CONSULTANT IN CRISIS

by Alison Roberts

  A run back to town, having transferred a patient to a rural hospital twenty minutes out of town, gave Kelly the chance to consult Callum. Well into his forties, Callum was a paramedic with many years’ experience. He was also intelligent and interested in his career. Kelly was enjoying working with him.

  ‘How much do you know about diabetes, Callum?’

  ‘Heaps.’ The response was less than modest. ‘What do you want to know?’

  ‘The diagnostic criteria are symptoms like thirst, weight loss, blurred vision and so on, plus a fasting glucose level greater than seven mils per litre, right?’

  ‘Basically.’

  ‘So diabetes is diagnosed when blood-glucose levels rise because of a lack of insulin production or interference with its function.’

  ‘That’s right.’

  ‘Someone couldn’t present with a hypoglycaemic crisis as the first symptom of diabetes, could they? They’d have to be already taking insulin for that to happen.’ She and Fletch had spent so much time together—in bed and out of it. Surely she would have noticed him injecting himself? Or testing his blood-glucose level? Or seen the wealth of medical supplies he would have had to have available?

  ‘If they’re diabetic then the most common cause for a hypoglycaemic episode is an overdose of insulin or a missed meal or increased exercise. Or maybe an infection or too much alcohol.’

  ‘Mmm.’ Kelly tried not to get sidetracked by the mention of alcohol.

  ‘Of course, there are other ways of becoming hypoglycaemic. You don’t have to be diabetic.’

  ‘No. Some drugs can do it,’ Kelly agreed. ‘Aspirin and beta-blockers.’

  ‘Alcoholics or even binge drinkers are prone to it. Their livers don’t have good stores of glycogen and missing a meal or two can precipitate a big fall in BGL.’

  Back to alcohol again. Kelly knew that she had made a mistake making that assumption. No. There was a key to the puzzle that was missing here.

  ‘There’s carcinomas, too, of course.’

  ‘Cancer!’ Kelly was horrified. ‘How could I have forgotten that? An insulin-secreting tumour could cause a major hypoglycaemic crisis.’

  ‘I wouldn’t beat yourself up over it.’ Callum grinned. ‘They’re as rare as hen’s teeth. Even if you work till you’re seventy you’ll probably never come across anyone who has one.’

  Maybe she already had. Kelly was only half listening to the radio message that came through. She pulled out the map to check directions as Callum slowed and pulled the ambulance into a U-turn. She tried to keep her mind on the navigating but it wasn’t easy.

  ‘Go left at the next roundabout,’ she instructed Callum. ‘Do you know heaps about insulinomas as well?’

  ‘Not really,’ Callum admitted. ‘They’re islet cell tumours in the pancreas.’

  Kelly swallowed. Is that what Fletch was living through now? A terminal illness? ‘Would they treat themselves with glucagon?’

  ‘Doubt it.’ Callum was slowing again as he looked at street numbers. ‘They’d use medication to suppress insulin secretion and probably IV infusions of glucose if things got out of control. I seem to remember that glucagon is contra-indicated.’

  ‘Are they ever curable?’

  ‘Sure. Only ten per cent are malignant and if it’s just a single tumour it can be removed or part of the pancreas can be taken out. The overall cure rate is great.’

  ‘Is it?’ Kelly suddenly felt a lot happier. But, then, if Fletch had been cured, why would he still need to use something like glucagon? She intended to find out. She also intended to apologise. How or when she could tackle an apology that big was something that was proving progressively problematic, however.

  The ‘sick person’ they had been diverted to attend to was a fifty-six-year-old man who had been unable to get out of bed that morning.

  ‘Jim thinks he’s had a stroke,’ his wife informed the ambulance crew wearily as she led them into the house. ‘He’s had one before. I reckon he’s just got a hangover and doesn’t feel like going to work. He’s done that more than once as well.’

  It was Kelly’s turn to do the assessment.

  ‘Have I had another stroke?’ The man’s speech was slightly slurred.

  Kelly could smell the alcohol. She could also smell the contents of the plastic container by the bed. ‘Apart from the vomiting, Jim, what’s been happening to you?’

