by Kate Hardy
Mr Freeman managed a tiny nod.
She took a sample of blood and sent it for urgent haemoglobin, cross-matching and coagulation screen.
‘And now we’re going to take the wet towels and the dressings off so we can assess your burns, clean them and put new dressings on,’ Hayley said. ‘I know it’s going to be uncomfortable, but we’ll be as gentle as we can.’
Between them, Hayley and Sam gently unwrapped the towel and the dressings. The skin on his upper torso and the back of Mr Freeman’s hands and forearms, which had clearly taken the brunt of the injury where he’d tried to shield his face from the flames, was dry and white, with no blisters; there was no capillary refill.
Working to the rule of nines—where you could estimate the body surface area affected by using multiples of nine—they assessed the extent of Peter Freeman’s injuries.
‘Over twenty per cent, full-thickness burns,’ Sam said quietly. ‘He’s going to need surgery.’ Removing the burned skin and tissues would help to prevent infection and allow the wounds to heal.
‘And we need to watch out for shock,’ she said. The cling film dressing would have helped to stop leakage of plasma and blood—but the bigger the burn area, the bigger the likelihood of the patient sustaining hypovolaemic shock. This was where the circulatory system couldn’t provide enough oxygenated blood to the body, so the vital organs were deprived of oxygen. The problem was that the most common signs of shock—pallor, clammy skin, and shallow breathing—were masked by Mr Freeman’s condition and the fact that he was intubated. ‘We need to put CVP line in so we can keep an eye on his blood pressure, I think.’
Sam nodded.
‘Mr Freeman, we need to be able to measure your blood pressure, so I’m going to put a special catheter in your arm to let us do that. Is that OK?’ Hayley asked.
He gave a tiny nod.
She explained the procedure to him and why they needed to do it, and then between them she and Sam inserted a central venous catheter. At least now they’d have an indication of his blood pressure and it would also help them to manage fluid replacement.
‘We might need to do an escharotomy, too,’ Sam said quietly. The burned skin could act like a tourniquet if there was swelling and oedema in the tissues underneath the burn, and cause problems with the circulation; where the chest was concerned, it could also cause problems breathing because the lungs couldn’t expand properly. Putting an incision through the burned skin relieved the pressure and stopped the circulatory problems.
They cleaned the burns, then covered them with a pad and gauze bandage; covering the exposed nerve endings helped to reduce the pain.
‘We’re going to send you through to the burns unit, Mr Freeman,’ Sam said. ‘They’ll be able to keep monitoring you and they’ll be able to check your dressing and make sure there isn’t any infection. You’re going to need to have surgery and skin grafts on your chest and arms, but the surgeon upstairs will talk that through with you.’
Once Mr Freeman had been transferred to the burns unit, they had another patient in with burns, this time to her legs.
Sam introduced them both quickly. ‘Mrs Marchant, we’re going to assess your burns,’ he said, ‘and then we’ll clean them and put dressings on. We’ll talk you through everything we’re doing, but let us know if you’re worried about anything.’
‘I... I’ve never been so scared in my life,’ she said.
Hayley noted the hoarseness of the woman’s voice. Was it because she’d been crying or maybe straining to make her voice heard at the factory, or was it an early sign of problems with smoke inhalation?
‘Mrs Marchant, can I ask you to cough and spit for me?’ she asked, handing their patient a tissue.
Mrs Marchant looked confused, but nodded, and coughed and spat into the tissue that Hayley gave her.
Hayley took a brief look at the sputum and relaxed. There were no signs of soot, which would’ve signalled potentially serious problems, and there was no sign of cyanosis around Mrs Marchant’s mouth. All the same, she said, ‘Just before we look at your burns, I want to double-check your breathing, because if you’ve inhaled smoke it can give you carbon monoxide poisoning.’
‘Like the thing people get if they sleep in a house with a dodgy boiler, or in a tent with one of those disposable barbecue things?’
‘Exactly,’ Hayley said.
