Tom blinks at me. ‘I could say the same to you.’
There’s a brief moment of silence before it’s punctuated by the distant sound of shouting. I stick my head out into the corridor, then hear it again. Alice, calling my name, her voice sounding urgent. Anxious.
I grab my torch and run towards her, my knee protesting with sharp flares of pain every time I put weight on it. I catch up with Alice in the covered walkway connecting Beta to the main building.
‘Oh, thank goodness,’ she gasps, trying to draw breath. ‘Caro … she’s started bleeding. Down there,’ Alice mimes, pointing between her legs.
Fuck, I think, hurrying back to the lounge.
Could things get any worse?
39
7 July
By the time we arrive in the lounge, Caro is getting to her feet, face wincing with pain. Behind her, my torch picks up a large stain on the sofa, the fabric soaked red with blood. The sight is so reminiscent of Sandrine, still lying on her office floor, that I succumb to a rush of blind panic.
I can’t do this.
I can’t deal with this all on my own.
Despite Ark’s endorsement, I don’t feel up to the job. I’m frightened and exhausted, ill-equipped to cope with yet another unfolding emergency.
You’ve no choice, I tell myself fiercely, fighting to regain control of my emotions. Who else is there?
I take a deep breath and force myself to sound calm. ‘Let’s get you into the surgery.’ I glance around at the others. ‘Can you give Caro a bit of assistance?’
Rob and Sonya lift Caro’s arms around their shoulders, and start slowly walking her towards the clinic, Alice leading the way with her torch. I follow behind, mind racing through all the possible diagnoses – none of them good.
‘I think she’s haemorrhaging,’ Sonya whispers, as we help Caro onto the exam bed in the surgery.
I nod, handing her my torch, and turn to Rob. ‘Can you find a couple of the fuel stoves?’ The air in the clinic feels wintry – despite the insulation, we’re fast losing all residual heat.
Sonya trains the torch beam on Caro while I examine her. There’s blood all over the crotch of her blue leggings; as I ease them off, she grimaces, clearly in a lot of pain.
‘Where does it hurt?’ I grab an absorbent pad from the cupboard and place it between her legs.
‘Down here.’ She puts a hand on the base of her abdomen.
I press gently on her stomach, watching her face. Her eyes water at even the slightest pressure from my fingertips.
How many weeks is she now? I do a quick mental calculation. Anywhere between twenty-seven and thirty-one – hell, she isn’t due yet for at least a couple of months.
I pick up my stethoscope and place it on Caro’s stomach, listening for the baby’s heartbeat. Nothing.
Keeping my expression deadpan, I try again, positioning the cup on a different part of her abdomen.
‘Is everything okay?’ Caro asks weakly.
‘One sec.’ I try a third position and listen carefully. To my relief I pick up the faint sound of a heartbeat. Eyeing the second hand on the clock on the wall, I count the beats in six seconds. Around 18 or 19. That’s over 180 beats per minute.
Too fast. A clear sign of foetal distress.
I quickly attach a cuff to Caro’s arm to check her blood pressure. Fifty-five over forty.
Hell. That’s way too low.
The diagnosis seems clear. Placental abruption, probably caused by her fall.
But what to do? My mind blanks with anxiety and a desperate ragged fatigue from sleeplessness and withdrawal. I need an ultrasound machine, a foetal heart monitor, and advice from an expert at UNA. None of which are available.
I’m on my own.
‘Is the baby okay?’ asks Caro again, anxiously.
‘Strong heartbeat,’ I reply, trying to sound as reassuring as possible. I check the pad between her legs, already soaked with fresh blood. If she carries on haemorrhaging at this rate, Caro and her baby could die within hours – if not sooner.
I turn my back on Sonya and Alice, on their worried expressions, their faith that this is a situation I can handle, and consider the options before me: only one I can think of, and that’s an impossibly tall order without power or proper medical support.
Plus I have absolutely no experience in the field.
I stand there, head spinning. What should I do?
Think, Kate. Think.
‘Can you and Alice go and find Drew?’ I say quietly to Rob, who’s just returned with two stoves and several kerosene lamps and set them up in opposite corners of the room. ‘Use one of the walkie-talkies to track him down. Tell him I need him to assist.’ I widen my eyes at them so they read the urgency without my having to state it in front of Caro.
