Joshua sighed and glanced at the number. A&E. He’d get to it in a minute. But the minute hadn’t even passed before the pager sounded again, this time not stopping.
MIA—a major incident alert. It only happened a few times a year. A code red was a paediatric cardiac arrest. Unfortunately, they happened frequently, particularly with the really sick kids in ICU. But MIA was slightly different and always came from A&E. He glanced quickly around the ward and shouted, something he rarely did. ‘Ron! Find Isaiah and Clara. Tell them there’s a major incident and to assemble in A&E.’
Joshua ran down the stairs of the hospital, meeting several other senior colleagues heading in the same direction. ‘What is it this time?’ one asked.
He shook his head. ‘Don’t know yet.’
As they walked through the swinging doors to A&E there was a momentary lull. All the A&E staff were crowded around the nurses’ station. Alan Turner was standing on a chair that looked decidedly wobbly.
Alan gave Joshua and a few other Department Heads a nod as they joined the group. ‘Okay,’ he said, lifting a hand in the air. ‘Five minutes ago we got a call about a major Road Traffic Accident, involving up to an estimated seventy casualties. Two buses have collided. One a tour bus, and one a bus with kids on a school trip. A major incident alert has been declared. Our flying squad emergency team have just left to assist on the scene. The Royal Hampstead is the nearest major trauma receiving centre. Twenty ambulances and two air ambulances are on their way to the scene. If you have patients currently in A&E then clear them out. We need all areas. If you have patients upstairs you can discharge, then get some of your colleagues to do it. Beds will be needed.’ Alan started pointing at areas and shouting instructions as Clara ran up to join Joshua.
‘What is it?’ she whispered.
‘Major RTA. Up to seventy casualties. A busload of kids is involved.’
She nodded as Alan turned to them. ‘Paediatrics will be led by Joshua Woodhouse, Clara Connolly and Isaiah Orun. They’ll be based in Resus One and Area Six. Bess, Reid and Fran will assist.’
Joshua spun around and nodded. ‘Let’s set up,’ he said as the nursing staff joined them. They all moved methodically, requesting any specific paed equipment they might need and setting up their own small triage areas for children. Clara and Isaiah moved like the professionals he would have expected. Once they were set up, the silence across A&E was almost deafening. Patients had been moved to X-ray and short-stay areas. Others had been transferred up to ward areas for further assessment. Walking wounded had been sent to a nearby GP practice who helped in emergency situations. And the rest of the staff were just...waiting in an ominous silence.
It was only a few moments before the shrill ring of the red phone at the nurses’ station broke the silence. Alan answered quickly, talking in a low voice and taking a few notes. As soon as he replaced the receiver he shouted to his colleagues, ‘First set of ambulances are five minutes out. Eight adults, three paeds—all major trauma.’
Joshua put his hand on Clara’s arm. ‘Do what you can do—and if you need help just ask. We’ll work alongside each other. Hans is on his way down—he’s finishing up in Theatre—along with a few of the surgeons. They’ll be available to assist.’
He watched her take a deep breath and give a slow nod. He wondered for a few seconds if he should worry about her. A major incident alert wasn’t for the faint-hearted. It could be a time of chaos. Lots of professional staff were unprepared for what they might encounter and have to deal with over a short period of time. But as he watched he saw her give him a serious kind of smile. She was just taking a minute, preparing herself for what lay ahead.
As soon as he’d got the page, Clara and Isaiah’s names were the first he’d thought of. They were skilled practitioners, and good at dealing with staff and patients. Clara’s straight to the point attitude was perfect for a situation like this, and Isaiah’s range of clinical skills would complement the teams.
Joshua glanced around again. Isaiah seemed to have attached himself to Bess, one of the most experienced A&E nurses. He was finding himself an anchor for the storm ahead. It made perfect sense. At a busy time, an experienced A&E nurse was worth their weight in gold. ‘Reid, with me please, and Fran with Clara. We’ll take resus,’ Joshua said, knowing that meant they would have the most badly injured children. But he walked to the main receiving door to stand alongside Alan. If he had a chance to triage all the children first, he would do that.