Her level of consciousness was fine; although her pulse rate and blood pressure were both raised, that was most probably a reaction to the terrifying event she’d been caught up in. Hayley listened to Mrs Marchant’s chest; everything sounded normal, and her breathing looked normal, too. Mrs Marchant had clearly been crying, so the hoarseness was probably due to that. But, with smoke inhalation and carbon monoxide poisoning, things could change rapidly. She needed a blood sample analysed for carboxyhaemoglobin, to see how serious the carbon monoxide poisoning was. ‘I’m just going to take a small sample of blood for testing,’ she said.
‘I used to hate needles. But they’re like nothing after you’ve been in a fire and don’t think you’re going to get out in time,’ Mrs Marchant said, sounding shaky.
Was that how it had been for Evan? Those last few moments, knowing that he wasn’t going to get out?
She pushed the thought aside.
Not now.
Focus.
‘We’ll assess your burns now,’ she said.
These were deep dermal burns: the skin was dry, cherry red and blotchy, and there were blisters. There was no capillary refill, she noticed.
‘We’d like to check where you can feel things,’ Sam said, ‘so I’d like you to close your eyes for me, Mrs Marchant. I’m going to touch the skin on your legs with a piece of cotton wool, and I’d like you to tell me when you can feel it. Is that OK?’
‘Yes,’ she said, and closed her eyes.
He dabbed the cotton wool lightly against their patient’s skin; Hayley knew that he needed to touch rather than stroke, because a moving sensation was conducted along pain pathways and wouldn’t tell them where she actually felt sensation.
By the time Sam had finished and said that Mrs Marchant could open her eyes again, she looked terrified. ‘I couldn’t feel anything. Does that mean I’m not going to walk again or something?’
‘No,’ Sam reassured her. ‘It means that you have deep dermal burning.’
‘What’s that? Second degree? Third degree?’
‘In between,’ he said. ‘It’s not as serious as full-thickness burns—what we used to call third degree—so you’ll recover without needing surgery. With this sort of burn, it’s common not to be able to feel anything on your skin. It will heal within the next three to eight weeks, but you will be left with some scarring.’
She put a hand to her mouth, and a tear trickled down her cheek. ‘My husband always said my legs were my best feature.’
‘Your husband,’ Hayley said softly, ‘will just be glad you’re alive. He won’t care about the scarring. It’s you that matters.’ And she knew that from bitter, bitter experience. She wouldn’t have cared if Evan had come home with scars. She’d just wanted him home.
* * *
Hayley’s face had no colour in it at all, Sam noticed.
‘Do you need five minutes?’ he asked her quietly.
‘No. I’ll manage. The patients always come first.’
This must be so hard for her, he thought, remembering his own nightmare case. But it was typical of Hayley to put the patients before her own feelings. And maybe keeping busy and keeping her focus on her patients would stop her remembering the worst of the day that Evan had been killed.
They were in the middle of cleaning and dressing Mrs Marchant’s burns, careful not to burst the blisters, when a middle-aged man came into the room. ‘Brenda? Brenda Marchant?’ he asked. ‘The nurse said she was
in here. She said I could come and find her.’
‘Over here,’ Sam called.
The man rushed over to them.
‘Oh—Timmy.’ Mrs Marchant burst into tears, and her husband hugged her fiercely.
‘Oh, God—when I heard it on the news, I thought I’d lost you. I went to the factory and they told me they’d sent you here.’
‘My legs,’ she said. ‘They’re burned. They’re going to be scarred. I’m going to be ugly.’
‘No, you’re not. And I don’t care if you’ve got scars, as long as you’re all right.’
Sam glanced at Hayley and saw a film of tears in her eyes. She’d been in precisely that position last year. And he was pretty sure that she wouldn’t have minded a few scars if her fiancé had at least made it out of the building alive.
‘Sorry, am I getting in the way?’ Mr Marchant asked.
‘You thought you’d lost her. Of course you want to be with her. Give her another hug, and then if you wouldn’t mind sitting to the side, that’s fine,’ Hayley said.
