Therapeutic Window

by Steve Low

Professor Boatwood talked to us briefly. Behind the horn-rimmed spectacles, his eyes darted about. I sensed the dialogue was going to be transient. In the learned man’s visual field, a more important conversant awaited. Sure enough, the Professor conjured an escape. He called over his colleague, senior-lecturer Nigel Green and introduced him to us.

  “We’ve been in England for a year.” I said, after Green had enquired of our origins.

  Green raised an eyebrow. “Really? Whereabouts?”

  “Tunbridge Wells,” I said.

  “Tunbridge Wells? I don’t know it” Green mused. “How big is the hospital there?”

  “It’s quite small. It’s a district-general.”

  “Oh . . . well . . . it’s all experience.” Green stared at the wine in his glass. “June and I spent two years at Oxford.” He emphasised the last word and looked up at me. “It was not long after we were married. I was fortunate to get the opportunity. It was a great place to learn. They were the best years of my life.” He stood on tip-toes and scanned the room. “I can’t see June at the moment . . . I’d like to introduce you both . . . How about you Eleanor? Did you work over there as well?”

  “I did some temporary teaching work,” she said, shifting stiffly from one leg to the other. Her thin face looked pinched and drained under the professor’s bright ceiling lights.

  “Excellent. It’s a great way to get to know the people,” he said. “You’re starting with us soon at the Intensive Care Unit, aren’t you Gerry?”

  “Next week. I start on the day shift.”

  “That’s the way to do it. There are plenty of admissions during the day,” Green said, his eyes sparkling. “The bulk of our ICU patients are from the cardiac theatre. Mainly coronary bypass graft operations. They can be quite unstable for the first twenty-four hours after the surgery. That’s where we intensivists get involved. The surgeons stress the patients to the limit and we rescue them back to safety.”

  I nodded. I downed the last of my wine and searched for something to say. “It’s a bit daunting,” I said. Immediately wishing I hadn’t. Betraying weakness was probably not a wise thing to do.

  “You’ll love it,” Green said. “I’m sure you’ll both be happy here.” He touched me on a shoulder. “We look after you in Dunedin.” With a wink he was gone, circulating to another part of the room.

  Eleanor and I escaped to the sanctuary of a plate glass window. The professor’s house was high up in the North-East Suburbs and afforded panoramic views over the city. Below, the expanse of city lights shimmered against an inky backdrop. Rising lines of orange dots, marked the main routes of exit from the city centre. The adjacent Otago Harbour was identifiable, merely as an absence of light. I felt fingers digging into a shoulder muscle. I turned enquiringly to look at Eleanor, but the groping hand belonged to David Young, the other new Intensive Care registrar.

  “I’ve discovered the professor’s hobbyhorse,” he said in his Canadian drawl. “He uses massive doses of PEEP.”

  “What’s PEEP?” Eleanor asked.

  “How much is a massive dose?” I interrupted, turning my back on the view. The Canadian, I noticed, continually wrung his hands together, as though they were wet.

  “Seventy apparently,” the Canadian said, laughing. “The lungs must be stretched up like Zeppelins.” He looked at Eleanor. “PEEP? It’s a pressure used to expand a sick patient’s lungs. Because of the expansion there’s more lung area exposed to oxygen. The Professor’s ideas are controversial though. Because he wants to use so much PEEP, the blown up lungs are likely to crush the heart. That reduces the ability of the heart to provide a decent blood pressure.”

  I could see the perpetrator of the heart crushing therapy across the room. He had collared someone else, a squat grey haired individual. The Professor was waving a finger right in front of the smaller man’s nose. It was a large nose, flared at the nostrils.

  Who’s that short guy the Professor is arguing with?” I asked.

  The Canadian paused in his hand wringing. “That’s Gibbs, the other senior lecturer. He’s a bit obnoxious I’ve heard . . .”

  Smoke hung listlessly in the air. Outside, rain lashed the windows. Remington leaned on his cue. “Tunbridge Wells is a long way from the heights of Oxford,” he said. He advanced to the table and smacked the white ball. A red raced away into a side pocket.

