The emergency doctor claims his wife

by Margaret McDonagh

  There was little time to lose, and Nathan scooped Annie up in his arms and carried her swiftly but gently to the resus bay, setting her down on a trolley bed just as Gail rushed to his side, immediately beginning to help him attach monitors and check Annie’s vital signs.

  ‘Her blood pressure is low and falling,’ Nathan announced, his voice rough with emotion he couldn’t hide. ‘Come on, sweetheart. Hold on,’ he pleaded with her as he worked. ‘Stay with me, Annie.’

  Two more nurses and a junior doctor arrived, wasting no time asking questions but setting to work doing what was needed, including cutting off Annie’s scrubs to reveal the site of a penetrating stab wound by her left breast, immediately over her heart. The doctor in him knew this had to be done. The man in him wanted to cover Annie up, to protect her from indignities and exposure.

  He swiftly studied the chest wound. The hole looked small, but Nathan knew from experience that the damage inside could be deadly. They needed to know what was going on and get the bleeding stopped as soon as possible. He’d always been calm, whatever the crisis, but this was his Annie, and his hands were uncharacteristically shaky as he tried to find a vein and insert a cannula in her arm.

  ‘Nathan, step aside,’ Will instructed, taking the needle from him.

  ‘Will—’

  ‘You’re too close, mate. Trust me.’ The other man was firm, in control, focused on inserting the cannula with the minimum of fuss. ‘Robert’s on his way. So is the anaesthetist. And Francesca—we’ll need an ultrasound scan of Annie’s chest.’

  Thankfully, both Francesca and the anaesthetist were still in the department after the day’s various emergencies, and were there in seconds.

  ‘Equal bilateral air entry—even breath sounds. No indication of pneumothorax,’ the anaesthetist reported. ‘Oxygen saturation ninety per cent, respiration rate twenty. How’s her heart?’

  ‘BP’s still dropping and cardiac output is unstable. Pulse thready,’ Gail informed him.

  The anaesthetist worked swiftly, choosing drugs and muscle relaxant with care. He soon had an endotracheal tube inserted, and Annie fully anaesthetised and ventilated.

  Nathan had to move away briefly as Francesca took a chest X-ray, but he returned at once to Annie’s right side, clutching her hand, feeling helpless and more frightened than he had ever been. He stared in numb disbelief, unable to move, his brain fuzzed as all his knowledge deserted him at the shock and pain of seeing Annie’s life draining away in front of him. He shook his head, trying to pull himself together.

  ‘I’m thinking cardiac tamponade,’ he said, as Robert Mowbray stepped up on Annie’s other side.

  ‘Get a chest drain in, Will, and gain central venous access,’ the consultant demanded as he carried out a thorough examination and double checked the vital signs. ‘Fast-bleep the cardiothoracic consultant. Are the fluids warm? I want blood cross-matched.’

  ‘Annie is A positive,’ Nathan told him.

  ‘Are you sure?’

  ‘One hundred per cent certain. We went as blood donors together for several years.’

  Robert barked out an order for six units of A positive blood and a nurse scurried to the phone. ‘How’s the BP?’

  ‘It’s still dropping,’ Gail replied, worry evident on her face. ‘Eighty over forty now.’

  ‘Annie hit her head on the floor when she fell,’ Nathan remembered, furious he had not passed on that information sooner.

  ‘We’ll worry about a CT scan when we have her stab-ilised,’ Robert replied, turning to the radiographer as she did a follow-up ultrasound. ‘Francesca, what news?’

  ‘Definite fluid in the pericardium,’ Francesca confirmed, moving back out of the way and showing Robert the images from the X-ray and scan.

  Nathan’s panic intensified. Why didn’t they hurry? He wanted to push them all aside and do the job himself, but he recognised that he was too emotional, too unsteady to be safe. He could see from the monitors that Annie was failing. Something bad was going on inside her chest, and the team needed to work fast if they were to save her life. His fingers linked with hers as he tried to instil her with the strength and determination to keep fighting, even though she was unconscious and couldn’t hear him.

  ‘Damn, the blood is pouring out of this drain,’ Will called, sounding shaken.

  ‘We’re losing her,’ Robert muttered.

