by Rebecca Lang
‘Hi,’ Jay said, coming forward to shake her hand. ‘Pleased to meet you, and welcome to the team. I’ll be the circulating nurse for the first case. It’s great to have you with us.’
‘Hi. Good to be here.’
‘If you could just open up the gown pack and put out the gloves, Em,’ Jay said, ‘I’ll do the rest.’
‘Sure.’
The anaesthetist for the room came in then. ‘Hi, girls. How are you?’ he said, tying a disposable face mask over his nose and mouth. He was wearing the usual green scrub suit.
‘Pretty good, thanks,’ Jay said. ‘We have a new nurse, Dr Jarvis. This is Anna Grey…Anna, this is Ray Jarvis.’
They shook hands. He was middle aged, grey-haired, and looked exhausted. ‘Welcome to the team,’ he said. Then he began to check his complex anaesthetic machine, which would administer anaesthetic gases and oxygen to the patient.
‘Come on,’ Emma said to Anna, when she had opened the gown pack and put out latex gloves for them and the surgeons. ‘Let’s go out and get scrubbed. You can meet Dr Ruelle out there.’
The scrub sinks were immediately outside the door to the room, each operating room having its own set of sinks. As they went out, she saw Seth talking to his patient who was on a stretcher near the sinks, and the sight of him made her feel incredibly uptight, as though he would somehow be judging her. She also felt an unwelcome pull of attraction. Unwelcome because she didn’t know how to deal with it. There was an inscrutability about him. Immediately he raised a hand in greeting to them and excused himself from the patient.
‘You know Anna, Dr Ruelle,’ Em said, making her voice sound formal. ‘This is her first day.’
‘Yes,’ he said quietly, holding out a hand, his eyes searching her face—what was visible of it behind the face mask and the soft paper hat that covered every bit of her hair. ‘Congratulations on getting the job, Anna. Quite a coincidence that we should find ourselves here. Welcome, and I hope you enjoy working here.’
‘Thank you,’ she said, taking his hand and looking, briefly, into his astute blue-grey eyes that looked back at her as though he could see into her soul. His hand was warm and firm. Although his words were welcoming, he did not smile. For her part, she hoped that he could not sense how attractive she found him, in spite of her ambivalence towards him. His somewhat cutting words at their first meeting were very prevalent in her mind.
‘And how are you, Emma?’ he said, letting go of Anna’s hand, his tone taking on a lighter note.
‘Very well. We’ll both be scrubbing for you,’ Emma said.
Anna turned away, determined then and there to keep a low profile, if she could, where Seth Ruelle was concerned.
The two nurses started the scrub process, then before long the anaesthetist and Jay came out to wheel the patient into the room. ‘See you in there,’ Seth said to his patient, a middle-aged man, touching him briefly on the shoulder.
Anna already understood, from what she had observed in the last few minutes, that Seth had a good rapport with his patients, that he had empathy and compassion, a good bedside manner, good communication skills. Those were attributes that were not as common as one might imagine, she speculated. People went into medicine for different reasons, she knew that, so it was idealistic to suppose that they all had the human quality of empathy that was so vital. Almost reluctantly she found herself warming to him.
At the same time she felt a sense of dissonance as she heard others refer to him by his name, and instantly had visions of Simon, the other Dr Ruelle, who had been at Gresham General. The frustration of not knowing where he was assailed her again.
Tactfully, Emma went ahead of her into the operating room, leaving her alone with Seth, who had started the scrub process at the sink beside her. Emma had probably sensed that they would like to have a few words with each other.
‘Take your time, Anna,’ Emma said, as she left them.
His presence made her feel gauche somehow, and she wondered what he thought of her, a young woman who had entered into a sexual relationship with a colleague she had known only a short while. Then she had become pregnant in this day and age when it was relatively easy to avoid pregnancy.
There was no way that she could explain it adequately herself, except that they had loved each other, that there had been a rare rapport that she, for one, had never experienced before. Now, subdued by circumstances, she could not always understand her own earlier behaviour. From the perspective of time passing, she could see now that what had seemed extraordinary to her must seem commonplace to an observer…like Seth Ruelle, for instance.
