скачать книгу бесплатно
‘The patient’s BP has hit the floor, Harry,’ Joel said. ‘She’s obviously bleeding again—you have no choice but to operate again now.’
‘It was a nightmare the first time around,’ Harry said. ‘I think an angiogram and embolisation would be a better choice for controlling the bleeding.’
‘Listen, Harry,’ Joel said. ‘She’s pouring blood and wouldn’t survive the trip to X-Ray, let alone a couple of hours on the X-ray table, having films done. The blood loss has got to be stopped or at least slowed a hell of a lot first. Maybe embolisation, then.’
‘Damn it! I wish I’d never become involved in this case,’ Harry grumbled. ‘I could see it was trouble as soon as we opened.’
‘Use the theatre here,’ Joel suggested. ‘It’s on site, it’s staffed and it’s got angiography capability. Why don’t you talk to Radiology now so they come in and set up in case you want to do on-table embolisation?’ He turned as he saw Allegra, his expression visibly hardening. ‘I thought Tony called for the anaesthetist on duty.’
‘I’m the one he called, but if you’d prefer someone else, fine—go ahead,’ she said with a flash of her green eyes.
He shifted his mouth in what was clearly reluctant resignation and turned back to Harry. ‘Dr Tallis can anaesthetise for you. I’ve got to get a new central line in quickly to catch up with volume.’
‘Right.’ Harry nodded in agreement and with a quick grimace in Allegra’s direction headed towards Radiology and the ICTU theatre.
Once Harry had left, Joel turned to fill Allegra in on the patient’s condition. ‘Mrs Donovan’s MAP’s 50, pulse 160, sats 80—not good. I’ve got a norad infusion up and fresh blood pouring in, but she needs surgical control of the bleeding. I’m replacing your central line from this morning—it seems to be kinked or compressed somewhere and I just can’t get enough volume through it. Harry’s using the theatre here.’
Allegra had to force aside her personal issues with him to maintain professional calm. ‘I’ll head down now and set up. Will you bring her down?’
‘Yes, in about ten minutes. How much blood altogether did she have in Theatre this morning? I haven’t had time to familiarise myself with the anaesthetic charts here—it would take me ten minutes to add it all up.’
‘Yes, they are confusing. Fifteen units of packed cells and four units of whole blood. She also had four packs of albumin volume expander and three fresh-frozen plasmas. How many have you crossed-matched now?’
‘Twenty packed cells—that’s the current hospital supply of B at the moment. Red Cross are bleeding call-ins tonight to replenish supplies,’ he answered.
‘Good. I’d better get going,’ Allegra said, and left the unit.
Joel turned back to the patient, his brow tightening with tension as he called on all his intensive care skills to work to salvage the rapidly developing disaster in front of him.
Gaile Donovan had two young teenage daughters and a loving husband waiting anxiously in the waiting room for news of their loved one’s condition. Gaile’s cancer diagnosis had been bad enough, but to suffer this complication during surgery added an element of potential tragedy that would be very hard to announce to the family if things didn’t go well.
With the help of Danielle and the nursing staff, he replaced Allegra’s previously inserted central line over a guide-wire and ensured it was running rapidly.
‘Danielle, increase the noradrenaline infusion to three now, please, to help maintain blood pressure. I’m starting a vasopressin infusion to reduce venous pressure in the pelvis,’ Joel instructed.
‘Dr Addison, she’s bleeding from every puncture site,’ Danielle observed with growing alarm.
Despite massive transfusion, it was clear to Joel that coagulopathy was developing, and his inner tension went up another notch. Gaile’s young daughters’ faces swam before his eyes and his stomach clenched uncomfortably at the thought of having to face them with the worst news in the world.
‘Unless we get this blood loss stopped now, no amount of intensive care is going to help her,’ he said. Turning to the nurse at his side, he instructed, ‘Get me four packs of FFP and I’ll call the blood bank myself to retrieve ten packs of platelets.’
The ICTU nurse left to retrieve the packs of fresh-frozen plasma, which were stored in the ICTU blood fridge, as Joel reached for the nearest telephone.
