Rivals in Practice

by Alison Roberts

  ‘I don’t give a damn about that either,’ Jennifer said briskly. ‘You’re qualified to help. And you need medical attention yourself. You’ve already lost quite enough blood.’

  ‘What about the camper van?’

  ‘Stop arguing and get in,’ Jennifer ordered. She looked at Tom. ‘Can you sort out the van?’

  ‘Sure. Where do you want it?’

  ‘The hospital car park is blocked. Have it taken up to my place.’

  ‘Hang on a minute—’

  Jennifer ignored Andrew’s protest. ‘Did Wendy get hold of you, Tom?’

  ‘About extra staff? Yes.’ Tom nodded confirmation. ‘I got hold of Janey and she’s going to round up Michelle and Suzanne.’

  ‘Great.’ Jennifer’s head swivelled. ‘Let’s get going, then, Mickey.’

  The fire officer climbed down the steps and looked at Andrew. ‘You’d better get in,’ he told him, ‘so I can fold these steps up and shut the doors.’

  Andrew paused for another moment, shaking his head in disbelief. Then he climbed into the back of the vehicle, sitting heavily on the bench seat that ran parallel to the stretcher.

  ‘I knew this holiday was going to be a disaster,’ he informed Jennifer. ‘I’ve known it for nearly a year.’

  ‘Why did you come, then?’ Jennifer was fitting the electrodes from the lifepack to Liam’s chest and a pulse oximeter to his finger. Her tone was unsympathetic.

  ‘I couldn’t miss it.’ Andrew gave a snort of laughter that held no amusement. ‘After all, it is my honeymoon.’

  CHAPTER TWO

  IT WAS not a moment to offer congratulations.

  Jennifer Tremaine ignored Andrew Stephenson’s statement regarding his holiday and the odd implications it carried. Jennifer didn’t care about the reasons Andrew had returned to this side of the globe or why the trip might be proving less than satisfactory. If there was a new wife sulking in the back of the camper van because of some marital dispute, Tom could sort it out. Andrew certainly didn’t seem bothered but that was hardly surprising to Jennifer, given what she remembered about the man. She could put aside what she thought of his personality, however. The fact was, he was here, and Jennifer badly needed the professional skills he was capable of providing. When Mickey slammed the back doors of the Land Rover closed she almost smiled with satisfaction. She had Andrew Stephenson trapped for the moment and she was taking him in the direction she had chosen.

  Despite the protective wet-weather clothing, Jennifer was soaked and cold. She took a moment away from her assessment of Liam Bellamy’s condition to reach for some towels in an overhead locker. The thick, dark blonde curls of her hair were plastered to her head and still dripping enough water to be a real nuisance.

  ‘Blood pressure’s 100 over 60,’ she informed Andrew as she roughly dried her face and hands. ‘Heart rate’s up to 130. He’s shocked, but his airway’s still clear and his breathing hasn’t deteriorated any further.’ She shoved a fresh towel towards her passenger. ‘Get yourself a bit drier,’ she ordered. ‘You must be frozen. Wrap yourself in a blanket as well.’

  ‘Thanks.’ Andrew took the towel with one hand. His other hand was still holding the dressing on his lower leg. The thick gauze wadding was saturated and a trickle of blood moved through the fingers holding the pad in place.

  ‘Put some pressure on that,’ Jennifer directed. ‘Thanks.’ Andrew’s tone was much less appreciative this time. ‘But I do remember the basics of haemorrhage control.’

  ‘Try to implement them effectively, then,’ Jennifer suggested. She turned back to Liam, her stethoscope in her ears again. The gap in time since she had last had any contact with Andrew Stephenson seemed to have evaporated effortlessly. A casual snipe at each other and they were back to communicating the way they always had. Time clearly hadn’t changed Andrew, but Jennifer was faintly ashamed that she could slip so easily into what she considered an immature and less than professional mode of interaction. She rose quickly, bracing herself against the stretcher as she pulled open another locker. She took out a bandage and one of the largest sterile dressings available, ripping open the packages as she turned back.

  ‘Fold this up,’ she directed Andrew, handing him the large gauze wadding. ‘I’ll put a pressure bandage on and maybe that will stop the bleeding.’ She tried to smile at Andrew as he looked up—a form of apology for her lapse in courtesy—but he didn’t return the gesture. As Jennifer stooped and began to bind the bulky dressing firmly to his leg, he picked up the towel and dried his face. Jennifer worked rapidly, taking only seconds to finish her task. It was long enough to gain a physical impression of the man, however. The muscle beneath her hands felt like iron. Andrew hadn’t gained an ounce of flab over the years. If anything, he was even leaner than he had been.

