The Hollow Men: A Novel

by Rob McCarthy

  ‘Ready, steady, lift.’

  They carried Idris out of the takeaway like pall-bearers at a funeral. Got him onto the trolley and onto the lift at the back of the ambulance. The police medic looked up at Harry, his hands still pressing on the wound in Idris’s chest, while the male paramedic ran to the front door and started up the ambulance, blue lights on, so they could leave the moment the lift was up. They rolled Idris into the back of the ambulance on the trolley, and locked the doors.

  Blasted sirens as the street lights, snow and concrete flew past through tinted windows.

  ‘Got the line in,’ the paramedic shouted. ‘Want the fluids?’

  Harry looked up at the vital signs monitor. No blood pressure recorded yet, so he wrapped his fingers around Idris’s wrist and squeezed. A faint, fast pulse rebounded against the bloodied, sticky material of his gloves.

  ‘He’s got a radial, let’s hold off for now,’ said Harry. ‘Can we get a pre-alert in, make sure Resus knows we’re coming.’

  The voice from the paramedic driving the ambulance squawked over his colleague’s radio. ‘This is call sign Papa 2-4-2, we have a Code Red trauma call. Seventeen-year-old male with a gunshot abdomen, unrecordable blood pressure. ETA three minutes.’

  Truncating the tragedy of everything Harry had seen in the last half-hour into a couple of sentences transmitted over the radio. His fingers were still wrapped around Solomon Idris’s wrist, feeling the pulse slowly weaken.

  ‘Solomon! Can you hear me, Solomon? Squeeze my hand!’

  Just a shiver, a hint of movement, even with the ketamine in his system. What else can we do for him? There were plastic tubes in his nose and mouth providing a temporary airway; he was on high-flow oxygen to optimise his ventilation; there were big peripheral lines in place, ready for a massive transfusion. Only blood and surgery could help him now, and antibiotics and ventilation to sort out his chest. Harry could think of a few surgeons good enough to help Solomon Idris, and every one at the Ruskin fitted that description.

  ‘Solomon! Talk to me!’

  Pulse still there at the wrist, vital signs monitor reading an ECG trace. Blood pressure crashing now, just like Harry knew it would. Eighty over sixty-five.

  ‘Get me a grey cannula, please, I’m putting in another line!’ he barked as the ambulance blared its horn, cutting through another red light.

  As his gloved, bloodstained fingers squeezed Solomon Idris’s wrist more tightly, Harry felt the pulse disappear.

  In a typical shift, a staff member at the Accident & Emergency department of the John Ruskin University Hospital can expect to watch one person die. On nights where the young men of Camberwell are feeling particularly virile, it isn’t unusual for six or seven teenagers to come in, wounded, bleeding and hopeless. Often with a moment’s notice, a team would assemble, like the one waiting in Resus now, gathered in the three minutes between the pre-alert and the ambulance’s arrival. A trauma consultant, team leader, at the foot of the bed, checklists and algorithms on a clipboard in front of her; surgeons, anaesthetists, nurses, junior doctors, radiographers. The porter was running to the blood bank for the emergency blood, O-negative, the universal donor type. There could be a hundred years of medical training between the team combined, but the man who could run for blood trumped them all. Tonight’s porter was Wallace, a semi-professional footballer who’d been working at the Ruskin for six years. His personal best, from bedside to blood bank and back again with four units of O-neg, was two minutes and thirty-six seconds.

  ‘He’s going into six!’ the charge nurse shouted as the paramedics wheeled Idris through the door.

  Harry pushed the trolley into Resus and immediately recognised three of the faces. The first was the team leader, Bernadette Kinirons, who watched over her team from behind wire-rimmed glasses, dark grey scrubs accentuating her mottled skin. Another was George Traubert, a senior consultant anaesthetist, and Harry’s educational supervisor. Traubert was in a blue scrub top but below that were cream chinos and Italian shoes, the uniform of someone who’d been ready to go home when the call had come in. The third face was tucked away in a corner of the resuscitation bay, disguised behind a green plastic apron and gloves and rectangular Armani glasses. James Lahiri had been his best friend in medical school, and gone with him to Afghanistan and back again, but they didn’t speak any more. Day to day, Lahiri was a GP in Camberwell, but three or four times a month he worked locum shifts in A&E. Plenty of GPs did, especially the younger ones, to keep their skills up, for a bit of a challenge.

