Night Mares

by Manda Scott

  ‘No. It’s your friend with the hair.’

  Steff, back in her scrub suit and a blood-stained mask. She leant against the doorframe, a tired smile somewhere round her eyes. She shrugged an apology. ‘I seem to keep breaking up the party,’ she said.

  ‘Not this one. We’d broken up anyway.’ I stood up. Introduced her to Eric and the other way around. Because, this time, she had a right to be there.

  Eric shook her hand, raised an admiring brow at her theatre kit. ‘Did you want a job in surgery? There’s usually a junior Reg. post free.’

  ‘No.’ She smiled a washed-out smile. ‘I just want to know I’m not too late.’

  ‘You’re not.’

  We walked together across to the bed. Steff leant over and put a hand to Nina’s forehead. ‘She looks better.’

  ‘She is. She was conscious earlier on.’ I spoke it softly, not to wake her. ‘How’s Rain?’

  ‘The same.’ She slid papers from a bag at her shoulder. ‘But I found out what we need. There’s a human anti-endotoxin on the market that cross-reacts with the one we found in Branding Iron. I had a word with Sean in Microbiology. He thinks it might work in horses if we get it in early enough. We could be too late but it’s worth a try.’

  ‘Have you got any in pharmacy?’

  ‘No.’ She looked sideways at Eric. ‘We need to get it from a human hospital.’

  ‘Get what?’ A voice from the bed. Sleepy and pushed through the crashing pain in her head. ‘What are you doing to my cases now, Stephanie Foster?’

  There was a smile on both of them you could have seen even without the monitor light.

  I lifted the papers from Steff’s fingers and tugged at the sleeve of Eric’s white coat. ‘Let’s go somewhere else and have a look at these.’

  You have to believe everything they tell you about the hell of hospital bureaucracy. All of it is true. But when you get to be senior consultant, most of the rules begin to flex. We went for a walk and a coffee and talked about horses and infected theatres and about what it is that drives surgeons to the brink and residents to spend their days wired up to the internet and when we came back to the ward half an hour later, I had the entire hospital stock of E. coli strain 1507 anti-endotoxin tucked away in a specimen bag with someone else’s name on the front. It wasn’t much. Just three vials. And all of them ten days past their shelf date so that, technically, they should have gone down to the incinerator anyway. But just enough, according to Steff’s notes, to bring a horse back from the dead. If you got it in soon enough.

  Nina was asleep. Steff was sitting where I had been, watching her as if she might never get another chance. I palmed the bag and slid it into her pocket. ‘You found these in the skip outside,’ I said. ‘You didn’t get them from here.’

  She smiled. Sniffed and shrugged in her best imitation of an East-End trader. ‘Fell off the back of a lorry, mate.’ She fished in her pocket and checked over the goods. ‘How much is there here?’

  ‘Enough.’ Eric stood behind me, his hand on my shoulder. ‘If you get it in fast, there should be enough.’

  She bounced her car keys on the palm of her hand, buoyant, full of hope. ‘I’ll let you know,’ she said.

  I heard his footsteps before I felt his hand on my shoulder. He treads softly for someone so big. ‘It’s after eleven, Kellen. You could go home, you know.’

  ‘I know.’ I am becoming nocturnal. I sleep by day and by night I watch the jagged edge of an ECG count out someone else’s life. ‘I’m still trying to figure out the ketamine.’

  ‘Me too.’ He held a paper mug in either hand, waved one of them under my nose so that I could catch the smell and nodded his head back towards the staff room. ‘Fancy something to wash down another biscuit?’

  ‘Sure.’

  In the staff room, he handed me a lukewarm coffee and sat me down opposite yet another sheaf of scribbled notes. ‘I’ve been to the library,’ he said. ‘Read some stuff about the sub-anaesthetic effects of ketamine.’

  ‘And?’

  ‘And it’s weird stuff. What happens depends how much you take. At the kind of doses we’re talking about, you’d get some analgesia. Nasty hallucinations. You might be verging on the catatonic but you’d probably need a tad more than she had on board. Apparently it also induces a state in which the subject no longer cares whether they live or die, which is an interesting one if you’re contemplating suicide.’

  Thanks.

  ‘Eric, you’ve read her notes from last time. She didn’t need Dutch courage if she wanted to go.’