A few minutes later a courier came in with the thawed platelets and Joel stabilised the patient to the point where she could be transferred to the operating theatre for a further attempt at pelvic packing and possible embolisation.
In Theatre, Allegra had set up the anesthetic machine, arterial line and monitoring equipment, and Harry and the scrub team were already scrubbed and waiting.
‘She’s extremely unstable, Dr Tallis—I’m just keeping up with fluids and she’s coagulopathic. She’s on norad at three and a vasopressin infusion. I’ve got FFP and platelets running and we’re onto unit ten of fresh B blood, with ten left to go. Blood bank is scouring for more,’ Joel said as the patient was transferred to the operating table.
Allegra gave him a worried look. ‘I’ve really got my hands full here. Once we open up, her BP is going to hit the floor again.’
‘I know that. I’ll stay here and help with fluid and coag management while you manage the anesthesia,’ he offered.
‘That’s a first,’ Harry said, as the scrub nurse handed him scissors to open the previous incision. ‘You don’t often see an intensivist in Theatre.’
‘That’s the whole point of this new unit,’ Joel said, as he assisted Allegra to attach the arterial line and monitor. ‘Overlap of skills to break down the rigid barriers between specialties.’
While Allegra concentrated on anesthesia, Joel juggled fluid input, coagulation factors, consultation with the haematologists and blood bank, and provided general support to Allegra during the procedure. After rapid prepping and draping of the abdomen, Harry opened the previous incision to be greeted by welling up of venous blood from the pelvis.
‘Her blood pressure’s 60, Dr Addison,’ Allegra said with concern, as she pumped in blood through two lines.
‘Harry, we’re not winning up this end. Can you control anything down there?’ Joel asked over the drapes.
‘I’m doing my best, guys, but there’s no one bleeding point,’ Harry rasped back, beads of sweat appearing on his brow above his mask.
Harry rapidly removed the old packs and repacked the pelvis, this time using multiple thumbtack-shaped staples to pin down every obvious bleeding vein to the pelvic walls before compressing with packs. In addition he ligated both internal iliac arteries. Although a drastic step, the bleeding finally slowed then stopped with repacking the pelvis.
‘I can see clotting. You must have improved her coag profile significantly,’ Harry said with obvious relief in his eyes as they connected briefly with Joel and Allegra’s.
‘She’s just about used up the entire supply of platelets and FFP. I think she’ll run into ARDS after all of this,’ Joel said.
‘Her ventilation pressures are up, she’s got pulmonary oedema—she’s already in respiratory distress. I appreciate your help in Theatre, Dr Addison, but I’ll be fine in here now. I’m sure you’ve got other concerns in the unit apart from this one patient,’ Allegra said with brisk formality.
Joel gave her an indecipherable look before shifting his gaze towards the surgeon. ‘See you later, Harry. Good luck with the rest of the procedure.’
‘Yeah, thanks, Joel. I think I like this cross-over idea, ICU, anaesthesia and Theatre all in one for this sort of case. I just hope this poor lady makes it. She’s put up one hell of a fight so far.’
‘It’s not over till it’s over,’ Joel said as he shed his theatre overgear and dropped it into the bins as he went. ‘I’ll speak to the relatives if you want me to, and then I’ll do a quick changeover round with Tony Ringer before I leave.’
‘No, don’t worry, Joel, I’ll see them. It’s my responsibility,’ Harry replied.
Joel nodded and left the theatre.
Harry looked at Allegra once Joel had left. ‘I know I’ve said it before, but you two work well as a team,’ he remarked. ‘Are the rumours true, then?’
Allegra gave him a quelling look. ‘I thought it was only the nursing staff who indulged in such a useless pastime as gossip.’
‘In spite of your little formal act just then, anyone can see you and he have something going on.’
‘Yes—an argument,’ she said.
‘He’s a nice chap,’ Harry said, as the nurse handed him another pack. ‘I’ve worked under a lot of directors in the past but I can tell Joel Addison is switched on.’
