A Doctor's Christmas Family

by Meredith Webber

  ‘So, who’s in the hospital now?’ Esther asked, realising how little she knew about the logistics of the aftermath of the cyclone.

  ‘We kept most of the people in the geriatric ward. A lot of them are semi-permanent residents awaiting beds in nursing homes. We decided it would be too traumatic to move them. Apart from them, we’ve mainly dengue fever patients, and a number of post-cyclone emergency admissions, accidental injuries. We’re still seeing people from outlying, less affected areas as outpatients and A and E cases, so a few new admissions from them. In reality, the hospital is working at about a quarter capacity, perhaps less. It would have been a breeze, except for the dengue…’

  He didn’t need to spell it out. The moment the first dengue case had been confirmed, Bill would have led the fight against it.

  ‘You jumped right in,’ Esther finished for him, as they pulled into what must be a staff car park outside the hospital. Shredded strips of shadecloth showed where wide sails must once have offered the cars some protection from the tropical sun, and from the number of cars around, the place must be bigger than it looked. Though it was past dusk, the area was brightly lit, and from above, Esther thought, it must look like an oasis in the darkness.

  ‘I’d have been doing hands-on doctoring even without the dengue,’ Bill told her. ‘Because there were no essential services—no power, water, sewerage works—after Hugo, the civilian authorities used the army to evacuate everyone who wasn’t needed either to keep basic services going or for restoration work. Most of the women with children were pleased to go, and elderly people, because they’d be the most vulnerable should gastro and waterborne diseases like giardiasis break out, were also encouraged to leave.’

  ‘Women and children first? Yet Gwyneth and your daughter are still here? And Mallory, too, you said?

  Bill stopped and turned towards her.

  ‘If I’d known we were going to have an outbreak of dengue, I’d have insisted they go, no matter what argument Ma put up, but by the time we realised what it was and that it was serious, the evacuation was complete.’

  ‘So they stayed.’

  Bill nodded, then he smiled at the memory he was about to share.

  ‘Can you imagine even the army being able to shift my mother if she didn’t want to leave? And it wasn’t as if we had family anywhere in Australia who could take her in if she did agree to go! She told the young lieutenant who came to the building that she’d obeyed all the pre-cyclone instructions, she had a torch, radio and plenty of batteries, a gas hot-plate and gas bottle, enough tinned and dried food for a month if shops didn’t reopen. She had enough water for six weeks and, no, she wasn’t going anywhere. She made some slight miscalculations with diapers and formula but didn’t tell him that. What she finished with was that her son was staying to do an essential job and she and Chloe were staying right with him.’

  ‘And the lieutenant didn’t argue?’ Esther said, though she could imagine most people backing down before the force of Gwyneth’s personality.

  ‘He did for a little while,’ Bill replied, ‘then she pulled the citizenship card. She was a US citizen and if the President told her to go she would, but as she didn’t come under the jurisdiction of the Australian government, or their army, she was staying.’

  ‘I doubt that’s quite true,’ Esther said, and Bill chuckled.

  ‘Entirely untrue I would think, but the lieutenant knew when he was beaten.’

  The laugh had lightened a little of the tiredness in Bill’s face, and reminded her of how easily they’d once laughed together—often over his mother, whose antics were the cause of their amusement now.

  ‘She casts a powerful shadow on those around her.’ Esther hadn’t realised she’d spoken the thought aloud until Bill shrugged and moved on, changing the subject back to where it had been before the ‘Gwyneth’ diversion.

  ‘In the evacuation, they also took all those whose houses had been totally destroyed. If you didn’t have a roof over your head, whether you liked it or not, you went.’

  ‘Even doctors and nurses?’

  Esther was now trotting beside him as he strode towards the hospital.

  ‘In the beginning, immediately following the cyclone, every medical person in the city was involved in the immediate disaster relief, caring for the injured, helping search the wreckage of buildings for people who were missing. It was full-on, twenty-four hours-a-day relief work.’

