Rivals In Practice

‘I’ll find another airway for you.’ Andrew reached into the kit to extract one of the plastic devices. The abrupt halt of the Land Rover caused him to overreach.

‘There’s a bloody great tree blocking the driveway,’ Mickey shouted. ‘I nearly hit the damned thing.’

‘Sorry.’ Jennifer braced herself as the vehicle began reversing. ‘I should have warned you about that. We’ll have to go around the back by the kitchens.’

Andrew handed her the airway. He rapidly assembled the bag mask components and Jennifer plugged the tubing into the oxygen supply before fitting it over Liam’s mouth and nose. She glanced at Andrew.

‘GCS is dropping again. He’s lost his gag reflex and his breathing is getting worse. He’s going to need intubation as soon as we get him inside.’

‘He needs evacuation to the nearest major hospital. You can’t possibly have the facilities to deal with a patient in this condition here.’

‘We’ll have to,’ Jennifer said tersely. ‘We’re the only chance he’s got. There’s no hope of evacuation in this weather.’ She sent Andrew a warning glance. ‘And I’m including you in that ‘‘we’’.’

Andrew shook his head. ‘I told you—I’m no longer a doctor. I gave up medicine nearly a year ago.’

‘Why?’

‘That’s my business.’

The Land Rover had stopped moving again. The engine idled and Jennifer could hear rain on the vehicle’s roof in the silence that followed Andrew’s cool comment. She squeezed the bag she was holding again, turning her astonished stare back to her patient. ‘I don’t care what your reasons were,’ she announced. ‘And you don’t stop being a doctor just because you chucked your job in. Right now I need to assess and stabilise my patient. I need help and I’m going to use whatever resources I can find. Including you.’

The back doors opened and Jennifer moved swiftly, unhooking the end of the stretcher. ‘Bring the lifepack and the suction kit,’ she ordered Andrew. ‘And follow us.’

Wendy and Margaret were both waiting by the open door as Mickey and Jennifer raised the stretcher and wheeled it towards the back entrance of the hospital.

‘Tom Bartlett rang us,’ Wendy informed Jennifer in a rush. ‘Janey and Michelle are here, looking after the other patients. Sue’s coming in as soon as she’s dropped off her children. The treatment room’s clear.’ Wendy took a quick breath. ‘How’s Liam doing?’

‘Not great.’ It was Andrew who spoke as they moved past Wendy. ‘Sats are dropping fast. Probably a tension pneumothorax from the rib injuries.’

Jennifer let Margaret take her place pulling the stretcher. ‘I’ll get a chest-drain kit set up,’ she said, moving rapidly ahead and shedding her oilskin parka as she moved. The astonished stare directed at Andrew by both Margaret and Wendy had not been lost on Jennifer but she couldn’t afford to be distracted by introductions just yet. Within seconds they were all crowded into the treatment room. Mickey, Margaret and Wendy positioned themselves around the backboard as Andrew held the head end and directed the transfer of their patient to the bed.

‘On my count,’ he instructed. ‘One, two…three!’ Andrew reached for Jennifer’s stethoscope which had been left draped across Liam’s abdomen. He glanced up as he lifted the earpieces clear a short time later. ‘We’re going to need a drain on both sides,’ he informed Jennifer. His gaze raked Wendy. ‘You’re a nurse?’ he queried tersely. ‘I need some gloves.’

Jennifer could feel Wendy’s hesitation. She gave her nurse a reassuring glance as she reached for a second sterile chest drain package. ‘It’s OK, Wendy,’ she said calmly. ‘Andrew’s a doctor. A surgeon. He knows what he’s doing.’

The tension in the room wasn’t limited to the nurses’ wariness of the strange doctor. The situation was critical and both Andrew and Jennifer worked in a tense silence as they dealt with Liam’s respiratory collapse.

‘Got it!’

Jennifer had heard the characteristic hiss of air escaping from the side of the chest Andrew was working on. She concentrated grimly on inserting her own drain, dimly aware of a familiar frustration at Andrew achieving a successful result first. It lasted only seconds.

‘Haemothorax on this side.’ Jennifer attached the drain to the bottle that Margaret had prepared. She watched the flow of released blood. ‘Rather a large one.’

‘A single rib fracture can cause a loss of 150 mls into the pleural cavity.’ Andrew was picking up the stethoscope again. ‘And this lad’s fractured a fair few.’ He nodded as he shifted the disc on Liam’s chest. ‘We’ve got equal breath sounds.’ He glanced at Mickey who was ventilating Liam with the bag mask, then he looked at Jennifer. ‘Are you going to intubate? Have you got mechanical ventilation available?’

‘I’ll do it now.’ Jennifer was pleased to see that Wendy was already setting out the intubation kit. She stripped off her soiled gloves and reached for a new pair.