  Sod’s law said he was working tonight.

  ‘Harry!’ Traubert exclaimed. Lahiri looked up, the expression on his face frustrated surprise.

  ‘Do we have blood?’ Harry barked.

  ‘On its way,’ Kinirons replied, as if scolding Harry for ever doubting the team.‘Are we going to get a handover?’

  Harry nodded and took his place at the foot of the bed next to her as the nurses and junior doctors helped the paramedics slide the unconscious seventeen-year-old from the ambulance trolley to the bed. He found himself subconsciously assessing the team: Kinirons was rock solid, the surgical registrar he didn’t recognise, and then there was Lahiri. Even if Lahiri’s presence was unfortunate, there was no one he’d rather work with. On the other hand Dr Traubert was an academic at heart, and only ventured into A&E if the rota was in a dire state; the on-call anaesthetists must all have been busy with emergencies elsewhere, otherwise he wouldn’t have been there.

  ‘OK,’ Harry said, beginning the handover. ‘This is Solomon, he’s seventeen. About fifteen minutes ago he was shot by a low-velocity weapon. There is an entry wound in the left upper quadrant, just beneath the costal margin, no identifiable exit wound, no other obvious injuries. He has a background of suspected atypical pneumonia and baseline saturations around eighty-seven before being injured. Currently, he has no radial pulse, a central pulse of one-thirty, a respiratory rate of twenty-eight, and sats of eighty-two on fifteen litres of O2. I’ve put in airway adjuncts, he’s had two hundred of saline before he got shot but none since, seven hundred of IM ketamine for sedation, and he’s got a line in. He’s allergic to penicillin, and he’s got no known medical history.’

  Everyone present recognised the description of a young man holding on to life by a thread, entering severe shock. The team each moved into their assigned task like a pit stop crew. Traubert straight to the head, checking the plastic airways Harry had placed in Idris’s mouth and nose. Lahiri and the surgical registrar assessed his breathing and circulation. Kinirons stepped back, looking at the big picture.

  ‘Did you say you gave him saline before he got shot?’ she asked.

  ‘Long story,’ said Harry. ‘I’m a police surgeon with the Met. He’d taken hostages, I was treating him, and then the police shot him.’

  He looked across to see Kinirons staring at the ground, shaking her head. The doctors around Idris shouted out their findings, and Harry was back in the room.

  ‘We need to intubate!’

  ‘I don’t have any breath sounds on the left.’

  ‘Ultrasound shows fluid in the abdomen!’

  Of course it does, Harry thought. He’s been shot there, and he’s going to bleed to death unless we get him on the table and a surgeon opens him up and stops it. Harry looked around the resuscitation bed and realised there was no senior surgeon present – one must surely be on their way. No breath sounds in the left chest, which was worrying. Kinirons barked an order, then a question.

  ‘James, make sure it’s not a pneumothorax. Have we a blood pressure yet?’

  One of the nurses shouted a reply. ‘Eighty over fifty.’

  Wallace the porter came crashing through the doors to Resus at a sprint, sweat dripping through his polo shirt, the insulated freezer bag of blood bouncing in his hand.

  ‘Are the blood warmers set up?’ said Kinirons.

  ‘Yes!’

  ‘We should have another line in, please,’ Kinirons continued. ‘Ge
t O-neg going through his right arm in the meantime. Get the BP up. Then we’ll intubate and straight to CT.’

  One of the A&E nurses hung up the first bag of blood on a drip-stand and ran it through the fluid warmer, connecting it up to the line the paramedic had placed in the ambulance; the other crouched by Idris’s other arm and started searching for veins. Harry realised he was pacing relentlessly.

  ‘Use me,’ he said. ‘We need to get access, I can help.’

  ‘You’re right,’ said Kinirons. ‘Wash your hands, and go get yourself an apron on.’

  Harry returned to the resus bay with a plastic apron and fresh gloves, only to feel his heart sink at what he saw. The blood bag, the bridge between Solomon Idris and life, was up and running in, but the line had tissued – the blood was running into the soft tissue of Idris’s elbow instead of into his veins and thence to his heart, where it was needed.

  ‘That line’s blown!’

  ‘We know!’ Kinirons said. ‘Dr Traubert’s working on another one.’

