Toni wouldn’t leave an obviously unwell child just sitting to one side of an emergency department and waiting too long for assessment because of pressure on resources, would he?
The small boy looked febrile. His face was flushed and appeared puffy. What bothered Pip more, however, was how quiet the child was. With the alien bustle of an overworked emergency department flowing past in what should have been a frightening environment, the boy was just lying limply in his mother’s arms and staring blankly.
Even from several metres away Pip could see that the little boy was in respiratory distress. A small chest was heaving under a thin T-shirt…way too fast.
Pip moved towards him, pausing for a moment beside the central triage desk.
‘Doris has gone to X-Ray so we’ve got an empty cubicle for a while. Could you find me a bed, please, Suzie? I think I should take a look at that little boy over there.’
‘Oh, would you?’ Suzie sounded relieved. ‘That would be great. I was just going to upgrade him for an urgent assessment. He’s looking a lot worse than he did when he came in.’ She sent a nurse aide to find a bed in the storage area off the main corridor to the hospital. ‘Put it in cubicle 3. Hopefully we’ll have another free space by the time Doris comes back.’
A stretcher was coming through the double doors from the ambulance bay. Another one was lined up behind that.
‘What’s the history?’ Pip queried briskly, before Suzie could get distracted by the new arrivals.
‘Just became unwell today. Running a temperature, off his food. Family’s new in town so they didn’t have a GP to go to.’
‘Cough? Runny nose?’
‘Apparently not. Temp’s well up, though—39.6 when we took it on arrival.’ Suzie was moving to intercept the first stretcher. ‘His name’s Dylan Harris. Turns two next month.’
Pip smiled at a mother who was probably her own age. What would life be like for herself, she wondered briefly, if she had a two-year-old instead of a twelve-year-old? She certainly wouldn’t be doing what she was doing now—a job she loved with a passion.
‘Mrs Harris?’
‘Yes…Jenny.’
‘I’m Dr Murdoch.’ The thrill of saying those words had never worn off. Worth all those long years of hard work and heartache. ‘Follow me. We’re just finding a bed so I can check Dylan for you.’
‘Oh, thank goodness! I think he’s getting sicker.’
The bed wasn’t needed immediately. Pip carried the chair Jenny had been sitting on as she led the way to cubicle 3.
‘Keep Dylan sitting on your lap for the moment, Jenny. It’ll keep him happier and help his breathing as well.’
‘He’s started making funny noises.’
‘Mmm.’ Pip was listening to the soft stridor on expiration and a gurgle on inspiration with mounting alarm. ‘And how long has he been dribbling like that?’
‘Is he?’ Jenny looked down at her son. ‘I hadn’t noticed. It must have started just now.’
Something that could compromise a child’s airway this quickly was extremely serious and Pip already had a fair idea of what she might be dealing with. She signalled Suzie to indicate the need for assistance but the senior nurse was still occupied with a patient on an ambulance stretcher. Her apologetic wave and nod let Pip know she would do something as soon as she could. Pip reached for an oxygen mask.
‘Hold this as close as you can to Dylan’s face without upsetting him,’ she instructed Jenny.
Pip could see the way the skin at the base of his neck was being tugged in as Dylan struggled to breathe and the retraction of his rib-cage when she lifted his T-shirt to place the disc of her stethoscope on the small chest.
An empty bed was being pushed into the cubicle behind her.
‘Get me a nurse, please,’ Pip told the orderly. ‘Preferably Suzie, if she’s available.’ She took another glance at Dylan’s face. ‘You’re being such a good boy. You’re not feeling too good, are you, sweetheart?’
She got no response. Not even eye contact from the toddler. Pip looked up at Jenny.
‘Has he been talking much today?’
‘He hasn’t said anything since we got here. He’s not even crying, which is weird. He usually cries a lot. Does that mean it’s not that serious?’
‘Not necessarily.’ Pip wasn’t going to alarm Jenny by telling her that it was the quiet children that were usually most at risk. With the oxygen mask held close to his face, Dylan was leaning back on his mother’s shoulder, his chin raised. The ‘sniffing the air’ position that indicated an instinctive method of maximising airway calibre.
