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Their Own Little Miracle
by Caroline Anderson
CHAPTER ONE
‘ED TRAUMA CALL, ten minutes.’
Iona’s heart sank. Another one? The previous trauma patient had only just arrived, and they were seriously short-staffed. Andy Gallagher was on holiday, Sam Ryder had gone for lunch five minutes ago at three thirty, they were rushed off their feet and she was virtually on her own because James Slater, the clinical lead, was already up to his eyes in Resus with the trauma patient who’d just arrived, a construction worker with severe crush injuries to his chest who from what she could gather was resisting all attempts to resuscitate him.
Which made her, a brand new registrar, the most senior doctor available, so it wasn’t a surprise when she was called into Resus. James didn’t pause what he was doing. ‘Iona, can you take the trauma call, please? I can’t leave my patient but I’ll be right here, so you can run things by me if you need to.’
‘Sure.’
She went back to her patient, handed her over to the F2 junior doctor she was with, found out as much detail as possible about the incoming casualty, went into Resus and put on a lead apron. Their patient had been hit by a car and had suspected pelvic injuries, which she really hadn’t wanted to hear, so he’d need X-rays to check for fractures. She hoped they wouldn’t be too serious because James was still tied up and looking at him she was fairly sure he would be for some time, because he and his team were now opening the patient’s chest and it wasn’t looking pretty.
Around her a new team was assembling: Tim, an F1 junior doctor fresh out of medical school who was totally out of his depth, Jenny, thankfully a highly competent nurse, Sue, a radiographer she trusted, ready with the portable X-ray and ultrasound, another nurse who she’d worked with in the past and who seemed OK, and a recently qualified health care assistant as the scribe.
Well, she just hoped the patient wasn’t too bad, because as teams went, this one was inadequate on several fronts. Not Sue, though, who was already surrounding the bay with lead screens, and not Jenny. Just her, Tim and the HCA, then. It was a good job James was right beside them, even if he was up to his eyes.
She briefed them quickly on what little she knew, allocated them their positions in the team and made sure they were ready. ‘Right, lead and plastic aprons, please, everyone, and you all know what you’re doing?’ she checked, then it was too late to worry because the patient was being wheeled in and they were given the handover by the paramedics.
‘This is Jim Brown, age fifty-six, hit on his right-hand side by a large van about forty minutes ago, suspected pelvic injury. We put a pelvic binder on and secured his spine at the scene. BP one-twenty over eighty, sats ninety-eight per cent, we’ve given him ten of morphine and started him on saline. No apparent head or chest trauma but he’s complaining of pain in the right wrist so we’ve splinted it.’
The pelvic injury wasn’t good news, but at least his blood pressure was all right so hopefully he could be transferred to Orthopaedics shortly. ‘OK, everybody, can we get these clothes off so I can do a primary survey, please? Sue, we need a FAST scan, and somebody book an urgent CT? Jenny, take bloods, cross match for four units, and we’ll have packed cells and FFP on standby, please. Sue, after the FAST scan I’d like X-rays of C-spine, chest and pelvis. And make a note of the time. Fifteen forty-six.’
The team went into action and she bent over the patient so she was in his line of sight; he was conscious but in obvious pain and distress, and she smiled reassuringly at him. ‘Hello, Jim. My name is Iona, I’m a doctor and I’m going to be looking after you. Can you tell me where it hurts?’
‘All down there—don’t know, it’s all blurred together.’
‘Anything else? Head? Chest?’
‘No, they’re fine. My right wrist hurts, that’s all.’
‘OK.’ She looked up at the monitor to check his blood pressure. One-ten over seventy, slightly down. She’d need to keep a close eye on it. ‘How’s the FAST scan, Sue?’
‘Some free fluid in the abdomen,’ Sue murmured softly. Which was highly suggestive of a pelvic fracture. And his blood pressure had dropped since the paramedics had reported it.
