Safety, level of consciousness, airway, breathing and circulation were covered within twenty minutes. Assessing the level of disability and exposing the chest and abdomen to assess injuries took another fifteen minutes. Kelly was relaxed now and enjoying herself. She teamed the non-medical members of the class with partners who could coach them when she directed a practice of the skills she had covered. Amidst the lack of confidence some people had to overcome and the humour that lightened the more serious aspects of the subject was a willingness to learn and a new respect for someone who had been one of the quieter members of the class up till now.
‘Kelly, my patient reckons he’s bleeding to death from a ruptured artery. Do I fix that before the airway?’
‘If he’s telling you he’s bleeding to death, his airway’s fine. You can’t talk if you’re not breathing. You’re onto circulation straight up in this case. Get some direct pressure onto the bleed.’ Kelly looked up to address everyone in the room.
‘Remember we’re trying to identify the life-threatening problems in order to deal with them quickly. Don’t move on to the next item on the agenda until you’ve managed whatever problem you find.’
‘What if they stop breathing when you’ve finished the checklist?’ Kyle was kneeling beside June with his hand gripping her wrist.
‘Then go back to the beginning and start again. There are three things that are going to kill people very quickly—respiratory arrest, cardiac arrest and severe haemorrhage. We have to identify and try to rectify those situations.’
Dave called a halt to the session. ‘That was fantastic, Kelly. Thanks.’
The spontaneous applause from her students made Kelly blush but she looked happy. Somehow, that irritated Fletch. Or was it that Roger’s appreciation was so noticeable that was the annoying factor?
‘We’ve spent over an hour learning some very important skills but don’t forget what Kelly said. A primary survey should only take thirty to sixty seconds.’ Dave paused for a moment as a few people made some last-minute notes. ‘Ross is going to run us through what vital signs are and how to measure and record them. Then we’ll have a break for morning tea.’
The break was welcome. Fletch had not enjoyed the morning so far. He felt out of sorts. The unwelcome memories Kelly had stirred surely weren’t entirely responsible for his mood. He had learned to deal with those memories long ago and he couldn’t care less if the attraction that Roger the fireman was advertising was reciprocated. The irritation was augmented by a faint touch of nausea that Fletch knew he couldn’t blame on the odd beer or two he’d had with a mate the night before. He knew what the cause was likely to be and he headed for the men’s toilet with a decisive stride as soon as Dave signalled the timetable break.
The small pouch fitted into the back pocket of his jeans as neatly as a wallet. Fletch unzipped the pouch and removed the contents. He was so focused on his task that it wasn’t until the door swung open behind him that Fletch realised his mistake.
‘Damn!’ The drop of blood fell from the end of his finger and splattered the side of the ceramic handbasin.
‘Fletch!’ Ross Turnball sounded shocked. ‘What are you doing, mate?’ He stepped closer. ‘Oh…I had no idea.’
Fletch had a new drop of blood on his finger now. He touched the end of the test strip to the drop and watched the blood travel up the central line. The beep signified that the device had started its measurement. The result was only thirty seconds away. Fletch rinsed his finger, still cursing inwardly that he’d forgotten to shut himself into the privacy of a cubicle.
‘It’s not something I advertise,’ he told Ross curtly.
‘Are you insulin dependent?’
‘No.’ Fletch smiled wryly. ‘Quite the opposite.’
Ross raised an eyebrow. ‘That sounds unusual.’
Fletch pulled the test strip from the device and threw it away. ‘Four point one,’ he murmured. ‘I just need a bit of morning tea.’ He glanced at Ross as he packed away his kit. ‘It’s a long story,’ he said casually. ‘Remind me to bore you with it some time.’
Low blood sugar was not the culprit as far as Fletch’s mood was concerned. Maybe it was being close to Kelly that was disturbing his equilibrium after all. With a cup of coffee in one hand and two biscuits in the other, Fletch moved away from the class group. He found a seat around the side of the building that had the advantage of being in full sunshine, but the pleasant solitary respite didn’t last long.
‘OK, I’m dead curious.’ Ross sat down beside Fletch. ‘You can tell me it’s none of my business but my professional instincts are making me nosy. How long have you been a diabetic?’