  “Yeah well, he probably thinks I’m an under-achiever,” I said.

  “He’s right then,” Remington said, failing to sink the green.

  “Oh yeah?” I said in a dumb voice. I took the cue from my friend. The handle was sticky. “If he thought that, then he was too polite to say anything about it.”

  “Oh sure, he’s a nice guy, Nigel Green - too nice really.” Remington said. Behind him, anachronistic metal freaks operated a juke-box. In a dark corner, three Samoans sat staring silently. Black frizzy hair framed their faces. “He’s one of those guys who you never hear slagging off anyone else . . . Boatwood excepted maybe.”

  “Ah . . . so, he’s the antithesis of someone like yourself.” I said.

  Remington scratched the top of his head. His long top lip gave him a belligerent disposition. “Hard to talk to a dude like that for more than a few minutes – what can you say? I prefer a bit of edge – a bit of scepticism.” He took a mouthful of beer. Some of it spilled out onto his pink tie. “Actually, they reckon he‘ll move to Aussie soon. Boatwood could hang on as the Prof here for years. So Green will have to move if he wants to climb the academic ladder. Same applies to Gibbs – Mr Odious himself.”

  I doubled the yellow towards a side pocket. It missed. “I see . . . So when’s your radiology exam?”

  “It’s the same time as your intensive care one – May. Life’s going to be abysmal until then. When I pass I’m going to punch a hole in the sky. No more grovelling as a radiology registrar. But for you Davenport – life will continue to be abysmal – after you fail.”

  I grimaced. I watched thousands of dust particles swirling in a column of light emanating from a ceiling window. “Nostradamus,” I said.

  The wind gusted in from the south. The sea was in a frenzy. From a distance, the sail-board would seem to skid along without effort. The segment of harbour I crossed lay between the high-rise cityscape and the peninsula suburbs. Now and then I adjusted the sail, to counter changes in wind speed or direction. They were fine movements, not detectable from afar.

  Despite the velocity of the ride, my mood was sombre. My chest felt like a hollow drum. My throat was thick – eyes swollen with salt. Eleanor was out of town. I should be missing her. But deep within, a flame flickered and danced. I was free.

  I was almost at the wharf. I threw the board into a gybe and it carved a gracious arc across the boiling surface. I flipped the sail over and realigned for the next tack. But I was too slow adjusting the rig. A twist in the top of the sail, drove the mast to windward and it exploded into the sea. White foam blasted into the air. Under the sail, I wrenched my body harness free from the sunken boom and swam out to the surface. Gulping down air, I clung to the board, staring at the distant shores. I had been hers for ten years. We were a defined unit. But something fundamental was missing – had always been missing. I felt the onset of panic. When I thought about my life with her, I felt as though I was suffering a great loss. It was time that was being lost. There had been too many dead years. I shook my head and braced myself, as over the turquoise stippled sea, a fresh gust accelerated towards me.

  “Christ, you’re early.”

  I looked up to see who had spoken. I saw a puffy faced man with narrow slanted eyes. He wore green ‘theatre’ garb similar to my own. I had entered the Intensive Care Unit through opaque swing doors emblazoned with the notice, Intensive Care Unit, No Entry. The man, who had several breathing circuits laid over one shoulder and carried a bucket full of intravenous fluid bags, stood before a backdrop of beds and nurses, cables and tubes, monitors with winking lights and strident alarms – all sand
wiched between painfully bright roof lighting and reflective flooring. I stood on the threshold, mouth dry and heart pounding.

  “David Young said to be here by seven-thirty,” I said.

  “The Handwringer lives on his nerves,” the squat man said. He jumped forward and offered his hand. He was a head shorter than me. “Tony Drummond,” he said. “I’m the respiratory technician. It’s bad luck you’ve got Gibbs first up.”

  “Is it?” I queried.

  Drummond grimaced and headed for the double doors. “The Handwringer is in the tearoom,” he said.

  At that moment the Canadian came bolting out of a side door, his face ashen, his lips pinched.