  ‘That saline’s almost run through. You’d better start another unit.’

  ‘OK.’ Jennifer reacted promptly. Perhaps Andrew was taking more notice of Liam’s condition than the impression he had given. Maybe he would be more inclined to offer his assistance when they had some better facilities available. If they ever got back to the hospital. Mickey seemed to have brought the Land Rover to a complete halt.

  ‘What’s going on, Mickey?’

  ‘I’m watching the waves,’ Mickey called back. ‘The wash is right over the road just here and I don’t want us stuck in the middle if we catch a big one.’

  At least they were only minutes away from the hospital. They only had to head up the hill a little way and turn onto Napoleon Drive. There was a tense silence in the vehicle as they waited. Jennifer listened to the roar of the surf as it covered the sound of more hail on the roof above them. They moved with a jerk as Mickey accelerated to clear the patch of road between waves. Jennifer leaned closer to Liam.

  ‘We’re almost there,’ she told him. ‘Don’t worry, Liam. We’ll soon have you sorted out.’

  Her patient moved convulsively, coughing and then retching. He was gagging on the plastic airway and the oxygen mask filled up with blood. Jennifer uttered a dismayed oath as she wrenched it clear of his face before he could inhale any of the contents. The airway tube fell to the floor and rolled beneath the stretcher.

  ‘Get him on his side,’ Andrew ordered crisply.

  Jennifer was already doing her best but Liam was a well-built young man and hardly moved when she grasped his shoulders to pull him over. Suddenly it seemed as if Liam was rolling himself onto his side and Jennifer realised that Andrew was beside her, lifting and turning the heavy body with apparent ease.

  ‘Have you got a suction kit?’

  ‘On the wall behind you. There’s a clip underneath.’ Jennifer was holding Liam’s head, keeping his airway open. She hoped the rough manoeuvre hadn’t exacerbated any injury. ‘I hope he doesn’t have a pelvic fracture.’

  ‘I’d say his airway and breathing are more of a priority right now,’ Andrew responded coolly. ‘Here…’ He handed her the tube from the suction kit and switched the unit to full power.

  ‘You do it,’ Jennifer told him. ‘I need to find another OP airway and a bag mask.’

  ‘I’m not wearing gloves.’

  ‘Then put some on.’ Jennifer snatched the tube and cleared the blood from Liam’s mouth and nose. She noted the cut inside his lip, the broken teeth and the probable broken nose, but were they enough to explain the amount of blood in the mask?

  ‘I’ll find another airway for you.’ Andrew reached into the kit to extract one of the plastic devices. The abrupt halt of the Land Rover caused him to overreach.

  ‘There’s a bloody great tree blocking the driveway,’ Mickey shouted. ‘I nearly hit the damned thing.’

  ‘Sorry.’ Jennifer braced herself as the vehicle began reversing. ‘I should have warned you about that. We’ll have to go around the back by the kitchens.’

  Andrew handed her the airway. He rapidly assembled the bag mask components and Jennifer plugged the tubing into the oxygen supply before fitting it over Liam’s mou
th and nose. She glanced at Andrew.

  ‘GCS is dropping again. He’s lost his gag reflex and his breathing is getting worse. He’s going to need intubation as soon as we get him inside.’

  ‘He needs evacuation to the nearest major hospital. You can’t possibly have the facilities to deal with a patient in this condition here.’

  ‘We’ll have to,’ Jennifer said tersely. ‘We’re the only chance he’s got. There’s no hope of evacuation in this weather.’ She sent Andrew a warning glance. ‘And I’m including you in that ‘‘we’’.’

  Andrew shook his head. ‘I told you—I’m no longer a doctor. I gave up medicine nearly a year ago.’

  ‘Why?’

  ‘That’s my business.’

  The Land Rover had stopped moving again. The engine idled and Jennifer could hear rain on the vehicle’s roof in the silence that followed Andrew’s cool comment. She squeezed the bag she was holding again, turning her astonished stare back to her patient. ‘I don’t care what your reasons were,’ she announced. ‘And you don’t stop being a doctor just because you chucked your job in. Right now I need to assess and stabilise my patient. I need help and I’m going to use whatever resources I can find. Including you.’

