Consultant In Crisis

‘I’m hardly the most qualified person to start,’ Kelly reminded Dave. ‘You’ve got an emergency department consultant here, you know.’

The emphasis rankled. Was it so hard for her to use his name? To make him a person instead of a profession? Or had Kelly been surprised to discover that Fletch had gone from a registrar position to a consultancy in the space of only two years? Maybe thirty-two was young to have achieved such a senior position but it hadn’t been easy. He’d worked extremely hard and he deserved his success. Everyone was looking at him now. Except Kelly.

‘I disagree,’ Fletch said calmly. ‘By and large the trauma patients that turn up in Emergency have already been assessed and neatly packaged by the ambulance service. We work under controlled conditions with plenty of equipment and staff available. Hardly what we’re going to encounter in a USAR call-out.’

Dave nodded his agreement. ‘Don’t worry, Kelly. You won’t have to do it all by yourself. Your task is to take us through a primary survey. Ross is going to do vital signs and CPR. Joe’s going to cover immobilisation techniques. Fletch is going to talk about shock and Wendy and Jessica are going to cover treatment of soft tissue injuries. This afternoon we’ll try and pull it all together with some scenario work in small groups.’ Dave gestured towards the space he had left at the front of the class. ‘Over to you, Kelly. Let’s get stuck in.’

Kelly looked quite relaxed as she moved to lean against the table at the front of the room, but that was because most people wouldn’t know that the habit of tucking a tendril of dark hair behind her right ear only surfaced when she was nervous. Fletch knew. He also knew what she looked like when that magnificent mane of hair was unleashed from its restraint…when it fell like the softest curtain imaginable to screen a slim, naked back.

Shutting his eyes to kill the memories the sight of Kelly’s hair evoked, and shutting his mind to the emotional effect that kicked in like a bad aftertaste, Fletch tried to concentrate on what the young paramedic was saying.

‘A primary survey is a means of identifying life-threatening situations or injuries in order to treat them appropriately at the earliest opportunity.’

Fletch opened his eyes again. Now it was her voice that was stirring emotions he would rather not explore. It was a voice that had haunted him for months after she’d left. Deceptively soft, it belied a determination and courage that had been one of the qualities Fletch had admired most in this woman. He sighed inwardly. Last week he’d thought he’d had this unexpected reunion taped. He could handle seeing Kelly again. It made no difference. Had that brief confrontation at the pizza restaurant when they had made an acknowledgement, albeit understated, of a past relationship been enough to change things? Or was his resistance just wearing thin? Why was it that things that one knew to be self-destructive were still capable of exerting such a powerful attraction?

‘Assuming that the scene has been made safe enough for us to approach our patient, what’s the first thing we’re going to do to start our primary survey?’ Warming to her role as tutor, Kelly had written a series of letters on a whiteboard—S, L, A, B, C, D and E. S had just become the word safety.

Kyle, as usual, was the most eager to respond. ‘See if they’ve got a pulse.’

‘Are we going to check their breathing?’ June was a grey-haired woman with many years’ experience in civil defence work.

‘Good,’ Kelly responded. ‘But what will we do as part of, or even before, that check?’

‘Talk to them,’ June expanded. ‘Ask them if they’re OK.’

Kelly ignored Kyle’s dismissive head shake. ‘That’s exactly right, June. In other words, we’re going to determine our patient’s level of consciousness.’

Kyle slumped down in his chair and fiddled with his pen. Fletch watched as Kelly caught the attention of more people on the other side of the room.

‘We won’t worry about the more complicated methods of assessing LOC, like the Glasgow coma scale. Basically, we’re going to find out if the patient is spontaneously responsive or whether he responds to vocal or painful stimuli.’

The group of men sitting near June were all listening carefully now. Owen was the oldest of the four fire officers from various city stations.

‘What kind of painful stimuli are we going to use?’

‘What about a pen?’ Roger looked pleased to attract Kelly’s notice. ‘You put it between the fingers and then squeeze them together. Hurts a lot.’

Pens got picked up around the group and experimented with. Fletch was more interested in watching Roger. Why hadn’t he noticed before that the younger fireman was rather good-looking? That he wasn’t taking his own gaze off Kelly? Had Fletch missed something brewing between those two in the last couple of weeks? Roger had certainly been determined to find out what the past connection between Fletch and Kelly had been. If he was interested, then good luck to him, Fletch thought bitterly. He had no idea what he was letting himself in for.

‘Try a knuckle rub on the sternum,’ Kelly told the group. ‘Just as painful and you don’t need to go hunting for a pen. OK. Let’s say there’s no response. What next?’

‘See if they’re breathing?’

‘Sure.’ Kelly nodded at Kyle’s suggestion. ‘But there’s something else we might need to do before that.’

Roger’s gaze was still locked on their novice instructor. As though he felt the observation he was under from Fletch, Roger looked up. He stared back at Fletch for just long enough to issue an unspoken challenge.

‘What could interfere with someone’s ability to breathe?’ Kelly prompted.

‘Oedema,’ Wendy responded. ‘Soft tissue injury.’

‘Being dead,’ Fletch suggested dryly.

