Her Emergency Knight

by Alison Roberts

  ‘Yeah.’ The look Jennifer received was closed off enough to appear blank. ‘Forget it, Jenna. It’s over. And it wasn’t your fault.’

  He closed his eyes and Jennifer glanced at her watch. ‘I’d better go. I hope you get well soon.’ She backed towards the door. ‘Thanks again, Guy…for everything. I’ll keep in touch.’

  Guy didn’t open his eyes. ‘Sure. Me, too.’

  But they wouldn’t. Jennifer knew that with absolute certainty as the wheels of her plane lifted from the tarmac and the aircraft pulled up into a sharp ascent to gain the height needed to leave the mountainous terrain.

  Maybe she would never forget but if she didn’t distance herself, the memories would haunt her far too deeply. Staying in touch with Guy would only prolong trying to move on from a shattering experience, to put it into a perspective that wouldn’t interfere with her future.

  Guy would feel exactly the same way. He was, no doubt, breathing a deep sigh of relief right now as he heard the plane circle above the hospital. Maybe he was even watching from a veranda, his relief evident in a wry smile.

  She was an alien and she was returning to her own planet.

  CHAPTER SEVEN

  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.

  The house surgeon was giving Jennifer a curious look so she smiled reassuringly, introduced herself to the patient and then caught the young 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 86. It’s gone up to 92 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 house surgeon. ‘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 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 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.’

  ‘OK, 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 1. ETA five minutes.’

  ‘Is the trauma room clear?’

  ‘Just.’

  ‘Get the team together. 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 encouraged. ‘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 10-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 flash-back. She withdrew the needle, leaving the plastic cannula in place. ‘OK. 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 the wire 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?’

  ‘Gentamicin 5-7 milligrams per kilogram IV as a single daily dose, and amoxycillin 2 grams IV six-hourly.’

  Jennifer nodded. ‘Put a Foley catheter in. 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.’

  The toddler was still screaming near the desk and an odd-looking man sat bolt upright on a stretcher beside the triage desk. A police office stood beside the ambulance crew.

  ‘Hey…Jennifer!’

  ‘Hi, Matt. What’s brought you down here?’ The orthopaedic consultant was not a frequent visitor to the emergency department.

  ‘Overload. You’ve used up all my registrars. There’s a nasty open femur and a fractured pelvis among the MVA patients that have come in. I’m just waiting for the X-rays to come through.’

  ‘Oh.’ Jennifer caught the eye of the triage nurse. ‘Is the trauma room covered, Mel?’

  ‘Yep. We’ve got a status 2 asthmatic coming in now, though. ETA two minutes. Can you cover that one?’

  ‘Sure.’ Jennifer’s attention was again caught by the man on the stretcher, who was staring at Mel with an increasingly disgusted expression.

  ‘Are you going to come out with us tonight?’ Matt’s voice was persuasive. ‘You’ve been having early nights ever since you got back to work, and that’s weeks ago now.’

  ‘It’s been tiring.’ Jennifer turned her gaze to the over-full whiteboard listing the department’s current patient load. No wonder beds were beginning to line up in the corridors. ‘Maybe I should have taken more than a week to recover in the first place.’

  ‘How’s the arm?’

  ‘No problem now. I just put a central line in and hardly noticed it.’

  ‘And the feet?’

  ‘Almost back to normal.’ Jennifer was keeping one eye on the doors to the ambulance bay and another on a patient being moved from one of the resus areas. She would need that bed for the asthmatic patient coming in. ‘I’m walking to work now but they’re not up to dancing quite yet.’

  ‘So just come to the drinks session and on to dinner. If you don’t want to do the club thing after that, we’ll let you go home.’

  ‘I’ll think about it,’ Jennifer said evasively.

  Matt’s face fell. ‘This isn’t like you, Jen. The crowd’s just not the same without you.’

  Jennifer just smiled. Why was the invitation so unappealing anyway? She had always worked hard and played hard, and a night on the town with a group of congenial people with exactly the same agenda had always been the perfect way to wind down after a stressful shift. Right now, however, it came across as being an empty way to spend an evening. Shallow, even.

  What would she rather be doing? Sitting in a hut in the middle of nowhere with a man who would have preferred that she’d never set foot on his planet?

  ‘Bitch!’

  The vehement accusation was startling, but it wasn’t directed at Jennifer. She whirled around to see the man on the stretcher still staring at Mel and making a vigorous attempt to get up. Fortunately, the safety belt was restraining his hips and the police and ambulance officers were quick enough to put pressure on his shoulders and force him back against the pillow.

