Maybe the mountain was finding the courage to initiate such a conversation with Toni in the first place. Or finding the time to make any contact at all.
Having thought about her mother’s advice all night, Pip had come to work determined to find a way to talk to Toni. A phone call had been deemed too impersonal but when she used her break time to visit his office, she found it empty.
It was even harder to summon the courage to make another attempt. Far easier to allow herself to be swept into the controlled chaos of an unusually busy afternoon in the emergency department.
Patient after patient to see. Assessments to be made, tests ordered, results reviewed and treatments decided on and initiated. The ambulance service was being run off its feet as well. Stretcher after stretcher rolled in. People were having heart attacks and strokes. Asthma attacks and accidents.
Pip barely registered the call for a paediatric consult from the neighbouring resus bay as the department dealt with the aftermath of an MVA involving two carloads of mothers and their young children. She was looking after one of the mothers and she had barely finished her primary survey of airway, breathing and circulation adequacy when her patient screwed up her face and groaned in an alarming fashion.
‘What’s wrong, Stephanie?’ Pip queried sharply. ‘What’s hurting?’
‘I think…it’s the baby.’
Stephanie was pregnant with her third child. Her oldest was in the next-door resus bay and sounded like he’d been concussed badly enough to warrant a specialist consult. With the pregnancy being almost full term, Pip had included a foetal check in her primary survey but there had been no sign of imminent labour and the baby’s heartbeat had sounded strong and regular. Pip had been about to order an ultrasound examination in any case, because of the possibility of abdominal trauma for the mother after the driver’s airbag had been deployed in the collision.
‘Try not to push.’ Pip was pulling on a fresh pair of gloves. ‘I’ll see what’s going on.’
It was immediately apparent that there was a lot going on. The bed was soaked with amniotic fluid and the bulge that was about to become a baby’s head was growing rapidly.
‘You’re right,’ Pip told Stephanie. ‘Your baby doesn’t want to wait any longer.’ She caught the attending nurse’s startled gaze. ‘Grab a birth kit for me, please. And some entonox.’
Stephanie groaned again and, as always, the undertone of agony triggered unpleasant memories for Pip. She knew exactly how excruciating the pain of labour could be but at least Stephanie wasn’t going to have to endure hours and hours of it. By the look of how fast this labour was progressing, it could well be over before they could even set up the entonox for pain relief.
‘How long did your last labour go for?’
‘About an hour. Ah-h-h!’ The sound became strangled. There was no point in asking Stephanie not to push. The force was clearly well beyond her control.
Pip held her hands ready to catch the baby. There was no time to call for assistance. Or even to check the position of the umbilical cord or use suction to clear the nasopharynx as the head emerged. It seemed that one moment the head was crowning and the next Pip was holding the slippery bundle, keeping it head down to help drain any fluid in its airways.
‘Oh!’ Stephanie seemed as stunned as Pip had been by the precipitous birth. ‘Oh, my God! Is he all right?’
‘He’s a she,’ Pip responded. ‘You’ve got a little girl, Stephanie.’
The baby’s warbling cry was a huge relief. An emergency department resus bay was probably not the ideal facility to resuscitate a limp newborn. There wasn’t even a paediatrician within shouting distance.
Or was there? The nurse had just arrived back with the birthing kit and an entonox cylinder. Her jaw dropped.
‘Can you see if anyone from Paeds has arrived next door yet?’ Pip asked.
‘I’m right here.’ The tall figure of Toni loomed behind the nurse. ‘I heard the cry. What’s the Apgar score?’
‘I haven’t done one yet.’ The baby was pinking up nicely, though. She was moving in Pip’s hands and her cry was increasing steadily in volume.
‘Here, let me.’ Toni held out his arms. ‘I’ll hold her while you cut the cord.’ He smiled at Stephanie. ‘I love babies,’ he told her.
The third stage of Stephanie’s labour was not going to be as fast as the rest had been. Pip waited, running a check of Stephanie’s vital signs and trying to watch Toni at the same time as he examined the baby, checking its muscle tone, heart and respiration rate, colour and movement.
