Clarke used an off-white handkerchief to wipe the sweat from his brow. As he approached the doctor, the Major reflected that he was getting too old for all this nonsense. It wasn’t so much working in the ER — this was effectively what he did for a living back in the United Kingdom after all — it was more about the heat and the stress of working with a new team almost every week. At least back in Derby Infirmary the air conditioning worked, and he knew all the people who worked in his department, having worked with many of them for years. The teams might change over time, but the core of senior doctors and nurses remained essentially the same which meant that they worked together well. Clarke knew very well that this wasn’t the case here, and that tensions between some of the staff were barely below the surface, ready to erupt seemingly over nothing.
Clarke nodded at Webb, who nodded back with a grunt. Clarke saw this as progress of sorts, thinking that this was the most interaction the two of them had had since coming on shift a couple of hours ago. If they were back home, the chances are that the two of them would go for a pint after a shift one evening, talk about football or rugby or something, and just get on with it. Then, over time, they’d build up a good working relationship, and maybe one day in the future even pass for friends. There’d been no time for that, though. They were in it together whether they liked it or not.
Clarke left the doctor where he was and walked across the room to stand next to the nurse who had been assigned the role of scribe for the incoming casualty. This was the best place to put more junior personnel, as they didn’t have to do anything other than write on the large A2 sized resuscitation chart on the dais in front of them. If they kept their eyes open and their wits about them, they couldn’t go wrong, and it got them used to the whole dance of a trauma resuscitation before they had to put their shoes on and go dancing for real. He knew that this particular nurse, Corporal Emma Wardle, was one of the most nervous nurses he’d worked with in the twenty or so years he’d been working in hospitals. She was also stunning, with fine blonde hair cut into a bob and the most kissable lips that Clarke had seen in years.
‘Are you okay?’ Clarke asked Wardle in a whisper, leaning in towards her so that he wouldn’t be overheard. ‘You look a bit nervous.’ He was being a bit too informal with her for two reasons; one was to try to relax her and not stress her out even more than she was already, and the second was the fact that she even looked good in combats. In Clarke’s opinion, that took some doing, although he knew from experience that the bar got lower the longer he was away from home.
‘Oh hello, sir,’ she replied. ‘I’m doing okay.’ Wardle looked at Clarke, and he could see that she was trying to smile. She wiped her hands on her scrubs and Clarke wondered if her palms were sticky from the heat, or nervousness. ‘I think,’ she added.
‘Listen, Corporal Wardle,’ Clarke said. ‘There’s plenty of time before the casualty gets here, so why don’t you go and get a cold drink, hydrate yourself a bit. Just take a minute or so.’
‘Are you sure, sir?’ Wardle said. ‘I mean, I’m scribe so I need to be here, don’t I?’
‘Who’s in charge?’ Clarke smiled. ‘Go on mate, go and take a minute to relax, or gather, or whatever it is you need to do. You’ll hear the helicopter landing anyway, and if you’re not here, then I’ll get started on the chart for you.’
‘Oh, thanks sir. I’ll just, er, nip to the bathroom then.’ She smiled at Clarke, letting out a deep breath. ‘I’ll only be a sec.’
Clarke watched Corporal Wardle walk across the ER to the main corridor, as did Webb who was still standing by the door. With a resigned sigh, Clarke mumbled to himself under his breath.
‘If only.’ He knew he could be a lecherous old bugger at times, but at least he was one with realistic expectations.
A few short moments later, everyone in the ER fell silent as they heard the thudding of rotor blades in the distance, getting louder and louder with every second.
5
In the back of the helicopter, Thomas wasn’t doing very well. The air that had been slowly building up in his thoracic cavity had virtually collapsed his right lung, and it was starting to compress his heart. Inside Thomas's chest, things were starting to get very serious indeed.
Adams didn’t know this just yet, but he had noticed Colonel Nick giving up on trying to listen to any breath sounds with his stethoscope. Every one of Adams’s instincts was telling him that something was wrong, very wrong, but he couldn’t work out what. Being thrown around in the back of a helicopter as the pilot flew low and fast to avoid any ground fire wasn’t conducive to concentrating anyway.