  “How was the nightshift?” I asked.

  “You’re here . . . O.K we got to get some drugs ready, for when the first cardiac bypass comes back from theatre.”

  “But, that won’t be till late morning will it?” I asked. My stomach knotted, as absorbed Handwringer’s nervous state.

  Handwringer laughed, although his face remained taut. “That’s right, but with Gibbs the consultant for the unit this week – things have to be prepared light years in advance. He’ll be here, on the dot, at eight o’clock. He goes straight onto the war path,”

  We moved across to the vacant space, where the cardiac bed would go. Handwringer reached under the bed-end table and produced a protocol. The plastic cover was twisted and barely transparent. It was headed, ‘Drugs for CABG resuscitation.’ I pointed at the abbreviation.

  “Coronary Artery Bypass Graft,” Handwringer explained. “They call the operation a ‘cabbage’ – for obvious reasons.”

  Detailed below were the drugs to prepare. adrenaline 1 mg/10 mls, atropine, lignocaine, isoprenaline . . . eleven drugs in all. We drew the contents of the ampoules into syringes. Handwringer showed me where to put coloured sticky labels for identification. The label was to be applied at the level of the fluid in the syringe. Gibbs, he said, was a stickler about that.

  Drummond reappeared, stopping by their table. “It’s a shame you don’t have Nigel Green on your first day,” he said.

  “Why’s that?” I asked, too nervous to enjoy a conversation.

  “Because he’s the best, that’s why. Gibbs is very clued up, but he’s a total bastard to all the registrars.”

  “What about Prof Boatwood?” I asked, moving to check the ventilator.

  Drummond laughed. “He’s an ideas man – but in practice he’s a bit accident prone. No, Nigel’s in a class of his own. It will be a tragedy if Dunedin loses him. He’ll get plucked away overseas one day – unless Boatwood goes first.”

  The conversation relaxed me a little. Soon though, that very much changed. The doors to the unit swung open, revealing the grey short man with a large flared nose. Gibbs – reminiscent of a camel, Remington had said.

  “Morning,” I said.

  “Is it?” the new man barked, crossing the floor on the march.

  “I’m Gerry . . .”

  “I know who you are,” Gibbs said. He scooped up a syringe and examined it at close range. “I always place the label at the top of the meniscus,” he said. “You can label all these again.”

  I felt my face flush. I said nothing. I watched Gibbs stump away to the central monitoring station. I wasn’t surprised by the welcome. Arrogance in the medical system was something I expected. After all, my father was Graham Davenport.

  We were about to start the ward round, in which Handwringer, the night registrar, would hand over the patients to me, the day registrar. However Nancy the charge nurse, an American aged 40 or so, came bustling over to speak. Mr Watkins, a bypass graft patient from the previous day, was rapidly losing blood pressure.

  We crossed to the patient, along with Gibbs who had sensed the urgent tone of the conversation.

  “What’s the central venous pressure?” Gibbs asked, his eyelids hooded like a bird of prey. It turned out there was no central venous line. It had been removed accidentally in the night. A technician had tripped on the connecting monitor cable, yanking the whole apparatus out. Handwringer had elected not to replace it. Gibbs did a complete circle on the linoleum before slamming his fist into the table top.

  “Christ David,” he said. “I’m the consultant of the unit. I make all the decisions. In future, if something like that happens, you ring me, OK?”

  Handwringer was a deep shade of crimson. “OK,” he said.

  Gibbs indicated that reinsertion of the central line was required. “Go wash your mitts,” he said, gesturing to me.

  I stole a glance at him. Beneath the hooded brow I could see the older man’s eyes. There was little comfort to be gained from the slate grey pupils. I made sure I scrubbed my hands for a full five minutes. The zealot would be timing me for sure. I returned to the sickening patient. Gibbs had exposed the front side of the neck. I applied antiseptic to the area above the internal jugular vein. I placed three sterile drapes around the painted area in a triangular fashion.

  “I don’t arrange the drapes that way,” Gibbs said in a truculent monotone.

  I looked at Gibbs. “Pardon,” I said.