‘She’s perfect,’ he pronounced. ‘We don’t have any scales here so we’ll weigh her as soon as we get you up to the ward.’
He wrapped the baby in a clean, fluffy towel the nurse had ready but he didn’t give her back to Stephanie immediately. He stood there, the tiny baby in his arms, smiling at it.
And something inside Pip simply dissolved.
He was born to be a father, this man. And she wanted him to be able to hold his own child like that one day.
Their child?
Was it actually possible that her love for this man was strong enough for her to overcome the massive block she had set in place after Alice’s birth and cemented into place a little more firmly every time she considered herself to have failed as a mother in some way? Was her reluctance really a memory blown out of all proportion because of the other circumstances surrounding it? Like being so afraid of being a mother. Of ruining her life. Alice had been a noisy, demanding, terrifying little bundle and Pip had always felt desperately out of her depth.
Maybe things would be very different now she was older. If she had a child who had a father.
If that father was Toni.
In a totally unexpected flip, Pip realised how sad it would be if Toni didn’t want children of his own. How sad it would be if she never had the joy of seeing him hold a child of theirs like that. Of having the chance to try again as a mother after all she had learned and do things differently. Better.
As he moved to hand the infant to her mother, Toni looked up and caught Pip’s gaze. She tried to smile but her lips wouldn’t co-operate. They wobbled. Worse, Toni didn’t even try to smile back. It was impossible to interpret the expression in those dark eyes.
Was he still upset with her?
Remembering those words that denied him the chance of having children if she was his partner?
Was there some way she could communicate, with just a look, what she was feeling right now? That her love for him was strong enough to overcome any obstacles—as long as he felt the same way?
No. There was no chance. Pip’s name was being called. She turned to see that Suzie had her head through the gap in the curtains.
‘What’s up, Suzie?’
‘There’s an ambulance coming in. Twelve-year-old girl who collapsed at school.’
‘You want me to take it?’ Pip was puzzled. It was taking a moment to refocus on a professional level. They must be very busy if she needed to leave a patient before she could arrange transfer to the next step in her care.
‘Not exactly…’ Suzie bit her lip. ‘I just thought you should know. I’m sorry, Pip…but it’s Alice.’
CHAPTER NINE
‘ON THE count of three. One, two…three.’
Pip couldn’t get near Alice just yet. They were transferring her from the stretcher to the bed in Resus 4, the only highly resourced area not in use following the influx of patients from the car accidents, and the paramedic was doing the handover to the only consultant available. Toni.
‘She’s febrile—temperature of 39.4. Tachycardic at 120, tachypnoea at 26 and hypotensive—75 over 45. GCS 13—she’s been drowsy and confused.’
‘What happened at the school?’
‘She started vomiting and complained of severe abdominal pain and then collapsed. Apparently unconscious for about a minute. She was rousable but confused when we arrived.’
‘Keep that oxygen on,’ Toni directed the nurs
e. He looked at the IV line in Alice’s arm. ‘Is that patent?’
‘Yes.’
‘Fluids?’
‘We’ve run a bolus of 500 mils 0.9 per cent saline,’ the paramedic responded.
‘Any change in blood pressure?’
‘No.’
‘Blood-glucose level?’
‘Didn’t get a chance to do one—sorry.’
Toni was at the head end of the bed. ‘Alice? Open your eyes, cara. Do you know where you are?’
Alice opened her eyes but turned her head instantly and closed them again, emitting a groan that cut through Pip like a knife.
‘It’s OK, Alice.’ Toni’s voice was like a reassuring caress. It wasn’t that he knew Alice—he would have been like that with any young patient. ‘We’re going to look after you.’ He touched her cheek. ‘Is it your tummy again? Is it hurting?’
The incoherent sound from Alice seemed to indicate agreement. Toni’s hand went to her stomach and Pip saw the frown that coincided with another groan from Alice.
‘Abdo’s rigid,’ he said.
This was bad. A rigid abdomen had to mean something serious. Internal bleeding or infection. Pip stepped closer as the barrier the stretcher had made between her and the bed was finally removed.