The first few ambulances appeared in a blaze of sirens and blue lights. Joshua stepped back once he realised the first few patients were adults. Then the children started to appear. The first boy clearly had open fractures. ‘Clara, stabilise and get ready for Theatre.’ The second boy had multiple facial lacerations. ‘Isaiah, assess, stabilise and page plastics.’
The third child was a little girl who was being bagged by one of the paramedics. He met Joshua’s gaze. ‘Flail chest. Natasha is ten. She was standing in the passageway of the bus and hit the central gear controls.’ He rattled off her heartrate, BP and respirations, filling Joshua in on her continued deterioration in the ambulance on the way to the Royal Hampstead.
‘Resus One,’ he said. ‘Any more kids on the way?’
The paramedic shook his head. ‘We were the first team. The next will be another ten minutes at least.’
Joshua worked quickly. Flail chests were difficult and quite uncommon in kids. Basically a portion of Natasha’s ribcage had separated from the rest of the chest wall. As the paramedic continued to bag her, he could see the uneven way her chest was moving.
One of the other nurses moved to take over the bagging as Reid connected the oxygen supply. Joshua was focused on the little girl, ordering analgesia and sounding her chest while the oxygen support continued. ‘Portable chest X-ray,’ he ordered. He was certain that at least one of the lungs had been punctured by a rib. He kept his eyes on the oxygen saturation monitor as the X-ray machine was wheeled in.
A face appeared in the doorway—Hans. ‘Do you need me?’
‘Great,’ said Joshua, looking up. ‘I was just about to call you. Ventilation may be required. I think there’s at least four ribs detached and a strong possibility of a pneumothorax.’ He looked down at Natasha again. Even though she was on oxygen her dusky colour was not improving much.
Clara was dealing with her child in the resus bed next to him. She worked smoothly and competently, ably assisted by Fran. He could see he had no need to worry about her.
A lead apron was passed to him by the radiographer and he slid it over his head, nodding to Reid that he would take over while the X-ray was taking place. Reid waited behind the door alongside Hans, Clara and Fran, for the few seconds it took to take the X-ray.
A few minutes later it was on the viewer next to them. Hans shook his head. Three ribs were obviously misplaced, with one clearly spearing the lung, causing a haemothorax. ‘This one needs to be done in Theatre,’ he said and Joshua nodded in agreement.
‘Absolutely,’ Clara agreed as she stepped up alongside him. Her patient was already on his way to Theatre.
Clara reached over and took Natasha’s hand, taking a few moments to stand next to the child and talk softly.
Joshua quelled his frustration that he couldn’t do something immediately to help this little girl. He’d inserted tubes before to drain the blood from a lung and help reinflate, but not while the rib was still causing damage.
‘Consent?’ asked Hans.
Joshua looked up once. ‘Reid?’ was all he said.
A few minutes later the nurse returned, shaking his head. ‘Police say parents have still to be contacted. They can’t find Natasha’s bag in amongst the wreckage of the bus.’
‘No parents?’ Concern laced through Clara’s voice as she continued to stroke Natasha’s hand.
‘Darn it. No other responsible adult who could give us the
information? Who was Natasha travelling with on the bus?’
Reid shrugged. ‘It’s bedlam out there. Police just say they’re still trying to identify Natasha and get in touch with family.’
Joshua looked down and touched the young girl’s arm, for a moment thinking that could be Hannah lying there. Hans was talking with one of the surgeons, making a plan to take Natasha to Theatre.
‘Reid? How did the paramedic know her name is Natasha?’ Joshua asked.
Reid was washing his hands at the sink. He looked over his shoulder at Joshua. ‘Apparently she told the paramedic before she passed out with the pain. But the only info he got was her first name and her age.’
Joshua couldn’t imagine this little girl going to Theatre with no one knowing. In an emergency situation like this, they didn’t need to gain consent from a parent. Her injuries were potentially life-threatening. He would make a final check with the police that they had no other way to identify Natasha right now and, as Head of Department, would make the call with the surgeon.