  ‘Terrible,’ Esther murmured, remembering the aftermath of an earthquake she’d once experienced when she’d been called in to help when disease had broken out among the survivors.

  ‘But after the initial emergency work, the evacuation began. With so many evacuees gone, and the worst of those injured in the cyclone flown out to larger hospitals down south, we didn’t anticipate a run on hospital beds so, yes, if doctors and nurses had lost their homes, and couldn’t find alternative accommodation, they were shipped out. We kept enough staff to run the reduced capacity of the hospital.’

  ‘But that capacity’s now increased so even if they did go, couldn’t some be brought back now, when you need help with this viral outbreak?’

  Bill halted inside the foyer, where air-conditioning brought blessed relief from the heat and humidity outside.

  ‘The accommodation problem remains, and the first priority for accommodation in the town are plumbers and electricians to get services working again, then builders and other tradespeople, who can get houses and apartment blocks habitable. Some other workers were allowed to stay, those in government offices, insurance workers, shop assistants to keep one shopping centre open—those services were considered essential. The hospital is more than adequately staffed. These new patients are different.’

  He frowned down at his shoes for a while, as if puzzled by whom they belonged to, then raised his head and met Esther’s enquiring eyes.

  ‘Anyway, I’m trying to manage the cases with as few staff as possible.’

  Esther heard the words but the implication of them was so horrific she could barely bring herself to voice it.

  ‘You think this might be something other than an arbovirus? You think it might be passed on by contact with a contaminated person or, worse, airborne?’

  The horrified whisper hung in the air for a moment, then she shook her head, certain Bill must be wrong.

  ‘But we’ve never had something like that in Australia. Not even close.’

  She didn’t say it, but the ‘something like that’ in her mind were the haemorrhagic fevers Ebola, Lassa and Marburg, potentially the most deadly triumvirate of diseases on the planet.

  ‘Not really,’ he said, nodding to the woman in the glassed-in reception desk who’d earlier directed Esther to his building. ‘I’m sure it’s a form of dengue. We’ve grown it in cultures and it’s tested as dengue on an IgM ELISA test.’

  Esther nodded, understanding he wasn’t talking about a woman called Elisa but an enzyme-linked immuno-sorbet assay. Different types of ELISA were available, each specific for the disease it was used to test.

  ‘And we know dengue’s carried by mosquitoes—so it’s arboviral. It’s just a form we haven’t seen before.’

  ‘In what way?’

  Esther had caught up with him at the bank of elevators, none of which, in the mysterious way of hospitals, was on the ground floor.

  ‘It proceeds rapidly, though not invariably, to a haemorrhagic fever, which is always possible with dengue but not common enough for haemorrhaging to be listed as a symptom of the basic disease. The patients we lost had all developed the next stage, dengue haemorrhagic fever, DHF, bleeding from IV sites and suffering internal bleeding as well. The first patient died of renal failure, but all the organs were shutting down.’

  ‘So it’s behaving more like the bad haemorrhagic fevers than any of the four common forms of dengue.’

  ‘Exactly!’ Bill told her, as he led her into the elevator and pressed buttons. ‘Most of the patients are in a ward on the sixth floor. I’
ve had one of the scrub rooms set up with stacks of protective clothing, and anyone going in has to wear a gown and overshoes. If they’re going to be in direct contact with a patient, then it’s gloves and a mask as well. The used clothing is taken off in another room across the hall and dumped into bins to be disinfected then destroyed. I’m also encouraging all staff to shower before returning to their homes.’

  ‘Do all the staff understand this?’ Esther asked. ‘I mean the aides, and the catering and cleaning staff?’

  ‘They should do,’ Bill said grimly. ‘I keep hammering it into all of them.’

  They stepped out onto what Esther assumed was the sixth floor. For a large hospital, it was very quiet, giving the place an eerie, unnatural feel. They passed through a swing door that shut behind them. In an anteroom off the corridor, they pulled on protective garments, virtually covering their bodies with disposable cloth.

  ‘The room opposite is the disposal room,’ Bill said. ‘Just drop all your gear into the bins in there when you come out. There’s a shower in there as well, and, of course, both the doctors’ and the nurses’ common rooms have showers.’