  “You heard,” Gibbs snorted. “I never have the drapes in a triangle. I square drape.

  You should know that.”

  “What does it matter . . .” I began to say.

  “If you’re gonna argue you can get out,” Gibbs yelled, pointing to the doors.

  “Huh?” I said. My skin pores opened and I became soaked.

  “Right, move over . . . I’ll do this,” Gibbs announced. He stumped away over to the scrub bay.

  Handwringer appeared at my elbow. “Now you know the true meaning of the word bastard,” he said.

  I nodded slowly and took off my gloves.

  It was the start of a bad day for Mr Watkins. Towards the end of the line insertion his prospects took a bad turn. The blood pressure went into a steep decline. As soon as Gibbs attained access to the internal jugular vein, he connected the catheter to a pressure transducer. The pressure was very high, indicating the heart was failing.

  “There’s a vessel bleeding inside, One of the anastamoses must have come apart,” Gibbs said. “The haematoma is compressing the heart. We’ll have to get King to come in and reopen the chest. David, get him on the phone now. Nancy, lets have the open chest packs ready. Gerry, put together an adrenaline infusion and start running it immediately.”

  King appeared after a few minutes with his entourage of junior staff trailing behind. While the surgeons scrubbed their hands, Gibbs injected Mr Watkins with an anaesthetic drug, inserted a breathing tube and began mechanical ventilation.

  After donning gown and gloves, Tom King reopened the chest wound with one slash of the knife. Wire cutters divided the sternal wires. Inside, the chest cavity was awash with blood.

  “Oh Christ - one of the grafts has come off,” King said.

  Red blood from the free end of the artery, spurted into the chest cavity. A lake formed that teetered on the edge of the wound cavity, then rolled off the wound on to the white linen. King, red faced, roared into action. Stitches raced across the failed anastamosis. At the head end, Gibbs barked out orders, as he and I drove blood and crystalloid fluids into the intravenous lines. Despite their efforts, the blood pressure plummeted.

  “Fifty five,” Gibbs snarled over the drapes, as though King was solely responsible.

  “The ECG shows ST elevation,” Drummond announced from the chart recorder.

  “He’s having a heart-attack now,” Gibbs said.

  “O.K guys, we’ve got control.” King said. The flow from the stitched artery became a mere trickle.

  However the heart, despite its restored bypass graft, didn’t perform well. Gibbs ran adrenaline and isoprenaline infusions, but the blood pressure wouldn’t rise above seventy five. “He stuffed it with that bleed out,” Gibbs muttered to Drummond.

  “We’ll have to keep external pressure off the heart,” King said. “Clamps please Nurse,” He inserted two connec
ting clamps into the chest wound to hold open the two halves of the bony skeleton. He glanced at his assistant. “This enables the heart to fill better. Hopefully as a consequence, we‘ll get a better blood pressure.”

  On the chart recorder, the blood pressure began to trend upwards. Encouraged, King covered the open chest cavity with a plastic dressing. Beneath it the heart was visible, gulping like a frog. The blood pressure settled at eighty.

  Nigel Green appeared. Caught between the polished floors and the overhead fluorescent tubes, his face seemed to be coated with wax. His orange hair lay in a frozen wave. “This is no good guys,” he said, eyebrows raised.

  “Tom King special,” Gibbs said. Green came around to the head end of the bed and peered over the makeshift drapes. “Failed graft anastamosis,” Gibbs continued. “Blood everywhere. We almost lost him prior to reopening the chest.”

  “Any damage?” Green asked frowning.

  “Probable heart attack I’d say. The heart just hasn’t performed since the bleed-out. We haven’t had a blood pressure over seventy-five until just now.”

  “His oxygen saturation is down a bit too,” Drummond chipped in. “His lungs must be filling up with oedema.”

  “Really?” Green’s face became serious. “It’s just as well the Prof wasn’t running the unit this week then. He’d have had the patient on a truckload of hyperPEEP.”