  ‘No! She’s not going to die.’ Nathan refused to countenance such an outcome. Whatever had happened last night, or for the last five years, he couldn’t lose her. He couldn’t. ‘I won’t let her.’

  ‘There’s no time to get to Theatre. We’ll have to do a thoracotomy here. Now. Before it’s too late.’

  The consultant’s decision brought Nathan a mix of relief and terror. Relief that someone was going to do something—the only thing that could now save Annie’s life—and terror that it wouldn’t work. An emergency thoracotomy, which involved opening up the chest to expose her heart, was high risk—especially outside the operating room. But without it Annie would die. Nathan had assisted in a few, and had done one once during his surgical rotation years before, but only under proper theatre conditions. He wondered at the A and E consultant’s experience with the procedure.

  As if sensing his troubled thoughts, Will took a moment to reassure him. ‘Robert’s done this successfully several times,’ he murmured, as the thoracotomy tray was readied.

  Nathan was absorbing what Will had said when Gail called out more bad news. ‘BP’s fallen.’

  ‘Central venous pressure?’ Robert asked, frowning at the reply.

  A nurse wiped Annie’s chest with generous quantities of a povidone-iodine antiseptic solution, to disinfect and prepare her pale skin for the operation, then Annie’s left arm was raised above her head to give access to the site. Feeling helpless, Nathan watched as Robert skilfully opened the chest wall at the medial end of the fifth inter-costal space and made a lateral cut above the sixth rib into the axilla. Retractors opened the cavity. Needing more space to work and access the heart, Robert extended the incision and separated the sternum. It seemed as if everyone in the resus bay held their collective breath as the consultant worked as swiftly as possible, making a longitudinal incision in the pericardium—the blue-coloured sac surrounding the heart, which had been punctured by the screwdriver. There was so much blood…

  ‘Suction!’ Robert called, and a nurse hurried to comply, keeping the cavity clear so he could see what he was doing.

  Nathan wanted to remind the consultant to take extra care not to damage the phrenic nerve, but he managed to halt the words as he saw Robert move to increase the pericardial incision with his fingers to avoid lacerating the nerve. He was no doubt already annoying everyone by demanding updates on Annie’s vital signs, Nathan acknowledged, but they were kind enough to humour him, and he was grateful for their tolerance and that he’d not been banished from the room.

  ‘There’s a hole in the right ventricle,’ Robert announced, once the heart itself was exposed.

  Will’s voice cut across the electric silence. ‘She’s arrested!’

  ‘Nathan, put your finger in the hole,’ the consultant ordered, maintaining his composure. ‘And do bimanual internal massage.’

  He didn’t think, he just acted, plugging the wound and stopping the haemorrhage, using the flat of both hands on either side of the heart to maintain a rhythmic compression. Having something constructive to do kept him focused. Despite having done this once before, he felt a moment of awe and wonder that he actually held Annie’s heart in his hands. The responsibility was overwhelming.

  Aware of Will beside him, it occurred to him for the first time to question why the other man was working as normal on Annie while he himself had been told to stand aside because he was too involved. Surely the same applied to Will? He shook his head, too stressed to fret about it now. He just wanted Annie safe. So did the team. They all cared about Annie and would give everything for her now.

  ‘The A positi
ve blood is here,’ a nurse called, hurrying into the room.

  ‘Good.’ Robert didn’t look up from his task, suctioning the remaining clots and blood from the cavity around the heart and checking for any other sites of damage. ‘Will, get the first unit up and running in.’

  When the consultant was ready to begin suturing the wound in the chamber of the heart Nathan had to adjust his hands to give him room to work. His own heart was in his mouth as Robert closed the hole in Annie’s right ventricle, using uninterrupted non-absorbable proline sutures buttressed with teflon pledgets. It seemed to be taking for ever, but he knew it was only minutes before the task was done and her bleeding stopped.

  ‘Cardiac rhythm and output?’ Robert requested.

  Gail was ready with the information. ‘She’s fibrillating.’

  ‘Internal paddles.’

  They were immediately placed in Robert’s hands, and as Nathan withdrew he inserted them into Annie’s chest, one over each side of her heart, ready to deliver the electric shock to defibrillate and bring back a rhythm.

