Chapter Seven
T he next Monday afternoon, Deirdre dragged herself through work. She trudged down the hall from labor and delivery past med-surg and headed toward the ED, cafeteria, and then admin. Even her bones ached. Too many meetings today, too many emails.
Too much work at the lodge this past weekend. Mav’s plan to host the guests had imploded when one of the EMTs called out sick. Exit Mav.
Enter Deirdre. While Mav pulled an impromptu twenty-four-hour shift, she had cleaned the lodge, fixed breakfast for the couple, knocked a few repairs off the lodge business’s to-do list, and took the sled dogs out for two slushy, yappy trots.
All of that extra work meant Deirdre had to bail on Saturday’s first fake-date with Calvin. Rescheduling to Sunday was a bust as well, as she had to pinch hit in med-surg for the Sunday night shift when two nurses called out sick.
Deirdre took pride in the care this critical access hospital provided, but having a small but dedicated staff meant that the healthcare delivery system strained under the weight of even one unanticipated absence. At the end of the day, patient safety came first. What Deirdre wished was to snap her fingers and poof , there would appear a bunch of extra nurses and nursing assistants. Harsh reality meant that regardless of ongoing recruiting efforts and generous incentives, rural areas everywhere had a steep hill to climb to find enough staff.
This Monday hit harder than usual, what with her job, the lodge, and sorting out the mineral rights for the property so Randy couldn’t try again to access their land. She and Mav had more paperwork to review and an upcoming meeting with an attorney.
Somewhere in all of these activities, she needed to pretend to date Calvin while trying to avoid feelings and not dealing with her past. Everything dragged at her like a lead radiology apron on weary shoulders.
There wasn’t enough caffeine to get through this day. Here she was at three o’clock, heading to the cafeteria to consider another cup. She tugged on the sleeves of her gray blazer and smoothed the matching gray pants and rosé wine-colored shirt, hoping she still appeared professional instead of flat-out haggard.
Last weekend illustrated exactly why she hadn’t entertained the idea of a real relationship. See? She couldn’t even get a fake relationship off the ground.
But she didn’t want it to get off the ground.
Damn it all, a small part of her had looked forward to dinner with Calvin.
Deirdre peered out the glass wall in the main entrance. A snow squall swirled, the pine and scrub-filled hills in the distance no longer visible. Typical for late March in Alaska’s interior. One minute sun and the next minute a whiteout. She had worn her mud boots to work, not her snow boots. Either would get her home well enough, but it was hard to plan attire for every weather possibility.
“Trauma alert, ED. Trauma alert, ED. Trauma alert, ED.” The voice blaring over the intercom startled her.
Deirdre spun and hurried to the ED. She wasn’t required to attend trauma alerts or codes, but oftentimes these events could use an extra set of hands.
Arriving in the emergency department, she skidded to a halt.
The raised voices in trauma room one didn’t catch her attention. The Velcro rip of a blood pressure cuff, an unidentified metal clank, and rumbling wheels of rolling equipment didn’t, either.
But the trail of thick, bloody gurney tracks on the floor leading from the EMS entrance into the trauma bay triggered a mental switch that took her from surprised to laser-focused in a split second.
She snagged a pair of gloves from the box hanging on the wall outside the trauma room, stepped over a fresh red puddle on the floor, and stopped short. Mav and Louise had just finished offloading their patient. Both the seasoned EMTs expressions were lip-tightened and grim.
Nurses Amberlyn and Clyde both had their jaws dropped, even as they scrambled to hook up leads and obtain vitals.
Deirdre’s neck prickled.
Leaning over the patient—or rather climbing on top of—was Calvin, his bloody, gloved hands pressed against the upper thigh of the patient. Deirdre peeked and gasped.
“Hi, Deirdre,” the patient said with a weak wave.
Tuli?
What the hell had happened?
Good God, blood was everywhere.
When Mav loosened the field tourniquet and Calvin moved his hand for a moment, a bright red spray fountained straight up from Tuli’s bare thigh and splattered his thermal shirt and what remained of his thin snow pants and thermal base layer. As someone who hailed from the local Athabascan native population, Tuli’s complexion normally had a warm tone.
Right about now, he was whiter than the one small remaining unstained portion of the hospital sheet beneath him.