‘He’s highly skilled, yes,’ Allegra agreed, not quite able to disguise a little scowl.
Harry gave her another quick glance before he positioned another pack in the patient’s abdomen. ‘Are you still worried he’s going to stop your project?’
‘He’s not keen on me working with the Lowe boy, especially now.’
‘That’s to be expected, I guess,’ Harry said. ‘God, it was a shock to think someone could waltz in and interfere with equipment like that on the mother. Have the police got any idea of who did it?’
‘Not that I know of.’
‘What about the father?’ Harry asked. ‘He’s certainly got a motive, I would think.’
‘He’s also got an alibi,’ Allegra pointed out.
Harry gave a grunt as he began to close the abdomen. ‘How very convenient for him.’
‘I don’t think he did it,’ she said, hoping her gut feeling was right.
‘Not personally, but perhaps he had someone do it for him,’ Harry said.
Allegra frowned as she checked the anaesthetic monitors. The same thought had crossed her own mind. Had Keith organised someone to get rid of his wife? It was clear he hated her for what she’d done to their son and if Tommy’s injuries proved to be permanent, how much more would he want to avenge his son’s life?
‘What if he was the one who drugged her up and sent her off in that car in the first place?’ Harry said into the silence.
Allegra swung back to look at him. ‘With his own son sitting in the back seat? Come on, Harry. Keith might not win the husband-of-the-year award, but he loves his son. Besides, he wants me to do what I can to get Tommy to wake from his coma. If he was involved in any way with his wife’s accident, I hardly think he’d want a seven-year-old witness on hand to testify against him.’
‘Yeah, I guess you’re right,’ Harry said. ‘But it pays to look at it from all angles.’
‘That’s what the police are for. There’s already been too much gossip and innuendo as it is.’
‘Speaking of gossip, Patrick Naylor was crowing about you and him having a drink later this evening,’ he said as he finished closing the wound.
Allegra let out a frustrated breath as she began to reverse the anaesthetic. ‘I’m only having a drink with him because he’s been supportive of my project, although he’s wavering on it in the Lowe boy case. It seems he’s joined the Addison camp.’
Harry removed his mask and stripped off his gloves. ‘There was a lot of opposition to your project, as you know. It was good of Patrick to stand by you, no matter what his motives.’
‘What’s your opinion, Harry?’ she asked. ‘Were you for or against my study?’
‘Look, Allegra, you know I’m not one for reading auras or any of that stuff, but what you did with the Greeson girl was beyond what anyone else in the unit could offer. Her parents drew a lot of comfort from how you handled things. Even if your study goes on to prove nothing of scientific value, who’s to say it’s not worthwhile? Everyone wants results these days but sometimes we have to settle for what is. You helped two devastated parents cope with the worst tragedy imaginable, and you did it by maintaining their daughter’s dignity right to the very end. So, yes, I was for your study, and still am.’
She gave him a grateful smile. ‘Thanks, Harry.’
He winked at her. ‘You remind me of my eldest daughter, Amelia. She wants to take on the world, and heaven help anyone who gets in her way.’
‘The only person in my way is Joel Addison,’ she said, with another downturn of her mouth.
‘He’s not in your way, Allegra,’ Harry said. ‘He’s just trying to make sure the unit brings in the results everyone is expecting. I know you would have preferred Dougal Brenton but personally I think Joel Addison is streets ahead. He’s had experience in a war-torn country and he’s got a clear, calm head under pressure. He’s innovative and focused, which is exactly what this hospital needs in its ICTU director right now.’
‘I know all that but he has such a bias against me,’ she said. ‘I don’t know how to get through to him.’
‘I don’t think you need to worry about getting his attention, Allegra,’ he said with a grin. ‘It seems obvious to me that you’ve certainly got that.’
She gave him a speaking glance. ‘I’ve got his attention, but for all the wrong reasons.’
‘I don’t know about that. He’s a reasonable enough man. If you can produce results, I think he’ll come round.’
‘I need more time to produce the sort of results he requires,’ she said. ‘It can take some patients weeks, if not months to regain consciousness. He’s given me a month, but it’s not long enough to do what I want to do.’
