‘Ex shirt,’ she told him. ‘Kim doesn’t make mistakes, and if she said you stopped breathing then you stopped breathing. And you were still unconscious when I got here.’
‘I just got a bit dizzy, that’s all.’
‘I’m fitting the pads in case we need them,’ she told him. ‘You know you’d do the same for any patient with collapse and a history of cardiac problems.’ She looked up. ‘Kim, contact Geoff and Ryan. Tell ’em we need to lift a prostrate patient...’
‘Prostrate?’ It must be hard to sound outraged when there was clear difficulty in breathing, but Robert managed it.
‘And you’ll stay prostrate until I say otherwise,’ Elsa told him, bossiness underpinned with a definite shake in her voice. ‘You taught me to be bossy in a crisis, Grandpa, so don’t you fight me when I follow your orders.’
‘It’s not a crisis.’ But he’d had enough. He’d been trying to lift his head. Now he slumped back and let his protests die to nothing.
‘Elsa, would you let me help?’
She was fitting the pads of the defibrillator. Designed to jerk the heart back into motion when it stopped, it wasn’t necessary now that Robert was conscious, but the elderly doctor had clearly lost consciousness, had clearly fallen. There was something else going on here. If there’d been a blockage then it could block again at any minute, and seconds would be precious.
She finished fitting the pads and then turned to Marc. ‘Go back to bed,’ she said quietly.
‘Elsa, I have a broken leg, not the plague. You have a cardiologist on site, and I may well be what your grandfather needs right now. Make use of me.’
He saw her hesitate, torn. Every instinct would be to protect her patient—him. Every desire would be to do what was best for her grandfather.
‘Please, then,’ she said gruffly, and he could hear the emotion in the two words. Then she turned back to Robert. ‘Grandpa, you remember Marc’s here—Dr Pierce? You know he’s a cardiologist from Sydney? He’s offered to ignore his broken leg and give his opinion.’
‘What’s he charging?’ Robert demanded, and there was a hint of humour in his thready voice that further reassured Marc. He might have lost consciousness for a moment, but the blood supply hadn’t been cut off for long enough to cause even minor mental impairment.
‘Cut rate special,’ he said as one of the nurses moved forward to help him hop from the support of the handrail to where Robert lay. ‘You fixed my leg, so I’ll have a shot at fixing your heart.’
‘Might be a damned sight harder to fix,’ Robert growled.
‘It might,’ Marc said quietly. Robert was still on the floor and he dropped to join him. It was hardly the usual medical scene—patient on floor, doctor dressed in pyjamas also on floor, his back slabbed leg stretched out before him.
He wedged himself around so he was side-on to Robert. Elsa was on the other side and a glance told him the strain she was under. Her face was almost as pale as her grandfather’s.
And there was reason. Robert’s breathing was fast, shallow, laboured. His skin was bluish, cool to the touch. Marc lifted his wrist and kept his face impassive as he noted the racing pulse. For all his fieriness, his attempt at humour, Robert was looking terrified.
‘Pain?’ Marc asked and watched him close his eyes for a moment and then decide to be honest.
‘Bad,’ he conceded. ‘Chest. Shoulder. Another bloody heart attack. Must be a minor one this time, though. I’ll be all right.’
‘You’ll have to go back to Sydney,’ Elsa managed, and Marc could still hear the tremor. Finding her grandfather unconscious must have been horrific. ‘We’ll get you stabilised and call for evacuation.’
‘Leave things for a moment,’ Marc said softly. He was looking further, seeing things he didn’t like.
The probability was that this was a heart attack, hopefully small, but there was no guarantee it wouldn’t be a precursor to a bigger one. Yes, evacuation was called for, to a hospital with a state-of-the-art cardiac facility, with a team of trained medics on board the flight. But the look on Robert’s face... And what was beneath...
He was seeing swollen, bulging neck veins and they were acting like flashing lights to Marc’s trained eye. The heart was pumping blood out, but there was some impediment to its return.
‘Can I have your stethoscope?’ he asked Elsa, and she handed it wordlessly across. He listened to the muffled heart sounds, and his unease deepened.