‘Have you,’ he said, looking at her sideways, ‘had any other word from the private detective since I last spoke to you?’
Quickly she glanced at him and away again, feeling unaccountably shy. Perhaps that was because he knew too much about her in some ways, and in other ways not enough.
‘He has called me twice,’ she said, ‘just to tell me that he’s pursuing some leads, and not to get discouraged.’
‘And are you discouraged?’ he asked quietly.
‘I…Well…I do feel somewhat depressed about the whole thing,’ she admitted thoughtfully. ‘And, yes, I think you could say that I feel discouraged—because so much time has elapsed.’
‘Mmm,’ he said.
‘Working with you, another Dr Ruelle,’ she blurted out, ‘makes me feel very…strange, to say the least.’
‘Then you must call me Seth, when we’re out of the actual operating room,’ he said. ‘Seth sounds very different from Simon.’
‘All right. Thank you,’ she said.
Two other young male surgeons joined them at the scrub sinks. Seth introduced them to her as the senior surgical resident-in-training and the surgical intern. That put an end to their conversation.
Then she left him to go into the operating room, to dry her hands on a sterile towel, put on a sterile gown and a pair of sterile latex gloves.
Emma was already making good progress in setting up the instrument tables for the case.
‘What can I do?’ Anna said to her.
‘First, you can help Dr Ruelle put on his gown and gloves,’ Emma said. ‘Then I’ll get you to open some of the suture packets and mount the needles on needle-holders. You can be responsible for those during the operation.’
‘OK,’ Anna said, going over to the gown table to wait for Seth to come in so that she could hand him a towel, then open up the gown.
Seth…Seth…I must think of him as Seth. She repeated the name to herself silently, over and over again. It was the duty of the scrub nurse to hold open the gown for the surgeon so that he could put his arms into the sleeves, then she would hold open each glove so that he could put his hand into it without touching the sterile outside part. She felt reasonably calm now, her knowledge of the familiar routine coming back to her with ease.
It was inevitable, being in an operating room again, that she would think of Simon. Even as she thought that, she could almost hear the cynical voice of Hector Smythe saying, ‘It always does seem natural,’ or words to that effect, when she had spoken of their love seeming right for them.
It had only been later, after Simon had disappeared, that she had been forced to consider their different backgrounds, that he came from a different social background from the one that she had come from, that perhaps he would not wish to marry her for that reason. And she had thought of marriage with him, in all her naïvety, she had to admit that to herself.
‘Thank you, Anna,’ Seth said to her as she dutifully handed him a towel.
Thoughts of Simon disappeared as she found herself very aware of this flesh-and-blood man who stood close beside her, of his broad shoulders, his powerful presence. He seemed to exude a quiet, confident manliness that came naturally to him. It served to make the memory of Simon, who seemed like a wraith then, existing in her imagination only, fade somewhat like an old photograph that had been exposed too much to the light.
‘Let me
tell you something about this patient,’ he said very quietly, ‘so that you can be prepared, Anna, as we may get into a blood-clotting problem with him. I’ve already told Emma about it.’
‘All right.’ Anna nodded.
‘Some years ago he had hepatitis C, which damaged his liver, leading to cirrhosis. That doesn’t show up right away after the acute infection, it takes time to develop. Now he has a cancer of the liver, a primary tumour, which is quite common in people who have cirrhosis. Fortunately, it’s only confined to one lobe, which we can remove. That’s what we’re going to do this morning. A cirrhotic liver is usually very vascular, with engorged veins, so we have one problem there.’
‘I see,’ she said. This was going to be an interesting case.
‘Because the liver has been damaged,’ Seth went on, ‘our patient has problems with blood clotting. That is, it does not clot as efficiently as it should do. I expect you know the detailed physiology of the blood-clotting mechanism?’
