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Dante’s authoritative voice snatched her attention back to where it counted. “Top up the muscle relaxant, and inject 10 milligrams of morphine direct into the cannula. That will have to do for anesthesia.”
He waited for her to finish then made his first incision three inches above the site of injury, exposing the external iliac artery. “Here’s where I deal with your clot worries. I’ll occlude the vessels above and below the site of injury, so that a hemorrhage doesn’t obscure the operating field. And the clot will have nowhere to go. Clamp!”
She handed him a non-crushing vascular clamp, watched him applying it gently to the artery. “Why didn’t you use slings?” She’d learned from experience that a special surgical shoelace-like string passed twice around an artery was the best way to occlude it.
He answered without raising his eyes from his task. “A sling may be the method of choice with every other artery, but not the aorta or iliac arteries. There’s too much risk of injuring the lumbar and iliac veins.”
She hadn’t known that.
“It’s incredible that you know about slings in the first place. Most schools of thought advocate non-crushing clamping as the only method of vessel occulsion.” Was he letting her off the hook after she’d boasted of her vast experience in trauma medicine? No, it had sounded like praise.
Heat rose inside her. Embarrassment? Gratitude? More? Whatever it was, it spread in places long untouched, believed untouchable, dead…
Dante was now incising the skin three inches below the site of injury, exposing the continuation of the femoral artery. This time he took the sling she handed him, wound it twice around the artery.
With hemorrhage and clot control now assured, she undid the bandages for him, anticipating his need.
His lips tugged. “Thanks. On to debriding the wound.” Now he’d dealt with the haemorrhage it was time to clean the wound.
Without him asking for it, she placed two self-retaining retractors strategically to open the surgical field. This time he didn’t thank her, but she felt his approval. She couldn’t remember the last time anything had felt so good.
A tap on the back of her hand attracted her attention. “See this? Vein is hanging by a thread and artery is transected. We’re very lucky it got severed below the origin of the collateral branch.”
A closer look showed both ends of the severed femoral artery had recoiled into the surrounding tissues. Dante dissected extensively to find the edges. “Do you think you will need to graft?” she asked.
He exhaled, pulled on one edge. “The vein can be directly sutured, thank God. As for the artery, that depends. If there has been too much tissue loss, or if I have to cut enough tissue that the ends won’t meet without tension, I’ll have to have a graft.”
Attached under tension, the reattached artery would die and probably cause gangrene or even a fatal hemorrhage.
Minutes later he sighed. “No use. Let’s harvest that graft.”
She nodded, swooped to inject both ends with saline to assess the potency of the artery and the vein, then reported. “Return rate indicates an extensive thrombus formation. Do you have a Fogarty catheter?”
He pointed without raising his head, picking a scalpel. “It’s with the other catheters.”
In seconds she’d cleared both ends of vein and artery of clotted blood. “Shall I flush it out with heparinized saline?”
That brought his eyes up and something like a smile to them. “Remind me to thank every mentor you’ve ever had, Gulnar.”
She glowed with pride. It wasn’t a sane reaction, but an unstoppable one.
He’d already moved to Mikhael’s other leg, made an incision at the groin identifying the greater saphenous vein. He began harvesting it through an incision over the course of the vein. He stopped at the inner knee. “I will need only this much. No need to extend the incision into the calf,” he explained.
After exposure of the required length of vein, he deepened his dissection then looked at her. “Need your help here, if you’re done.” She nodded eagerly. “Mix me 120 milligrams papaverine in 250 ccs Ringer’s.”
For a few seconds she couldn’t see where the papaverine was in the bag. Then she spotted it, snapped it up, but still couldn’t understand what he needed it for. Just hand the man what he asked for.
She did, just as he explained. “I’ll irrigate the vein with it, to prevent spasm and to distend it to a suitable size for grafting with the wider femoral artery.”
He then tied the major tributaries of the vein and cut them. Once he’d removed the vein segment embedded in surrounding tissue, he prepared it further for grafting.
After he’d examined the graft segment and deemed it dilated enough, he grafted it in place.
Throughout the delicate procedure, it was as if she’d always worked with him. She anticipated his demands, handing him materials, providing him with better access, swabbing blood, cutting sutures just as close or as far as he needed.
Satisfaction flooded her, as unlikely as it was in their conditions. But she couldn’t help savoring it. There was nothing better in life, nothing more worthwhile, than being part of the restoration of another human being. And Dante was indeed a miracle worker. She’d only ever seen one surgeon who possessed such speed, such unerring, almost prophetic skill. Lorenzo. Still, Dante had something over him, an artistic quality to his every move, a gentle, esthetic flair that went beyond precision, was above uncanny skill. This was talent.
He put the last suture into the arterial repair and exhaled. “What I wouldn’t have given for intra-operative angiography. But I guess we’ll just to believe you’ve cleared all the clots and prevented re-formation.”