‘And he hasn’t been coughing at all?’
‘No. This came on really suddenly. He seemed fine except he wouldn’t eat his toast this morning. I wondered if he might have a sore throat.’ She cast a worried glance at her son. ‘It’s getting worse, isn’t it?’
It was. Dylan’s eyes drifted shut and his head drooped. Pip touched his face.
‘Dylan? Wake up, love. Open your eyes.’ She got a response but it wasn’t enough. ‘I’ll be back in a second,’ she told Jenny. Slipping through the curtain, Pip nearly collided with Suzie.
‘Any of the consultants free at the moment?’
The nurse shook her head. ‘One of the trauma cases has arrested. It’s a circus in Resus.’
‘I need a paediatric anaesthetist here,’ Pip said. ‘And we need to get Dylan to Theatre. I’m pretty sure he’s got epiglottitis and his level of consciousness is dropping.’
Suzie’s eyes widened. ‘I’ll find someone.’
‘Get me an airway trolley in the meantime?’
‘Sure.’
Pip could only hope that intervention could be avoided until Dylan was safely under the care of an expert anaesthetist.
‘I think Dylan has something called epiglottitis,’ she told Jenny a moment later. ‘It’s a nasty bacterial infection of the epiglottis, which is at the back of the throat. If it gets inflamed it can interfere with breathing, which is why Dylan has started making these noises.’
‘What will you do?’
‘We treat it with antibiotics but we have to protect the airway in the meantime. I’m going to get Dylan taken to an operating theatre if possible to have a tube put down his throat.’
‘He needs an operation? Oh, my God!’
‘Not an operation,’ Pip said reassuringly. ‘Not unless it’s difficult to get a tube in place. In that case, it might be necessary to create a temporary external airway by—’
Suzie was back with a trolley. ‘Someone’s on the way,’ she interrupted Pip. ‘Shouldn’t be long.’
It was going to be too long for Dylan. The small boy’s eyes suddenly rolled and then closed. Jenny felt him go even floppier and when she moved the oxygen mask to look at her son, they could all see the blue tinge to his lips.
‘Dylan?’ Pip rubbed his sternum. ‘Wake up!’
There was no movement to be seen. Including the chest wall. The toddler was in respiratory arrest. Pip plucked him from his mother’s arms and laid him on the bed.
‘Oh….God,’ Jenny gasped. ‘He’s not breathing, is he?’
‘No.’ Pip was pulling on gloves and hoping she sounded much calmer than she felt. Where on earth was that consultant? ‘We’re going to have to put the tube in here. Could you hyperventilate him, please, Suzie?’
While the nurse used the bag mask to try and pre-oxygenate Dylan, Pip pulled the tubing from the suction kit and switched the unit on. She clipped a straight blade to the laryngoscope and picked out the smallest, uncuffed endotracheal tube from the sterile drape she had opened on the trolley.
‘Hold his head for me, Suzie.’ Pip peered over the blade of the laryngoscope moments later. ‘Can’t see a thing,’ she muttered.
‘Secretions?’ Suzie asked.
‘Yes. And the epiglottis is very swollen.’
‘I’ll give you some cricoid pressure.’ Suzie pressed on Dylan’s neck and Pip tried to take a deep breath and banish he
r mounting alarm. She knew how critical it was to get this airway secured and it was not going to be easy.
Jenny was sobbing loudly enough for another nurse to put her head around the curtain.
‘I can’t bear to watch,’ the young mother gulped.
‘Come with me for a moment, then,’ the nurse said. ‘I’ll look after you while the doctors look after your little boy.’
Pip was barely aware of Dylan’s mother being led from the cubicle due to her intense concentration on the urgent task, but even with the pressure on the neck, the secretions sucked away as much as possible and her best efforts, there was no way to get the tube past the obstruction of swollen tissue.
‘It’s no go,’ Pip said tersely.