Joe snorted with laughter. ‘Yep. That’ll do it every time.’

Kelly’s lips quirked. A tiny, one-sided curl and quick correction that Fletch recognised as easily as her hair-tucking gesture. A sign that his black humour had amused her but it was not appropriate to indulge the response. How often had Fletch deliberately evoked that quirk in the past? A private joke subtly hinted at in front of a patient, a not-so-subtle murmur in her ear as he passed. Did Roger have any idea how easily Kelly’s sense of humour could be tickled? Fletch had always been able to make her laugh and he had taken enormous pleasure in doing so, especially when she’d been stressed or unhappy. Sometimes she’d appeared to be under perfect control but he’d known she’d still been laughing on the inside. A sparkle of glee had made those gorgeous blue eyes dance and Fletch had been able to hug the satisfaction that he had been the one to provide that enjoyment.

Not that there was any hint of sparkle this time. The look that Kelly threw both Fletch and Joe was purely exasperated. She walked towards the firemen. ‘Owen, pretend you’re a disaster victim.’

‘No pretence needed,’ Gerry quipped. ‘He is a disaster.’

This time Kelly acknowledged the humour with a real smile. A quick grin that gave Fletch an odd sensation, as though he’d been kicked in the stomach by someone wearing very soft shoes.

‘You’ve been trapped for a long time in a collapsed building,’ Kelly continued. ‘You’re sitting against a wall. Your leg is caught under a timber beam. Oxygen level’s getting low. You’re in pain from a fractured femur and you’ve been bleeding from a laceration on your arm. Your blood pressure’s dropping. Rescue isn’t far away. You’ve been listening to them getting closer for hours now but you can’t hold out any longer. You lose consciousness.’

Obligingly, Owen made a gagging sound and his chin dropped to his chest.

‘Excellent!’ Kelly’s grin was broader this time. ‘What’s happening now?’

‘He’s snoring,’ Roger observed.

‘As usual,’ added Gerry.

‘He’s obstructed his airway,’ Jessica informed them.

‘And if he’s unconscious he won’t be able to correct it.’ Kelly nodded. ‘It could lead to a respiratory arrest and death, despite imminent rescue and non-life-threatening injuries. So—we get into the space. There’s no response. What do we do?’ Kelly pointed at Owen’s mouth. ‘We’d do a rapid finger sweep just to check that his false teeth haven’t fallen out and then…’ She took Owen’s chin with one hand and his forehead with the other and as she tilted his head back to open the airway the snoring sound stopped. ‘Now we can assess his breathing.’

Safety, level of consciousness, airway, breathing and circulation were covered within twenty minutes. Assessing the level of disability and exposing the chest and abdomen to assess injuries took another fifteen minutes. Kelly was relaxed now and enjoying herself. She teamed the non-medical members of the class with partners who could coach them when she directed a practice of the skills she had covered. Amidst the lack of confidence some people had to overcome and the humour that lightened the more serious aspects of the subject was a willingness to learn and a new respect for someone who had been one of the quieter members of the class up till now.

‘Kelly, my patient reckons he’s bleeding to death from a ruptured artery. Do I fix that before the airway?’

‘If he’s telling you he’s bleeding to death, his airway’s fine. You can’t talk if you’re not breathing. You’re onto circulation straight up in this case. Get some direct pressure onto the bleed.’ Kelly looked up to address everyone in the room.

‘Remember we’re trying to identify the life-threatening problems in order to deal with them quickly. Don’t move on to the next item on the agenda until you’ve managed whatever problem you find.’

‘What if they stop breathing when you’ve finished the checklist?’ Kyle was kneeling beside June with his hand gripping her wrist.

‘Then go back to the beginning and start again. There are three things that are going to kill people very quickly—respiratory arrest, cardiac arrest and severe haemorrhage. We have to identify and try to rectify those situations.’

Dave called a halt to the session. ‘That was fantastic, Kelly. Thanks.’

The spontaneous applause from her students made Kelly blush but she looked happy. Somehow, that irritated Fletch. Or was it that Roger’s appreciation was so noticeable that was the annoying factor?

‘We’ve spent over an hour learning some very important skills but don’t forget what Kelly said. A primary survey should only take thirty to sixty seconds.’ Dave paused for a moment as a few people made some last-minute notes. ‘Ross is going to run us through what vital signs are and how to measure and record them. Then we’ll have a break for morning tea.’

The break was welcome. Fletch had not enjoyed the morning so far. He felt out of sorts. The unwelcome memories Kelly had stirred surely weren’t entirely responsible for his mood. He had learned to deal with those memories long ago and he couldn’t care less if the attraction that Roger the fireman was advertising was reciprocated. The irritation was augmented by a faint touch of nausea that Fletch knew he couldn’t blame on the odd beer or two he’d had with a mate the night before. He knew what the cause was likely to be and he headed for the men’s toilet with a decisive stride as soon as Dave signalled the timetable break.

The small pouch fitted into the back pocket of his jeans as neatly as a wallet. Fletch unzipped the pouch and removed the contents. He was so focused on his task that it wasn’t until the door swung open behind him that Fletch realised his mistake.