  Anaesthetists were the experts at placing lines, and Traubert had the most experience of anyone in the room, but Harry immediately knelt down on the opposite side of the patient to his supervisor and began searching the other arm. Without a good IV line, there was no way to get blood into Idris, and it would keep leaking out of the hole inside his abdomen, and he would die. It was as simple as that.

  ‘I’ve got nothing here,’ Harry said. All the veins in the usual places – the back of the hand, the inner surface of the elbow, the forearm – had collapsed. These are the moments you live for, Harry told himself. The moments you were trained to overcome. Get a neck vein, or a scalp one. Use the ultrasound machine to guide you in. Find a way, any way. In these moments, the chaos in his head would eventually stop and he would know the right course of action in an instant.

  He knew. Turned to one of the A&E nurses.

  ‘Can you get me the IO drill, please,’ he called. Looked down at Traubert, waiting for confirmation from his consultant. Instead, what he saw was Traubert leaning over Idris’s ankle, scalpel in hand, methodically dissecting the fascia away as he searched for the great saphenous vein. It was a procedure so outdated Harry had only ever seen it in textbooks.

  ‘No need, Harry, I’m almost done here.’

  George fucking Traubert, Harry thought. Even if he managed to get the vein, at Idris’s ankle the line would be miles away from his heart and brain, where the blood was needed. Harry’s plan was the right one, even if it was more brutal. The nurse handed him the drill, a device that would place a needle straight into the medulla of Idris’s bone, through which they could infuse the blood that would save his life. Directly from the humerus into the great vessels, and the rest of his circulation.

  ‘I’m doing it, Dr Traubert,’ Harry said. Placed the drill against Idris’s arm, heard the buzz as he squeezed the trigger, felt the change in resistance as the needle screwed through flesh, then hard bone, then the soft marrow where it locked in place.

  ‘We’re in,’ Harry said. ‘Get the blood up.’

  Before he’d even said it, a familiar figure was behind him. Lahiri screwed in the connecting line to the bag of blood, and Harry stepped back, watching the viscous, red liquid start to flow into Solomon Idris’s arm, into his lifeless body, with its grey, pallid fingers, and motionless, bloodshot eyes. They didn’t have the look any more, the thousand-yard stare replaced by one of drug-induced indifference.

  Harry looked up at Lahiri and their eyes briefly locked before his old friend turned away. It had been months since they’d seen each other. At least it was in a situation without much room for small talk. It felt bizarre, a bit like turning up to work after a drunken one-night stand at the Christmas party.

  ‘Can we do the same on the other side?’ Kinirons barked while Lahiri squeezed the blood bag as hard as he could. With good pressure, a unit could be run in within two minutes. Traubert stood up, seeming almost perplexed at what had happened.

  ‘Dr Kent, have you forgotten who—’ he started.

  Harry handed him the bone drill.

  ‘We need a line in the other side,’ he said. You can bollock me later, he thought.

  Traubert looked between the device and Harry, the mess he’d made at Idris’s ankle and the teenager’s lifeless face. Behind him, two Trojan officers arrived in Resus, guns low.

  ‘Um, you do it. You do it, Harry.’

  Harry cursed under his breath as he bolted around the bed to the other side, fitted a new needle onto the drill and repeated the procedure in the other arm. As if in the distance, Kinirons was shouting out orders.

  ‘Get an aspirate from that line, and send it for urgent crossmatch, then hang up another unit, alright? James, let’s get a blood gas as well, please. A unit of FFP once the first bag of blood’s run through, yeah? Can we give him one gram of tranexamic acid and get ready to RSI. And where the hell is the surgeon?’

  ‘Abe’s on his way down,’ said the surgical registrar. Abe Gunther was an old-school trauma surgeon with a pox-scarred face, but he was one of the best in the country, and had pulled at least a hundred bullets out of bodies in twenty years at the Ruskin. If anyone could save Solomon Idris, Mr Gunther could. Harry took a step back, satisfied that they were now replacing the blood Idris had lost as fast as possible. Usually on a trauma call, Harry’s job was to wait at the head, ensure the patient had an airway, and put them under an anaesthetic if surgery was deemed necessary. As he stepped out of the bay, Gunther arrived, heralded by the sound of his rubber-soled Nikes on the floor. The surgeon was the shortest of the team by far.

  ‘Plan?’ was all he said.

  Harry glanced over at the vital signs monitor. There was a blood pressure recorded, seventy-five over forty. It wasn’t good, but it was better than nothing. The first transfusion, almost done, was ready to be replaced.

