The Surgeon: A Rizzoli & Isles Novel: With Bonus Content

seconds she made out the landmarks. The blood was oozing from the liver, but there was no obvious point of injury. It seemed to be leaking from the entire surface of the organ.
    “I’m losing his pressure!” a nurse called out.
    “Clamp!” said Catherine, and the instrument was instantly slapped in her hand. “I’m going to try a Pringle maneuver. Barrows, pack in more pads!”
    Startled into action, the medical student reached toward the tray and knocked over the stack of laparotomy pads. He watched in horror as they tumbled off.
    A nurse ripped open a fresh packet. “They go in the patient, not on the floor,” she snapped. And her gaze met Catherine’s, the same thought mirrored in both women’s eyes.
    That one’s going to be a doctor?
    “Where do I put them?” Barrows asked.
    “Just clear the field. I can’t see with all the blood!”
    She gave him a few seconds to sponge the wound; then she reached in and tore apart the lesser omentum. Guiding the clamp from the left side, she identified the hepatic pedicle, through which the liver’s artery and portal vein coursed. It was only a temporary solution, but if she could cut off the blood flow at that point, she might control the hemorrhage. It would buy them precious time to stabilize the pressure, to pump more blood and plasma into his circulation.
    She squeezed the clamp shut, closing off the vessels in the pedicle.
    To her dismay, the blood continued to ooze out, unabated.
    “Are you sure you got the pedicle?” said Littman.
    “I
know
I got it. And I know it’s not coming from the retroperitoneum.”
    “Maybe the hepatic vein?”
    She grabbed two lap pads from the tray. This next maneuver was a last resort. Placing the lap pads on the liver’s surface, she squeezed the organ between her gloved hands.
    “What’s she doing?” asked Barrows.
    “Hepatic compression,” said Littman. “Sometimes it can close off the edges of hidden lacerations. Hold off exsanguination.”
    Every muscle in her shoulders and arms went taut as she strained to maintain the pressure, to squeeze back the flood.
    “It’s still pooling,” said Littman. “This isn’t working.”
    She stared into the wound and saw the steady reaccumulation of blood. Where the hell is he bleeding from? she thought. And suddenly noticed there was blood oozing steadily from other sites as well. Not just the liver, but also the abdominal wall, the mesentery. The incised edges of skin.
    She glanced at the patient’s left arm, which poked out from beneath the sterile drapes. The gauze dressing over the IV site was soaked with blood.
    “I want six units of platelets and fresh frozen plasma STAT,” she ordered. “And start a heparin infusion. Ten thousand units IV bolus, then a thousand units an hour.”
    “Heparin?” said Barrows in bewilderment. “But he’s bleeding out—”
    “This is DIC,” said Catherine. “He needs anticoagulation.”
    Littman was staring at her. “We don’t have the labs yet. How do you know it’s DIC?”
    “By the time we get the coag studies, it’ll be too late. We’ve got to move
now
.” She nodded to the nurse. “Give it.”
    The nurse plunged the needle into the IV’s injection port. Heparin was a desperate toss of the dice. If Catherine’s diagnosis was correct, if the patient was suffering from DIC—disseminated intravascular coagulation—then throughout his bloodstream, massive numbers of thrombi were forming like a microscopic hailstorm, consuming all his precious coagulation factors and platelets. Severe trauma, or an underlying cancer or infection, could set off an uncontrolled cascade of thrombus formation. Because DIC used up coagulation factors and platelets, both necessary for blood to clot, the patient would begin to hemorrhage. To halt the DIC, they had to administer heparin, an anticoagulant. It was a strangely paradoxical treatment. It was also a gamble. If Catherine’s diagnosis was wrong, the heparin would make the bleeding worse.
    As if things could get any worse.
Her back ached and her arms were trembling from the effort to maintain pressure on the liver. A drop of sweat slid down her cheek and soaked into her mask.
    Lab was back on the intercom. “Trauma Two, I’ve got STAT results on John Doe.”
    “Go ahead,” the nurse said.
    “The platelet count’s down to a thousand. Prothrombin time’s way up at thirty, and he’s got fibrin degradation products. Looks like your patient’s got a roaring case of