‘Blood pressure?’ he asked, and the nurse fitted the cuff.
Low.
‘What are you thinking?’ It was Robert himself who demanded to know. This was doctor to doctor. There’d be no sugar-coating what he was starting to suspect, and it’d be an insult to even try.
‘I’m thinking we need to exclude cardiac tamponade,’ he said briefly. ‘Your veins are swollen. Low blood pressure. Muffled heart sounds. That’s Beck’s triad—the three symptoms that make me sound clever when I’m just fitting a pattern to what’s happening.’
There was an expletive from Robert, and Marc gave him what he hoped was a reassuring grin.
‘Exactly. No sweat though, Robert, because even if I’m right I’ve coped with cardiac tamponade before and I can cope with it now.’
He glanced up at Elsa then, and saw her face had bleached even whiter. She’d know the risks.
Cardiac tamponade was indeed frightening. Caused by trauma, by cancer or sometimes by a heart attack, fluid or blood built up between the heart and the pericardium, the sac surrounding the heart. The pericardium consisted of two layers of tissue, with a small amount of fluid preventing friction between the layers. If this fluid built up, it put pressure on the heart, affecting its ability to pump blood around the body.
Robert might have just suffered a heart attack, or he might have suffered a minor attack weeks ago. The pressure might have built slowly, finally causing collapse. Or the leak could be recent, the pressure building fast.
Regardless, cardiac tamponade meant there was no time for evacuation. The pressure had to be removed now.
The two guys who worked as occasional orderlies, handymen or gardeners appeared and seamlessly went into action, helping Elsa transfer Robert to a stretcher and then lifting him onto a trolley. One of the nurses helped Marc to his feet. He was swearing inwardly. He wanted two good legs. He wanted to be dressed—at least in the soft shirt and loose gym pants he’d worn to lunch. He wanted to feel professional, fully functional—he needed to be at the top of his game. This was a situation he was trained for, and he wanted the capacity to move fast.
‘Can you organise an echocardiograph and a chest X-ray?’ he asked Elsa. Dammit, he felt helpless. ‘And can someone help me get dressed?’
‘Marc, you can’t...’ Elsa’s voice trailed off. If the ECG and chest X-ray confirmed the diagnosis, there was no choice and she—and her grandfather—would know it.
‘Robert,’ Marc said, taking a moment to rest a hand on the shoulder of the elderly doctor, ‘you know what’s at stake here. If it is indeed tamponade then we need to get the pressure off fast. You’ll need to go to the mainland to get any underlying problems with your heart sorted, but the tamponade has to be fixed now. I might be a cardiologist with a gammy leg and a sore shoulder, but that doesn’t interfere with my skills. If the echocardiograph confirms my diagnosis you’ll need percutaneous drainage and that’s a skill I have. Will you let me and your granddaughter make you safe?’
And the old man’s hand came up and gripped his, hard. Marc could feel the tremor. He could feel the fear.
‘Do what you have to do, son,’ Robert managed. ‘You seem a damned idiot at bushwalking, but I assume you’re not the same in an operating theatre.’
‘I’m very good,’ Marc told him. This was no time for false modesty. ‘I’m who you need right now, gammy leg or not. Trust me.’
‘I trust you,’ Rob
ert said and the grip on his hand tightened.
‘Marc...’ It was Elsa, and there was fear in her voice, too.
‘And so must you, girl,’ Robert said, forcefully now, as he directed his attention to his granddaughter. ‘We’re lucky to have a cardiologist to hand, even if you did have to crawl underground and sleep with him for a full night to get him here.’
* * *
The echocardiograph reinforced Marc’s diagnosis. The chest X-ray and ultrasound confirmed it. Elsa stared at the image on the ultrasound screen and felt ill.
If she’d been on her own here she couldn’t have coped. She’d have had to evacuate her grandfather, and with the pressure building in the hours it would have taken to get him to Sydney... The outcome didn’t bear thinking of.
And doing such a procedure herself? She knew the principles, but to perform the drainage, especially on someone who was probably compromised with heart damage anyway... When that someone was her grandfather... To insert a needle into such a risky place, to do no damage...