  ‘No, I know. I’m not suggesting she did.’

  ‘So?’

  ‘So, I think you’re right. I don’t think she was using it to help herself die at all.’ He doodled again; a series of interlocking Celtic spirals, working himself up to something he didn’t want to say. ‘Kellen. Suppose she had it on board before she ever put in the catheter?’

  This is what he wouldn’t say earlier. Now, he is more sure.

  I looked at him warily. ‘Why would she do that?’

  He sighed. Tilted his chair back and stared at the ceiling. Brought it back to a place where he could look me in the eye. ‘Ketamine’s a pretty common drug of abuse, Kellen. “Special K”, huge street value. Creates God-awful paranoid hallucinations but it doesn’t stop folk using it. Repeatedly. It’s incredibly addictive stuff.’

  He let it hang. I listened and heard and failed to understand.

  ‘Are you trying to tell me that Nina Crawford was a junkie? On ketamine?’ It’s amazing how much feeling you can get into a whisper. ‘That’s insane. She loathed it, I told you.’

  ‘And she was having God-awful hallucinations the day before she died. Cats and maggots and horses with sharp teeth. You told me that, too.’

  ‘But that was hypoglycaemia.’

  ‘How do you know?’

  ‘She said so.’

  ‘You’ll believe anything when you’re paranoid, Kellen.’

  ‘And it got better with food. I saw it.’

  ‘How long did it take? How long to come round after food?’

  ‘I don’t know. Ten minutes. Quarter of an hour, maybe.’

  ‘The half-life of ketamine’s twelve and a half minutes, Kellen. I know. I just looked it up in the library.’

  ‘That’s coincidence, Eric. Pure coincidence.’

  He picked up his pen and drew savage lines across the page. ‘Kellen, think. You were a doctor once. You get ratty when you’re hypo. You get sleepy. You might pass out. If it’s really bad, you could start convulsing. But whatever else you do, you don’t start seeing things. You know that.’

  He said it gently. With compassion. And he kept his eyes somewhere else.

  Because he was right.

  Absolutely right.

  I stacked the biscuits into a tower. Knocked them down again. Made damp circles with my coffee mug and rubbed them in long, off-white smears across the table. Stared blindly at the far glimmer of the ECG and saw nothing. Looking, but not seeing. Listening, but not hearing. Thinking, but not understanding. A pattern of years.

  Voices, other voices played out in my head. Me … Steff …

  Was Nina seeing things before she walked out of theatre?

  Kellen, she couldn’t tell the difference between the needle holders and the scissors by the time she left.

  And Nina …

  It thinks … the world would be a better place if I joined the cat.

  What do you think?

  Just at this moment, Kellen, I couldn’t care less.

  And again. Much further back …

  I can feel it coming, sucking me in. Like gravity. I can’t fight it … I’m scared, Kellen.

  A warning. But I didn’t hear it as a warning. Because I wasn’t listening for a warning. I finished the coffee. Screwed up the mug and threw it in the bin.

  ‘How badly would she have been hallucinating, Eric? With the ketamine?’

  ‘Put it this way, I’m amazed she managed
to get an eighteen-gauge catheter into her arm. I’m completely astonished that she was together enough to put up the drip and get it running.’

  ‘No.’ I took every drop we had in the dangerous drugs cupboard, signed it all out and pumped it into a 500 ml bag of dextrose-saline. That bit was easy. ‘She’s been planning this for long enough. She probably had it made up and waiting.’

  ‘And you didn’t see it coming?’

  I don’t want to die now, Kellen. Of all people, you have to believe me.

  ‘No. I didn’t see it coming. Not now.’

  ‘I’m sorry.’ He pushed his half-finished coffee across the table towards me. We shared it in silence. Worked logically to all the obvious endings.

  ‘How was she getting it in? Did she have needle marks on her arm and I missed those too?’

  ‘I don’t know. I haven’t looked yet. And her arm’s that much of a mess at the moment, I think you’d be hard pushed to find any normal skin anywhere. But she could have drunk it. It works orally in kids. I expect it works in adults if you want it to. Saves having to explain away those inconvenient bruises round the veins.’

  ‘Great.’

  The ghosts of past conversations marched in ranks through my head. The afternoon just gone, sitting by her side in the ward. Saturday night in bed. Every therapy hour we’ve ever had. All of it based on fiction.