  The back doors opened and Jennifer moved swiftly, unhooking the end of the stretcher. ‘Bring the lifepack and the suction kit,’ she ordered Andrew. ‘And follow us.’

  Wendy and Margaret were both waiting by the open door as Mickey and Jennifer raised the stretcher and wheeled it towards the back entrance of the hospital.

  ‘Tom Bartlett rang us,’ Wendy informed Jennifer in a rush. ‘Janey and Michelle are here, looking after the other patients. Sue’s coming in as soon as she’s dropped off her children. The treatment room’s clear.’ Wendy took a quick breath. ‘How’s Liam doing?’

  ‘Not great.’ It was Andrew who spoke as they moved past Wendy. ‘Sats are dropping fast. Probably a tension pneumothorax from the rib injuries.’

  Jennifer let Margaret take her place pulling the stretcher. ‘I’ll get a chest-drain kit set up,’ she said, moving rapidly ahead and shedding her oilskin parka as she moved. The astonished stare directed at Andrew by both Margaret and Wendy had not been lost on Jennifer but she couldn’t afford to be distracted by introductions just yet. Within seconds they were all crowded into the treatment room. Mickey, Margaret and Wendy positioned themselves around the backboard as Andrew held the head end and directed the transfer of their patient to the bed.

  ‘On my count,’ he instructed. ‘One, two…three!’ Andrew reached for Jennifer’s stethoscope which had been left draped across Liam’s abdomen. He glanced up as he lifted the earpieces clear a short time later. ‘We’re going to need a drain on both sides,’ he informed Jennifer. His gaze raked Wendy. ‘You’re a nurse?’ he queried tersely. ‘I need some gloves.’

  Jennifer could feel Wendy’s hesitation. She gave her nurse a reassuring glance as she reached for a second sterile chest drain package. ‘It’s OK, Wendy,’ she said calmly. ‘Andrew’s a doctor. A surgeon. He knows what he’s doing.’

  The tension in the room wasn’t limited to the nurses’ wariness of the strange doctor. The situation was critical and both Andrew and Jennifer worked in a tense silence as they dealt with Liam’s respiratory collapse.

  ‘Got it!’

  Jennifer had heard the characteristic hiss of air escaping from the side of the chest Andrew was working on. She concentrated grimly on inserting her own drain, dimly aware of a familiar frustration at Andrew achieving a successful result first. It lasted only seconds.

  ‘Haemothorax on this side.’ Jennifer attached the drain to the bottle that Margaret had prepared. She watched the flow of released blood. ‘Rather a large one.’

  ‘A single rib fracture can cause a loss of 150 mls into the pleural cavity.’ Andrew was picking up the stethoscope again. ‘And this lad’s fractured a fair few.’ He nodded as he shifted the disc on Liam’s chest. ‘We’ve got equal breath sounds.’ He glanced at Mickey who was ventilating Liam with the bag mask, then he looked at Jennifer. ‘Are you going to intubate? Have you got mechanical ventilation available?’

  ‘I’ll do it now.’ Jennifer was pleased to see that Wendy was already setting out the intubation kit. She stripped off her soiled gloves and reached for a new pair.

  ‘What about X-ray facilities?’ Andrew queried. ‘We need chest, C-spine and pelvis.’

  ‘No X-rays, sorry.’

  ‘Blood pressure’s dropping.’ Margaret sounded worried. ‘Ninety over fifty.’

  Andrew’s attention flicked to Margaret. ‘Get the rest of his clothes cut off,’ he directed. ‘I’ll check his abdomen and pelvis. You get on and do the intubation, Jennifer.’

  Margaret’s hesitation was only momentary. Jennifer could sense her rapid acceptance of directions from someone who was clearly in control of the situation. Turning to pick up the laryngoscope, she caught Wendy’s gaze. Her nurse was clearly questioning Jennifer’s apparent acceptance of being cast into the role of an assistant by someone who was, after all, a complete stranger despite the demonstration he was giving of his obvious abilities. Jennifer merely nodded at Wendy and Mickey, who had stayed to assist.

  ‘We’ll get the collar off and you can provide manual in-line stabilisation for us, Mickey. You can do the cricoid pressure when I’m ready, Wendy. This may not be easy with the facial injuries Liam has.’