Calvin caught Deirdre’s eye. His intense, almost blank stare with the raised brows made her knees knock together. It took a lot to rattle the EMTs and the nurses. It took far more than that to rattle a doc from a Seattle tertiary center’s ED. He’d seen it all.
This situation was bad. Very bad.
“What the heck happened?” she said.
Mav shrugged. “Leave it to Tuli, but he decided to snowmachine his body directly into a broken tree branch.”
“What?”
Tuli shook his head. “That’s what I said. The trail was clear a few days ago. I was helping out Uncle Leonard by checking traps before the storm, figured I’d speed things up by using the snowmachine. Still not sure how it happened. It was like a bunch of branches had been shaved and set up to face the trail. I had stood up to see over a rise. One of the branches caught me. It was sharp enough to come through my clothes. Probably due to speed. Though I wasn’t speeding! Force plus velocity plus sharp pointy object equals…” He took a shaky breath. “Oh, man. It could have been someone else on that trail. A different injury. Worse.”
Deirdre glanced at Mav, who frowned. She knew that look. He’d make sure law enforcement checked out the accident site after things stabilized here.
She jumped in. “What can I do to help?”
Calvin paused and stared at Tuli, then met her eyes. “He needs emergency surgery.”
She squinted at the ceiling. Monday. “We don’t have our outreach surgeon here today. The CRNA is likely breaking away from an endoscopy case to get over here as soon as possible.” She turned to the unit coordinator to confirm. “OR crew should be in-house for the endoscopy cases, so they can prep an OR.”
The coordinator continued to scribe the trauma timeline while dialing her portable phone.
“An OR for whom?” He grimaced, his gray eyes wry and intense. “None of those things are a surgeon, just surgeon-adjacent.”
“Transfer?” she asked Calvin. Asked the room. Anyone.
Mav piped up from outside the room where he’d parked his gurney, “We could go by ground, but I don’t think that’s wise. Latest weather update says that this storm is set to turn into a blizzard here in the next hour.” He glanced over at Louise, who nodded as she wiped down the bloody EMS gurney. “Skies might clear tomorrow for Fairbanks to fly a fixed wing to our local airfield, but not anytime soon. No chopper today with the wind and snow, obviously.”
“Damn it.” Calvin’s chest rose and fell, slowly. It was a deliberate movement. His voice came out tight, controlled. “Okay. So, we have no transfer ability and no surgeon, but we need both right now.”
Tuli’s head rolled weakly from side to side, but he gave a small laugh. “Yo, people, I might not be a fancy doctor, but I am a first responder. I know what a punctured femoral artery acts like.” His voice shook. “Gotta say, the irony is not lost on me. I did not plan to go out in this kind of blaze of glory.” He glanced toward the glass door where Louise grimly continued to clean equipment.
Amberlyn placed a second large-bore IV and hooked up another bolus liter of IV fluid. “I’m surprised you aren’t livestreaming this on your socials, Tuli.”
“I asked Lou in the ambulance, but she wouldn’t let me,” he whined. “We’d be going viral by now.” He flashed a halfhearted smile, goofy if not for the white-rimmed fear in his eyes. “I like to say that I’ll do anything for likes and follows, but this isn’t what I meant.” He paused. “It was kind of weird getting a callout for myself after my cousin called 911. Glad he was riding in the machine behind me, not in front of me.”
Louise scowled at him as she shrugged out of her blood-soaked EMS jacket and cleaned her blood-spattered face with the skin-safe sanitizing wipes Mav offered her. Neither Louise nor Mav went far. As Yukon Valley district fire chief, Tuli was part of the local first responder team. He was one of their own. One of the community’s own. If he’d been any farther away when the accident occurred, he wouldn’t be alive right now.
Deirdre’s heart thudded double-time.
Calvin looked down at where his hand pressed against the upper leg, then said, “Let’s get two units of blood, stat. How fast can we have a crossmatch?”
The lab tech waiting at the doorway said, “As soon you give me the tubes, I should have crossmatched blood ready in fifteen minutes.”
“Let’s do that,” Calvin said.
Deirdre could only guess at what it took for him to remain this composed.
Amberlyn handed off the requested blood specimen from the rainbow set of vials she had drawn.