Sonya regards me gravely as they hurry out – she’s well aware that she and Drew are the two winterers trained to assist me in any surgical procedure. ‘Are we going to operate?’ she mouths.
I nod, trying to look decisive and confident, but I can tell Sonya isn’t fooled. I beckon her to follow me into the clinic, closing the door to the surgery so Caro can’t overhear. ‘We need to do an emergency caesarean,’ I say quickly.
Sonya’s eyes widen. ‘Is that the only option? That’s pretty risky, isn’t it? Given the circumstances.’
‘Not as risky as letting her bleed to death. And no, we haven’t any choice.’
‘But how can we give her a general anaesthetic?’ she asks, looking perplexed. ‘We can’t ventilate her without any power.’
‘We’ll have to use Entonox and local anaesthesia.’
After a brief pause, Sonya nods. ‘Okay.’
‘Can you set up an IV line?’ I ask her. ‘Remember how I showed you?’
‘I’m on it.’ She retrieves a bag of saline from the cupboard. I go into the clinic and hunt through the medical manuals on the shelf above my desk, the hard copies that UNA included as a backup. I scan the notes on placental abruption.
It’s not pretty. High risk of maternal and foetal death without swift intervention. I need to act fast.
This is insane, wails another part of my brain. You don’t have the experience, or anything you need.
‘You all right?’ Sonya asks, as she inserts the needle into a vein on Caro’s left hand.
‘Yes,’ I lie.
‘You can do this,’ she says firmly, as if reading my mind.
You can do this, I repeat to myself in my head, trying to believe it. You’re an experienced ER doctor – you know what to do.
Without medical support? Diagnostics? Power and light?
‘What’s happening?’ moans Caro, catching something in my expression.
I bend over her. ‘Listen, I’m pretty sure your fall caused part of your placenta to dislodge from the wall of the uterus, and that’s why you’re bleeding. So, I’m going to give you an anaesthetic and deliver the baby. Okay?’
Caro stares at me for a second or two, then nods weakly. She looks out of it, I think, wondering how much blood she’s already lost. If I don’t get a move on, she could go into shock.
A moment later the door swings open and Drew appears. ‘Alice said you needed me.’
‘Caro’s hurt herself. I have to operate. I need you and Sonya to assist.’
A flash of alarm crosses his face. ‘What do you want me to do?’
‘First, can you go and find where Sandrine has locked up the painkillers and analgesics. They’re somewhere in Beta.’
‘I know where they are.’
‘You do?’ I raise an eyebrow at Drew but don’t pursue it. No time to get into that now. ‘Bring everything. And some better torches – more than anything we need light.’
He nods and disappears. I turn to Sonya. ‘You ready?’
I grab a bottle of antibacterial gel and clean my hands as best I can without running water, donning surgical gloves and a gown before going back into the surgery. ‘Caro, have you ever had gas and air?’
> ‘No,’ she whispers, her voice noticeably weaker.
I drag over the cylinder and hand her the mask. ‘In a minute I’ll give you some drugs to take away the pain, but if you need more help, you put this over your face and breathe deeply. Do you think you can do that?’
Caro nods, then closes her eyes. I note she isn’t asking me for any details of what I’m about to do. Too out of it to care – or simply too scared.
Just as well. Ignorance is bliss – or at least more bearable.
As I prep her stomach with alcohol and antiseptic wipes, Drew returns with Luuk, each carrying a large torch attached to a telescopic stand. They arrange them on both sides of the surgery bed, beams trained on Caro’s stomach, then Drew hands me a carrier bag stuffed with medication.
Luuk’s eyes widen as he sees the blood-soaked pad between Caro’s legs. ‘She going to be okay?’
‘Right as rain,’ I say briskly. ‘Please make sure everyone who isn’t working on getting the power back up stays in the lounge. I can’t cope with any more casualties.’
Luuk dives out of the room without further prompting. I’m guessing he’s not good with the sight of blood.
‘Drew, can you gown up, then monitor Caro’s blood pressure and pulse, and give me readings whenever I ask?’