‘Two years.’
‘And you get hypoglycaemic even though you don’t take insulin?’
‘Not too often these days, fortunately,’ Fletch responded. ‘I still need to keep a close eye on my levels, though, especially if I’m not well or under stress or miss a meal or something.’ He bit into a biscuit. ‘I just don’t usually make it public.’
Ross nodded. He sipped his own coffee before breaking a thoughtful silence. ‘How were you diagnosed?’
‘Hypoglycaemic crisis,’ Fletch said quietly. ‘Rather a dramatic one, apparently. A taxi driver left me in the middle of the road. Someone called an ambulance and said I was so drunk I was a danger to myself. I was having a grand mal seizure by the time I got delivered to the emergency department and went into a coma after that.’
‘Good grief! Sounds like a major crisis.’ Ross stared at his companion. ‘Did you have some kind of insulin-secreting tumour?’
Fletch looked impressed. ‘You’re more clued up that my doctors were. I was in the intensive care unit for three days before they came up with a definitive diagnosis.’
Ross was nodding. ‘An insulin-secreting islet cell carcinoma. Not malignant, I guess, or you wouldn’t be looking like you do now two years down the track.’
‘No. I’d be dead,’ Fletch agreed. He grinned. ‘Never a good look.’ His smile faded. ‘Waiting to find out whether it was malignant or not wasn’t much of a joke.’
‘I’ll bet it wasn’t.’
‘It was a rough ride all round, actually. I had a partial pancreatectomy. When I got through the complications of pancreatitis and amazed the specialists by surviving, it was decided that my prognosis wasn’t so bad after all. I was in hospital for ten weeks altogether and I came out looking like I’d spent time in a concentration camp. It was another three months before I was back at work.’
Ross shook his head. ‘Amazing story, Fletch.’
‘Not one that I want spread around, mate. I don’t let it interfere with my life but some people would be inclined to regard it as an obstacle to a reliable performance.’
Ross nodded briefly. ‘Nobody will hear anything from me.’ He gave Fletch a curious glance. ‘This wouldn’t have anything to do with the hint of an atmosphere I detected between you and Kelly the other night, would it?’
‘You could say that.’ Fletch’s tone was grim. ‘We were an item…briefly. When she found out how sick I was she decided she didn’t want to deal with it. She left a message with my flatmate to say she wasn’t hanging around. I came out of my coma to find I’d been dumped.’
Ross whistled silently. ‘Hard to believe anyone could be that callous.’
Fletch’s snort was derisive. ‘One way to test a relationship, I guess. I reckon she did me a favour in the long run.’
‘I’ll bet it didn’t feel like it at the time.’
‘It was a fair kick in the pants,’ Fletch agreed lightly. ‘Along with the glimpse of my own mortality, it made me sort out my priorities. I concentrated on getting fit and then took a good look at my career. I’d been cruising for too long. Having fun and not taking anything too seriously. That had a big shake-up.’
‘No more wine, women and wild parties, then?’
‘Wasn’t difficult.’ The lopsided smile was a little poignant. ‘Kelly cured me of trusting women and I got
too involved in post-grad studies to have time for any parties—not that they were that wild, anyway. I got my consultancy last year and I have big plans for where the emergency department is heading. Disaster management strategy and this USAR stuff is just my latest hobby.’ Fletch stood up. ‘Speaking of which, we’d better head back inside, mate, before we start any rumours.’
The subject matter had made it an easy day for Kelly. If only she didn’t have the background worry about what was happening at home right now, it would have been a very enjoyable day. There had been no answer to her phone call at lunchtime. How long could it take to visit someone and tell them face to face that there was no going back? That decisions had been made and would not be changed. Face-to-face meetings were dangerous, Kelly knew that. But maybe her mother was right in saying that such a confrontation was essential for closure. Maybe it was the fact that she hadn’t been brave enough to do it herself that had left this uncomfortable impression that there was unfinished business between herself and Neil Fletcher.