Glancing at the screen of the monitor, Adams ran through Thomas's vital signs in his head. The airway was okay, and there was a Guedel airway that Adams had put in just to be on the safe side. There was plenty of oxygen in the rebreather bag on Thomas's face, but the oxygen saturations on the monitor were still only sitting in the low eighties and falling. According to the blue blood pressure cuff, his blood pressure was way too low, and Thomas's pulse was racing at over one hundred and twenty beats per minute. Staring at the screen again, Adams ran through Thomas's vital signs another time, trying to work out what was going on.
Adams didn’t need to count Thomas's breaths to see that his respiration rate was very high, but that wasn’t the only thing that wasn’t right. He grabbed the wounded man’s shoulders, causing Colonel Nick to look up sharply, but all Adams was doing was making sure that Thomas was flat on the stretcher and that he wasn’t leaning to one side. If Thomas was flat on the stretcher — and he was now — then one side of his chest wasn’t moving in the same way as the other one. If anything, Adams wasn’t sure the right side of his casualty’s chest was moving at all, but the vibration from the helicopter made it difficult to see. Adams put his hand on Thomas's neck, noting as he did so that the veins in the soldier’s neck were pumped up and rigid. As he started trying to find Thomas's windpipe with his fingers, the penny finally dropped.
‘Bollocks,’ Adams muttered. Thomas's windpipe was not in the middle where it was supposed to be, but was pushed across to the left. Adams scrabbled in his medical bag and grabbed a grey cannula and a handful of alcohol wipes.
‘Tension pneumothorax!’ Adams leaned forwards and shouted in the Colonel Nick’s ear, pointing a gloved finger at the screen where Thomas's oxygen saturations had dropped to eighty percent. From the look of surprise on the doctor’s face, Adams wasn’t sure whether he’d noticed or not.
Giving the cannula to Colonel Nick, Adams felt for the top of Thomas's sternum and moved his index finger into the rib space on the right-hand side until he was lined up with the middle of Thomas's collar bone. Counting in his head, he moved down three more rib spaces which put his index finger directly over the gap between Thomas's fifth and sixth ribs. He pushed down hard, hoping to leave a red mark in Thomas's skin for the Colonel to aim at with the cannula, and ripped the packaging open of a couple of swabs so that he could do his best to clean the area on the casualty’s chest.
Colonel Nick ran his fingers over Thomas's neck, confirming what Adams had just told him. How had he not noticed that? It was an almost textbook presentation. The doctor hid his irritation that he was pretty much being told what to do by a more junior member of the team and peeled the paper off the plastic wrapper of the cannula. Adams had scrubbed around the point where the cannula was going to have to go through Thomas's chest wall. The Colonel repeated the same procedure of counting the rib spaces, reaching exactly the same location as Adams had. Holding the cannula like a dart, Colonel Nick pushed the needle straight through the gap in between Thomas's ribs and into what was hopefully the collection of air underneath. It was far too noisy in the back of the Chinook to hear the hiss of escaping air that would tell him he was in the right place, but he could see a blood-stained bubble expand and then burst over the end of the cannula. That was, he thought, good enough for government work.
The doctor glanced at the oxygen saturation trace on t
he monitor, noting with satisfaction that they were starting to creep up slowly. Out of habit, he checked the flow rate on the oxygen cylinder, and the amount of oxygen left in the cylinder, before reaching for the button on the monitor to check Thomas's blood pressure. While the blue cuff was inflating on Thomas's arm, he looked up to see Ronald looking at him. Colonel Nick tapped his watch and raised his eyebrows.
‘What’s our ETA?’ he saw Ronald mouth after pressing the microphone toggle switch. A few seconds later, Ronald held up both hands, fingers and thumbs all extended. Ten minutes. Then he swooped his hand, miming a rapid landing.
‘Get me a chest drain kit ready!’ Colonel Nick shouted in Adams's ear. ‘Pronto.’