  Once dressed, they pushed through a second door, which brought them into a modern ward—nursing station, complete with nurse smiling radiantly at Bill, directly in front of them, doors open on either side revealing four-and two-bed patient rooms.

  ‘As I said, most of the cases are here but I’ve four patients in the ICU.’

  ‘And where’s that?’ Esther asked.

  ‘Two floors down.’

  ‘And you’re short-staffed, and the acting medical superintendent, which must mean even with the hospital only partially operational, there’s still paperwork and admin duties, and on top of that you’re dashing between two different floors to see your patients?’

  ‘I can hardly put mildly ill patients into the ICU,’ Bill snapped at her. ‘I haven’t been here long, but I know the cost of running that unit is enormous. You have to look at per-person-per-day costs, Esther. Have you any idea what it costs to keep a patient in ICU? The idea of putting a less than critical patient in there is ridiculous.’

  ‘No, I’ve no idea of the costs but is it so ridiculous? Just in case this is a new strain that spreads in other ways, it would provide you with properly manageable isolation as well as saving you, personally, a lot of time and energy,’ Esther argued, ignoring the look of horror on the nurse’s face. The woman obviously wasn’t used to seeing a hospital boss told what to do—even an acting hospital boss. ‘This is a modern hospital. The ICU would have high-tech air filters and air-pressure systems built into its structure. It would make an ideal isolation unit. That’s the first thing we need to do—shift these people down there.’

  ‘That’s overkill, surely,’ Bill argued. ‘There’s no need for strict isolation with dengue.’

  ‘Would you let any of your ambulatory patients walk down to the canteen, say? Or wander into other wards?’

  ‘No, I wouldn’t, but that’s only because we’ve never seen this strain before and we don’t know if it might have different transmission properties.’

  ‘Exactly!’ Esther said, though she wasn’t sure she’d won the battle. ‘In fact, before I came up, my boss was talking to me about this. His view is that though, as we all know, the virus needs an incubation period of eight to ten days inside the mosquito, so person-to-person contamination, even through blood, seems unlikely, the course of this disease is so devastating and its spread’s been so rapid, it could be a variant which, at the haemorrhagic stage, could be transmitted like other haemorrhagic fevers through the blood.’

  ‘Putting into words my deepest, darkest fears, Esther?’ Bill said, nodding his head and looking more worried than ever. ‘That likelihood has been rattling around in my head for days. I’ve even emailed the CDC about it, asking for someone to trawl through all the information for even a suspicion that dengue might have been transmitted this way in the past.’

  ‘So, we’ll put them all into the ICU and run the place as an isolation ward? Go further than gowns, masks and gloves—use total barrier nursing? Double gloves and goggles as well?’

  He was calmer now and didn’t seem perturbed that she was, well, nagging really—but, then, Bill had always listened to other people’s opinions. The fact that he usually went right ahead doing things his way was neither here nor there.

  Though not this time, Esther decided.

  ‘The costs of using the ICU are still prohibitive,’ he said, as if to prove her thoughts correct.

  ‘Do the costs matter if we want to make absolutely certain we contain it?’ Esther asked. ‘And the costs needn’t be that bad. We’re not going to be using it as an ICU for most of the patients. We can put two to a room with the less ill ones, and use the same staff you’re using here to work with them. For most of the patients we won’t need all the gadgets, or the staff to monitor them. Doesn’t it make sense? You asked for help and you got it—me—so you’d better start listening, Bill Jackson.’

  The nurse’s jaw dropped, but Esther guessed Bill was just gearing up for this argument.

  ‘We are containing it within this ward,’ he said, lifting his argument from her first sentence and ignoring the common sense of the rest of her suggestion.

  ‘And running yourself ragged doing it,’ Esther reminded him. ‘And are you sure you can contain it here? Are your budgetary considerations more important than people’s lives? Than allowing this disease to spread further? Even if it isn’t transmitted through blood at some stage—which we don’t yet know—look through that ward. Open windows. I know it’s better for patients to have fresh air rather than breathing air-conditioned air all the time, but if one mosquito makes its way up here, then out again to bite someone on the street, you’ll have a disease spreading beyond whatever known confines you now have.’

