The patient had undergone an ERCP (Endoscopic Retrograde Cholangiopancreatography) earlier that same day. ERCP is a procedure that combines an endoscope with X-ray imaging to examine and treat problems in the bile ducts and pancreatic duct. It is generally considered a low to moderate risk procedure, but it carries known complications, and in this case something had gone catastrophically wrong. The patient had deteriorated rapidly enough to require an emergency return to theatre for a laparotomy, the surgical opening of the abdomen to identify and control the source of whatever was causing the collapse.

By the time the surgical team had opened the abdomen, the extent of the problem was clear. There was a major vascular injury, with haemorrhage of a severity that demanded immediate manual control. The surgical registrar had applied direct pressure to the aorta itself, a technique known as aortic compression, using his hand to physically reduce the blood flowing into the abdomen below that point. It is a last-resort manoeuvre, exhausting to maintain, and a clear signal that the patient was on the very edge of survivability.

Before my arrival, the patient had already arrested multiple times. All episodes were PEA (Pulseless Electrical Activity), a rhythm where the heart's electrical system continues to fire but produces no effective mechanical contraction and therefore no pulse. No shocks were given because PEA is a non-shockable rhythm. Defibrillation has no role when the problem is not the electrical pattern but the heart's inability to convert that pattern into a pumping action. Each return had been achieved through CPR and blood product administration alone.

On arrival I found the Belmont Rapid Infuser in the process of being set up. The Belmont is a high-speed fluid and blood warming system capable of delivering blood products at rates of up to 500ml per minute. In a patient bleeding at the rate this man was, standard gravity or even pressure bag infusion is nowhere near fast enough. The Belmont, when running correctly, can genuinely keep pace with catastrophic haemorrhage.

I took over blood delivery and assumed responsibility for the transfusion. What followed was one of the most sustained and demanding transfusion efforts I have been part of. Over the course of the resuscitation I administered over 40 units of blood products in total, a combination of packed red cells, fresh frozen plasma, platelets, and cryoprecipitate, each component playing a specific and essential role in restoring not just volume but the blood's capacity to carry oxygen and to clot.

In the middle of a life-or-death resuscitation, the blood bank informed us they were busy. There was a significant delay in the supply of blood products. In a patient who had already arrested multiple times and was losing blood faster than we could replace it, a delay from the blood bank is not an administrative inconvenience. It is a direct threat to survival. Every minute without product arriving is a minute the patient moves closer to a threshold he cannot return from.

The Major Haemorrhage Protocol (MHP) pack took over 30 minutes to arrive. Thirty minutes! The protocol exists precisely for situations like this: to eliminate delay, to ensure pre-prepared products are immediately available, and to remove the need for individual phone calls and requests in the middle of a crisis. When the pack fails to arrive within its expected timeframe, the entire rationale for having the protocol is undermined.

Theatres like this one do not run on a single person. The room was filled with a full multidisciplinary team: scrub staff, circulating nurses, anaesthetic team, and surgeons. The anaesthetic team managed the airway, depth of anaesthesia, and haemodynamic monitoring throughout. The scrub and circulating staff kept the surgical field supplied and maintained the controlled chaos that a case like this demands. Every role mattered. Every person in that room was working.

The surgical registrar had been holding that aorta for some time by the point the consultant surgeons arrived. There is something quietly extraordinary about that: a young surgeon, on his last day in post, standing at an open abdomen with his hand physically holding a man's life inside his body, waiting for senior help to arrive. When the consultant team took over, they moved to the spleen.

The operative finding, once the full surgical team was able to properly assess the abdomen, pointed to the spleen as the critical source of haemorrhage. A splenectomy, the surgical removal of the spleen, was performed. The spleen is a highly vascular organ sitting in the upper left abdomen, intimately associated with the splenic artery and vein. When it is injured or diseased to the point of uncontrollable bleeding, removal is often the only definitive solution.

After the splenectomy, the bleeding stopped. The abdomen, which had been a scene of catastrophic haemorrhage for hours, was finally quiet. The patient was stabilised enough for transfer to the ward.

There are cases that sit with you. Not just because of the clinical complexity, or the physical and mental demand of the resuscitation, but because of the unanswered question at the end. Did he survive? Did those 40 units of blood, the hours of sustained effort, the surgeon's hand on the aorta, the splenectomy at midnight amount to a man going home? We do not know. And not knowing is its own particular weight.

What we can do is examine what the system failed to provide. The blood bank delay and the late MHP pack are not aberrations. They are patterns that appear, in different forms, across multiple cases in this series. When haemorrhage is the killer and speed is the only variable that matters, systemic delays are not acceptable. They need to be investigated, named, and fixed.

All staff and patient details have been fully anonymised. These accounts are shared in the belief that honest, open reflection on what happens inside operating theatres makes those theatres safer for the patients who depend on them. New episodes every week at www.skillfullscrubs.co.uk.