  ‘Get him stable enough, intubate, then to CT,’ said Kinirons. ‘And then to theatre.’

  Stable was a nice word to use, Harry thought. In situations like this it meant that the patient wasn’t at risk of instantly dying, which was something they couldn’t achieve here until they stopped the blood loss, turned off the tap. In the bay, Lahiri had commandeered the ultrasound probe from the surgical registrar and was running it over Idris’s bloodied chest, looking for a collapsed lung.

  ‘He’s got a left-sided pneumonia,’ Harry called.

  Lahiri turned back. ‘If you say so,’ he said. ‘I can’t hear anything over his left chest, but it doesn’t look like a pneumothorax. Pneumonia would fit.’

  ‘Let me get in there,’ Gunther shouted. He moved in and began directing the ultrasound probe across Idris’s belly. Lahiri stepped backwards, out of the bay, taking a place between Harry and Kinirons. As he moved, he looked at Harry again.

  ‘Just like old times, eh?’ he said.

  It was. He and Lahiri had made a good team. There was at least one squaddie walking around who wouldn’t have been without them, and a good few more who were wheeling. Locals Harry had put under while Lahiri operated, the two of them alone inside a forward operating base, fighting to keep some poor Afghan bastard alive until the helicopter could get them out. When we were inseparable, Harry thought, brothers-in-arms. Before Harry had fucked everything up.

  One of the A&E clerks arrived. ‘Do we have a name yet?’ she said.

  ‘Idris,’ said Harry. ‘Solomon Idris.’

  ‘Yeah, there’s blood in the belly,’ said Abe Gunther. ‘He’s pretty damn unstable, isn’t he? Not sure CT’s a good idea. I’d say put him under and go straight to theatre.’

  ‘Fuck,’ said Lahiri. Out loud, and he didn’t swear much, so Harry knew something was wrong.

  ‘What is it?’ said Harry, heart pounding. Eyes running over the vital signs monitor, double-checking that nothing had changed.

  ‘He’s one of mine,’ said Lahiri.

  Lahiri wasn’t like most GPs. His practice wasn’t far from the Ruskin, the other side of Camberwell Gr
een. It covered some of the most deprived streets in the country, let alone London, and while it saw its fair share of toddlers with ear infections, it was known for registering gang members and previous victims of youth violence.

  ‘I’m sorry,’ said Harry, though he wasn’t sure who he was saying it to. Maybe it was to Idris, sorry that he hadn’t been able to stop what had felt inevitable from the moment he’d walked into that chicken shop.

  ‘OK, we go to theatre,’ said Kinirons. ‘Dr Traubert, are you happy with that? Let’s have the six crossmatched units sent there and the rest of the O-neg, along with some FFP and cryo. Get some O2 ready for intubation.’

  ‘He needs volume,’ said Gunther. ‘I’m not happy taking him to theatre with only the IOs in place. I’d like a central line.’

  ‘Sure,’ said Kinirons. ‘James?’

  Lahiri nodded and swung round to Idris’s neck, ready to pass a cannula straight into his jugular vein. It would get the blood into him faster than the ports they’d drilled in his bones would.

  ‘We’ll intubate once the pressure’s up to eighty,’ said Kinirons. ‘George?’

  It was the final stage between Idris and the operating table where Abe Gunther could save his life: passing a breathing tube into his lungs so they could ventilate him during the surgery. After five agonising minutes, Lahiri had the central line sorted and a nurse hooked up Idris’s fourth unit of blood, his blood pressure up to ninety. Stable enough for them to have a crack at the tube. Harry would do it in a heartbeat, if Traubert looked like he was going to fuck it up.

  ‘OK,’ Traubert said, heading up to Idris’s head. ‘Harry, can you sort the pre-ox, please. And I’ll need some ketamine and rocuronium, thank you.’

  Harry headed up to join Traubert, placing a high-flow oxygen mask onto Idris’s throat while Traubert prepared the intubation equipment and injected the anaesthetic drugs, one to place Idris into a medically induced coma, the other to paralyse every muscle in his body. That one took a minute to work, so Harry looked at his watch the instant Traubert injected it, memorising the position of the second hand. He watched as Traubert prepared the laryngoscope he’d use to sweep away Idris’s tongue and locate the vocal cords, through which he’d slide the breathing tube.