‘I’m here, Alice,’ she said, trying to sound calm and as reassuring as Toni had. ‘It’s OK, hon. You’re going to be OK.’ She caught the small hand lying on the bed, confident that this crisis would have done what no amount of talking had been able to do in the last few days and would have overcome the barrier Alice had erected between them. She had always turned to Pip as a mother whenever she was hurt or frightened.
But not this time.
Alice dragged her hand out of Pip’s grasp. ‘Go away,’ she said clearly. ‘I don’t want you here.’
The paramedic at the foot end of the stretcher that was disappearing through the curtains turned to give Pip a startled glance, as though she had no right to be there. Already upset at Alice’s public and very unexpected rejection, it didn’t help.
‘I’m her mother,’ Pip snapped.
The paramedic shrugged, steering to one side to allow registrar Graham to enter the space.
‘I don’t want you here,’ Alice sobbed. ‘I want Nona.’
She was obviously becoming more distressed. Her breathing rate had increased until she was gasping between sobs. Her arms moved wildly enough to threaten the security of the IV line and Toni caught the hand before it hooked the plastic tubing coming from the bag of fluids suspended overhead.
‘Take it easy, cara,’ he said. ‘It’s all right. Everything’s all right.’
Amazingly, Alice did start to settle, either because of Toni’s words or the fact that Pip had taken a bewildered step backwards. She didn’t understand. Why was Toni’s attention acceptable when hers wasn’t? Wasn’t it Toni that Alice held at fault for the disruption to their lives? Had Pip put him at arm’s length for no good reason and just suffered herself under the mistaken belief she was doing what Alice wanted?
Fear mixed with confusion took Pip back to a response she would never normally have considered acceptable as an adult.
It wasn’t fair!
‘Oxygen saturation is dropping.’
Toni looked up at Graham’s observation. ‘Right. I want an arterial blood gas and two sets of blood cultures,’ he ordered. ‘And urinalysis. Full blood count, urea, creatinine, electrolytes, and a coagulation profile.’ He looked at the nurse. ‘Let’s do a bedside BGL and a 12-lead ECG. I want a chest X-ray and someone here with a portable ultrasound machine, stat. Page a paediatric anaesthetist, too.’
He was unhooking his stethoscope as he moved around the bed to speak to Pip. He put his hand on her elbow and guided her towards the curtains.
‘This looks like septic shock,’ he said quietly, ‘You should be prepared in case we need to put her on a ventilator.’
Alice was that sick? Instinctively Pip tried to move back towards her daughter but Toni’s grip on her elbow tightened. His tone was apologetic.
‘She’s sick,’ he said sympathetically, ‘which is probably why she’s decided she doesn’t want you here.’
‘But I—’
‘I know.’ The hand squeezed her arm, conveying more than words could. ‘But if it’s upsetting her, it would be better if you weren’t here just for now. I’m sorry, Pip.’
He’d called her Pip, instead of his special ‘Pippa’. It didn’t feel right. Toni was being so professional here. Understanding and caring but…distant. Was that why Alice was prepared to accept him treating her? Could she sense the authority and skill and lack of personal attachment under the current circumstances?
He was doing exactly what Pip was failing to do.
Toni seemed to sense what she was thinking. ‘Be strong,’ he said softly. ‘I’ll look after her.’
Pip knew that he would and his words, or perhaps just that personal encouragement, were enough to give her strength. She knew he was right. If Pip’s presence was going to distress Alice further when she was already in trouble, she would be doing harm by insisting on staying. However heart-breaking it was, she had to take herself out of this. The only reason she could find that strength was in knowing that Toni would be caring for her daughter.
‘Thank you,’ she whispered. She cleared her throat and spoke with more certainty. ‘I’ll call Mum. You can tell Alice I’m sure she’ll be here as soon as it’s possible.’
By the time Shona arrived at the hospital, Alice was deeply unconscious in a drug-induced state to allow mechanical ventilation.
Shona gasped with shock. ‘Oh, my God, what’s happened to her?’