Suzie sounded just as tense. ‘What do you want to do?’
Pip had to think fast. She couldn’t rely on a senior doctor arriving in time to take over. If she didn’t do something herself, now, this little boy could die.
‘Ventilate him again for me, Suzie.’ She ripped open another kit on the trolley. ‘I’m going to do a cricothyrotomy.’
Stripping off her gloves and reaching for a fresh pair, Pip had to fight a moment of pure panic as the consequences of not succeeding with this next procedure forced themselves into her mind.
Then, for some strange reason, she thought of Toni Costa.
Well, not so strange, really, because Dylan would probably end up being the paediatrician’s patient.
And she had been thinking of Toni at rather disconcertingly frequent intervals over the last week anyway.
For whatever reason, Pip could almost sense his presence in the cubicle right now, and it brought an underlying confidence to her determination to succeed. So that Dr Costa would be impressed at the emergency care a patient of his had received.
Her fingers were as steady as a rock as she palpated the cricothyroid membrane on Dylan’s neck. There was no need for local anaesthetic as the child was deeply unconscious, and there was no time in any case. Pip stabilised the ring of cartilage with one hand and made a single, decisive incision with the scalpel.
Part of her brain registered the movement of the cubicle curtain and the fact that someone had entered the space and was now standing behind her. A large figure. Maybe it was Brian Jones, one of the emergency department consultants, answering her plea for back-up. She couldn’t look up at this point, however, or hand over to anyone else, even if they were far more experienced.
Reversing her hold on the surgical instrument, Pip inserted the handle of the scalpel and rotated it ninety degrees to open the airway. Then she slid the tube into the incision, removing the introducer and replacing it with the tip of the suction apparatus tubing.
She attached the bag mask to ventilate Dylan and listened with her stethoscope to make sure both lungs were filling adequately with air. Then she checked for a pulse and looked up just as the curtain twitched back for the second time, allowing herself an audible sigh of relief.
A sigh that was abruptly terminated. It was Brian Jones who had just entered the cubicle, so who had been watching over her shoulder for the last few minutes? Pip’s head swivelled for a second to find Toni Costa standing behind her.
‘What’s been happening?’ Brian queried.
‘Epiglottitis,’ Pip informed her senior colleague succinctly. ‘Respiratory arrest. Intubation failed due to the amount of inflammation.’
Dylan was making a good effort to breathe on his own now and was stirring. He would need sedation and the assistance of a ventilator urgently, but the consultant took a moment to nod with satisfaction.
‘Well done, Pip’ was high praise from a doctor known for being taciturn. ‘Let’s get him on a ventilator. Where’s his family?’
‘I’ll find his mother,’ Suzie offered.
‘And I’ll make sure they’re ready for this young man in ICU.’ Toni moved to follow Suzie but turned a second later. ‘Bravo, Pippa,’ he said quietly. ‘You certainly didn’t need my assistance.’
Warmth from that single, unusual word of praise stayed with Pip until she ended what had been a memorably long day. When her last patient, Elena, had finally been admitted for observation in the chest pain ward and Doris was in Theatre, having her hip joint replaced, Pip took a few minutes to visit the paediatric intensive care unit. She wanted to check up on Dylan and, if she was honest with herself, she wanted to enjoy that sensation of having done something special. And if she was really honest with herself, the possibility of meeting Toni Costa again had to be a distinct bonus, so she was more than happy to find him talking to Jenny and a man she assumed to be Dylan’s father.
‘Oh…it’s you!’ Jenny’s face lit up. ‘He’s going to be all right. Darling…’ She turned to her husband. ‘This is the doctor I told you about. The one who saved Dylan’s life when he’d stopped breathing.’
‘Really?’ The man stepped forward and gripped Pip’s hand with both of his. ‘What can I say? How can I thank you enough? It was…’
It was clearly too much to articulate further. Dylan’s father was overcome by emotion.
‘Sorry…’ he choked out.
‘It’s OK,’ Pip reassured him with a smile. ‘I totally understand. It was a frightening experience.’
