Chapter 7
The man looked far too fit to be sitting in an emergency department.
His tanned, lean chest had just a faint cover of dark hair in a V that pointed to an admirably flat belly.
Professor Jennifer Allen had yet another one of those momentary lapses, but it was easy enough to recover this time. Guy’s shoulders had been much broader and this man was on the skinny side of lean. His ribs were prominent rather than overlaid with a firm layer of muscle.
It was ridiculous to be still experiencing these lapses anyway. Despite the intensity of their time together, Guy was still a stranger. She would never see him again so it was high time she stopped thinking about him so often.
Missing him.
A registrar was giving Jennifer a curious look, so she smiled reassuringly, introduced herself to the patient and then caught the younger doctor’s eye again.
‘This is Peter Cowl,’ she was informed. ‘He’s twenty-six and has a history of spontaneous pneumothorax. He came in with sudden onset, unilateral, localised chest pain and shortness of breath.’
The patient did not appear to be in a state of respiratory distress that might indicate the development of a tension pneumothorax. ‘What’s the oxygen saturation?’
‘He came in at eighty-six. It’s gone up to ninety-two on high-flow oxygen.’
‘How are you feeling, Peter?’
‘Bit puffed. Not too bad.’
‘How many times has this happened before?’
‘Three or four.’
‘Have you needed aspiration with a needle or tube before?’
‘Twice.’ The young man grimaced. ‘Would prefer not to… do it again.’
‘Sure. We’ll keep an eye on you and run a few tests, then we’ll decide how we’re going to manage this.’
Jennifer turned back to the registrar. ‘Get chest X-rays, both inspiratory and expiratory. And we’ll need an arterial blood-gas sample. Have you done one of those yet?’ She smiled again at the nervous head shake.
‘Get one of the senior registrars to assist you then. I’ll help if I can, but it’s a bit busy out there.’
Jennifer was already moving away from the cubicle. Busy was the kind of understatement that made light of their workload – a coping mechanism. The emergency department of Auckland Central was currently stretched to its limit. It would fit right into Jennifer’s day if Peter Cowl did develop a tension pneumothorax that required urgent decompression – probably when she was tied up with another critical intervention.
At least there were a dozen or so other people somewhere in this department qualified to perform such a procedure, plus all the equipment and backup they could possibly need. None of these doctors were ever likely to have to try and manage an emergency perched on top of a mountain in a makeshift tent, with only limited gear and no hope of assistance. Or success, in the long run.
They had no idea how spoilt they all were.
‘Dr Allen, can you spare a minute?’
‘What is it, Doug?’ The senior registrar was competent enough for his anxious expression to ring an alarm bell.
‘I’ve got a sixty-nine-year-old chap with sepsis from a urinary tract infection. He’s as flat as a pancake and I can’t get any peripheral IV access. He needs fluid resus, stat, and it’s going to take too long to do a surgical cutdown.’
‘Try a central venous line then.’ Jennifer caught the message in the glance she received and remembered that Doug had had major difficulties the last time he’d tried the procedure, but if this patient was in septic shock, this was hardly the best situation for a teaching session.
‘Are you set up?’
‘Yes.’
‘Okay, I’m all yours.’
‘Are you sure?’ Doug eyed the cast on her arm, but Jennifer nodded decisively. ‘It’s not a problem anymore. See?’ She waggled her fingers at him. ‘I’ve got full mobility in my hand.’
Doug led the way towards one of the curtained resuscitation areas past the central desk.
‘MVA coming in,’ the triage nurse warned Jennifer. ‘Three patients. Two status one. ETA five minutes.’
‘Is the trauma room clear?’ Status one meant that these patients were in a critical condition from their car crash. They could need every resource the department had available.
‘Just been cleared.’
‘Activate the trauma team. John or Adam can lead if they’re free. I’ll be tied up for a few minutes.’
A woman with a shrieking toddler in her arms stepped out of their way, but Jennifer had to swerve to avoid a bed being rapidly manoeuvred.
‘Sorry, Prof,’ the orderly called.
‘Not a problem, Deane. I’m just as bad with supermarket trollies!’
The patient with the UTI was looking extremely unwell. Doug rapidly gave her the information that added up to a shocked condition. Colin Smith was febrile, hypotensive, tachycardic and confused. He had a forty-eight-hour history of urinary frequency and pain, had been to his GP that morning, having passed blood, but hadn’t filled his prescription for antibiotics yet.
