8
by robspace54
The characters, places and situations of Doc Martin, are owned by Buffalo Pictures. This story makes no claim of remuneration or ownership, nor do I make any attempt to infringe upon any rights of the owners or producers.
Thank you for reading and reviews are much appreciated.
WARNING! This is a post-Series 6 story. If you have not seen Doc Martin Series 6, this story may ruin any number of surprises for you. Proceed at your own peril…
Patient was an elderly primagravida, nearly twelve months post-partum, aged 38. She is now married and has a son. She is generally in good health. Blood pressure is normal, although slightly elevated at 122/76 with a pulse of 77, but given the circumstances of the emergency admission, such findings are not unusual.
The angiogram clearly outlined what the MRI with gadolinium contrast showed; patient has a medium-size arteriovenous malformation in the left frontal lobe, located rearward, almost at the border with the parietal lobe, and located on the motor cortex surface. The scan show the AVM may be a volume of 5 cubic millimeters, and thusly average.
Patient suffered a broken collar bone, and numerous bruises and contusions, from an auto accident (car to pedestrian) plus a pulmonary embolism secondary to impact one month ago. Wafarin has been administered for four weeks, and patient is still on a low dosage.
If I listen carefully, I can tell that the muffled shouting from outside the room has abated, as Mr. Westmore has realized no one will be coming to let him out of the storage closet as a floor mop handle effectively blocks the handles and his exit from his makeshift prison.
If the fool had been able to properly rattle off the five types of AVMs which every vascular specialist knows are classified as true, occult, venous, hemangioma, and dural I would have not intervened. Well… perhaps.
The patient is stable, complains of a mild to moderate headache. No confusion noted upon neurological exam, nor any seizures or their post-effects noted. Patient was oriented as to date, place, and circumstances. Husband was on hand but his assistance was not required for answering any questions.
The Versed acted well, although she vacillated from giddy to morose pre-op, which is entirely typical. When the anesthesiologist injected the IV Valium the patient quickly fell unconscious. I settled the oxygen mask over her nose and mouth.
"Blood gasses are good. I checked that, she's doing fine," admonished the anesthetist and I grunted at her, which shut her up.
I took a slow measured breath. "I'll have the blade please."
The surgical nurse handed it to me and I located the subclavian artery below the right collar bone. Some surgeons prefer to use the femoral artery, but in this case I didn't want to muck about with her lower extremities given the recent history of impact trauma and deep vein thrombosis.
The skin was well scrubbed and dyed the yellow-orange of the antiseptic. Her skin… was warm.
Weight is 140 lbs, height five foot eight, grey-blue eyes, chestnut hair, slim of build. No other major medical history other than occasional anemia, well controlled for two years, and acute glaucoma four years ago. Eats a generally healthy diet, with vitamins, but is known to hanker after chocolate digestives.
I slid the blade along the skin for two centimeters and it parted easily, under tension from the underlayment of subcutaneous adipose tissue, covering the muscles of the chest wall and upper shoulder. A small amount of blood welled up and soaked the gauze pad I held in my left hand. The fluid was warm, and bright red, meaning it was well oxygenated, and also non-clotting. I stared at it for a few seconds as it flowed over the gloved ends of my thumb and forefinger. This was her blood.
Patient reported some confusion, which resolved during transport hospital but opined that it may have been due to personal stress and not a medical issue, due to personal anxiety.
Blood. Red blood. Warm red blood. The patient's blood. The sight of it reminded me the patient was someone's friendd, daughter, wife, and mother. Blood… without it we'd all be dead, at least our brains would be in less than four minutes, or least suffer irreparable and irreversible brain damage. Brain damage is what this procedure will correct, or at least eliminate the possibility of a hemorrhage into the frontal lobe.
The frontal lobe , which as a major and very important component of the brain, houses tissues in which resides the capability to formulate complex reasoning and decisions, initiate and control major voluntary motor functions, and is the major seat of personality, memory, and experience. Soldiers wounded in war or persons having major brain trauma resulting in extensive damage to the frontal lobes can be said to be "changed," effectively becoming one who is less capable, less able to think, feel… I hurriedly stopped that line of thought. The blood glistened on my gloves… and I skittered away from the thought.
A former patient had suffered an AVM from a car accident, another in a fall from a ladder, three were congenital, like this one, and the seventh was… I had to think, for the blood distracted me. Yes, that one, also congenital but a rupture was under way when I injected the fixative agent, the twitch was tiny, oh so tiny, then blood pressure began to fall.