  I believed her because I wanted to believe her.

  Matt Hendon knew better.

  I stood up. ‘Now, I think we need to talk to Nina.’

  ‘Do you think she’s up to it?’

  ‘You’re the doctor. But I’d have said if she can talk to Steff Foster, she can talk to us. And better us than the hospital cyclist. To begin with, anyway.’

  ‘Go easy, huh.’

  ‘Trust me.’

  We sat by the bed. One on either side. The ECG chirruped. Steady. Rhythmic. Stable.

  Nina Crawford slept. Sound and deep. We couldn’t wake her.

  ‘She’s gone back under, Kellen. It happens like this with pentobarb. Leaks back out of the tissues and the blood levels go back up for a while. You should sleep. Talk to her in the morning.’

  ‘Maybe.’

  I sat on her left side. Ran my fingers up and down her arm. Searching. Feeling for marks to show where she’d slipped in the drug.

  I thought I knew this arm.

  I thought I knew all of her.

  I traced the scar, long and sinuous, from wrist to elbow. And the small, finer, horizontal scars of Matt’s sutures. Twelve of them. I never spotted those, either.

  I traced on. Up along the scarred and knotted tracks of veins ruined by the first, catastrophic mistake.

  … It’s more difficult than I thought. I don’t have veins like a horse. And there’s only one vein on my left arm that’s worth going for. All the rest were shot to bits after last time.

  I never thought to ask her how she knew.

  I ran my fingers up the thin, blue line of that one, remaining vein.

  Stopped.

  Traced back.

  I used a twenty-three-gauge cat catheter because I thought it would be easier to get in. Even so, it took me two tries.

  ‘Eric, where was the catheter? The one she put in herself?’

  ‘Here.’ He lifted the arm on his side and jiggled the end of the fluid line. Carefully, not to disrupt the skin. ‘This is it. We didn’t move it. Right antecubital fossa. Very neat. Doubt if I could do better myself.’

  ‘What size?’

  ‘Eighteen, I think.’ He checked the hub. Nodded. ‘Eighteen gauge.’

  I rolled up my sleeve. Had a look at my veins. Worked it through. Stood up and hunted through the drawers of the monitor trolley for a catheter. A big, eighteen-gauge catheter.

  ‘Here. Try something for me. You’re right handed, yes?’

  ‘Yes.’

  ‘So’s she. Try putting that in your right antecubital the way she’s done it. Don’t do it for real. Just see if you can.’

  He rolled up his sleeve and mimed a swab of the site, out of habit. He looked up, amused. ‘I’ve got a pressure cuff raising the vein, have I?’

  ‘Whatever you need. Just go for the vein.’

  He started to mime the catheter. Stopped.

  ‘I can’t. If I was putting it in, I’d use my right hand and put it in my left arm.’ He looked at me. Shrugged. ‘Maybe she’s ambidextrous, Kellen.’

  ‘No. But pretend she was. Try putting it into your right arm with your left hand. Just lay it on. Where does it go?’

  ‘Like this?’ He was playing along. Humouring me. ‘Lying along the vein like this.’ He held the catheter flat to his arm, along the line of the vein.

  ‘Good. So where’s the tip and where’s the injection port?’

  ‘Tip’s pointing down. I couldn’t get the angle otherwise.’

  ‘OK. Now put it in me. Like you would if I was a patient.’

  He did. Swabbed the site and laid the catheter on my skin. Neatly up the line of the vein.

  Up. Not down.

  He noticed it, too. ‘It’s the other way up. The tip’s pointing up. The usual way.’

  ‘Right. Now which is Nina’s?’

  We both looked. Eric leaned over to the head of the bed and switched on the light. Bright and intrusive and exactly what we needed. She lay calm on the bed. An angelic, sleeping doll. Free of vice. There was more colour in her face than I’d seen in weeks.

  He lifted her arm and looked at the catheter. Laid her arm back down on the bed.

  ‘It’s the same as yours,’ he said. ‘Right arm. Pointing up the vein.’

  ‘Exactly. And she was so high on the ketamine, you were amazed she got it in at all. Never mind the wrong way up.’ I followed the logic. ‘If she was that far gone, Eric, could someone else have got it in, without her fighting?’