But Sam heard the crack in her voice. You thought you’d lost her.
She’d been there. The difference was, in her case, her worst fears had been confirmed.
Once they’d finished dressing Mrs Marchant’s wounds, explained everything to her husband and sent her out into the department for continued monitoring from the inhalation risk, Sam turned to Hayley. ‘Coffee break. Now.’
‘We haven’t got time,’ she protested.
‘Hydration’s important,’ he said, ‘because this is going to be a long day. We’re taking five minutes to grab a coffee, stick enough cold water in it so we can gulp it straight down, and maybe grab a sandwich.’ He wrinkled his nose. ‘Technically, you’re my superior so I can’t pull rank. But I can still nag. And I’m nagging now.’
‘I’m fine.’
‘You don’t look it,’ he said.
She lifted her chin. ‘I’m fine.’
She was far from fine, he was sure, but maybe now wasn’t the time or place to push it. ‘OK, coffee and food.’
As he’d suggested, they grabbed half a cup of coffee each, poured enough cold water in it so was cool enough to drink straight down, and shared the first pack of sandwiches they could grab from the vending machine.
Their next patient was a man who’d inhaled smoke and fallen unconscious.
‘He was identified by one of his colleagues as Keith Cooper. We’re not sure of his age—mid-forties, perhaps,’ the paramedic said. ‘His chest wall moved normally and symmetrically,’ the paramedic continued, ‘but the cyanosis was obvious so we intubated him and put him on high-flow oxygen. He hasn’t regained consciousness yet.’
‘OK. I’m glad you intubated him before the oedema caused by the inhalation made it impossible. Thanks,’ Sam said.
He took a blood sample for analysis; if it turned out that more than ten per cent of the total haemoglobin was carboxyhaemoglobin, they’d give Keith some protein thromboprophylaxis as well as keeping him on high flow oxygen. If he’d inhaled carbon particles or toxic fumes, there was a risk of tracheobronchitis and pneumonia.
Between them, they checked Keith’s pulse rate, blood pressure and circulation.
‘There’s some singeing of his eyebrows and around his nose,’ Hayley said.
‘We’ve got him on oxygen and a drip, and there’s not much more we can do until he’s conscious again and the blood results are back,’ Sam said. ‘I think we should send him up to the burns unit because he’s going to need mechanical ventilation for a while.’
‘Agreed,’ she said.
They alternated between seeing burns victims and smoke inhalation victims for the rest of the day. Sam kept an eye on Hayley, ready to support her if she had the slightest wobble; but she was completely professional and focused on their patients’ needs. Then again, he hadn’t expected anything else from her. He’d liked her strength and calmness right from the outset, when he’d first seen her helping a middle-aged man with an asthma attack and no inhaler.
While they were between patients, one of the firefighters came in to see them.
‘Haze! I heard you were in here so I’ve sneaked in for thirty seconds to say hello. You doing OK?’ He gave her a one-armed hug, which she returned.
‘Joe! It’s good to see you.’ She frowned. ‘What happened to you?’
‘The building collapsed on us,’ he said. ‘I got caught by a bit of falling debris. Bust my shoulder.’
Sam noticed that she went white again at the firefighter’s words.
Wasn’t that how Evan had been killed—the building had collapsed on him?
‘I’m fine,’ Joe said. ‘Just cross that I didn’t get out of the way in time.’
‘Uh-huh,’ she said.
‘I know you’re busy, and I’ll let you get on, but I had to come in to say a quick hello. Don’t be a stranger, Haze. We’ve missed you.’
‘Give my love to the crew,’ she said.
‘I will. Take care,’ Joe said, and walked out of Resus.
When they’d finally processed all the casualties from the fire and the waiting room had returned to just the normal kind of evening cases, it was time to go home. And Sam made sure he was waiting by Hayley’s locker when she walked into the staffroom.
‘Someone very wise once cornered me when I’d had a really bad day and she made me put one foot in front of the other,’ he said softly.
She just looked at him and said nothing.