They stepped back briefly so Sue could X-ray his pelvis for confirmation, then Iona shut her mind to everything else and concentrated on Jim. Pupils equal and reactive, airway clear, good bilateral breath sounds, no significant pain when she felt his chest, no obvious bumps on his head, but his right wrist was almost certainly fractured.
And so was his pelvis. The X-ray showed multiple fractures of the pelvic ring, some displaced. No wonder he was bleeding, but hopefully his neck and chest were clear and he still had circulation to both feet. Small mercies, she thought.
‘Right, Jenny, can we start the PRBC and FFP, and can someone page Orthopaedics please? Multiple pelvic fractures. Sue, can you get the neck and chest shots, please.’
‘If he’s got pelvic fractures you need to page IR,’ James said over his shoulder, and she took a breath and nodded. At least he was listening and keeping her on track. She could do this.
‘OK. Can someone page Interventional Radiology as well, please? How about CT, James?’
‘No, wait for IR. They’ll probably take him straight to the IR suite to embolise the damaged arteries.’
If she was lucky...
She was scanning the X-rays when she heard the swish of the door opening and closing behind her. She glanced round to see who it was, and her heart did a funny little hitch. The interventional radiologist? He didn’t look old enough to be a consultant, but he had the firm tread of someone who knew what he was doing. She could only hope—
‘Hi. I’m Joe Baker, IR Specialist Registrar. You’ve got a pelvic fracture for me?’
She met his eyes and her head emptied. Framed by the longest, darkest lashes, they were very pale blue, almost azure, with a dark rim. Utterly gorgeous and curiously penetrating. Mesmerising, in fact...
She gave herself a mental kick and tried to focus. ‘Yes. Hi. I’m Iona Murray, Registrar. This is Jim Brown, fifty-six years old, hit by a car on the right, BP one-twenty over eighty on admission, now...’ her eyes flicked to the monitor, and her heart sank ‘...ninety-five over sixty. Sats were ninety-eight per cent, now ninety-six. FAST scan shows free fluid, X-ray confirms multiple fractures of the pelvic ring. I think the chest and neck are clear but they haven’t been checked by a radiologist.’
He nodded and held out his hand. ‘May I?’ He took the tablet from her, scrolled through the images and frowned. ‘Right, they are clear but the pelvis is a mess and I’ll need to embolise him. Has he had a CT yet?’
‘No. We haven’t had time.’
‘How’s his airway? Any obvious chest trauma or signs of head injury? Cardiac tamponade? Pleural effusion?’
‘No.’
‘Are you leading?’ he asked, and she nodded.
‘Right, I’ll take over from here. Go on.’
; She didn’t know whether to be relieved or furious, because frankly it was a close-run thing. She went for relieved.
‘He’s also got a query fracture of right radius and ulna, but good cap refill and sensation.’
‘OK, that can wait, then, so can the CT. Can you cancel the slot, please, if you’ve booked it, and alert IR?’
Joe reached for his neck, then frowned. ‘Stethoscope?’ he said briskly, holding out his hand, and she lifted her stethoscope over her head and handed it to him reluctantly.
‘You’re dead meat if anything happens to it, it was a graduation present from my sister,’ she muttered darkly, and he rolled his eyes, introduced himself to Jim and checked his chest.
‘OK, his chest’s clear so I’ll take him straight to IR—’
‘BP falling. Sixty-five over forty.’
Jim was crashing. He groaned, and Iona took his hand.
‘It’s OK, Jim, we’re here, we’ve got you,’ she said, squeezing his hand for reassurance. But it was cold and lifeless, clammy now as well, and she felt her pulse spike.
‘Right, can we have the REBOA kit, please, we need to do this now,’ Joe said. ‘And get me an arterial kit before we lose the femoral artery.’
He was going to insert a balloon into his aorta in Resus? Her eyes widened. She’d never seen it done, far less assisted, and she felt a moment of panic.
‘I can page Sam,’ Iona said hopefully. Sam, who was an ex-army medic, had done it dozens of times in the field and would know exactly what to do, but Joe Baker wasn’t waiting.