‘There’s no time!’ Adams shouted back. ‘We’re only ten minutes out.’
‘He needs a chest drain,’ Colonel Nick replied.
‘They’ll have one prepped in the hospital!’ Adams shouted. ‘There’s no time. We need to get ready for the transfer.’ He held the Colonel’s gaze for a few seconds, and then glanced up at Lizzie who was retrieving an observation chart from the floor under the stretcher. Colonel Nick wasn’t sure if Lizzie had seen the exchange and chosen not to join in, or just not seen anything. Adams was avoiding his eyes as he started to pack up the equipment onto the stretcher ready for the transfer to the land ambulance when they landed.
Ten minutes later, Colonel Nick sat on the hard bench in the back of the battlefield ambulance, holding onto the edge of the seat as it bounced its way across the uneven ground between the helicopter landing site and the hospital. Even though it was only a few hundred yards, there was still no proper road between the two locations. Over the noise of the engine, he could hear the engines of the Chinook behind them start to wind up as it prepared for the short hop back to the main helicopter pan at the other end of the camp. Only the military would locate the helicopters about as far away as possible from the hospital that they were supposed to be serving.
He stared across the ambulance at Adams and wondered for a second what the nurse’s game was. Nick couldn’t believe that he’d refused to set up a chest drain. It only would have taken a couple of minutes to put in, and could have made a big difference to the casualty. Although, he thought as he looked at the screen of the monitor, he didn’t seem to be doing too badly with the needle decompression. Oxygen saturations were about where they should be. That wasn’t the point though, the point was that he — the doctor — had asked for something and then not got what he had asked for.
Adams looked up and their eyes met for a second. Colonel Nick raised his eyebrows slightly, seeing if he could get a reaction from him, but there was nothing. Adams really was a difficult man to read.
‘He looks stable anyway.’ Adams nodded at the monitor. ‘For the moment at least.’ He looked back at Colonel Nick before continuing. ‘Colonel, I know that you’re pissed off with me about the chest drain, but the risks of putting one in mid-flight are really high. It’s not just the environment, it’s everything. The vibration can throw you anywhere, and you have to work entirely by feel because you can’t hear sod all.’
‘Put many chest drains in then, have you?’ Colonel Nick snapped back.
‘That’s not the point,’ Adams sighed. ‘It doesn’t matter how many I have or haven’t put in. I just don’t want to see you fuck up. Not on your first shout anyway.’ There was the hint of a smile playing on Adams's face, which at first irritated the hell out of Colonel Nick, but the more he thought about it, the more he realised that Adams might have a point. ‘He responded well to the needle decompression and was holding his oxygen sats well. Where would you rather put a chest drain in? The back of a Chinook that’s flying tactically, or a stable, well-lit Emergency Room?’
‘We can talk about it later,’ the Colonel said, determined to put a stop to the conversation for the time being. ‘Let’s get him in first, then we can argue the toss.’
‘It’s up to you,’ Adams replied. ‘But at the moment, it’s just the two of us chatting. If we go over it later, then it’ll be in front of the others as part of the hot wash-up. Your call.’
Colonel Nick stared at Adams for a few seconds. The problem was, Adams was right. That didn’t mean he had to like it, but the nurse was offering him an olive branch of sorts.
‘Fine,’ Colonel Nick said after a brief pause.
When he had completed his handover to the hospital personnel, Colonel Nick took a step back to let the Emergency Room personnel get to Thomas and start their dance. The sound level in the ER went up as the staff went to work, each performing a well-rehearsed role. Looking around, he spotted Adams over by the fridge in the corner and walked across to join him, undoing the clips on the front of his combat vest. When Colonel Nick got to the fridge, he grabbed the bottle of water that Adams was holding out for him.
‘Thanks,’ Colonel Nick muttered, still annoyed about the earlier conversation. He took the bottle anyway. Adams had already got rid of his combat vest and body armour and was just in the process of undoing his combat jacket to try to cool down. They were both soaked in sweat and red-faced.