Blood, oh so necessary for life shone up at me like a brilliant and setting sun. I grabbed the nurse's hand and pressed it to the gauze over the wound. "Hold that."
The bin I had placed carefully at hand, so I used it, quickly ripping off my mask to expel my stomach contents. The smell of my vomit made me break out in a cold sweat, both from the vaso-vagal response and the fear that I felt. I wiped my mouth, snapped on new gloves and went back to work.
Patient reported no bright lights or random movements of limbs, yet did describe a moment of confusion in radiology, moments before being brought into theater. She asked me will I be alright?
The ruptured AVM was a problem, and a major one for the intracranial hemorrhage was massive as it flowed over the dura, before penetrating the brain. I was three years into my surgical work after vascular training but it… startled me.
"Cannula."
The nurse slapped the cannula into my waiting hand and I fished it into a tiny hole I made in the vessel below her collar bone. A tiny clip applied slight pressure on the blood vessel to roughly seal the edge.
"Good. Catheter."
Here came the catheter, a full meter of it, an obscene thing to be poking into a body, anyone's body, let alone… I gulped.
"I'm in the artery," I said and pushed it forward about six inches feeling the kink at the base of the neck.
"X-ray. Let's see where we are."
The radiologist flipped the scope on after I pulled my hands away. "There, just… about." I pushed the endovascular catheter forward, seeing it slide up and over to the left side of her neck towards the head. A twist of the thing made it slightly stiffer and I saw it slide higher around the bend of the vessels. "Vitals?"
"She's doing well," the anesthetist said and batted brown eyes at me. "She's pretty."
"Shush." I pierced her eyes with mine. "I asked for signs."
"BP 116 over 78, pulse 58. Sorry, Doctor."
"Mm," I grunted. "It's okay. Okay…" I pushed the catheter forward another ten centimeters. "X-ray."
No reported instances of seizures or other sequelae, reported by patient or her husband. Since patient was struck by a car, and the AVM did not rupture at that time, it is likely a very stable and congenital structure.
My male patient with the bleed writhed as the blood coursed from the ruptured vessel, and I could see it then on the X-ray, a white layer starting to flow over the brain. "Damn."
"Blood pressure is going," I was told. "Pulse is going up, though."
That time I nudged the catheter forward with a will, and someone cried out.
"It's stopped! You plugged it with the instrument! How did you do that?"
I shook sweat from my eyes. "Give me more CA. NOW!"
Cyanoacrylate was now the chosen surgical glue; hard to believe that at one time they actually injected small particles of rubber or foam into these vessels. Now N-butyl cyanoacrylate was the chosen and approved sealant, at least for typical AVMs like this one.
The man on the table shuddered as the CA (I hate to call it super-glue), the cyanoacrylate, flowed into the vessel, but then he started to pink up and stopped moving, his breathing becoming smooth and slow.
"Well he's back," said the nurse and touched my elbow. "Golden hands, Mr. Ellingham."
The student on my other side was shaking his head. "Marvelous work."
"Shut it!" I said to them. "Let's give that a few seconds to catalyze, then we'll get this blasted catheter out and see… if it holds."
Patient told me I had a huge head – full as the moon. Versed makes one say silly things. She also prattled on about beaches and flip-flops.
"Will he be alright, Doctor?" his wife asked me. Her tearful eyes looked at me across his swaddled body in recovery.
"There was a slight bleed, just as I injected the sealant, the uhm, super-glue, into the vessel. It must have just been about to burst."
"Oh my God!" she screamed and her cry echoed down the ward. "Will he be alright?" she grabbed my hand and squeezed it.
I had performed the operation seven times before with only one mishap, and the patient recovered, fortunately. A review of his radiology showed the AVM was started to bulge even before I entered the theater, so I was exonerated, even applauded for my quick work in jamming the catheter in just the right spot. I dared not tell them it was an act of desperation, that tiny nudge of the catheter.
"You should have seen it!" I yelled at the head of radiology, who withered under my ire. "This man could have died, or worse!"
He shook his head at me. "Ellingham, look…"
"NO! YOU look! By not reporting that tiny bulge just there," I stabbed at the computer screen, where the offending vessel took up five pixels, "YOU did not prepare ME with all the facts!"