He moved around the other side from Clara and took Natasha’s hand, bent down and spoke quietly next to her ear. ‘Hi, Natasha, I’m Joshua. I’m the doctor that’s looking after you. I know you’re scared, and I want to promise you we’ll look after you. Can you try and give my hand a squeeze?’
He waited for a few moments, sad when nothing happened. He looked up and saw Clara blink back tears. There was no obvious head trauma. Natasha’s eyes weren’t opening but he checked her pupils again and they reacted as normal to the light he shone in them. She just wasn’t showing clear signs of consciousness. When he checked her motor responses, she flinched when he applied a little pain to her fingertip. That was something positive.
He recorded all her responses, then spoke to her again. ‘I know that breathing is really tricky right now and we’re going to do something to help you with that. You need to go for an operation, but we’ll make sure you’re sleeping, and when you wake up things should feel a bit easier. We haven’t managed to find your family right now, but we’ll do our best to sort that out while you’re having your operation.’ He put his hand gently on her shoulder. ‘I’ll come back and see you once you’ve had your operation, but I’m going to let my friend Hans look after you from this point.’
Hans had appeared at his side and checked over the paperwork and electronic charts. As paediatric anaesthetist, he had the final say on whether Natasha would get taken for surgery or not. He gave a nod and took over from Joshua. ‘I’ll call you when we’re out of Theatre.’ As he looked around he said, ‘I imagine you’ll still be here.’
Joshua could hear sirens again as more ambulances pitched up outside. He hated the thought of leaving Natasha with other colleagues, and he could see Clara felt the same way, but he knew they would take good care of her. On a normal day he’d assign a member of his paediatric staff to stay with her, but right now he didn’t know how many more paediatric cases they might get, and it was a decision that would have to wait. The surgeon signalled him for a quick chat about agreement on consent for surgery, and Joshua waved to one of their nearby police colleagues for an update on any family. ‘We’re doing the best we can, but we still have no way of formally identifying Natasha any further right now.’
Joshua nodded and turned to the surgeon. ‘In this case we have to treat her under civil law.’
The surgeon also nodded. ‘Agreed. If we find parents or relatives later I’m happy to do the explaining with you.’
Joshua waved his hand. ‘It’s fine. I’m happy to take responsibility.’
The scream of sirens sounded from close by. He looked quickly over to where Clara was reluctantly releasing her hand from Natasha’s. For some reason, it seemed entirely natural to be close to her. ‘Need anything?’ he said quietly.
She lifted her gaze to meet his and gave him a soft, grateful smile in amongst the chaos. ‘Just sad that Natasha doesn’t have anyone right now. The orthopods have already taken my patient to Theatre.’ She snapped on a pair of fresh gloves as Reid helped them wheel Natasha out the resus room. ‘I’m ready for the next one.’
She was doing her best to appear cool, calm and collected, even though he’d seen the emotion on her face earlier, and he appreciated that. Something flitted across her eyes. ‘What about you?’
He glanced upwards. ‘I’m just thanking someone upstairs for coincidences. Hannah is staying at the house of one of her school friends who is having a birthday party tonight. This will be a late one. I’m glad I can stay without panicking about babysitters.’
‘I’ll stay too,’ said Clara quickly. ‘You’ll need all the help you can get and anyway—’ she gave a shrug ‘—what have I got to go home to if you and Hannah aren’t around?’
His heart missed a beat in his chest. She’d said it in a light-hearted tone. But it felt like something more. Like the declaration they’d kind of been heading towards, with both of them tiptoeing around.
He wanted to say so much more, but instead he swallowed and smiled. ‘Thank you.’
‘No probs.’
‘Josh!’ The shouting voice made them both turn. ‘Four paed cases.’