Yeah. He knew how that felt. ‘I think,’ he said, ‘that’s the sort of day you’ve had. So I’m taking you back to my place and cooking you dinner. Nothing fancy. Whatever I’ve got in the fridge, which could be anything from cheese on toast to pasta and pesto.’
She shook her head. ‘I’m not hungry.’
And he knew that tone, too. Where you’d reached the bottom and you had nothing left to give. When you needed someone to take the burden of thinking from you.
‘I don’t care if you’re not hungry. You need to eat. Get your stuff.’
Dully, she took her things from her locker. She let him put his arm round her and shepherd her out of the hospital.
‘What about your bike?’ she said when they went out of the hospital gates.
‘It can stay here overnight and I’ll walk in tomorrow,’ Sam said. ‘It’s not a problem. Come on. We’re going home.’
CHAPTER NINE
SAM TOOK HAYLEY back to his flat. Just as she’d done for him on the day when Pauline Jacobs had had a silent heart attack in the department, he simply got her to do a simple task to take her mind off things; he asked her to lay the table in his kitchen while he made them both an omelette.
‘There’s water in the fridge,’ he said, ‘and there’s a bag of salad, a box of baby plum tomatoes and some dressing. You know where the crockery and cutlery are.’
She busied herself putting the salad in a bowl and pouring them both some water; by the time she was done, he was ready to serve up.
She picked at her omelette, and ate about half of it.
‘I’m sorry,’ she said. ‘You’ve gone to all this trouble, and I...’
A single tear spilled down her cheek and she lapsed into silence, as if all the pain inside had grown so much that it blocked her words from coming out.
Sam knew what that felt like. When everything seemed hopeless and you were choking with misery. So he pushed his chair back, went round to her side of the table, scooped her out of her chair then sat down in her place and settled her on his lap. He held her close, stroking her hair. ‘It’s OK, Hayley. It was only an omelette—nothing fancy. It doesn’t matter that you didn’t finish it. You ate something, that’s the main thing.’
‘I just...’
Her shoulders heaved, and finally she
began to sob.
He held her until she was all cried out, then reached across the table for a glass of water. She sipped it gratefully.
‘Talk to me,’ he said. ‘Don’t let it all stay in your head and your heart, where it’ll destroy you. Let it out. Tell me.’
‘The clothing factory fire.’ She dragged in a breath. ‘It just brought the day of the workshop fire straight back. Especially as it was Evan’s crew dealing with it.’ She gulped. ‘His friends—my friends—I’ve been avoiding them because it’s too hard seeing them without him. Today was the first time I’d seen any of them since the funeral. Joe was so nice about it. And I hate myself for being so selfish and pathetic. For being such a coward.’
‘You’re not selfish, pathetic or a coward,’ he reassured her. ‘It’s completely understandable. It’s hard to face people when you’ve lost someone.’
‘If it had been the other way round, if I’d been the one who was killed, Evan wouldn’t have avoided the social stuff, the way I have. He would’ve still come to the ward’s Christmas party and the summer barbecue. I just...’ She shook her head. ‘Today brought back all the bad memories and I hate that I had to push myself through it. This is my job. I ought to be able to deal with major incidents—just as you have to face treating patients with heart attacks. I know we can’t save everyone; but the next time you get a case similar to someone you lost, you’re supposed to try and put it out of your head and just get on with it and help people—because that’s what doctors do.’
‘That’s exactly what you did today. You got on with it and helped people.’ He stroked her hair. ‘I’m guessing this is the first big fire the department has dealt with since Evan died?’
‘Yes.’
‘It’s really hard, having to repeat the worst day of your life.’
‘And then you have to pull yourself together afterwards. You’ve got people asking you all the time if you’re all right, and you know you’re supposed to say yes even when the real answer’s no, because it’s the polite thing to do. Plus, if you admit how bad things are, people will start going silent when you walk into the room, because they simply don’t know what to say to you. The next thing you know, you’re the subject of the hospital grapevine, with everyone talking about you and suddenly changing the conversation and looking guilty when you walk over.’