  Jennifer concentrated on her task of securing Liam’s airway, confident that Andrew and Margaret would be dealing with anything else that might need urgent attention. If Andrew’s involvement came with the price of giving up leadership of this small team, Jennifer was quite willing to pay. This was no time to even remember old battles but Wendy wouldn’t have questioned Andrew’s take-over if she’d known him like Jennifer did. Andrew had never been able to resist taking command of any situation he found himself in—particularly one that included her own presence. Jennifer was more than happy to let this one go. She had a professional colleague whose skills matched—probably exceeded—her own, and Jennifer was grateful for the shared responsibility as she registered the comments she overheard from further down the table.

  ‘Pelvis doesn’t feel unstable,’ Andrew was saying. ‘Any femoral fractures?’

  ‘Nothing obvious.’

  ‘We need some more fluids. Find me a 12-gauge angiocath.’ Andrew spoke to Margaret as though they were familiar colleagues. ‘I’ll go for the groin. He’s completely shut down peripherally. Do another blood pressure, too, would you, please?’

  ‘Sure.’

  Jennifer had Liam’s head positioned now and stable. ‘Hyperventilate with the bag mask, Wendy. I’m ready to intubate.’

  ‘Blood pressure’s 80 on 55,’ Margaret told Andrew.

  Jennifer tried to concentrate on visualising the larynx and vocal cords. Part of her brain registered Margaret’s comment with dismay. Liam was becoming progressively more shocked. He was losing more blood than could be accounted for by the injuries they had identified so far. If they were going to save Liam Bellamy’s life they needed to find the source of the blood loss and control it. Until then they had to maintain an adequate circulation.

  ‘We’ll push saline into this larger line,’ Andrew decided. ‘Have you got haemaccel as well?’

  Jennifer eased her laryngoscope into its final position. ‘Pass me a 9-mm tube, thanks, Wendy, but don’t release pressure on the cricoid cartilage just yet.’

  Andrew had instigated the rapid fluid replacement by the time Jennifer had inflated the cuff on the endotracheal tube and set up the ventilator. He was eyeing the chest-drain bottle on her side of the bed.

  ‘He could have a diaphragmatic rupture,’ he suggested to Jennifer. ‘It would explain a continued blood loss of that rate and a lack of abdominal distension if he’s injured his spleen. Given the rib fractures on that side, it seems quite likely as a source of major blood loss.’

  ‘Find another bottle, Margaret,’ Jennifer requested. She looke
d at Andrew. ‘What about a peritoneal lavage?’

  ‘What about it?’

  Jennifer suppressed a flash of annoyance. The reminder of how often she and Andrew had disagreed over a diagnosis or method of treatment again wiped out the gap in time very effectively. They had always challenged each other, demanding justification for opinions or decisions. Trying to prove themselves more capable than the other.

  ‘It could be diagnostically useful.’ Despite the inappropriate setting to dredge up old battle skills, Jennifer couldn’t quite help the edge of sarcasm in her tone. ‘If we got lavage fluid coming from the chest drain, then we’d know for sure that there was a diaphragmatic rupture.’

  ‘And what then? Are you proposing a laparotomy if it’s indicated?’ Andrew’s eyebrow was raised sceptically. ‘Are you qualified to undertake a procedure like that?’ He glanced around the treatment room. ‘Here?’

  ‘No, I’m not qualified,’ Jennifer said quietly. ‘But you are.’

  ‘No, I’m not.’

  Jennifer could feel the astonishment of both her nurses and Mickey. She ignored the rising tension. ‘You’re a specialist surgeon,’ she reminded Andrew. ‘The last I heard, you were so good you got poached from the Boston Memorial to join some very prestigious private outfit.’

  ‘That’s ancient history. I told you, I’m not practising any longer.’ Andrew’s tone suggested that either Jennifer’s memory or her ability to understand were well below par.

  ‘Why?’ Jennifer was blunt. She wasn’t about to let Andrew back out now. ‘Did you kill somebody?’

  Andrew’s face darkened as his features froze for an instant. His eyes met Jennifer’s directly. ‘No.’ His tone was as cold and calm as the stare she was receiving. ‘And I’m not about to take the risk of doing precisely that by operating on someone in less than ideal circumstances.’

  The alarm that sounded on the cardiac monitor was brief. The arrhythmia settled spontaneously after a few erratic heartbeats but it was enough to remind both doctors of their patient’s still critical condition. The tap on the door of the treatment room came in the short silence that followed the cessation of the alarm. A young nurse aide poked her head around the door.