  ‘I can’t get up. I can’t talk properly. I feel really sick.’

  Kelly turned to Jim’s wife. ‘Does his speech normally sound like this?’

  ‘Only when he’s been drinking.’ The woman looked thoroughly fed up and Kelly could sympathise. She would make this assessment as brief and professional as possible. She noted that Jim’s radial pulses were strong and equal on both sides. He looked pale and his skin was clammy.

  ‘Let’s get some vital signs, a BP and an ECG,’ she instructed Callum. ‘Jim, have you got any medical conditions you’re being treated for?’

  ‘High blood pressure.’ His wife answered for him. ‘And indigestion. And headaches. He’s been getting a lot more of those lately.’

  It all fitted with the clinical picture of a stroke presentation. ‘Do you know what day it is today, Jim?’ Kelly wanted to check her patient’s level of consciousness.

  ‘Wednesday.’

  ‘And the date?’

  ‘Sixteenth.’

  ‘And you had a bit to drink last night?’

  ‘Not that much.’

  ‘BP’s 190 over 105,’ Callum reported. ‘He’s in sinus rhythm at a rate of 96.’

  ‘Squeeze my hand,’ Kelly ordered her patient. ‘And this one.’

  The hand grip was noticeably weaker on the right side. Kelly checked his feet to find the right-sided weakness still obvious. ‘Smile at me, Jim. Show me all your teeth.’

  The droop on the right side of the face added another piece to the picture.

  ‘Have I had a stroke?’

  ‘It looks like you may have.’ Kelly nodded. ‘We’re going to take you into hospital so they can check you out properly.’ She turned to Callum. ‘I think nasal cannula will be enough for oxygen. I’ll get an IV in and then we’ll hit the road.’

  She checked her patient again as they travelled to the hospital. Jim reported a pain score of six out of ten for the headache he still had.

  ‘You didn’t have a fall last night, did you?’

  ‘Don’t think so.’

  Kelly examined his head for any sign of trauma. She listened to his chest and reassessed all the neurological signs and symptoms before documenting all the findings with care. Fletch might be on duty in Emergency again today and Kelly wanted her paperwork to be perfect. Under the provisional diagnosis slot she wrote ‘CVA’. On arrival, the discovery that Neil Fletcher was on duty and was probably within earshot of the triage nurse made Kelly pay particular attention to her handover.

  ‘Mr Wallace is fifty-six,’ she stated. ‘He has a previous history of hypertension and CVA. He woke with a severe headache, vomiting and right-sided paresis. No history of trauma. Strength is markedly diminished and he is unable to lift his right leg. Peripheral pulses are equal. GCS is 15. Pupils equal and reactive to light. Chest and abdomen are clear.’ Kelly lowered her voice so that her patient couldn’t overhear. ‘He’s vomited twice en route and there’s still a strong odour of alcohol. Apparently his general consumption is pretty heavy.’

  ‘Resus 3, thanks, Kelly.’ The triage nurse put the paperwork on top of the central island bench, close to where Fletch was standing as he completed a phone call.

  ‘What was the BGL?’

  Busy manoeuvring the stretcher between the ECG and IV trolleys, it was easy for Kelly to pretend she hadn’t heard the consultant’s query. Callum looked apologetic.

  ‘Sorry, Fletch. I didn’t get that done.’

  Kelly concentrated on where she was heading. She had been running that job. And she should have done a blood-glucose level. During the time it took to clean up
the ambulance and ready themselves for a new call, Kelly became increasingly annoyed with herself. It was a basic vital sign measurement that should have been done. The distraction of a priority-one call to an accident on a building site was welcome.

  The rest of the shift turned out to be busy enough to make it difficult for Kelly to follow up their CVA case. The opportunity came when Callum took advantage of their shift being due to finish to have a quick coffee with a mate in the ED staffroom.

  ‘Really interesting case,’ the triage nurse told Kelly. ‘Turned out it wasn’t a CVA at all.’

  ‘What was it?’

  ‘Hypoglycaemia. BGL was too low to record. We gave him some IV dextrose and the right-sided weakness and slurred speech disappeared in less than five minutes.’