"I… we'll do better next time," he offered weakly.
I stalked towards the door. "You are a fool Perkins, for there might not be a next time, for a patient!"
Patient is well perfused and unresponsive during the procedure, although some do report a twilight sleep effect of memories and sounds.
"There," I said softly, just as I reached the target in the patient's brain.
The nurse told me, "You push that thing in there like you own that blood vessel, Doctor. Calm and steady. Never seen Mr. Westmore like that."
"Mm. Give me the CA."
The nurse handed me the tube with the saline which would push the sealant into the vessel. "Ready."
"Vitals?"
"Steady as she goes. BP holding at 116 over 76, pulse at 56. Valium is holding her well. Not a care in the world."
I stared at the screen. "Perfusion?"
The anesthetist looked at the readout. "Pee oh two is excellent."
Patient said that she needed a break. A break from me, from…us. But she did have a care, with me, and how I was acting rubbish – silent, remote, even more distant and isolated than usual.
I told her minutes ago that I needed her help. She laughed at me saying well we are both in trouble if I needed her help to perform an operation!
Truth be told, I needed far more than her help. I needed… and she did have a care. She cared about James and herself, and, and…
I tried to swallow but my mouth had gone dry. I've performed this operation seven times, and this was number 8. No, not this, Ellingham! SHE was number eight! Louisa is number eight!
I sighed.
"Doctor?" the nurse was staring at me.
I glanced at her. "I'm fine. Let's seal this. X-ray."
The screen showed the catheter was just where I had left it, a fraction of a millimeter from the AVM.
"Good," I said. I had told her this was like filling a tooth, only in the brain.
Brain – the patient's brain – Louisa's brain. God! A filling in her brain! Damn me for telling her that in the mad dash to hospital! What sort of husband was I to say that to her!
At the moment I was not her husband, just her doctor, and I would do everything in my power to make her medically fit. As for the husband part, well, that needs work.
I slowed down my thinking, my breathing, and remembered Milligan's CDs. "You are in control, in theater. All is well. Just do what you know how to do," the CDs would say and I played them over and over. This was no different – no different; but it was.
There was no other surgeon in hospital who would or could do this properly, so here I was not that baby Westmore that I had locked in the hall closet. I had sworn an oath to tend the sick, to heal where able, to counsel those in need…
I depressed the plunger on the syringe and the saline in the reservoir pushed the tiny bit of cyanoacrylate liquid sealant into the tube, flowing towards her body.
Her body was warm and the skin smooth and soft and I cradled her desperately as I lifted her from the Police Rover into the wheelchair. Her hair was brushed across my face and I sensed the smell of her shampoo, the scent she wore - Kenzo Flower - the deodorant under her arms… and her – her.
Penhale had told me, as they wheeled Louisa into A&E, "Good luck. You go and do what you do best, doc."
I looked at Penhale in his ridiculous costume. "Take James to Ruth, she'll take care of him." Then I turned back to face him, "Thank you," I told him.
Louisa lay on the operating table under bright lights inert and still, other than her soft breathing, assisted by pure oxygen from a mask. Her vital signs were perfect, and I almost cried out as I saw the sealant move inside her body – the living body that I would do ANYTHING to save – to have and hold to… to cherish… and to love.
"Good…" I muttered, "good…"
A quick X-ray showed the radio-opaque bolus of sealant flowing towards the brain where her AVM waited like a lover to accept it.
"About there," the radiologist said. He stepped on the pedal once more and the low-level X-ray showed the CA flowing into the AVM.
I was holding still, afraid to move or breathe, yet blinking as I watched the screen.
"That's great," said the radiologist. "Smooth as silk." The man's eyes smiled at me over his mask. "Good work, Ellingham."
I shook myself from my trance. "Filled? Completely? Let me see." I brushed the nurse aside and I examined the screen where the image was frozen. Yes, it was as he said; the tiny malformation was completely filled with surgical sealant. Oh Louisa… I thought, oh my God.
"Textbook," said the man. "Fine work."
"Uh, thank you," I told him and he was startled by my words.
"She's your wife, I hear?"
"Yes," I answered softly, "and my patient."
"Wow. Tough moment I bet."
I nodded. "Yes. Now let's get this claptrap withdrawn and her stitched up."
Only later in the washroom, in the privacy of a toilet stall, did I allow myself to shed tears, for any number of reasons.