‘What about X-ray facilities?’ Andrew queried. ‘We need chest, C-spine and pelvis.’

‘No X-rays, sorry.’

‘Blood pressure’s dropping.’ Margaret sounded worried. ‘Ninety over fifty.’

Andrew’s attention flicked to Margaret. ‘Get the rest of his clothes cut off,’ he directed. ‘I’ll check his abdomen and pelvis. You get on and do the intubation, Jennifer.’

Margaret’s hesitation was only momentary. Jennifer could sense her rapid acceptance of directions from someone who was clearly in control of the situation. Turning to pick up the laryngoscope, she caught Wendy’s gaze. Her nurse was clearly questioning Jennifer’s apparent acceptance of being cast into the role of an assistant by someone who was, after all, a complete stranger despite the demonstration he was giving of his obvious abilities. Jennifer merely nodded at Wendy and Mickey, who had stayed to assist.

‘We’ll get the collar off and you can provide manual in-line stabilisation for us, Mickey. You can do the cricoid pressure when I’m ready, Wendy. This may not be easy with the facial injuries Liam has.’

Jennifer concentrated on her task of securing Liam’s airway, confident that Andrew and Margaret would be dealing with anything else that might need urgent attention. If Andrew’s involvement came with the price of giving up leadership of this small team, Jennifer was quite willing to pay. This was no time to even remember old battles but Wendy wouldn’t have questioned Andrew’s take-over if she’d known him like Jennifer did. Andrew had never been able to resist taking command of any situation he found himself in—particularly one that included her own presence. Jennifer was more than happy to let this one go. She had a professional colleague whose skills matched—probably exceeded—her own, and Jennifer was grateful for the shared responsibility as she registered the comments she overheard from further down the table.

‘Pelvis doesn’t feel unstable,’ Andrew was saying. ‘Any femoral fractures?’

‘Nothing obvious.’

‘We need some more fluids. Find me a 12-gauge angiocath.’ Andrew spoke to Margaret as though they were familiar colleagues. ‘I’ll go for the groin. He’s completely shut down peripherally. Do another blood pressure, too, would you, please?’

‘Sure.’

Jennifer had Liam’s head positioned now and stable. ‘Hyperventilate with the bag mask, Wendy. I’m ready to intubate.’

‘Blood pressure’s 80 on 55,’ Margaret told Andrew.

Jennifer tried to concentrate on visualising the larynx and vocal cords. Part of her brain registered Margaret’s comment with dismay. Liam was becoming progressively more shocked. He was losing more blood than could be accounted for by the injuries they had identified so far. If they were going to save Liam Bellamy’s life they needed to find the source of the blood loss and control it. Until then they had to maintain an adequate circulation.

‘We’ll push saline into this larger line,’ Andrew decided. ‘Have you got haemaccel as well?’

Jennifer eased her laryngoscope into its final position. ‘Pass me a 9-mm tube, thanks, Wendy, but don’t release pressure on the cricoid cartilage just yet.’

Andrew had instigated the rapid fluid replacement by the time Jennifer had inflated the cuff on the endotracheal tube and set up the ventilator. He was eyeing the chest-drain bottle on her side of the bed.

‘He could have a diaphragmatic rupture,’ he suggested to Jennifer. ‘It would explain a continued blood loss of that rate and a lack of abdominal distension if he’s injured his spleen. Given the rib fractures on that side, it seems quite likely as a source of major blood loss.’

‘Find another bottle, Margaret,’ Jennifer requested. She looked at Andrew. ‘What about a peritoneal lavage?’

‘What about it?’

Jennifer suppressed a flash of annoyance. The reminder of how often she and Andrew had disagreed over a diagnosis or method of treatment again wiped out the gap in time very effectively. They had always challenged each other, demanding justification for opinions or decisions. Trying to prove themselves more capable than the other.

‘It could be diagnostically useful.’ Despite the inappropriate setting to dredge up old battle skills, Jennifer couldn’t quite help the edge of sarcasm in her tone. ‘If we got lavage fluid coming from the chest drain, then we’d know for sure that there was a diaphragmatic rupture.’

‘And what then? Are you proposing a laparotomy if it’s indicated?’ Andrew’s eyebrow was raised sceptically. ‘Are you qualified to undertake a procedure like that?’ He glanced around the treatment room. ‘Here?’

‘No, I’m not qualified,’ Jennifer said quietly. ‘But you are.’

‘No, I’m not.’

Jennifer could feel the astonishment of both her nurses and Mickey. She ignored the rising tension. ‘You’re a specialist surgeon,’ she reminded Andrew. ‘The last I heard, you were so good you got poached from the Boston Memorial to join some very prestigious private outfit.’