  ‘You’re all the same,’ the man shouted. ‘You need to be wiped off the face of the bloody planet!’

  Jennifer’s eyes widened, but Matt grinned. ‘I don’t think he’s too happy with the fairer sex at the moment, do you?’

  Mel stepped hurriedly back behind the central counter. Jennifer stepped forward.

  ‘What’s going on?’

  ‘Midazolam’s wearing off,’ the paramedic told her.

  ‘History?’

  ‘Police were called to a department store where he was slicing up women’s clothing with a carving knife.’ The paramedic raised an eyebrow. ‘He was cross enough to be rather uncooperative. Seems that his girlfriend doesn’t find his company too appealing anymore so she left…in the company of his best mate.’

  The man on the stretcher spat on the floor near Jennifer’s feet and struggled against the restraining hands. An IV pole crashed to the floor.

  ‘Bitch!’ he screamed again. ‘It’s your turn next!’

  ‘Call Security,’ Jennifer ordered. She caught the eye of a house surgeon emerging from a cubicle to see what the commotion was. ‘Michelle, could you draw me up a 10 milligram dose of haloperidol, please? Matt, can you give us a hand? Mel, call Psych and tell them we need an urgent consult.’

  The ambulance bay doors were sliding open and a young girl could be seen struggling for breath.

  ‘Resus 3,’ Jennifer called.

  She pulled Doug from Resus 2 to help, leaving Matt and a very nervous house surgeon to deal with the psych patient.

  ‘We need two secure IV lines,’ she instructed Doug. ‘Continuous nebulised salbutamol and aliquots of 0.1 milligrams adrenaline, IV. What’s the oxygen saturation?’

  ‘Less than ninety per cent,’ the paramedic reported. ‘We’ve got one patent IV. Sixteen gauge.’

  ‘Good. Let’s get her off the stretcher. Doug, get someone down from Anaesthetics. We may well need to intubate.’

  ‘On the count of three,’ someone said. ‘One, two…three!’

  ‘Sit her up,’ Jennifer ordered. ‘It’s OK, sweetheart,’ she told their patient. ‘We’ll get on top of this really soon.’ She had her stethoscope in position, noting with dismay an almost silent chest and increasing panic in the girl. They were on the verge of a respiratory arrest. It was no problem to tune out the scream from behind the curtains.

  ‘Bitches! You’re all the same! Don’t touch me! Ah-h!’

  Twenty minutes later Jennifer’s young asthmatic patient was on the way to the intensive
care unit. Colin, the man with the septic shock from his urinary tract infection, had also gone to Intensive Care. The MVA victims were under control, two having gone to Theatre and one having a CT scan. The disturbed psychiatric patient was well sedated and had two burly security officers in attendance pending his transfer to a secure ward. Peter, the young man with the spontaneous pneumothorax, was still stable but the chance to grab a cup of coffee remained elusive.

  ‘How long has the nosebleed been going on for?’

  The epistaxis patient in Cubicle 7, Mrs Bennett, had presented enough of a challenge for a junior registrar to go in search of assistance. ‘Over an hour,’ she told Jennifer. ‘And there’s no response to direct pressure.’

  ‘Spontaneous bleed?’

  ‘Started after she sneezed.’

  ‘Any past history?’

  ‘Not of nosebleeds. She has hypertension and angina. She’s on aspirin, 300 milligrams a day.’

  ‘That won’t be helping. Is the bleeding anterior or posterior?’

  The registrar looked disconcerted. ‘I’m not sure. Presumably posterior, if direct pressure isn’t enough to control it.’

  ‘Get a Y suction catheter,’ Jennifer instructed. ‘And find out where the site of bleeding is. When the catheter is passed beyond the bleeding site you’ll get blood appearing at the nostrils again.’

  The registrar nodded.

  ‘Take bloods for haemoglobin, blood group and a coagulation profile. What’s the blood pressure?’

  ‘One-ten over 60.’

  ‘And she’s normally hypertensive?’’

  ‘Yes. She’s on a beta-blocker for that.’

  ‘Keep a close eye on her, then. With beta blockade, she won’t be showing a rise in heart rate to warn you of hypovolaemia. Get IV access and put fluids up.’

  ‘Will it need packing?’

  ‘Get back to me when you’ve decided on the bleeding point. If it’s posterior and still severe, we might need to use a Foley’s catheter in combination with anterior packing. She’ll probably need some sedation to cope with that. She’ll also need antibiotics if it’s packed, and we’ll have to admit her.’