‘Sure.’
‘Sonya, I need you to swab while I work, so I can see what I’m doing.’
She swallows. For once she seems to have dropped her stoic demeanour and looks genuinely anxious.
I root through the bag of meds and find a bottle of Fentanyl. Ignoring the surge of longing it sparks in my brain, I load it into a syringe. ‘Right, Caro,’ I say, careful to keep my voice steady. ‘This should completely eliminate the pain. But if you feel anything at all, start breathing deeply with the mask covering your face. Drew, you might have to hold it for her.’
‘You done this before?’ His eyes fix on mine.
‘Dozens of times,’ I lie, knowing Caro can hear us. Truth is I observed a couple of caesareans during my training, but have never actually performed one. Slowly, carefully, I inject Caro with the powerful painkiller, then open the sterile packet containing the scalpel. Cup the icy metal in my palm.
It’s still freezing in here, the little stoves struggling to combat the rapidly encroaching cold. Another reason to act fast.
I grip the scalpel and mentally draw the line for the incision. Then stand there, hesitating.
‘Kate?’ Sonya asks, looking at my hand. ‘You sure you’re all right?
I glance down, see my fingers are trembling. I close my eyes briefly and take several deep slow breaths. Take some of those pills, whispers a voice in my brain. Just to steady your nerves.
No.
On the next inhale, I make a neat transverse incision low into the pubic line, all the while alert for a cry or moan of pain.
Thankfully there’s nothing.
‘Sonya, could you swab please? Drew, check her BP and pulse – you’ll have to do it manually.’
As Sonya deals with the blood, I work my way down to the uterus and make another careful lateral incision.
‘BP is fifty-five over forty,’ announces Drew. ‘Pulse one hundred and five.’
No change. Though neither, of course, tell me anything about the condition of the baby.
A sudden rush of fluid as I rupture the amniotic sac, gushing everywhere. Sonya grabs some towels and mops it up as best she can.
I take a pair of surgical clamps and pass them to her. ‘I need you to hold the incision open while I work.’
As she gets them in position, I reach into Caro’s uterus, feeling for the dome of the baby’s head. There. Small, but reassuringly warm. Cradling it in my palm, I slide in my other hand and pull gently.
A moment of resistance, then a second later the tiny infant emerges from Caro’s stomach.
‘Jesus,’ Drew gasps, eyes wide. ‘Why is it that colour?’
‘It’s the vernix,’ explains Sonya. ‘Standard for pre-term babies.’ We all gaze at the diminutive white bundle in my hands. It looks like a tiny lifeless ghost.
A tiny female ghost.
‘Is she breathing?’ Sonya whispers.
I shake my head, pushing the tip of my little finger into her mouth to ensure her airway isn’t blocked. Even under the vernix, I can see her skin is blue with lack of oxygen. I need a Ambu resus bag, I think desperately. I have to get her breathing, fast.
‘Get the oxygen,’ I urge Drew, ‘and another mask.’
He brings me both. I prise open the baby’s mouth and carefully blow inside, then hold the oxygen mask over her, hoping this will work.
It doesn’t. I try again, but to no avail.
Oh God, I find myself praying. Please.
‘Give her to me.’ Sonya reaches out. ‘You deal with Caro.’
I pass her the tiny bundle and watch as Sonya breathes into her mouth a few more times, then expertly turns her over and pats her between the shoulders. Miraculously there’s an almost inaudible snuffle, and the little arms stiffen and move.
Tears in my eyes as I turn back to her mother, readying myself. Gently, carefully, I begin to pull on the umbilical cord, silently uttering another prayer that the placenta will come away freely; if the uterus can’t contract and cut off the blood flow, Caro could bleed out in a matter of minutes.
For a moment or two nothing happens, then the afterbirth slithers out into my hands. I grab one of the torches and examine it carefully – thankfully it seems intact.
‘Drew, could you give me a hand?’ I nod at the swabs as I find a needle and sutures and set to work closing up the wound in Caro’s stomach. ‘How’s the little one?’ I ask Sonya.
‘She’s doing okay.’