‘Something,’ she said. ‘I’ll certainly look it up to refresh my memory when I get home tonight.’
‘I won’t go into all that now. For us, today, the implications are that we have to be prepared for excessive haemorrhage during the operation, even though we’ve given him blood transfusions, with whole blood and blood platelets,’ he said. ‘We may need to renew those during the operation.’
‘I understand,’ she said.
‘Just as well I’m going to have two scrub nurses,’ he said, smiling. ‘We’ll need a lot of sponges, and probably more ties and sutures than usual.’
‘I’ll be ready,’ she said. While nervous, she felt herself gearing up to meet the challenge, and she would have Em with her, who would be the primary scrub nurse.
‘I’m sure you will,’ he said.
When he was gowned and gloved, the other two surgeons came in and she went through the same process with them.
Their patient had a new intravenous line in place, two in all, put there by Dr Jarvis, and when Seth had had a few reassuring words with him he quickly became unconscious as Ray Jarvis injected the anaesthetic drugs into one of the intravenous lines.
They all waited quietly for their patient to be intubated. Then, before too long, the operation was under way, the skin prepped, the patient’s body covered with sterile drapes.
‘We’ve got extra sponges,’ Em said to Anna, in a whisper, ‘because of the possible heavy bleeding. We’d better take that as a given. Maybe you could help me keep track of the sponges, Anna, as well as dealing with the ties and the sutures. OK?’
‘Sure,’ she said. Quickly she began to organise her sutures in the packages in the order that they would be needed.
There were a few seconds of quiet. ‘Are we ready, Emma, Anna?’ Seth said.
‘Ready.’
Seth looked at Emma. ‘Knife, please, Emma,’ he said.
CHAPTER FIVE
ANNA concentrated totally on the job, methodically tearing open small packets of suture material, mounting each needle on a needle-holder in the order in which they would be used.
‘Fortunately for our patient,’ Seth explained, ‘the tumour is relatively small and confined to one lobe of the liver. Just as well, because this cancer is compounded by the severity of the liver damage from the cirrhosis that I was telling you about.’
Anna nodded. Jay had given her a long, flat stool to stand on, which gave her a good view of what was going on inside the abdominal cavity. At the same time she could watch very closely what Emma was doing. There was nothing out of the ordinary about this operation—it was not fundamentally different from any other major abdominal case—and Anna anticipated that before very long she would be scrubbing for Seth on her own.
Only once did her mind wander for a few seconds, and that was when she thought of the first time she had scrubbed for Simon. He had explained what he had been doing, without talking down to her, even though she had been familiar with the gut resection operation that he’d been engaged on. Then, when the operation had ended, he had taken her aside to thank her personally for her calm and competent assistance, as he had put it.
She had grinned back at him. When he had taken off his mask and smiled at her, she had been instantly in love. From then on he had smiled at her a lot. It had not been long before they had gone out to dinner together. Then they had held hands in a movie, like two young teenagers. It had all been so innocent and sweet. They had not planned to sleep together, to get really involved—it had happened, seemingly as inevitable as the rising sun.
Again the image of Simon faded from her mind.
As Seth was part way through the procedure, the excessive bleeding started. ‘As you can see,’ Seth said, for the benefit of the surgical intern and Anna, ‘there is a lot of scarring and fibrous tissue in a cirrhotic liver. The lobes are not as clearly defined as they would be in a non-cirrhotic liver.’
Anna and the intern, John, both nodded as they stared into the abdominal cavity. There was collective added tension and alertness among all of the staff. ‘Extra sponges, Emma,’ Seth said. ‘Ready with the suction, Ben.’ Emma had already anticipated his needs, as any good scrub nurse did.
Anna opened another bundle of large gauze sponges and counted them with Emma. They came in bundles of five, every sponge having to be counted and recorded lest it be left behind by mistake in the abdominal cavity. Ben, the surgical resident, became more active in suctioning blood with a suction tip and tubing attached to an electrical pump mounted on the wall. Blood ran into a clear receptacle, calibrated so they could see clearly the amount of blood loss in millilitres from that source.