Calvin called to the retreating lab tech, “Also send over two units of O negative blood to have at bedside, stat. In case it takes longer than fifteen minutes for crossmatch or we need blood sooner.” He took in another huge breath, his shoulders heaving up and down, like a methodical, centering movement. “What are the latest vitals?”
“Blood pressure one-oh-eight over sixty. Pulse one ten. Oxygen sat ninety-six percent,” Amberlyn responded.
Calvin nodded and glanced at the ceiling. “Someone get, ah, Fairbanks acute care surgery on-call on the phone.” He lifted his hand, and another gush of blood poured out. “Shit. Maverick, tighten that tourniquet again. Looks like I’m going to need a lot of exposure, good lighting, and an extra set of hands.” His grim gaze locked onto Deirdre’s with what felt like an iron clink of resolute determination.
She swallowed. She had some experience many years ago as an OR nurse. Time to dust off those rusty skills. She shrugged out of her jacket, which she placed on the counter. She took the laceration repair tray Clyde had retrieved, opened it in sterile fashion, placed it on the metal Mayo stand, and waited for Calvin’s next request.
“Which docs are here today?” she asked, eyeing her brother as he retightened the field tourniquet on the upper thigh until Tuli grimaced.
The unit coordinator pulled up information on her tablet. “Dr. Burmeister is doing the case in endoscopy right now. Nurse practitioner in the clinic. Dr. Tipton is in labor and delivery with a patient who is pushing.”
“So, you’re saying there’s lots of help, just not for me.” His mirthless laugh sent a chill down Deirdre’s spine. “We can’t wait for one of them.” Calvin turned to Tuli. “We’re going to take care of you.” As Mav increased the tourniquet tightness, Calvin released the downward pressure from his hands and grunted in what sounded like temporary satisfaction.
“I trust you, Doc,” Tuli’s voice had grown weaker. “You got this.”
“Pull up twenty ccs of lidocaine for local injection,” Calvin said to Clyde.
“Wait, what?” Tuli squawked. “My atta boy didn’t mean you could try to repair my femoral artery while I’m awake.” He eyed the large syringe. “Are you kidding me?”
“If our CRNA rolls in here soon, you can take a nap.”
“Sure, tempt me with the good drugs.” Tuli’s speech slurred. “Hoo, boy. I don’t feel so good.” His eyes rolled back, and his head lolled to one side. Out.
“Repeat vitals now,” Calvin said, so calmly. Too calm. He glanced over to the unit coordinator. “Do we have Fairbanks yet?”
The woman held out the phone. “I’ve got Dr. Yang on the line. She’s on call for trauma surgery.”
“Put her on speaker.” Calvin projected his voice toward the phone that the coordinator placed in the nearby vitals machine basket. “Hey, this is Cal Garrett, ED doc out here in Yukon Valley. We’ve got a femoral artery puncture, snowmachine rider versus sharp object. Unstable vitals. No surgeon and no ability to transfer for at least twenty-four hours. This facility doesn’t have enough blood products to stay ahead of the hemorrhaging.”
“Sounds like you need to do a femoral artery repair.”
“That’s where you come in,” Calvin said.
After one crisp chuckle, Dr. Yang got down to business. “With the right tools, you can fix most anything anywhere. It might be a little messy.” She paused. “You’re going to do great. Can we establish a proper telehealth link so I can see what you’re doing?”
The coordinator and Clyde rolled in the telehealth video console and set up the connection.
Sweat rolled down Deirdre’s back. This room was getting more crowded by the minute.
Calvin tilted his chin. “Thanks, Dr. Yang. This isn’t a situation I personally encountered at Harborview, due to having ample operating room availability and acute care surgeons always in-house.”
The trauma surgeon adjusted the camera remotely, so it angled toward Tuli. She peered at her screen. “This is par for the course for remote Alaska sites. I walked a family doctor through an appendectomy in Kotzebue a while back. Yours will not be the first assist I’ve performed from hundreds of miles away.”
“Glad you’re confident.” Calvin grimaced. “Deirdre, can you help?”
“Yes.” If he was going to attempt to save Tuli’s life and limb, then she would do her best to assist him. Her mouth dry, she gulped, donned a mask and eye shields, then shrugged into a sterile gown, cuffing on fresh gloves.