  ‘Mosquitoes don’t fly in through sixth-floor windows. And you’re exaggerating.’

  Esther heard the same tired scorn he’d used in the word ‘women’ earlier, but a little scorn wasn’t going to stop her.

  ‘You once told me you have to exaggerate an epidemic,’ she said quietly. ‘Otherwise people don’t listen.’

  He moved away from the desk and spoke again, not so much defending himself as explaining things to her.

  ‘It’s more than a financial consideration. This is a middle-sized regional hospital, not a big city concern. The ICU has ten beds—that’s it. And if we take it over for these patients, where will we put patients who need intensive care?’

  ‘You told me most of the inhabitants of Jamestown have been evacuated. The majority of the people left here are fit young men doing clean-up work and personnel—and the army always brings its own hospital. Who’s going to need ten beds in an ICU?’

  ‘Fit young men can have accidents doing clean-up work,’ Bill argued. Damn it all, Esther should realise this wasn’t really ‘his’ hospital—he couldn’t just reorganise the whole place. They’d been in each other’s company less than an hour and already they were arguing.

  He pressed his fingers to the throbbing ache in his temple and frowned at the woman exacerbating his problems.

  ‘If that happens you can pop them into the CCU,’ Esther told him. ‘A hospital this size would have one, and coronary care units have all the same gear as an ICU. They just don’t have such sophisticated air systems.’

  She was right, he realised, then he cursed himself for not thinking of it earlier. He didn’t do enough hospital work to be able to think laterally in this environment, and, with the dengue outbreak hot on the heels of the cyclone emergency with its injuries and deaths, he’d barely had time to do more than react to the next crisis.

  But once he’d given in to Esther on this issue, she’d be demanding more and more.

  Not that it mattered, if her measures stopped the epidemic…

  ‘We’ll take a look at this new patient then I’ll run it by the CEO,’ he said, but, rather than looking pleased with his agree
ment, Esther was frowning again.

  ‘Of course, there are admin problems to consider. I’m sorry,’ she said, backing down far faster than he could believe. ‘You’ve been handling all of this on your own and you’re obviously exhausted, then I barge in here and start telling you what to do.’

  Esther apologising when she should be crowing over her victory?

  This was an Esther he wasn’t sure he knew.

  Though certain parts of him were in no doubt as to who she was…

  Heartbreakingly familiar…

  Oh, no, he wasn’t going there again!

  He turned away from her, partly to talk to the nurse at the desk but mainly to give his brain and body a break. If he wasn’t looking at Esther, maybe he wouldn’t be so confused.

  Through the open door of the first room Esther could see a patient, lying still and shrunken on the bed. Haemorrhagic fevers caused capillaries to break down and blood loss seemed to empty the body of form as well as life.

  ‘How are you treating them?’ Esther asked, seeing another man, similarly flat-looking, in the second bed of the four-bed room.

  Bill was turned away from her, apparently studying something the nurse had given him, and he replied without looking at her.

  ‘All I can do is treat the symptoms. Fluid replacement, bathing the rash for people who have developed one, pain relief. That’s a problem, as normal analgesics like aspirin which would work to reduce the temperature as well as relieve the pain also act as blood-thinners and we’re trying to get the blood to clot, not become thinner. We’re using acetaminophen to control fever and help with the pain.’

  ‘But the pain’s terrible with dengue—wasn’t it called breakbone fever in the old days?’

  Bill nodded.

  ‘Unfortunately it is, pains in the back and joints especially. But with liver problems associated with acetaminophen—and likely liver involvement if the dengue proceeds to DFHS—we have to be very careful with the dosage. With patients well enough to drink, I’m using oral fluids to help prevent dehydration. More severe cases need IV infusions for the fluid replacement, but blood oozes from the IV sites so we’re always losing some of what we replace.’