‘Jay, would you get me a bag of whole blood and one of platelets from the cooling cupboard, please?’ Dr Jarvis asked their circulating nurse, gearing up to deal with the bleeding crisis. He was the one who would have to keep the patient hydrated and alive during the operation.
‘Sure,’ Jay said, going out of the room. The cooling cupboard was just outside in the corridor, containing bags of blood which had already been typed and cross-matched for specific patients who were being operated on that day. Very quickly she was back, carrying the bags of blood. Before long, the bags had been mounted on the intravenous poles, connected to the IV tubing, and were dripping blood into their patient’s veins.
Anna felt tense as she watched blood soaking up into the sponges that she was handing up to the surgeons and the blood that was being sucked into the plastic container.
‘I’d like some catgut ties, Anna,’ Seth said to her, ‘then give me a fine black silk suture.’ Although Seth was calm, she could hear the tension in his voice. ‘I want to do a bit of sewing here before I continue dissecting. Ben, would you grab the catgut with the tip of artery forceps? I want to tie off some of the bleeders.’
Anna had the appropriate suture ready, mounted on a long metal needle-holder. Quickly she handed it up to Seth when he had finished the catgut ties, and then she made sure that she had another ready of the same type.
Apart from the sporadic verbal requests, the sighing of the anaesthetic machine, as it transferred gases to their patient and took them away again, and the sound of the suction, all was quiet in the room, no noises from outside penetrating.
Time moved quickly, yet also seemed to stand still, as they fought to control the massive bleed. Anna thought of it as a sort of battle. Ray Jarvis, very calm, manipulated the various bags of intravenous fluids and blood that he was giving to their patient. Carefully, expertly, and as swiftly as possible Seth continued to dissect out the lobe containing the tumour and sew up and tie blood vessels at the same time to control the bleeding.
Jay dropped more bundles of sterile sponges onto their sterile set-up, then waited while they counted them. It was Jay’s job to record all the sponges, instruments and needles that they were using, one of her many jobs as the circulating nurse.
When the lobe of the liver, with the tumour in it, was finally lifted out, there was another surge of blood which they had to stem
, even though Seth had carefully tied off and sewn up bleeding vessels as he’d gone along.
* * *
When the operation was finished and their patient transferred to a stretcher to be wheeled to the recovery room, Anna felt drained and somewhat tremulous. There were blood-soaked sponges on sheets and on the floor, where they had been counted, and the plastic bottle on the wall was almost full.
‘Thank you, everyone,’ Seth said, taking off his surgical gloves and throwing them into a waste bucket. ‘That all went as it should, given the circumstances. We’ll take a coffee-break, all of us, of at least twenty minutes.’
Just as Anna was gazing around the room at the mess of bloodstained linen and used instruments and equipment, thinking that it would take them more than twenty minutes to clean up and prepare for the next case and that they would not get a coffee break, two relief nurses came into the room.
‘Coffee-break, girls,’ one of them said, bright and breezy. ‘You look as though you could use one. We’ll do the clearing up.’
‘Thanks, girls,’ Emma said. ‘We sure could use it. Come on, Anna, get that gown off before they change their minds.’
In the staff coffee-lounge, Anna followed Emma, picked up a cup and filled it from one of the urns, adding cream and a generous portion of brown sugar.
‘Ah, I’ve been longing for this,’ she said to Emma, as they moved out of the way to stand against a wall, all seats having been taken for the moment.
When Seth came into the room a moment later, she found herself tensing, very aware of his presence, thinking again of what he had said to her when they had first met. Obsessively, she could not get it out of her mind, feeling that he did not trust her. When he came over to her, bearing a full cup of coffee, she tensed even more, hoping he planned to talk to Emma.
Instead, he gave her his full attention and she felt her cheeks warming. ‘You were great in there, Anna,’ he said, ‘obviously a very good and experienced OR nurse, who is going to be a great asset to this department. Thank you again. I was very impressed.’