‘No time. Can I have a pair of scissors? The first thing we need to do is cut a chunk out of the pelvic binder to give me access.’
He cut a slit above the femoral artery on Jim’s left leg and removed a V from the fabric with a deft snip of the scissors. ‘First I’m going to secure access to the CFA so we don’t lose it. I’m going in on the left because the fractures are worse on the right, so this is our best chance,’ he explained, searching for the artery with his gloved fingertips, his hands rock steady. ‘OK, Jim, sharp scratch coming,’ he warned as he inserted the needle, but Jim was beyond noticing.
‘Right, we’re in. Someone open the REBOA pack and cover him in the sterile drapes. Just leave the site accessible, please. Iona, you’re assisting, come and scrub.’
She felt her pulse rate go up another notch. The IR was already scrubbing and she followed him, joining him at the sink. ‘Isn’t it dangerous without imaging?’ she asked under her breath as she scrubbed. ‘You can’t see what’s going on in there. Wouldn’t it be safer in the IR suite?’
He skewered her with those mesmerising eyes, and they’d turned to ice. ‘Are you questioning my clinical competence?’
She held the icy stare with difficulty and shook her head. ‘No, no, not at all! I’m questioning mine. I’ve never assisted with one of these—’
‘Well, here’s your chance, because he won’t make it to IR and if we don’t do this now, we’ll lose him, so I suggest you take a deep breath and get on with it, because frankly he doesn’t have time for this and nor do I. What do you know about a Zone III REBOA?’
She searched her brain, her heart hammering. ‘It stands for Resuscitative Endovascular Balloon Occlusion of the Aorta, and it’s a balloon catheter inserted via the common femoral artery to cut off the blood supply from the aorta below the balloon. Zone III occlusion is below the renal and mesenteric vessels, and it stops the bleeding from the damaged arteries in the pelvis, so it’ll keep his heart and brain alive until you can get him into the IR suite or Theatre and stop the bleeding.’
‘Contraindications?’
‘Chest trauma, cardiac tamponade, pneumothorax, haemothorax, pleural effusion, aortic dissection—’
‘OK, we’ve ruled them out, so what are the dangers?’
‘Damage to the femoral artery or aorta, and reperfusion injury from cutting off the blood supply for too long.’
He nodded. ‘Exactly, so time is of the essence. Right, let’s get on with this.’
She swallowed and sucked in a breath and reached for a paper towel as someone helped him into a sterile gown. ‘What do you want me to do?’
‘Get gowned up.’ He crossed to the bed, snapping on gloves as he went. ‘OK, we’re ready. Let’s go.’ Jim was completely covered with the sterile drapes, leaving just the small area with the cannula sticking out uncovered for access. He glanced at the team as he reached for the REBOA trolley and injected a local around the site of the cannula, then flushed it with heparinised saline and inserted a fine guide wire.
‘Someone phone the IR suite and get them on standby for immediate transfer as soon as I’m done,’ he said as he was working. ‘Tell them I’ll be ten minutes. OK, Iona, watch and learn.’
She watched, and she learned how wrong she’d been to doubt him. His hands were steady and confident, sensitive as he removed the cannula from the guide wire and inserted the large bore introducer with great care. ‘This is the tricky bit,’ he said. ‘You don’t want to tear the artery, and the Twelve French makes a damn great hole, so you have to be subtle. OK, that’s good.’ He pulled out the fine wire and threaded the stiff guide wire in to the mark he’d made by holding it up against Jim’s body. Hence the gowns and extensive drapes, she realised, so he could do that without risk of contamination of the wire.
‘Right, it’s in. Can you hold that steady, please, Iona, I don’t want it to move. Keep an eye on the mark on it. Good. X-ray check, please, around T4.’ He watched the screen, then nodded. ‘OK, that’s good. Then I slide the balloon catheter in over it, up to the mark, which is below the end of the guide wire, and then I inflate—like that, until I feel the resistance change,’ he said, squeezing the syringe steadily to fill the balloon with saline.
‘OK, that should be it. X-ray check here, please,’ he said, indicating the level.