  ‘You’re kidding.’ Kelly shook her head. ‘I’ve never seen a hypo present like that.’

  ‘Neither had we.’ The nurse grinned. ‘Wish we could cure all our CVAs that easily.’

  Kelly returned the smile with difficulty. Fletch would probably be wondering just how qualified she was to do her job right now. It had seemed like such a straightforward case of stroke. Coupled with the alcohol consumption, it had been enough for her to feel quite confident of the diagnosis. Had there been any suggestion of a lowered level of consciousness she would have checked the BGL automatically. The error was going to make it even harder to speak to Fletch but the background guilt Kelly was dealing with was enough to prompt her to walk past his office. Maybe she could throw in an apology for missing that diagnosis as well. It was small fry compared to the real apology she needed to make.

  ‘Hi, Fletch.’ Kelly poked her head around the door. ‘Are you busy?’

  ‘Not particularly.’ Fletch didn’t look welcoming but Kelly entered the office anyway. ‘What can I do for you?’

  ‘I…um…’ Kelly took a very deep breath. There was no easy way to lead into this so she may as well get it over with. ‘I wanted to apologise.’

  ‘What for?’

  ‘For thinking that…’ Kelly hesitated and then tried again. ‘When I left the country I had absolutely no idea that you were sick, Fletch.’

  ‘Yes, you did.’ The contradiction was matter-of-fact. ‘You spoke to my flatmate. He told you I was sick and you said, “I’m not surprised.”’

  Kelly flushed. ‘I thought he meant you had a hangover.’

  ‘And that was enough for you to tell him to pass on the message that you never wanted to see me or speak to me again.’

  ‘I…It was…’ Kelly was completely at a loss now. She had known this would be difficult but what she hadn’t factored in had been Fletch’s response. Her mental preparation had seen him listening with increasing sympathy to a frank account of the kind of violence and emotional trauma she had grown up with thanks to her father’s problem with alcohol. The worst-case scenario had been that he would refuse to speak to her or dismiss any apology. She hadn’t expected an angry attack because she knew it wasn’t justified. Not entirely.

  ‘I was angry,’ she said quietly. ‘You put me in a position I couldn’t handle.’

  ‘And how did I do that?’

  ‘That night in the restaurant.’ Kelly avoided meeting Fletch’s angry stare. ‘It was…’ She hesitated again. ‘Really awful,’ she finished inadequately.

  ‘It must have been.’ The agreement was calm. ‘I’d like to know what happened. Why don’t you sit down and tell me about it, Kelly?’

  It was a second opportunity that Kelly couldn’t afford to pass up. She sat down slowly, trying to collect her thoughts. Unpleasant memories flooded back as soon as she started speaking.

  ‘I had been really looking forward to going out that night. The meal was really nice and then it all started to go horribly wrong when I was having coffee and you were finishing that bottle of champagne. We were talking about having children.’ Kelly swallowed painfully. ‘We agreed that neither of us liked being only children and you thought we should start a family straight away so we could have three or four. I wanted to wait until I’d finished my paramedic qualification.’

  ‘And?’ Fletch’s prompt was impatient. It all sounded perfectly reasonable to him so far, however troubling it was to have no memory of the conversation.

  ‘You said the reason you were an only child was because your mother had left it too late to start a family. You started asking other people in the restaurant what they thought. You got very loud and you just wouldn’t stop. You called the wine waiter over and asked his opinion. And then you ordered more champagne and they refused to give it to you.’

  Kelly could almost feel the escalating embarrassment all over again. ‘You decided to go to the toilet and you couldn’t keep your balance when you tried to walk. You bumped into a waitress who dropped the plates she was carrying and a woman’s dinner went all over her dress. We were asked to leave. We were asked to cover the cost of replacing the ruined meal. You refused. They threatened to call the police. You threw up on the floor in the middle of the restaurant.’

  Fletch’s eyes widened as he listened silently.

  ‘Everybody thought you were drunk. Including me.’ Especially me, Kelly added silently. ‘I’d seen more than I wanted of behaviour like that in my life, which is the reason I don’t drink alcohol myself.’ Kelly gave her head a tiny shake. She didn’t want to dredge up her family history quite yet. She had spent too many years keeping it hidden and Fletch was in no mood to listen sympathetically.