He moved instantly, triaging quickly and being surprised by a nudge at his elbow. Alice, one of the charge nurses from upstairs, was next to him. He lifted his eyebrows in surprise. ‘Executive decision,’ she said quickly. ‘I’ve called in extra staff. Lynn’s already clearing more space in the assessment unit. You triage and give me all the minors and I’ll take them upstairs for assessment. Arun’s on the ward and can do his thing.’
He should have known his staff would pull out all the stops in a crisis situation. Lynn was the other charge nurse and Arun one of the other paediatricians. ‘I was just about to call you.’
She shrugged. ‘You don’t need to. We have a shared brain.’
It was true. Staff who had worked together for a long time often anticipated each other’s needs. Both Lynn and Alice had been charge nurses in the unit when he’d first arrived. He had a great team and as he noticed Clara giving him a smile as she pulled on a protective gown over her scrubs, ready to receive the next patient, he was reminded how well she was fitting in.
The doors rolled open and an array of patients were brought through. He triaged quickly—one kid unconscious but breathing, another with a crush injury to a leg, one with abdominal wounds. There were another four kids with a variety of bruises, scratches and one little one who was crying. He gave them all a quick check for any hidden injuries. ‘Last four mine?’ asked Alice as she picked up the weeping four-year-old.
‘Perfect,’ he said quickly. ‘And thank you.’
As Alice dashed off with the other children, Joshua assigned the three more serious kids between himself, Clara and Isaiah. And so the afternoon, and early evening, continued.
He and Clara continued to work side by side in resus. They were a good team, often checking X-rays together or assisting each other when required.
The injuries of the children who arrived became less severe. But all the children who’d been involved in the accident still needed to be assessed to ensure nothing was missed. Several of the parents of the children had also been travelling on the school bus as volunteers, and they had a variety of injuries ranging from minor to severe.
The police did a wonderful job of trying to track and trace the families, considering the tumbling of the bus had meant that nothing had been where it started. A whole host of bags and suitcases had been strewn across the road, some contents unsalvageable.
One of the teachers on the bus had been trapped for a number of hours and had to be cut out, so some of the other school teachers from the same school had come to A&E to help with the children. It turned out that Natasha had been on the tour bus and not, as first presumed, on the school bus. Her grandmother had accompanied her as they were both going on holiday to Spain to meet her mum and dad, but her
gran had required surgery for a broken hip. As soon as she’d come round from Theatre she’d started babbling about her daughter, becoming distraught. One of the theatre nurses had immediately recognised the name she kept mentioning and realised the elderly lady was confused from the anaesthetic and managed to join the dots. Both parents were now flying back from Spain. Things were finally starting to fall into place.
* * *
By the time Joshua and Clara were finished in A&E they were both tired. ‘I need food.’ Clara sagged against the nearby wall and wiped her hand across her forehead. She’d needed food about four hours ago but there just hadn’t been time.
‘Give me five minutes,’ said Joshua, the lines around his eyes more pronounced. ‘I just need to give Hannah a quick call.’
Clara smiled and followed him into the A&E staff room whilst he grabbed a seat in the corner and pulled out his phone. She poured them both some water from the cooler and sat down beside him. Within a few moments he shook his head, laughing, then spoke for a minute before finishing his call.
‘All good?’ she asked.
He let out a long slow breath and shook his head and laughed. ‘Hannah didn’t even want to talk to me. She’s having far too much fun. I let the little girl’s mum know that I’m likely to spend the night here because of the accident and she can get me on my mobile if she needs me.’
He closed his eyes for a second and rested his head back against the leather chair. It was lumpy, with some ragged tears, but was one of the few chairs in the room that wasn’t made out of hard plastic.
She couldn’t help herself. She reached over and grabbed his hand. ‘Hey, we did good. Things could have been much worse. Everyone who got here got looked after.’
It was true. They’d heard about a few adults on the coaches who had life-threatening injuries. One kid who was seriously injured had been helicoptered to a more specialist hospital, and they’d since heard that the child was serious but stable. But all the kids who had come through the Royal’s doors had been assessed and treated as required. Some would have surgical scars, some might need other supports, but all were alive, and as well as could be expected.
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