Fortunately, Mary had learned how to give transfusions from a surgeon at the hospital where she formerly worked in Chicago. The surgeon was curious to know why she wanted to master an obsolete technique. She explained that she thought it might come in handy if there was a major disaster and the hospital’s supply of whole blood ran out. He winked and said, “Oh, so you’re one of those survivor types.” The surgeon was very precise in his instructions. He also gave her a complete description of the equipment needed. “None of the large companies make traditional person-to-person transfusion sets anymore,” he explained. “Everything is geared to working from bladder-packed units of whole blood, plasma, or solutions like Ringer’s lactate like the paramedics use.
However, all the tubing connectors are modular, they use the same fitting as a Luer lock. You can even set up a piece of tubing with needles at both ends for a direct transfusion if absolutely necessary.” He instructed that it was generally better to collect blood for transfusion, rather than making a direct transfusion.
“There is too much risk of losing track of how much is coming out of the donor if you don’t take out measured units. Donors have gone into shock and died from giving too much blood in direct transfusions. It happens a lot in Third World countries where they do direct transfusions.”
Soon after her conversation with the surgeon, Mary added six disposable sets of transfusion rigs to her mini-surgical kit. Although she had long hence memorized blood type compatabilities, for everyone else’s benefit, she typed up “cheat cards.” The rules were generally accepted for packed red blood cells from blood banks, but could be used for freshly donated blood in an emergency. She photocopied and laminated them, and put them in each transfusion kit. They read:
O+ can receive [O+ and O-] and can give to (O+, A+, B+, AB+)
O- can receive [O-] and can give to (all blood types… universal donor)
A+ can receive [A+, A-, O+, O-] and can give to (A+, AB+)
A- can receive [A-, O-] and can give to (A+, A-, AB+, AB-)
B+ can receive [B+, B-, O+, O-] and can give to (B+, AB+)
B- can receive [B-, O-] and can give to (B+, B-, AB+, AB-)
AB+ can receive (all blood types… universal recipient) and can give to (AB+)
AB- can receive [AB-, A-, B-, O-] and can give to (AB+, AB-)
Mary taught a class to the group members on basic transfusion techniques. In the class, she stopped just short of starting an actual transfusion, but she showed how to position both the donor and the recipient, how to set up and monitor the flow of blood, and demonstrated how to “prep” an arm or leg artery on two group members.
Both Dan and T.K. had their arms prepped to give transfusions. T.K. was the group’s only type-O negative universal donor. Dan was positioned on the couch. Mary then loosened the catheter cap and inserted the end of the tubing to start the flow of blood down to an empty bladder pack on the floor. By that time, the IV that was connected to Rose was nearly empty, so Mary replaced it.
She said tersely, “I’m going to put another unit into her, again at a rapid drip, while we are drawing Dan’s blood.” Mary continued to check on Rose’s vital signs in the next few minutes while Dan was giving his first unit. She noticed that Rose was drifting in and out of consciousness. Soon, Dan’s first donor bag was full. She waited until the second bag of colloids was nearly empty, and replaced it with the unit from Dan.
Then she dashed across to Dan and started to fill a second bladder pack.
“Let me know if you start to feel dizzy at all, Dan. We’ll be drawing you down this second unit.” Next, Mary prepared a heavy dose of Ketalar, a disassociative general anesthetic. The dosage was based on a table included with each bottle.
She adjusted the dose based on Rose’s body weight of 120 pounds, and her already semiconscious state. She judged that with this dose Rose would be fully unconscious for four hours. Mary introduced the Ketalar into the flow of transfused blood coming from Dan, using a small bladder of saline linked to the T-connector positioned just below the unit of Dan’s blood.
After about fifteen minutes, Mary cut off the supply of blood from Dan, and had T.K. take Dan’s place on the couch. She slowed the rate of flow from the unit of Dan’s blood to Rose, using the roller clamp, explaining, “We don’t have an unlimited supply of blood, so we’ll hold off on the transfusion until after I get started with the exploratory.”
Washing her hands once again, Mary donned a surgical mask and a pair of sterile gloves. The mask wasn’t necessary, but since she had them handy, she used one. “Ninety-nine percent of the risk of infection comes from my hands and the instruments. But it doesn’t hurt to add a bit of insurance with a mask.”
She then gingerly removed Rose’s bandages, sodden with half-clotted blood.
“I’m going to probe the entrance end of the wound first.” Thirty seconds later, she declared, “It looks clean. The bullet didn’t hit anything major on this end.”
Mary then shifted to the top of her shoulder. “There’s a lot of blood-shot here,” she mumbled. To T.K., Mary’s last sentence sounded more like something someone quartering a deer would say.
“I’m going to have to debride quite a bit of this muscle tissue. If the wound channel is this large after collapsing inward, the temporary channel must have been enormous when the bullet went through. There are also some bone fragments from her scapula. It’s really trashed. What did she get shot with, anyhow?”
“A .357 magnum. And boy, am I pissed,” Jeff replied.
Mary set down the dull probe she had been holding, and picked up a number four curved scalpel. After resuming the transfusion from Kennedy, she began slowly and carefully cutting away some of the most badly damaged tissue.
A few minutes later, Mary spoke again. “Ah haaaah. I see our culprit now.
An artery less than two millimeters across, but just a bit too big to clot closed by itself. I’m not skillful enough to rejoin it, so I’ll just have to suture it off, and hope that nothing goes necrotic. Supposedly a fairly safe bet with arteries this small. The Good Lord was prescient and provided a dual supply to most areas of our bodies. Some of the smaller veins and arteries can be sacrificed and there is still a supply. You can’t do that with anything major like the femoral or sub-clavian arteries, but it is allowable with the smaller ones.”
As she spoke, Mary picked up a “derf ” suture needle holder and clamped a pre-threaded 3-0 absorbable suture into it. The suturing took an unnerving twenty minutes. “This is a real pain,” Mary groaned. “It would be a lot easier if this little artery would stay in place and if it weren’t spurting blood.”
When the suturing was completed, Mary asked T.K. to remove the clamp from the transfusion tubing, resuming the flow of blood. By now, Lisa had replaced the second bladder of blood from Dan with the first one from Kevin, tapping on the tube with her fingers repeatedly to force some air bubbles in the tube up to the expansion chamber. After a couple of more minutes of probing around, Mary asked, “Okay, now I’m going to have to do something with what’s left of her scapula. The only thing is, I don’t know what to do. I’ve removed the loose bone fragments, but that still leaves a really rough edge. Any suggestions?”
There was silence for a few moments, then Dan spoke up, “Couldn’t we just file the edge of it smooth?”
“Yes, I suppose so,” Mary replied, “but I don’t have anything like a file in my bag of tricks. The only thing that comes close is my bone saw, and that’s way too big for this job. What I need is a miniature version of a machinist’s flat file.”
Dan then offered with his characteristic smile, “I’ve got a set of Swiss pattern files in my gunsmithing box. You can take your pick from all sorts of profiles. I’ll go get them.” While Dan was gone, Mary again checked Rose’s vital signs.