She didn’t need to. She had a cardiologist right here. The knowledge made her feel dizzy.
Marc was scrubbing. The nurses had found a stool with wheels and height adjustment. At full stretch it made him tall enough to use the sinks, to operate, to be fully functional.
He looked across at her as Maggie helped him on with theatre gear, and he must have seen the tension.
‘It’s okay,’ he told her gently. ‘We have this in hand. We’ll try percutaneous drainage first. If that doesn’t work then we’ll move to the subxiphoid approach—taking away a slice of the pericardium. But I don’t anticipate that. We’ll give him the lightest possible general—I don’t want any more risk to his breathing than he already has. While you monitor that, then I’ll use the ultrasound to guide a nice fat needle into the cavity, set up a catheter and let it drain.’
Said like that it sounded simple. She knew it wasn’t.
‘Then we’ll move him to Sydney and let the big boys deal with whatever the underlying cause is,’ Marc told her, his voice calm, reassuring but firm. She wasn’t the doctor here. She wasn’t being asked to make decisions—she was being told the best course of action for her grandpa. ‘Given his history, I’m almost sure this’ll have been caused by another heart attack. Maybe a small one. There’s no sign of neurological impairment. This seems straightforward. For me this is common or garden repair work, Dr McCrae, so you can take that fearful look off your face, accept that your grandpa’s going to live and turn into the professional I know you are.’
His gaze was still on her face, his look steady, strong, sure. You can do this, his gaze said. And I need a doctor, not a whimpering relative.
Right. She could do this.
She must.
* * *
And half an hour later the thing was done. A light anaesthetic. An awful, breath-holding time while she watched as Marc used the ultrasound wand to guide the needle into position.
His approach was sure, unhesitating, skilled.
Using an eight-centimetre, eighteen-gauge angiocatheter—thank heaven for the comprehensive surgical kit the island possessed—watching the ultrasound every fraction of an inch of the way, he slowly, skilfully found what he was looking for. When the pericardial sac was entered there was a grunt of satisfaction as the ultrasound showed the needle where he needed it to be. Slowly he advanced the sheath and withdrew the needle. A guide wire was then advanced through the angiocatheter, followed by a dilator and a pigtail catheter.
‘Yes!’ he said with relief as the fluid started to flow, as the tamponade started to shrink, and that was the first time Elsa heard pressure in his voice. Even though he’d sounded sure, this was a procedure that took skill. Even now. Elsa was monitoring breathing, watching the heart monitor like a hawk, waiting for a reaction. Robert’s heart was damaged. Any minute now...
‘Not going to happen,’ Marc said softly, glancing at the monitor and then her face. ‘Fluid’s coming off, and things are looking good.’
And so it was. Once the catheter was in place the pericardial fluid drained like a dream. The fluid would be submitted for culture and cytological analysis, checking for signs of something other than heart attack—trauma or cancer—but there seemed no sign of either.
She watched on, staring at the monitor as if she could will the heartbeat to strengthen. And it did.
‘I’m only draining a thousand mil,’ Marc told her. ‘I don’t want hypotensive shock. But I’m pretty sure it’s enough to keep him safe.’
It maybe it was. Robert’s heart had returned to a reassuringly normal rhythm. He was breathing on his own now, and when Elsa removed the oxygen his chest rose and fell normally. His colour was returning. He was safe.
For now. There was still the underlying cause to treat.
‘I told one of the nurses to arrange evacuation,’ Marc said briefly, once again watching her face. ‘He’ll need more aspirations, usually every four to six hours. We’ll do another just as he leaves, and then the cardiac unit in Sydney can take over.’ Robert was already stirring. The anaesthetic had been the lightest possible. ‘Hey, Robert,’ Marc said gently, and he took the old man’s hand. ‘All done. How do you feel?’
There was silence for a couple of moments while Robert got his bearings, while his world settled. They watched him take conscious breaths, watched him feel his chest expand, watched him realise the pressure was no longer there.