His eyes flicked to the clock, then the monitor, then the X-ray screen, and she saw the tension go out of his shoulders. ‘Good. His BP’s picking up. Time sixteen seventeen. Make sure that’s on the notes, please. Right, secure this lot with a grip-lock dressing so nothing moves, and let’s go. The clock’s ticking and we’ve got an hour, max.’
Moments later the doors swished shut behind them, and as the team dispersed Iona stood there amid the litter of the procedure, staring after them in a mixture of bewilderment and awe.
Had all that only taken thirty-one minutes? It had been the longest half-hour of her life, but Joe Baker seemed to have taken it in his stride, not seeming even slightly fazed by it.
Good luck, or good judgement? Maybe a bit of both, but Jim was still alive and she knew if it hadn’t been for Joe they would have lost him.
It wasn’t going so well for James and his team, though, from what she could hear, and definitely not his patient.
Then she heard James sigh heavily. ‘OK, everyone, I’m calling it. Are we all agreed?’ There was a low murmur, followed by silence. ‘Time of death, sixteen twenty-one. Can somebody cover him, please, but leave everything in place for the post mortem. I’ll go and talk to his family.’
Her eyes flicked to James, and he was stripping off his gloves and gown and coming over to her.
She smiled at him sympathetically. ‘Thanks for your support. I’m sorry about your patient.’
‘Yeah, me, too, but that’s life. You did well, by the way. Are you OK?’
She smiled properly this time, slightly surprised to find that she was, even though she was shaking from head to foot. ‘Yes, I am. He was quite hard on me, but I probably deserved it. I was freaking out a bit, but he made it look so easy.’
James smiled. ‘I’ve heard great things about Joe. He’s only been here a few weeks, but his clinical lead says he’s red hot, and he thinks he’ll go far.’
‘Unlike me. I was like a rabbit in headlights.’
‘No, you weren’
t, you were just faced with a dying patient and no real way of dealing with it, even though you were doing everything right. Sam couldn’t have got here in time, and if Joe hadn’t been here you would have lost him, or I would have had to abandon my patient to save yours. Not that it would have mattered, as it turns out. Sometimes we just can’t save them.’
She swallowed. ‘I know.’ She stripped off her gown and gloves, dumped them in the bin, took off the heavy lead apron and realised her stethoscope, her anchor that reminded her on an hourly basis that she really was a doctor and it wasn’t just a dream, wasn’t there. And Joe had already mislaid his own.
‘Rats. He’s still got my stethoscope.’
‘They’ll have one on the desk. You’ll get it back.’
She smiled grimly. ‘Too right I will. Thanks, James.’
He pushed open the door. ‘You’re welcome. Right, I need to talk to my patient’s family, and you need to talk to yours. Ah, here comes the cavalry. You’ve just missed Iona’s first REBOA, Sam.’
Sam’s eyes widened and he looked at Iona. ‘You did it?’
‘No, of course I didn’t, I just assisted. Joe Baker came down and he was going to take him to IR, but then the patient crashed and it was—he did it, just like that.’
‘Of course he did. That’s all they do in IR, stick things in blood vessels. It’s their job. I should damn well hope he was good at it. Did he talk you through it?’
‘Yes—once he’d lectured me for doubting him.’
Sam laughed. ‘Yeah, that wouldn’t have gone down well.’
‘It didn’t. He got his own back, though. He’s nicked my stethoscope.’
‘The one your sister gave you?’ He chuckled. ‘He’s a brave man. I suggest you go and look for a nice quiet ingrowing toenail until it’s time to go home. That should keep you out of mischief. And don’t worry, you’ll get it back.’
* * *
He still had her stethoscope.
The graduation present from her sister, the one he’d been told in no uncertain terms not to lose or damage. He could see why, it was a really expensive one, although it had to be a few years old now. No wonder she’d been precious about it. His own was only slightly better, and he’d bought it last year because he’d mislaid the one identical to this.
Finding His Wife, Finding a Son Page 17
