the premises, and for a brief, delusional moment, everything seems as it should: Dr Jones and I are finishing up a surgery, with Dr Burke sat in the corner. But then I catch sight of the Shabbars in the corner of the room with the guns at their waists, and reality slaps the delirium out of me.