  I noticed there was much eyebrow raising and laughter about Boatwood’s penchant for high PEEP. It was clear that Boatwood’s ideas were not widely respected by his colleagues. “Is he really using seventy?” I asked, remembering my conversation with Handwringer.

  Green laughed. “No, those kind of numbers are strictly theoretical. You’d never use that on humans. At seventy, there would be so much pressure in the lungs, the heart and blood vessels in the chest would be almost squeezed flat. No, thirty of PEEP is about our upper limit. Isn’t that right Trevor?”

  Gibbs grunted and pointed at Mr Watkins. “We’re not out of the woods here yet.”

  A nurse with straight bobbed hair came up to me. “Has the Handwringer handed over the other patients to you yet?” she asked.

  I hardly looked at her. “He will – as soon as we can.”

  Green came over. “How is the super-nurse?” he asked. I glanced up at her. She rolled her eyes.

  Handwringer and I walked over to the next bed, intent on starting the hand-over. “Gibbs is nice as pie today,” I said.

  “Oh for sure,” Handwringer said, worry lines vanishing from his forehead.

  “Do they leave the chest open like that in Canada?” I asked, grinning. “I’m wondering if it’s only Tom King who does it. He’s a bit of a maverick apparently.”

  The Handwringer seemed uncertain.

  At that moment the ECG trace of Mr Watkins deteriorated from its regular conformation to a rapid fine oscillation.

  “VF!” Gibbs roared.

  “Oh shit,” King said from across the room. “Get the paddles, quickly”

  Handwringer, who had rushed back over to help, reached for the external defibrillator paddles.

  “Not those ones stupid – the sterile ones,” Gibbs yelled at Handwringer.

  “You bungling incompetent,” I whispered in Handwringer’s ear.

  King whipped on a pair of sterile gloves. He tore away the plastic dressing. The heart was shaking, as though it was having its own private seizure. “O.K. I’m ready for the paddles,” he said. Green’s ‘super’ nurse dropped the correct paddles to King from a sterile packet. King threw the cable ends over the drapes to Green, who plugged them into the defibrillator. King applied the paddle blades to the fibrillating heart. “O.K shock now,” he said.

  “Stand back,” Green shouted. He pressed a button on the defibrillator. There was a sharp resonance. The heart jumped under the paddles before coming to lie still. King tapped it with the palm of his gloved hand. It contracted each time he touched it.

  “Come on you bastard,” King implored.

  “Asystole,” Gibbs shouted from the monitoring screen.

  “O.K. lets give adrenaline. One milligram,” Green said.

  King began squeezing the heart, once a second. “It’s hopeless,” he said, his shoulders dropping.

  “Atropine,” Green ordered, observing the flat ECG trace.

  “He’s stuffed,” Gibbs said

  “0.6 or 1.2?” the ‘super’ nurse asked.

  “The bigger dose, thanks,” Green said.

  “And now more adrenaline – three milligrams,” Green continued.

  “It’s a waste of time, it was never gonna survive that bleed out,” Gibbs said

  “Yes, maybe, but let’s at least go through the protocol,” King said, sweat soaking his green top.

  As soon it was over. King headed out the door, to confront the relatives. Gibbs and Green shuffled away towards the central station, discussing where the blame lay for the dismal outcome. Handwringer stayed to help the ‘super’ nurse and I remove the tubes and lines from Mr Watkins. Surreptitiously, I eyed up the nurse. Her freckled skin was pale but the shape of her face had a benign disposition. The corners of her mouth seemed to angle upwards so that she always appeared good humoured. She was leaning forward into the wound, gloves on, removing the clamps. Her hair fell forward half obscuring one eye. Her uniform was loose at the top. I could see her cleavage disappearing downward, between shadowy curves.

  “Do we throw these tubes away super nurse?” I asked.

  She laughed. She said her name was Melanie.

  “How long until you start the nightshift Gerry?” It was the Handwringer who spoke. Melanie glanced up at me and our eyes met momentarily.

  “It’s only a week away,” I said. “You’d better wash out the red carpet for me.”

  Melanie smiled and walked away with the clamp.

  Chapter 2