‘Beautiful,’ he murmured, and Elsa smiled and smiled and gripped Robert’s hands and then decided she needed to wipe away a stupid tear that was tracking down her cheek. Only she couldn’t because she was holding onto her grandpa.
And then Marc was leaning over the table and wiping it away for her, smiling at them both. ‘Well done, Dr McCrae,’ he told her.
‘There was nothing well done about it,’ she said gruffly. ‘Marc operated, Grandpa, not me.’
‘And your granddaughter held it together, acted professionally with a brilliant anaesthetic and didn’t once behave like you’d scared her out of her wits,’ Marc said, still smiling at her. ‘But now she needs to act like a relative. Elsa, I want you to go pack for your grandpa and for yourself. Robert, we’re evacuating you to Sydney. You know the underlying cause of the tamponade is most likely to have been another heart attack, or complications from the last one. There’ll be an emergency physician on board the plane to keep you safe in transit. You’ll be assessed fully in Sydney, so you need to be prepared to stay for a while. Hope for the best—maybe another stent—but prepare for a full bypass. That could mean a two-week stay before they let you fly home. Elsa, you know there’s relative accommodation at the hospital. When we asked for the evac plane we asked for that to be organised as well.’
‘But...’ Elsa was staring at him in dismay ‘...I can’t go. Two weeks...’
‘You have no choice.’
‘When Grandpa had his last attack and had the stent inserted, I was away for two days,’ she told him, almost stammering. ‘There was no one here to take over. We got away without a disaster that time, but for the island to have no doctor...’
‘Elsa’ll stay here,’ Robert growled. ‘There’s no need to come with me. It’s a fuss over nothing.’
But there was every need. Elsa stared down at her grandpa and saw it in his eyes.
This latest episode would have terrified him. Not being able to breathe... Feeling the pressure build... Oh, thank God for Marc, but the old man wasn’t out of the woods yet, and she could see by his face that he knew it.
Yes, there’d be an emergency physician on the plane, but Grandpa needed family beside him. He needed her. She had to be with him, but she could see the warring needs on her grandfather’s face. He would know the risks. And for there to be no doctor on the island at all...
‘You have to stay,’ Robert muttered grimly. ‘Don’t be a fool, girl. You think we can ge
t a locum at this short notice, at this time of year? You know after Christmas half of Australia goes to sleep and the other half goes to the beach until mid-January. Or they come here and break their necks doing damned silly things. You have no choice. I’ll be fine, girl.’
But still she saw the fear—and she glanced up at Marc and realised that he’d seen it too.
‘There’s no need for a locum,’ he said gently. ‘Aren’t you lucky that you already have a resident doctor?’
They both stared at him, their expressions suggesting he’d suddenly grown two heads. ‘You?’ Elsa stammered, as if such a thing was tantamount to suggesting a five-year-old took over the medical needs of the island.
‘Don’t look at me as if I’m an idiot,’ he told them. ‘I know I’m a cardiologist, but I have basic skills as well. I’m sure I can remember the treatment for nice normal things like the common cold. Isn’t it to give the patient honey and lemon drinks and it’ll cure itself? I can probably cope with that.’ He grinned, his smile encouraging them to override their fear.
‘Seriously,’ he continued, ‘you have a great nursing staff. My shoulder’s sore but it’s firmly back in place and I won’t be needing to lift any weights. I know a slightly battered doctor is less than ideal, but it seems a darned sight better than no doctor at all. I have a bung leg but I’ll not be running any races. We can organise someone to drive me if I need to go off site. I have the next two weeks off. I know I should be in St Moritz but as far as prestige points go when I finally head back to work, two weeks on Gannet Island with a climbing injury cuts it almost as well.’
‘A climbing injury? More like a falling down a hole injury,’ Elsa said before she could help herself, and his grin widened.
‘Are you intending to mess with my hero image, Dr McCrae?’
‘Let him be heroic if that’s what’s needed for him to stay here,’ Robert said gruffly, and reached out and took Marc’s hand. ‘I’ll even sign something to say you fell down the hole saving...what, a kitten? Would that do?’
Mistletoe Kiss with the Heart Doctor Page 11