‘Just do what you can in the time you have. You’ve got a chance with the Lowe kid—he’s young and his brain damage may not be as bad as first expected. I’ve seen kids like him on ventilators for weeks and then suddenly they’re up and running about as if nothing had happened.’
‘I hope that’s how it will be for Tommy,’ she said. ‘He’s just seven years old.’
Harry gave her a probing look. ‘You’re not getting too emotionally involved in this, are you, Allegra? I know you had a rough time with the Greeson girl but we all have to move on. They’re our patients and we do what we can, but it’s not our fault if we can’t pull a miracle out of the hat every time.’
‘No, I’m fine,’ she said, wondering if it was true. ‘I just want to give this my best shot. I know there’s potential in this study. I can sense it.’
‘You have to show it, not sense it,’ he reminded her, with scientific pragmatism.
‘I know that, Harry. I’m well aware of the parameters I have to work within. I just think there are ways we’re not utilising that could help patients regain consciousness. Everything seems to be economically rationalised these days—if there’s no EEG activity after X days and Y dollars of ICU support, pull the plug. But with a different theoretical approach and some time and effort, I believe we could start a paradigm shift in the management of post-traumatic coma.’
‘I hope to God you’re right, Allegra,’ he said, as he removed his surgical gown. ‘I hate it when ventilators are switched off on live bodies. It doesn’t matter how many CT scans and EEGs, I still can’t help feeling there might have been …’ He didn’t need to complete the sentence.
‘I know,’ she said with a heartfelt sigh. ‘“Brain dead” is a cold, hard term. I realise we can’t keep people alive indefinitely on a ventilator when there’s clearly no hope. I just want to make absolutely sure there is no hope, that we’re covering every aspect, not giving up before every option is explored.’
‘I know it’s a well-worn adage, but I really do believe that where there’s life there’s hope. Joel was right when he said earlier that it’s not over until it’s over. Even Gaile Donovan here—sick as she is—still has a slim chance of making it.’
Allegra looked down at the pallid features of the patient under her care. ‘I certainly hope so, Harry.’
He gave her a weary glance as he helped move the patient from the operating table to the ICTU bed. ‘I’m going out to speak to the husband and daughters now. I wish I could promise them more but I’m not a miracle-worker.’
‘She’s alive, Harry,’ Allegra said. ‘That’s all that matters right now. That’s all they’ll want to hear.’
‘I know, but for how long?’ he asked as she wheeled the patient past him out of Theatre.
Allegra didn’t answer. She didn’t like Gaile Donovan’s chances either, but to voice them seemed to be inviting the worst. She’d already had enough of the worst. What she needed now was a miracle and she was going to go looking for it, no matter what Joel Addison said to the contrary.
CHAPTER TEN
PATRICK Naylor was sitting in the bar, waiting for her, when Allegra finally arrived, the two empty glasses in front of him suggesting he’d been there for quite a while.
‘I’m sorry I’m late but I had to go back to Theatre,’ she said as she sat down opposite him.
‘I wasn’t worried … not really,’ he said, giving her a quick on-off smile before his eyes moved away from hers as he stared into the empty glass in front of him, his shoulders suddenly slumping. ‘I just needed to see a friendly face.’
‘Is everything all right, Patrick?’ Allegra asked.
He gradually brought his gaze back to hers, the moisture shining there indicating he was having trouble keeping his emotions at bay. ‘My wife is pregnant to her lover,’ he said. ‘I found out about it this morning.’
‘I’m so sorry. That must be awful for you.’
He wiped at his eyes with the back of his hand. ‘The irony is it was me who kept putting off having a family. I guess that’s why she went looking elsewhere.’
She reached for his hand and gave it a gentle squeeze. ‘Is there anything I can do?’
He shook his head and covered her hand with his. ‘No, there’s nothing anyone can do. I have to deal with it myself.’ He released a little sigh and continued, ‘I’ve booked in to see a counsellor. I think it’s time I did some work on myself.’