‘Job done,’ Adams said, looking back at the ER staff swarming around their casualty. ‘He should be okay, I would have thought. Lucky chap though — if that round had been an inch or so lower, he’d be freight.’
Adams bent over to retrieve his kit, and the two of them left the ER to go back to the TRT tent where, hopefully, someone would have put the kettle on despite the heat. As they walked back down the main hospital corridor Nick noticed that Adams was carrying his Kevlar helmet.
‘Oh crap,’ Nick said, stopping. ‘I’ve left my bloody helmet back in the helicopter.’
‘Don’t worry Colonel,’ Adams replied as he continued walking. ‘I’m sure that Lizzie or Ronald will have picked it up and shoved it in the back of the wagon for you.’
‘Oh, okay,’ Nick said before cursing to himself under his breath, annoyed that he’d forgotten something so simple as that. He hadn’t thought before blurting out that he’d forgotten it, and if he’d been a bit more switched on then he could have kept quiet and gone down to the pan later to get it back. If one of the others had picked it up though, then it was too late by now anyway.
‘I mean, it could be worse,’ Adams continued. ‘You could have left your gun behind. That’d be a lot more difficult to explain. And besides, it’s not as if anyone’s going to take the piss out you for the next four months or anything like that.’ Nick grimaced. That was exactly what he was afraid of. He glanced across at Adams, who was looking at him with a wry smile.
They reached the TRT tent, and Adams held the canvas flaps that served as a door open for Nick. He mumbled a ‘thank you’ and walked through, throwing his kit down on the floor. He pulled a handkerchief out of his trouser pocket and was wiping the sweat from his forehead when he heard Adams say:
‘Before you get too comfortable Colonel, the first one back makes the tea.’ Nick looked up at Adams.
‘Really?’ he asked.
‘Yep. TRT rules. I’ll have a NATO standard. Lizzie’s a Whoopie Goldberg, and Ronald’s a Julie Andrews if I remember right. Makings are over there.’ Adams pointed towards a small fridge with a kettle on top of it and a piece of paper which described who drank what. A ‘NATO standard’ was white tea with two sugars, ‘Whoopie Goldberg’ was no milk or sugar (or black, none), and a ‘Julie Andrews’ was milk but no sugar (white, none).
‘Very good,’ Nick said as he read the paper and got the nun references. ‘Very good.’
At the other end of the camp, the Chinook was winding down its engines, having landed on the pan after the short hop back from the HLS outside the hospital. Lizzie waited until the whine of the rotor blades had decreased to a reasonable level and took her green plastic military issue ear defenders off with relief. They might do the job in terms of keeping the noise out, she thought, but why on earth did they make them of plastic?
Using the top of her left arm, she wiped the sweat from the
side of her head and then did the same for the other side. Looking across at Ronald, she smiled as she saw that he was doing the same thing.
‘Bugger me, it’s hot,’ she said. ‘And we’re dressed for the bloody Arctic.’ She started to unclip her combat vest so that she could get to the Velcro which held her body armour together. Heavy and inflexible, this was the main culprit in terms of being uncomfortable when it was this hot. Her breasts were aching from being compressed by the heavy armour, and she could feel the sweat rolling down her cleavage. ‘Ronald?’ she asked.
‘You ok, mate?’ he replied.
‘Do your tits get squashed by the body armour like mine do?’ Ronald muffled a laugh and looked across at Lizzie with what looked to her like an expression of anger on his face.
‘Lizzie?’ he responded.
‘What?’
‘Fuck off.’
They both laughed at the same time. Ronald was quite a well-built man, courtesy of what Lizzie considered to be far too much time in the gym. It had been a running joke between them for some time about which of them had the larger chest. Lizzie shrugged herself out of her combat vest and undid the Velcro on her body armour, sighing with relief as the pressure of the armour was relieved. They both walked to the ramp at the back of the helicopter, and she shrugged the body armour off her shoulders, placing it on the rear ramp. It was closely followed by her combat vest and helmet. Ronald, who’d made an identical but much neater pile with his own kit, looked across the HLS towards the Land Rover.
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