Chapter 19—FOCUS!

BREA

“Let's begin.”

The words left my mouth quietly, but everyone in the operating room seemed to hear them. I lowered my gaze to the patient's head, where the surgical drapes had left only the prepared area exposed. The monitor beside me continued its steady rhythm, each beep marking another second the patient remained alive. My attention settled on the surgical field, and the world outside that room disappeared completely.

I reached for the scalpel the scrub nurse had placed in my gloved hand and positioned it carefully against the scalp. “I'm making the initial incision now,” I said, more for the team than for myself. “Keep the suction ready and watch the blood pressure closely. I want every change reported immediately, no matter how small you think it is.”

I made the incision, following the planned line with controlled precision. The scalp began to bleed almost immediately, which was expected because the scalp has a rich blood supply, but I needed the field clear before I could proceed any deeper. “Suction,” I requested, and the nurse brought the suction tip into position. The device drew away the accumulating blood, keeping my view unobstructed while I continued working.

“Bipolar forceps,” I said next. The nurse placed them into my hand, and I used them to control the small bleeding vessels rather than allowing blood to collect over the area I needed to see. The bipolar instrument allowed me to apply controlled electrical energy directly around the bleeding vessels, sealing them while limiting unnecessary damage to the surrounding tissue. “Good. Keep the field clear. I don't want pooled blood hiding anything from me.”

Doctor Jason stood opposite me, watching every movement while assisting when needed. “The field is clear, Doctor,” he said. “Your incision is clean, and the bleeding from the scalp is being controlled. The patient's pressure is still holding, although it is lower than ideal.”

I glanced toward the monitor before returning my attention to the procedure. “Then let's not give it a reason to fall further. We already know there is intracranial bleeding. Once we reach the skull and relieve the pressure, we will have a better chance of stabilizing her.”

A retractor was placed into my hand next. I positioned it carefully to hold the edges of the scalp apart, creating enough space for us to see the skull beneath. “The retractor keeps the tissue away from the operative field,” I explained to the younger nurse assisting us, whose eyes remained fixed on my hands. “It gives me exposure without requiring someone to hold the tissue manually, which means the entire team can concentrate on their own tasks.”

With the scalp held aside, the white surface of the skull became visible beneath the surgical lights. I examined the area against the imaging we had reviewed before entering the theatre, mentally matching what I saw with what I expected to find. “High-speed drill,” I said. The nurse immediately placed the instrument into my hand. I adjusted my grip and positioned the drill carefully. “We are creating an opening through the skull to reach the area of bleeding. Keep the suction close because bone dust and blood can obscure the field.” The drill came alive with a controlled mechanical sound, and I worked gradually rather than forcing it. The instrument was designed to remove bone precisely, allowing me to create the access I needed without causing unnecessary damage. Doctor Jason kept his attention on the operative field while the nurse maintained suction.

The moment the bone flap was sufficiently prepared, I stopped and examined the opening. “Good. Suction.” The nurse cleared the field while I carefully prepared to access the tissue beneath the skull. The atmosphere in the room had changed. Nobody was speaking unnecessarily anymore. Every person understood that we had reached the part of the procedure where precision mattered even more.

“Blood pressure?” I asked. The anesthesiologist checked the monitor before answering. “Eighty-four over fifty-two. It has fallen slightly, but it is still responding.” I nodded. “Keep monitoring it continuously. If it starts dropping quickly, tell me immediately.” My eyes returned to the opening. The bleeding inside the skull had created pressure that could damage the brain if it remained untreated, and my job now was to relieve that pressure while controlling the source of the hemorrhage.

I continued carefully, using the appropriate instruments to expose the area without disturbing tissue unnecessarily. “Cottonoid patties,” I requested. The nurse placed them into my hand. I positioned them carefully around the operative field to protect delicate tissue and absorb small amounts of blood without allowing loose material to interfere with what I was doing. “Suction again.” The nurse responded immediately. As the field cleared, I could finally see the collection of blood beneath the skull. It was darker than the fresh blood from the scalp and had accumulated where it should never have been. “There it is,” I murmured. “The hematoma is creating significant pressure.”

Doctor Jason leaned slightly closer. “Do you want to evacuate it now?”

“Yes, but slowly. I don't want to release everything at once without controlling the field. We need to see exactly what we're dealing with.” I reached for the suction and began removing the accumulated blood carefully, allowing the operative field to become clearer little by little. The suction was not simply there to make the area look clean. It allowed me to remove blood and fluid that obstructed my view while giving the team a chance to recognize changes immediately. “Keep the suction steady,” I instructed. “Don't press it directly against the tissue. I need visibility without unnecessary trauma.”

The nurse nodded. “Understood, Doctor.”

As more of the hematoma was removed, the source of the bleeding became clearer. A damaged vessel was still leaking. I narrowed my eyes. “Bipolar.” The instrument was passed to me. I carefully approached the bleeding vessel and used the bipolar forceps to seal it. For several seconds, the bleeding slowed.

Then, the monitor began beeping faster.

“Blood pressure is dropping,” the anesthesiologist announced.

“How low?”

“Seventy-six over forty-eight.”