  ‘I called a taxi for you,’ she concluded calmly. ‘And I stayed behind to try and sort things out. I paid for our meals, the meals that got dropped, the drycleaning for the woman’s dress and the cost of having the carpet cleaned. People were walking out of the restaurant and the manager was threatening to sue us for lost business. I had never been so humiliated in my life.’

  There was a long, long silence in the small office.

  ‘I had no idea,’ Kelly whispered finally, ‘that it might have had a medical cause. I would never have sent you off in a taxi by yourself if I had. And I would never have considered breaking our engagement as a result.’ She looked up and held Fletch’s gaze. ‘I made a dreadful mistake, Fletch, and I’m sorry. I’m terribly sorry.’

  Fletch raised his eyebrows but his expression remained still. ‘You thought I was obnoxiously drunk,’ he said. ‘And that was a good enough reason to dump me?’

  ‘I thought you had a problem with alcohol,’ Kelly amended. ‘That you might be an alcoholic. It wasn’t something I could deal with because—’

  ‘You thought I was drunk,’ Fletch interrupted. ‘And that was enough to leave a message that you’d pass on marrying me, thanks.’ He shook his head. ‘You never really loved me at all, did you, Kelly?’

  ‘That’s not true! I—’

  ‘Even if I had been paralytically intoxicated on that one occasion, it shouldn’t have made any difference. Not if there’d been any genuine love on your part.’

  ‘It was because it was genuine that it made such a difference. I wanted to spend the rest of my life with you, Fletch.’ Kelly was desperate to make him understand. ‘It was knowing that I might be making the same mistake my mother did that made me realise I couldn’t do it.’

  Fletch wasn’t listening any longer. Not properly. He wasn’t looking angry now either. He was looking disgusted. ‘You always did have a holier than thou attitude to drinking. Just because you choose not to touch the stuff, it doesn’t mean that’s what everybody should do. People can drink alcohol sensibly and enjoy it. They can even be forgiven for having too much on the odd occasion. But not by you, obviously. That’s sheer arrogance, Kelly Drummond. You make assumptions all the time, don’t you? And you’re so sure you’re right.’

  ‘I don’t,’ Kelly protested.

  ‘And what about this morning? That patient of yours was terrified he’d had another stroke and would be paralysed for life this time. You’d made up your mind and that was that.’

  ‘It was a classic presentation of a
CVA.’

  ‘And let’s face it, you’d already decided that he had a problem with alcohol and you wanted to get the job over and done with.’

  Kelly didn’t want to admit the element of truth in the statement, even to herself. ‘I know I should have done a BGL. That was a mistake.’

  ‘You make a lot of mistakes, don’t you, Kelly?’

  Kelly stood up. It was time to leave. It had been a certainly been a mistake thinking she could apologise to Fletch. He wasn’t interested. The damage was irreparable. She barely acknowledged the thanks given to her by the relatives of the last patient she had brought in as she walked back through the emergency department. She bypassed the staffroom in favour of waiting for Callum out in the ambulance. How long would it be before the people she had to work with here gleaned the attitude of the consultant who knew her better than anyone else in this department? Fletch thought she was cold-hearted and ruthless. Selfish. Now she could add arrogant and probably professionally incompetent to the list.

  Neil Fletcher hated her.

  Kelly sighed heavily. It was easy enough to see things from his point of view. He had no memory of their last evening together and no inkling that any reminder of the kind of humiliation Kelly had grown up with would be enough to make her panic. He had simply been dumped without explanation and at a time when he would have been more in need of support than he’d ever been. He must have really loved her to still feel so angry after all this time.

  Kelly buried her face in her hands. She hoped Callum would take his time over his coffee. She wasn’t in any hurry to go home. She had never expected her break-up with Fletch to come back to haunt her so directly. Or that it would become so interwoven with the problems that faced her at home. There was no escape from Fletch, whatever direction she took.

  Fletch was right. She had made a lot of mistakes. And one of them had been returning to New Zealand. She couldn’t change the past and she couldn’t escape it. She had allowed it to destroy her future.