‘It was Grandparents’ Day at Alice’s kindy,’ his wife explained to Jennifer. ‘He said he was fine and he’d start the pills later, but then he just got so sick so quickly. He started vomiting then so there didn’t seem much point in trying to get him to swallow pills.’
Colin had tufty grey hair rather like Digger’s had been. Jennifer could just imagine him toughing it out and pretending he was fine. She picked up his hand, noting the cool, clammy feel of his skin.
‘Colin? Can you open your eyes?’ She smiled at him when he complied. ‘Hi, there. I’m Dr Allen, one of the consultants here.’
‘You’d better watch out.’ Her patient managed to return her smile. ‘My wife might see you holding my hand.’
‘Do you know where you are, Colin?’
‘Heaven,’ he murmured. ‘Are you the boss angel?’
‘We need to get an intravenous line into you to treat your infection,’ Jennifer told him. ‘And your veins aren’t cooperating so I’m going to put one in just under your collarbone. Are you happy for me to do that?’
‘You do whatever you like, love. I’m just…’ The words trailed off into an incoherent mumble and he closed his eyes again.
Mrs Smith pressed her hand to her mouth. ‘He’s really sick, isn’t he?’
‘You hold his hand,’ Jennifer said. ‘And we’ll get on with getting him better.’ She plucked a mask from the wall dispenser. ‘Let’s have a head-down tilt, Doug. Is there some local drawn up on that trolley?’
‘I’ll get it.’ An assisting nurse was holding a gown out for Jennifer. Another nurse was preparing to swab Colin’s chest for the sterile procedure.
‘Thanks.’ Jennifer turned to get the ties on her gown attended to. ‘I’ll need one large glove to get over this cast.’
Seconds later, they were ready. With the skin well infiltrated with local anaesthetic, Jennifer picked up a ten-gauge cannula.
‘Turn his head for me, Doug, and keep things nice and still.’ Feeling along the clavicle, Jennifer chose the point of entry and was pleased to find an instant flashback. She withdrew the needle, leaving the plastic cannula in place. ‘Okay. I’m ready for the guide wire.’
The flexible wire was passed into the vein and then a catheter introduced over the wire. Jennifer watched the screen of the monitor as she threaded the guide wire, making sure it didn’t travel far enough to irritate the heart and cause a rhythm disturbance.
Now that access had been established, the rest of this procedure was straightforward. The catheter would be stitched into place and covered with a dressing. A chest X-ray would confirm its correct positioning and blood samples could be drawn before fluids and drugs were administered.
‘Do you want me to take over?’ Doug asked.
‘I’m fine for a minute or two.’ Jennifer reached for the suture needle. ‘You’re doing really well, Colin. We’re almost done.’
The relief on Mrs Smith’s face was patent, but she still held her husband’s hand tightly. ‘You’re going to be fine, love. Alice is going to come in to see you later. She’s drawing you a special picture.’
‘How old is Alice?’ Jennifer queried.
‘She’s four. Her little brother’s two. We’ve got six grandchildren now… and they all adore their grandad.’
‘I’m sure.’ Jennifer smiled as she tied off the last knot. ‘Do they get lots of time with him?’
‘Now that he’s finally retired they do. It was hard to get him away from work, though.’
‘I’m not retired,’ Colin mumbled as they raised his head position. ‘I’ve just cut down my hours a bit.’
‘What do you do?’ Doug’s eyebrows had been rising steadily during the conversation, but Jennifer ignored his surprise. Why shouldn’t she take the time to get to know her patients a little better?
‘I’m a vet,’ Colin told her. ‘Small animal practice.’
‘He breeds Corgis, too,’ his wife added. ‘They win at every show we go to.’
‘Good for you.’ Jennifer finally turned back to the registrar. ‘You’ll need to draw off blood for cultures, Doug. Then start fluid resus and antibiotics. What are you planning to use?’
Doug told her what drugs and dosages he was going to use and Jennifer nodded her approval. ‘Put a Foley catheter in, too. Get a urine sample and start monitoring output.’ She turned back to her patient. ‘I’ll be back to see you later, Colin. Doug’s going to look after you again now.’
* * *