For her as well. What would Dr Costa think if he knew that he’d provided the confidence Pip had needed to succeed, even before the surprise of his genuine presence? She didn’t dare look at him.
‘I’m so pleased to hear Dylan’s doing well,’ she added.
‘He’s doing very well.’
Pip had to look up as the paediatrician spoke. She found herself basking in a smile she could remember all too easily.
The warmth of this man!
‘And I must congratulate you again,’ Toni added. ‘I didn’t get the chance to tell you how impressed I was with what I saw. I couldn’t have managed that procedure any better myself. You did, indeed, save young Dylan’s life.’
Pip had never felt so proud of herself. It had taken so much hardship to cope with the long training and compromises in her personal life to get to precisely this point, but Toni’s approval and the gratitude of Dylan’s parents made it all seem worthwhile. More than worthwhile.
But then Pip’s gaze was caught by the sight of the young parents moving to sit with their son. They were holding hands with each other and they both used their free hands to gently touch their child. The bond between the three of them was palpable and Pip was aware of a sense of loss that took the shine off her pride. Life could be so complicated and there was no doubt that sacrifices had been made for her to get to where she was. Sometimes things got lost that could never be replaced.
‘Don’t look so worried,’ Toni said. ‘He is going to be fine.’
Pip nodded. And smiled—happy to let the paediatrician assume she had been thinking of the child they could see. The return smile gave no hint that he might have guessed her real thoughts, although his words were startling.
‘How’s Alice?’ he queried.
Nobody could read minds that well, Pip reassured herself. ‘She seems fine at the moment.’
‘Have you received the appointment for the ultrasound examination?’
‘Yes, it’s next Thursday. Faster than I would have expected.’
Toni didn’t seem surprised but then his attention was being diverted by a nurse approaching with a patient’s chart.
‘Could you sign off these medication adjustments, please, Dr Costa?’
‘Sure.’ But Toni was still looking at Pip as she turned away with a nod of farewell. ‘I’ll try and drop by to see what they find on ultrasound. Ten o’clock, isn’t it?’
Pip’s nod slowed and she left the unit feeling oddly dazed. How on earth had Toni known the time of the appointment? And why would he want to interrupt what had to be a gruelling work schedule in order to attend?
For one, extremely disconcerting, moment, Pip thought that maybe Alice was right. Maybe Toni Costa was attracted to her and was looking for an op
portunity to see her again. She couldn’t deny that the possibility of seeing him again had not gone unremarked in her decision to follow up on Dylan Harris’s progress.
How would she feel if that was the case? Pip walked through the hospital corridors barely noticing the people or departments she passed. If the tingling sensation in her body right now, coming in rather pleasurable waves, was anything to go by, she would feel very good about it.
Very, very good!
Alice was not feeling very good. Pip entered her home that evening to find her daughter looking downright mutinous.
‘Nona’s taken my phone,’ she announced by way of greeting for Pip. ‘It’s not fair!’
‘It’s perfectly fair.’ Shona appeared in the kitchen doorway. ‘You spend half your life texting your friends. You’ll get it back when you’ve finished your homework.’ She smiled at Pip. ‘You’re home, finally! Wash your hands, love, it’s almost dinnertime.’
The tone Shona used to speak to both Pip and Alice had been…well…motherly. Caring but firm. Possibly a little close to the end of a tether. Alice and Pip exchanged a glance. They both knew it would be a good idea to smooth potentially troubled waters. Alice disappeared upstairs, to at least look like she was doing some homework. Pip followed her mother to the kitchen.
‘You OK, Mum?’
‘I’m fine. Bit tired, I guess.’ Shona pushed strands of her greying hair behind her ears as she bent to open the oven. ‘It’s just casserole and baked potatoes. Hope that’ll do.’
‘It’ll be fantastic,’ Pip said sincerely. How many other overworked and stressed junior registrars could bank on going home to a warm house and delicious hot meal? Or having their laundry done or messages run when time simply wasn’t there for mundane chores?
The Italian Doctor's Perfect Family Page 3