Not that Fletch seemed bothered. If it had been an easy day for Kelly, it must have been downright boring for the emergency medicine specialist. The session he had taken on shock had been excellent. Unfortunately, Kelly had been distracted from using the tutor’s expertise to advance her own knowledge. The excuse to observe Fletch for such a long period of time had been irresistible and it was the first time she had allowed her gaze to remain on the man for more than a second or two.
Two years had left their mark. Fletch looked thinner. The brown hair was worn a little shorter these days and were those highlights still sun-streaked blond or had some grey crept into those soft waves? Kelly’s fingers actually tingled as the memory surfaced of just how soft those waves were.
‘So. We’ve defined shock as a state of wide-spread inadequate perfusion at a cellular level. What are the things we need for adequate perfusion?’
Kelly glanced away as Fletch looked in her direction. She wasn’t about to contribute any suggestions. She was too busy trying to figure out what the difference in Fletch’s appearance was. It wasn’t anything physical making him seem so unfamiliar. It was something to do with his manner. He was scribbling on a whiteboard now. Perfusion relied on a functioning pump, an intact set of plumbing and an appropriate volume and content of fluid. Fletch was making the physiology lecture very user friendly for non-medical people. Even funny at times.
That was it. That was the difference. Fletch’s humour and his smile had a different quality. It was more restrained and less frequent. Fletch had never been a serious type. The way he had made Kelly laugh had been why she had fallen in love with him in the first place. Virtually the moment they’d first met. Kelly could remember that first meeting as though it had happened yesterday. Fletch had been a new registrar in Emergency and Kelly had come in with a patient at the end of a long, hard day. The patient had been drunk—found comatose under a hedge with two empty rum bottles nearby. His level of consciousness had improved enough for him to become abusive on the way into hospital and Kelly had had enough. Finishing a long day with her least favourite type of case had been enough to noticeably test her professional manner.
‘This man presented with a GCS of eight, hypotension and bradycardia,’ Kelly informed the triage nurse. ‘There is evidence of an ETOH overdose.’
Fletch heard the tail end of Kelly’s handover as he walked past. He glanced at the empty rum bottles now lying on the end of the stretcher. He leaned towards the triage nurse and spoke in a stage whisper.
‘The technical medical term is “totally pissed”.’
Kelly controlled her threatened giggle more effectively than the triage nurse.
‘We don’t have any details on the patient other than his surname.’ Kelly took another glance at Fletch who seemed in no hurry to move away. ‘Which appears to be Ikkey.’ She spelt it out.
Fletch looked thoughtful. ‘Icky,’ he repeated. He eyed the evidence of recent vomiting on the stretcher blanket and then winked at Kelly. ‘He is, rather, isn’t he? That’s another technical term I went to med school to learn,’ he added to the nurse beside them.
‘Cubicle three.’ The triage nurse was grinning broadly now. ‘Fletch, he’s all yours. In fact, we’ll make sure you get every icky patient that comes in from now on.’
‘I don’t know,’ Fletch grumbled. ‘Here I am sharing my professional knowledge and what thanks do I get for it?’
The humour rescued Kelly’s day and it was so easy to accept that first invitation for a date with the new registrar. That humour underpinned the whole relationship, in fact. Fletch could make anything funny and yet his jokes often displayed a real sensitivity. They helped to achieve a closeness that Kelly had never had with anyone before. Or since. She loved that sense of humour more than anything about Fletch. Not that he couldn’t be serious when he needed to be. He could turn it off in an instant and look intense and serious. Like he did when dealing with an emergency. Or, in a very different way, when he was about to make love to her.
Oh, help! Kelly had to shut her eyes to stifle that particular jog down memory lane. There was no point going there. Things had changed. Fletch had changed. Maybe he’d grown up finally and the change had made him more trustworthy. No. Kelly clamped that train of thought down as well. Her father had taught her only too well how little credence could be placed on any promises or even intentions of becoming trustworthy when it came to that kind of behaviour. And it wouldn’t make any difference now, anyway. Not with the opinion Fletch now held of her.