  ‘Five joules to start.’

  ‘Still fibrillating,’ Gail called, after the first jolt had been given.

  ‘Again…ten joules this time.’

  Nathan stared at the tracing on the monitor and prayed as he’d never prayed before. It took three more attempts, with increasing amounts of energy, before Annie’s heart began to beat on its own.

  ‘We have a pulse!’ The announcement from Gail brought a cheer to the room. ‘And a rhythm!’

  ‘OK, let’s guard against hypovolaemia and any cardiac concussion,’ Robert directed.

  ‘Cardiac output is stabilising,’ Will updated, giving details of the central venous pressure, too. ‘And her BP’s up; her pulse is strong.’

  ‘Sats are improving. We’re up to ninety five per cent and rising,’ the anaesthetist added, a broad smile on his face.

  Nathan wanted to burst with joyful relief. They still had a way to go, a voice in his head cautioned, but Annie was back and clinging to life, and he wasn’t going to allow her to do anything less. Still tense, he watched closely as Robert closed the pericardium with vertical mattress sutures. Will and Gail continued to gave updates on Annie’s stabilising cardiac output and rising BP.

  ‘I can’t see any damage to the lungs, major vessels or anything else,’ Robert commented in apparent satisfaction, doing a thorough examination now the bleeding had been stopped. Nathan’s relief increased. ‘Insert an arterial line and a urinary catheter,’ he instructed. ‘And redo U&E, glucose, FBC and clotting. I’ll ligate the internal mammary arteries and then we’ll defer to the cardiothoracic surgeon for further management. He can double-check everything and do the closure in Theatre.’ Robert glanced up and looked at him. ‘I assume you’ll be going up with Annie?’

  ‘Yes, please.’ Nathan was grateful for the understanding. ‘Thank you—for saving her.’ He looked round the bay at all the colleagues who had worked so swiftly and diligently, trying to keep his wayward emotions in check. ‘Thank you all.’

  Nodding, allowing a brief smile of his own, Robert concentrated once more on what he was doing and called for antibiotics. ‘Give cefuroxime 1.5g IV.’

  The next minutes passed in a blur as the specialist, Gordon Smith, arrived, with a couple of his assistants, and was brought up to date on the details. He was handed a copy of the notes, with information on all drugs, fluids and bloods given. He cast a curious glance at Nathan, who clung determinedly to Annie’s hand as she was prepared for the transfer.

  ‘Good job,’ Gordon said, in praise of Robert’s handiwork.

  Then they were whisking the trolley away from Resus, through the still crowded but calmer A and E department, and up to the operating theatre, where the rest of the cardiothoracic team were ready to go.

  Nathan was upset when the surgeon refused him entry to the theatre, but he didn’t waste time arguing, knowing that it was Annie who was important here, not his own feelings. He sank to a chair in the waiting area, nervous exhaustion overwhelming him. Shaking, he put his head in his hands, hardly able to take in everything that had happened in the last half an hour, or how close Annie had come to dying. His scrubs were covered in her blood. So were his hands. As he became aware that the other people in the room were looking at him nervously, he rose to his feet and walked stiffly and unsteadily to the nearest restroom to clean up.

  That done, he stopped at the office on his way back to use the phone and ring Annie’s mother. It was one of the most difficult calls he’d ever had to make. Eve was understandably shocked and emotional. Nathan reassured her as best he could, only hanging up when she sounded more together, knowing she would make arrangements to travel to Strathlochan straight away.

  Bone weary, he went back to the waiting room. To keep himself focused and hang on to the threads of his control, he closed his eyes and imagined what was happening in the operating theatre. In his head he went through the details of how the surgeon would be ensuring there was no other internal damage before methodically rejoining the sternum using wire, then suturing closed the muscle, tissue and skin of Annie’s chest.

  Footsteps sounded in the corridor and Nathan looked up, hope and tension warring inside him as he anticipated that Annie’s operation was over. But it was Will who appeared in the waiting area, and slumped into a seat beside him with a heavy sigh.

  ‘Any news yet?’

  Nathan shook his head. ‘No.’