‘Can you clamp the cord, then cut it? I’ll—’
A sudden moan from Caro, who seems to be rousing from her semi-conscious state. ‘Press the Entonox mask over her face,’ I tell Drew quickly, then address Caro directly. ‘Hang on in there, sweetheart, it’s nearly over. Long deep breaths, okay?’
I work as fast as I can, thankful I know what I’m doing now. With so much practice in A&E, I could sew up a wound in my sleep. As I tie off the last stitches and apply the dressing, I beckon Sonya over.
‘I need to look over the baby. I want you to massage the top of the uterus like this, to encourage it to contract – that will help stop the bleeding.’ I give her a quick demonstration, then check the pads between Caro’s legs. Both sodden, but the blood flow appears to be easing.
Far from out of the woods yet, but it’s a good sign.
Taking the baby from Sonya, I pull back the towel to examine her. Her skin is now tinged with pink, and she seems – despite her prematurity – to be breathing on her own. Perhaps Caro was a little further along than either of us realised. I marvel for a second or two at her perfect little features, her tiny limbs, then cover her up against the cold.
‘Keep her on oxygen for the time being,’ I tell Sonya, as I hand her back, ‘and make sure she’s warm.’
I return my attention to Caro. The blood loss is definitely decreasing, I note with relief. I squeeze her hand and she opens her eyes and blinks blearily at me over the top of the Entonox mask.
‘It’s over,’ I say, taking it from her. ‘I’ll give you some morphine to help with the pain, but it’ll make you drowsy, and I thought you might like to see your baby first.’
Caro blinks at me as if my words make no sense, then seems to wake up as the gas and air clears her system. ‘Yes,’ she croaks, trying to pull herself upright, but I put a hand firmly on her chest to stop her. ‘No, don’t move, not yet.’
I fetch a couple of pillows and ease them under her head, then take the baby from Sonya and lay her in Caro’s arms.
‘Oh my God,’ she gasps, her voice croaky. ‘It’s so small.’ She looks up at me. ‘Is it a boy or a girl?’
‘A girl.’
Caro gazes at her, a single tear rolling down her cheek. I leave them together for a minute
before gently removing the baby and injecting Caro with a good dose of diamorphine. With any luck, that should get her through the next few hours.
‘Can I hold her?’ Drew asks.
I look at him, surprised, as Sonya hands over the little bundle. We both watch him study the baby’s diminutive face with an expression of tenderness I’ve never seen on him before. Clearly witnessing a birth has brought out Drew’s paternal side, made him rethink that whole no-children thing.
‘She needs oxygen,’ Sonya says, taking the baby from Drew’s arms. He seems almost reluctant to let go of her.
‘Could you possibly find another stove,’ I ask him. ‘And a clean duvet. We need to keep them both warm.’
He nods, and disappears. Sonya and I exchange a look, smiling, as the door closes behind him. Who knew Drew was such a softie?
I give Caro some broad-spectrum antibiotics, and we watch her drift into a hazy sleep. As long as she doesn’t get an infection, she should be fine.
‘Can you manage in here for a while?’ I ask Sonya. ‘I want to check again how Ark is getting on, make sure everyone else is all right.’
‘Do we need to feed her?’ Sonya nods at the baby. ‘I don’t imagine Caro will be up to it for a while.’
‘I’ll get Rajiv to bring you some powdered milk.’
Sonya frowns. ‘Will that be okay?’
‘It’ll have to be – he sure as hell doesn’t have any baby formula. We can warm it on one of the stoves and offer it to her in a syringe, but get Caro to put her to the breast when she wakes up. Chances are the baby’s too small to have a strong sucking reflex, but it’s worth a try.’
I fetch a few more phials of morphine, plus clean needles and syringes, then leave them on the counter. ‘You remember how to administer injections?’ I ask Sonya.
‘Yes.’
‘Give her another dose if she needs it. No more than 20 ml every four hours.’
Sonya frowns at me again. ‘Why can’t you give it to her?’
‘I’ve got to deal with the power issue,’ I hedge, not wanting to admit I don’t trust myself around these narcotics. Or my fear that something – or rather someone – might prevent my return to the clinic. ‘I’ll send Alice and Rob with the milk and bottled water. Lock the door behind me, won’t you?’
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