With the tourniquet in place, the bleeding from the open puncture wound had slowed to a trickle.
Tuli’s right leg blanched.
Minimal blood flow to the limb. How long could that go on without causing damage? She didn’t know.
The CRNA, Tom, arrived out of breath and already banging open drawers on the ED anesthesia cart he had dragged behind him into the room. “What can I do?”
Calvin answered while shucking off his bloody Patagonia vest and donning a sterile gown and gloves. “Twenty-eight-year-old, no known medical conditions or allergies, traumatic puncture to the femoral artery. Passed out from large volume blood loss. I’m about to do a vascular repair. Can you get him anesthetized so that he doesn’t wake up mid-procedure?”
If they couldn’t fix the leg, Yukon Valley did not have enough blood for the massive transfusion protocol. If this procedure didn’t work… damn it. Deirdre clenched her hands together, hoping that anyone watching would think she was simply keeping her gloves sterile.
Tom quickly pulled medicine into syringes, labeling each one and laying them in a neat row on top of his cart. He got to work pushing meds, intubating Tuli, and hooking him up to the ER ventilator.
Dr. Yang turned to talk to someone off screen. “Yes, hold my next case. I’m going to be a while.” She glanced back to the scene. “Do you have vascular clamps in that kit?”
“No, this is a laceration tray,” Calvin said. “Before staff runs down to the OR, are there other surgical tools you want us to use?”
Dr. Yang nodded. “At least two small vascular clamps, a small Weitlaner retractor. Suction. For suture, use 4.0 Prolene if you have it. Give a dose of Ancef because—”
“Surgeons love Ancef?” Calvin interrupted.
“You’re not wrong.” Dr. Yang gave a dry chuckle.
“I’ll be back in a sec.” Amberlyn dashed out the door, past Mav and Louise who still hovered nearby with twin worried expressions.
Clyde said, “How much Ancef do you want?”
“Two grams,” Calvin and Dr. Yang said at the same time.
In spite of her fear, Deirdre broke the tension. “Look at you, Calvin Garrett, junior surgeon. Pretty soon that will be the only antibiotic you’ll use.”
Calvin rifled through the laceration tray and ripped open the chlorhexidine swab packets. He called over his shoulder, “Any issue with me scrubbing the hell out of this area?”
Dr. Yang nodded. “Scrub away. You’ve got plenty of time. Besides, the IV antibiotics will take care of any remaining bacteria before this patient reaches Fairbanks.”
“I don’t feel like I have time, Doc.”
“You could keep that tourniquet on for hours or more, if you had to. There’s some collateral blood flow to the leg from the profunda femoral artery, which doesn’t look like it was torn.”
Calvin grunted agreement. “Do we have an updated set of vitals?” He cleaned the surgical site and the surrounding area, smearing blood and cleaning solution with the sponge on an applicator stick.
Tom hit some buttons on the monitor. “Pressure ninety over fifty. Pulse one twenty. O2 sat ninety-four percent.”
“ETA on blood products,” Calvin asked.
The unit coordinator murmured into the phone, “Five more minutes for two crossmatched units.”
Clyde held up two bags. “Or you can use these O negatives right now.”
“Dr. Yang?” Calvin glanced up at the camera.
“I think we’re okay to wait for typed blood. Believe it or not, you really do have some time to work with.”
Clyde called out, “I’ll hang the crossmatched blood when it gets here.”
Calvin looked at Deirdre. “Are you ready?”
Her hands shook. Her heart drummed in her chest. But by God, if Calvin needed her help, she was going to do whatever it took to help him save Tuli’s life. “Yes.” She draped the field with sterile towels Clyde partially unwrapped for her to pluck from the packaging.
Amberlyn returned another few minutes later with more materials. “Got the extra equipment.” With loud crackles of sterile wrapping, she opened the packs and dropped the metal devices onto the tray.
Dr. Yang peered at the screen. “Cal, go ahead and start like you would for a vascular cut-down procedure. Make it a generous incision. Give yourself some extra room to operate.”
“Thanks.” Calvin’s neck muscles flexed as he worked. His lower face was covered by the mask. “Then use the Weitlaner to visualize the vessel for clamping?”
“Yes, basically. Your first job is to get as much exposure as possible. Don’t be shy about extending farther than you think you need to go. You need to see both ends of that cut artery.”