  ‘On half of the anaesthetic dose?’ He shrugged. ‘It’s possible. If they took it gently and fitted in with whatever it was she was seeing.’ He closed over the case notes and laid them on the floor. ‘But if it was someone else, we’re talking murder, Kellen. Attempted murder, anyway.’ He picked up her wrist and felt her pulse. For something to do. ‘Don’t start clutching at straws, Kells. You’ll need a lot more than a dodgy catheter before you can make that one stick.’

  ‘No.’ I sat in the light and watched the sheen of damp on her forehead as it caught the wavering light of the ECG. ‘I don’t have to make anything stick. That’s not my problem. I only have to work out who it is and make sure they don’t get a chance to try it again.’

  ‘Or talk to Nina and find out what actually happened.’

  ‘If she ever remembers.’ And then, because there was something about her colour and the damp sheen on her face that wasn’t right. ‘Eric, can you check what her temperature’s doing?’

  There are three house officers on duty in the west wing of the Infirmary at that time of night. None of them knew me or Nina. All three of them knew Dr Eric Dalziel and were prepared to run circles for the sake of his newly pyrexic patient. Within ten minutes we had blood samples run through the lab and a printout with full haematological and biochemical results.

  ‘PCV’s up. Plasma proteins are up. White cells are crashing.’

  I don’t believe I’m hearing this.

  A gaping hole opened in my solar plexus. Gravity sucked.

  ‘She’s septicaemic, isn’t she, Eric?’

  ‘Looks like it.’

  ‘Can you run her bloods through for circulating E. coli?’

  ‘Sure. Why?’

  ‘They’ve had a whole run of horses die of E. coli endotoxaemia at the clinic. Every one of them started like this.’

  He picked up the phone. Gave orders. Came back to the bedside. ‘It’s on its way,’ he said.

  There is something particularly efficient about a teaching hospital, even at night. The gram stain took less than five minutes and most of the time was lost running the sample to the lab. Somewhere in the middle, they
set up a new drip bag and loaded it with cephalosporins.

  Nina Crawford lay, sleeping the sleep of the dead, her colour rising with her temperature. An electronic thermometer fed data back to the monitor and the monitor plotted it, dot by minute dot, to the screen. Core temperature in degrees centigrade expressed to the nearest one hundredth of a degree: 38.74°C and rising. A steady, unwavering rise.

  The sheen on her forehead beaded; became sweat and ran in runnels down her temples to the pillow. She sighed and turned in her sleep.

  A lad with black corkscrews for hair ran in with the last set of results. Remarkably awake for the time of night. Another nocturnal soul. Hospitals gather them.

  Eric took his offering. Read it. Dismissed him with a nod. Waited till he had left. Handed me the readout from the gram stain: ‘No micro-organisms visible. Advise aerobic and anaerobic culture on other tissue samples.’

  ‘There’s no E. coli.’ I felt oddly deflated.

  ‘Nope.’ He shook his head. ‘But that doesn’t mean she isn’t endotoxic’

  ‘Doesn’t it?’ It’s a long time since I did clinical medicine at this level but I thought that was impossible. ‘How would you get endotoxaemia without circulating bacteria?’

  ‘I’m not sure.’

  The lad with the corkscrew hair came back with packs of fresh plasma. Between them he and Eric set up a transfusion.

  I sat on the end of the bed, sidelined, inactive and helpless, and watched clear yellow plasma drip into the vein on her arm. It’s taken a lot of abuse over the past few days, that vein.

  The houseman left. Eric came and sat down opposite me. ‘Tell me about the horses,’ he said.

  ‘They were all surgical cases. They started symptoms of endotoxaemia within forty-eight hours of surgery.’

  ‘And they all had E. coli on blood smears?’

  ‘Yes … no … Not all of them.’ I remembered Steff.

  The blood smear’s clear but that means nothing.

  ‘All except the last one. Except Rain. Our mare. She’s the one that started the night Nina … on Monday night. The smear was clear when we brought her in. I don’t know if anyone’s looked since.’

  ‘Uhuh?’ He pulled a pad from the pocket of his clinical coat. Made notes. ‘So, in five out of six cases, you have endotoxic signs in the presence of an E. coli. That’s fair.’ He nodded. ‘Did they run sensitivity tests on the bugs?’