Joe’s session on immobilisation techniques had been a lot more fun. The quips about bondage and the good-natured teasing of Wendy and Ross now that their relationship was public had made the time pass swiftly. Wendy, Jessica and Sandy had made a good job of soft tissue injury management and the practical scenario at the end of the day would have been a great way to finish if only their instructors hadn’t put her and Fletch into the same group, where she’d also had Kyle to contend with. Wendy had been coerced into being a patient again. This time she had been a crush injury victim with a slab of concrete on her leg. Cardboard boxes had represented the hazards they had marked and the surrounding debris had been removed, allowing access to their victim.
‘Hi, there, Wendy.’ Fletch shifted a last piece of ‘rubble’. ‘Here we are, finally.’
‘Check her airway,’ Kyle said excitedly. He reached out and Wendy ducked her head instinctively to avoid the physical contact.
Kelly suppressed a sigh. ‘We’ve been talking to her through the wall, Kyle. She’s been answering us. She’s told us she doesn’t have any breathing problems. There’s no sound of respiratory distress and her respirations are normal depth and rate. We can probably assume her airway is patent.’
Tony was supervising their scenario. ‘Airway is patent,’ he told them, ‘but the respiration rate is 30 and shallow. What are you going to do next, Kelly?’
‘Check circulation.’
Kyle reached for Wendy’s wrist. ‘Good radial pulse,’ he said happily.
‘No.’ Tony shook his head. ‘Pulse is weak and thready. Tachycardia of 120.’
‘I’ll do a body sweep.’ Kelly smiled at Wendy’s look of relief as she got in before Kyle to run her hands down each side of their ‘patient’s’ body.
‘No evidence of major haemorrhage,’ Tony confirmed.
‘We’re assessing the general condition as we look at our patient,’ Fletch contributed. ‘Her colour is good and she’s not diaphoretic.’
Tony smiled. ‘Your patient is pale, sweaty and cool to touch.’
‘We want to check for neck tenderness and put a C-collar on if it’s indicated.’
‘No neck pain,’ Tony decided.
‘She’s in shock,’ Kelly said. ‘We need to get an IV line in and start some fluids.’
Wendy gave a convincing groan. ‘My leg hurts,’ she moaned.
‘We need some pain relief on board as well,’ Fletch murmured.
Kyle s
hook his head impatiently. ‘Her leg hurts because she’s got a dirty big bit of concrete on top of it,’ he stated. ‘What we need to do first is get rid of it.’ He made a show of putting real effort into shifting the polystyrene ‘concrete’ slab. ‘Now we can extricate her,’ he announced with satisfaction. ‘Let’s go, team.’
‘No hurry now, Kyle,’ Fletch said dryly. ‘You’ve probably just killed our patient.’
Kyle’s grin faded as it dawned on him that Fletch was being serious.
‘That was a large piece of concrete, Kyle. Fortunately it would have taken more than one person to shift it, which would have given us time to give some prophylactic treatment for a crush injury.’
‘But it was the concrete causing the injury. The sooner it gets shifted the better. It’s hardly likely to kill her.’
‘Actually, it could,’ Kelly told Kyle. ‘We were told in the scenario set-up that Wendy had been trapped like this for more than twenty-four hours. Crushed tissue exudes toxins and when you move the weight the toxins get released into the body. The patient can die very suddenly and very quickly due to a cardiac arrhythmia.’
Kyle’s face tightened angrily and his voice rose. ‘How the hell am I supposed to know something like that?’
‘You’re not,’ Tony said quietly. ‘The lesson here is that no unilateral decisions should be made. Especially by the least medically experienced person on the team.’
Other groups in the classroom had finished their scenario work. Kyle’s angry query had attracted attention and people edged closer to see what was going on with the crush injury scenario.
‘How would you have dealt with this, Kelly?’ Tony queried.
‘I’ve only dealt with one serious crush injury victim before and we worked under a radio link to an emergency department at a major hospital in Melbourne.’ Kelly searched her memory eagerly. ‘We gave a huge fluid loading of four or five litres of saline. We didn’t have some of the drugs indicated so we had to make do with what we had. We gave Ventolin and glucose and insulin and I think it was atropine.’ Kelly frowned. ‘It’s a while ago now.’ She looked directly at Fletch without hesitating. ‘How would you deal with it?’
CONSULTANT IN CRISIS Page 4