Deirdre gulped in the now-silent room as Calvin tried to place the retractor into the small puncture opening. It didn’t fit. He shook his head, then took the number ten blade and extended the area several more centimeters down and up from the injury. The extra space allowed him to insert the self-retaining retractor.
Despite the tourniquet, fresh blood oozed, and Deirdre dabbed with gauze. Her back-aching position leaning over the bed was OSHA nonstandard for workplace ergonomics. No way would she complain, given the situation.
Clyde adjusted the overhead light then stepped back.
The only sound was that of the ventilator’s regular whoosh and click.
Deirdre glimpsed the damaged femoral artery as she swiped away more blood. It was a thick-walled vessel with ragged edges torn completely apart and leaking blood. “I see it!”
“Good job,” Calvin murmured, his praise creating a different warmth in her chest.
Dr. Yang said, “Try to get that proximal femoral artery with a vascular clamp.”
Calvin tried, but he had an awkward angle. “Deirdre, can you get it from your side?”
“Yes, I think. I can. Hold on a moment…” A dull metal click sounded as she carefully locked the clamp around the artery. “There. How’s that look?”
Calvin flashed a smile at her. “You’re hired. Let’s do the same with the distal artery.” He locked the ratchets of the second vascular clamp with a metal clink. “Both are in place.”
Deirdre paused. What if they fixed the damaged vessel but Tuli lost function of his leg? Or got an infection? Or required amputation? A wave of panic rushed up from the depths of her belly.
No, Deirdre wouldn’t think beyond fixing the present injury.
Dr. Yang said, “Describe to me what you see in terms of the vasculature between those two clamps.”
Deirdre dabbed with a sterile swab while Calvin examined the blood vessel.
“Femoral artery is in two pieces.” He pulled gently on the damaged vessel edges with forceps. “There’s some play in the vessel.”
“We can work with that.” Dr. Yang’s words seemed to infuse hope in the situation. “What you’ll want to do is place interrupted sutures to reapproximate the ends of the vessel. It’s either that or a graft, which I don’t recommend attempting out there. Can you do the primary repair?”
Calvin tugged the vessel edges, and they met in the middle. “Yes, I think I can do it.”
“First, release the lower clamp and shoot some heparinized saline down the distal vessel to keep it open and reduce clots,” Dr. Yang said.
A few moves later and Calvin looked up. “Done and reclamped.”
“Blood’s here, Doc,” Clyde said. “I’m running the first unit wide open and the second over an hour if that sounds okay.”
“Yes, great idea.” He continued to examine the damaged artery.
Deirdre tried to anticipate his movements with retractors and gauze. “How else can I help you?” she murmured.
“You’re doing so well.” Lines crinkled at the edges of his gray eyes as he glanced at her. “Does this count as our first date?” He pitched his voice low.
A brief wave of warmth flowed from her toes to her head as she resisted checking to see if anyone noticed. “Ha. Hope not.”
Turning back to the tray, he selected a suture, loaded the needle on the driver, and placed the first stitch. Sweat glistened on his forehead. With a few flicks of the instruments, he tied a knot and gingerly tugged on it.
The suture held.
Deirdre threw up a thanks to the heavens and snipped the suture.
For the next fifteen minutes, Calvin painstakingly placed fine, closely spaced sutures, tying each one individually.
Once he was done, he said, “I think we’re good. Do I need additional stitches for reinforcement?”
Dr. Yang shook her head. “If you feel like you have a solid line of suture, then release the distal clamp slightly and see if the repair holds under a small amount of backflow.”
The room was dead silent except for the beeps of the monitor and the sounds of the ventilator keeping Tuli alive while Calvin worked. He carefully opened the clamp, and the vessel slowly expanded. No oozing around the suture site. No pooling in the surgical field.
Had this amazing physician actually repaired a femoral artery at the bedside?
Deirdre stared at the vessel as if she could hold it together by sheer force of will.
“Now for the moment of truth,” Dr. Yang said. “Release the proximal vascular clamp.”
“I really don’t want to do that,” Calvin said in a droll tone.
Deirdre snorted but gently rested her gloved hand on his. “You’ve got this.”
Calvin took a deep breath. “Here goes nothing.”