There was no need for Pip to be excluded from the area now. Her patients had all been handed to the care of other staff members and Shona needed her support. Her shocked gaze had gone from the paediatric anaesthetist, who was adjusting controls on the ventilator, to Toni, who was scrubbed and gowned and using forceps and a swab to clean the side of Alice’s neck in preparation for inserting a central venous line.
‘What’s happening?’ Shona asked in distress.
‘Alice’s blood pressure is still too low,’ Pip told her. ‘Toni’s putting a line into one of the bigger veins, which means they can administer fluid faster and also measure the pressures more accurately.’
‘But why is she on a machine?’
‘She’s got some fluid in her lungs, which means she’s not getting as much oxygen as she needs. The machine can improve that.’ Pip watched as Toni felt Alice’s neck with his gloved hand, identifying the carotid pulse so he could insert the needle into the internal jugular vein that ran parallel to the carotid artery.
‘But why? I thought you said she had an infection.’
‘She does. It’s got out of hand. She’s got something known as septic shock.’
‘What sort of infection is it?’
‘That’s what we’re trying to find out,’ Toni said. ‘Her abdomen is rigid so that’s what we’re focusing on right now. We’re about to get a urinary catheter in place to get a specimen for analysis and we’ll be doing an ultrasound examination next. Graham, have you got all the blood you need for cultures?’
‘Yes.’
‘We’ll start antibiotics stat, then. Flucloxacillin 50 mg per kilo and Cefolaxime, also 50mg per kilo. She’s about thirty-two kilos, isn’t she, Pippa?’
‘She was but I think she’s lost a bit of weight in the last few days. She hasn’t been eating well.’
‘I thought she looked a bit pale last night,’ Shona said. ‘I asked her if she felt all right and she said yes.’
‘How did she seem this morning?’
‘Quiet.’ It was Pip who answered this time. ‘She didn’t say a word to me during breakfast but that’s hardly unusual at the moment.’
Nobody seemed to think the comment was strange but the staff members were concentrating on stabilising a very sick young girl.
‘I’m still not happy with this blo
od pressure,’ Toni said. ‘We’ll start infusion of an inotropic agent as soon as I’ve got this line secured.’
Dopamine, Pip thought. That’s what they needed to try and get the blood pressure up. Not that she could say or do anything medical here. She was reduced to the status of a relative, nothing more. She hadn’t been expected to even try finishing her shift in the emergency department. Any patients that had been under her care had been transferred by Suzie to other staff before the ambulance carrying Alice had arrived, which was just as well because Pip was in no state to treat anybody. Especially her own daughter.
‘She didn’t want me anywhere near her,’ she had told Shona. ‘She only wants you.’
‘She doesn’t know what she wants at the moment,’ Shona had said matter-of-factly. ‘We’re both here for her and she knows that.’
They both stood close to the head of Alice’s bed. Her eyes were shut and her mouth disfigured by the tube and mouthguard and the ties that were keeping them in place. Red-gold hair fanned out over the white pillow and the small face was almost as pale as the pillowslip.
‘I can’t believe this is happening,’ Pip murmured. ‘How could she get this sick this fast?’
The abdominal ultrasound gave them a provisional diagnosis.
‘There’s what looks like a pseudocyst here,’ Toni pointed out.
‘What’s that?’ Shona asked.
‘It can be a complication of acute pancreatitis,’ Toni responded. ‘It’s a collection of fluid and necrotic debris with the walls being formed by the pancreas and other surrounding organs. It can subside spontaneously or it can develop into an abscess. This area here…’ Toni scrolled back to put another saved image onto the screen ‘…looks like it could be an abscess that’s burst, which could explain the peritonitis and septicaemia.’
‘What needs to be done?’ Pip asked. ‘Could that other pseudocyst be infected as well?’
‘We’ll do a CT scan and a guided needle aspiration. If it is the source of infection, surgery may be necessary to clean things up. In the meantime, we’ll be monitoring Alice closely in the paediatric intensive care unit.’
The Italian Doctor's Perfect Family Page 14