  ‘Someone should call Annie’s mother,’ Will suggested.

  ‘I’ve already done it. Eve’s on her way.’

  Will gave his shoulder a quick pat. ‘Thanks, mate.’

  Time dragged. Each tick of the second hand on the clock on the wall dragged. Nathan was scarcely aware of the other people in the room, who were also stressed and worried and waiting for news of their loved ones. Will disappeared for a few moments, returning with two mugs of tea, but Nathan barely tasted the hot brew.

  ‘She’ll be OK, Nathan. Annie’s tough…a fighter.’

  They looked at each other in silent acknowledgement, united in anxiety and pain.

  ‘Yeah.’ He wanted to believe it. He had to believe it.

  ‘We should talk.’

  Will’s words filled Nathan with a whole new kind of concern. But whatever the other man was about to say was forestalled as Gordon Smith appeared in the doorway, dressed in his scrubs, his protective cap still on his head and his face mask hanging loosely now around his neck.

  ‘Later,’ Nathan commented in response to Will, rising to his feet and crossing to greet the cardiothoracic consultant. ‘What’s the news on Annie?’

  ‘She’s going to be fine,’ the surgeon reassured them.

  ‘Thank God.’

  Nathan seconded Will’s exclamation. ‘And thank you, Mr Smith. Can you update us on Annie’s condition?’

  ‘Of course.’ The surgeon led them to an office across the hall and gestured for them to sit as he walked around the desk to take his own chair. ‘We found no further internal damage. Robert did an excellent emergency repair. After the operation to close was over we sent her for a CT scan, and I’m happy to say that there is no sign of any skull fracture and no clots or bleeding on the brain,’ he continued. Nathan felt another welling of relief and gratitude. ‘At the moment she is heavily sedated and being moved to the Intensive Care Unit. When she does wake up she’s going to have a hell of a headache, not to mention discomfort from the surgery. We’ll keep her medicated, of course, and watch for any signs of complications, but all being well she should make a good recovery.’

  Nathan slumped back on the chair with a sigh, some of the tension leaching from him. He knew Annie was likely to be in hospital for between five to ten days, providing there were no setbacks, and that she would then need time to recuperate. But she was alive. Whatever they faced in the days and weeks ahead—and whatever role he played—that was the fact that he had to hang on to.

  ‘Can we see her?’ Will asked.
>
  The surgeon looked from one to the other, clearly puzzled at the dynamics of this relationship. ‘Briefly—for now.’

  Conscious of Will keeping pace beside him, Nathan made his way to the ICU. He guessed that Gordon Smith had phoned ahead, because the charge nurse was there to greet them and take them to Annie’s bedside.

  Will’s indrawn hiss of breath matched his own. The sight of Annie so still and pale, looking swamped and fragile in the bed, hooked up to machines and drips and drains, brought a fresh constriction to Nathan’s throat. No matter that they were doctors and saw this every day. It was different when it was personal to you.

  Drawn at once to Annie’s side, Nathan took her hand, holding fingers that felt cool and lifeless against his cheek. He would give anything not to have rowed with her, for last night’s lovemaking to have ended with them being back together and not further apart than ever. But more than anything, whatever happened between them, he just needed for her to live, to heal, to be well.

  He started when Will rested a hand on his shoulder. ‘Sorry,’ he mumbled, feeling a mix of guilt and resentment as he stepped back to give the other man access to Annie, hating that Will had more right to be with her than he did.

  ‘I’ll cover for you in A and E,’ Will announced, after staring down at Annie for several moments in silence, an almost greyish tinge to his normally healthy complexion. ‘You stay with her. We’ll have that talk later.’

  Without another word, Will hurried from the ward. Nathan couldn’t understand Will at all, but, no matter how puzzled he was at his exit, at his whole reaction to Annie’s trauma, he was grateful to be the one remaining by her side. Pulling up a chair, he sat down, taking Annie’s hand back in his. Listening to the rhythmic sounds of the machines, and instinctively monitoring her vital signs, he stayed as close to her as he was able, talking to her, giving her his strength, his love, everything he had within him, so that she would pull through.

  He wasn’t leaving until he knew she was safe.