Authors: Meredith Webber,Alison Roberts
‘We’re coming to you from the scene of a high-speed
multiple MVA. The chopper’s just landing to collect a second seriously injured patient who’s currently trapped, but we’re coming to you with a status-one seven-year-old boy.’
The grin had long gone. Status one was as serious as it could get. Under CPR, not breathing or uncontrollable haemorrhage were all possibilities for the priority designation. This ambulance would be coming towards the hospital under lights and sirens.
‘Injuries?’
‘Head and facial trauma. Partially unrestrained front-seat passenger—the safety belt wasn’t latched securely.’
This wasn’t the time to feel angry at someone failing to strap a child into a car seat properly. Or to wonder why they were travelling at 2 a.m. in the first place.
‘Vital signs?’
‘GCS of 3.’
The child was profoundly unconscious. Quite possibly due to bleeding around his brain.
‘Airway?’
‘Unsecured.’ The paramedic raised his voice as the siren came on in the background. The vehicle must be in heavier traffic now. At night, just having the beacons flashing could be enough warning of the urgency of their mission. ‘There’s severe facial trauma and swelling. We’ve got an OP airway in but that’s all.’
The boy needed intubation. Securing an airway and optimising oxygen levels were a priority in a head injury. Especially in a child because they had a greater chance of neurological recovery than an adult after a head injury and therefore warranted aggressive treatment in the early stages. If the paramedics had been unable to intubate due to the level of trauma, it could mean that this was going to be a challenging case.
Hannah could feel her adrenaline levels rising and the tension was spreading. Nearby staff were all listening avidly and the curtain on cubicle 4 flicked back to reveal that Ryan was also aware of what was happening. Hannah’s heightened awareness registered the interest and at some subconscious level something like satisfaction was added to the emotional mix. She was taking this call.
This would be her case, not Ryan’s. Just the kind of case she needed to showcase the skills that would be a major consideration in choosing the new consultant for the department.
‘What’s the oxygen saturation level?’ she queried briskly.
‘Ninety-four percent.’
Too low. ‘Blood pressure?’
‘One-thirty over sixty-five. Up from one-twenty five minutes ago.’
Too high for a seven-year-old. And rising. It could well be a sign of increasing intracranial pressure.
‘Heart rate?’
‘One hundred. Down from about one-thirty.’
Too slow for Hannah’s peace of mind. And dropping. It could also be a worrying sign. ‘What’s your ETA?’
‘Approximately five minutes.’
‘We’ll be ready for you.’ Casting a glance over her shoulder, Hannah could see Ryan moving towards the resuscitation area she and Jennifer had just checked. Not that she was about to decline any assistance for dealing with the incoming case but she didn’t want Ryan taking over. It wasn’t as though there was only one victim arriving, was it? She pushed the button on the microphone again.
‘Do you know the ETA for the chopper?’
‘Negative. Fire service is on scene, though.’
It shouldn’t take them long to cut the second victim clear of the wreckage, then. ‘And that’s also a status-one patient?’
‘Affirmative. Chest trauma. It’s the mother of our patient.’
Ryan would be able to lead the team on that case. In resus 2. Or they could share the main trauma room if necessary. Hannah’s plan of action was forming rapidly as she replaced the microphone.
‘Put out a call for an anaesthetist, please, Wayne,’ she directed. ‘And let’s get a neurosurgical consult down here. Sounds like we might need someone from Plastics, too. Jenny, you’re on the trauma team tonight, aren’t you?’
‘Yes.’
‘And you, Wayne?’
‘Yes. Resus 1?’
Hannah nodded, already moving towards the area. She pulled one of the protective plastic aprons from the large box on the wall. Ryan was already tying his behind his back.
‘Could be a tricky airway management,’ he said.
‘Mmm. I’ve called for some anaesthetic back-up but I’ll see how I go.’ The direct look Hannah gave Ryan could leave him in no doubt that she intended to lead this resuscitation effort. The subtle twitch of an eyebrow let her know the message had been received and understood. It also hinted at amusement rather than intimidation.
‘I’ll stay until the mother gets here,’ he said calmly. ‘In case you need a hand.’
‘Thanks.’ The acknowledgement was perfectly sincere. There was a child’s life at stake here and Hannah would never let any personal considerations affect her performance. She would stand back in a flash if she thought Ryan’s skills would improve the management. Never mind that he would get the credit for managing a difficult case.
It was just annoying that people that mattered were keeping a count of those credits at present. And disappointing that a competitive edge of any kind had crept into
Hannah’s working environment when one of the things she loved best about her work was the way a team of people could work together and the only kudos that really mattered was a successful outcome to that work.
The decision on the consultant’s position was only a week or two away. A position that represented everything Hannah was striving towards in a career she was passionate about. Why had Ryan decided to compete at the last minute like this? It wasn’t as if he really
needed
the position. He didn’t have a massive student loan, the repayments of which would benefit enormously from an increase in salary. He didn’t need to prove himself in a field that was still dominated by males in senior positions. He was an Australian. Auckland wasn’t even his home town.
She couldn’t help flicking a glance towards the tall man who had now donned protective eyewear and a pair of gloves and was lounging at the head end of the bed. Why hadn’t Ryan Fisher just stayed on his side of the ditch? In that Sydney emergency department where he’d honed his not inconsiderable skills? Life would be so much easier if he had. And it wasn’t just due to that professional competition.
Jenny pushed the IV trolley into an easily accessible position and then stood on tiptoe to check that the tubes attached to the overhead suction and oxygen supplies were firmly in place. It was still a stretch for her short stature and Ryan was quick to step forward.
Without a word, he saved Jenny the awkward task and then gave her one of those killer smiles in response to her thanks. The senior nurse turned back to the IV trolley but Hannah noticed the extra glance that went in Ryan’s direction.
Not that he had noticed. The registrar was lounging again, his keen glance taking in the mill of the gathering trauma team and registering the growing tension.
The few minutes before the arrival of a serious case was a strange time. A calm before a storm of unknown proportions. Equipment was primed and ready. Staff were wearing protective gear and waiting. Wayne stood behind a kind of lectern that had the paperwork necessary to document every moment of the resuscitation effort and he was fiddling with a pen.
Hannah had pulled on gloves and was unrolling the airway pack on the top of a stainless-steel trolley. Others were simply standing. Waiting. There was nothing to do until their patient came rolling through those double doors. Nobody liked to speculate in too much detail on what was about to arrive because that could give them tunnel vision. A conversation that required distraction of mental focus was just as unwanted. What usually happened was a bit of gossip or a joke. Light-hearted banter that could relieve tension before it achieved destructive proportions. Something that could be abandoned as easily as begun.
And Ryan could always be counted on to provide a joke that would make everybody laugh.
Everybody except Hannah. She made a point of never laughing at Ryan’s jokes because the vast majority of them were at the expense of women with blonde hair. Like hers.
Sure enough, he was telling one now.
‘So this blonde—Cindy—is in desperate financial straights and she prays for help. “Please, God, let me win the lottery or I’ll have to sell my car.” But she doesn’t win so she prays again, “Please, God, let me win the lottery. I’m going to have to sell my car
and
my house.”’
Everybody was listening. Or half listening. Waiting for the distant wail of the siren that would advertise that the calm was over. Hannah kept her gaze on the trolley, checking
that there was a range of paediatric-sized tubes and that the laryngoscope was still working.
She didn’t have to look at Ryan to know exactly what the image would be. He would be standing completely at ease with just a hint of a smile and a twinkle in those dark eyes that advertised an upcoming punchline. It might be a terrible joke but everybody would be listening and would be prepared to laugh because Ryan commanded that sort of attention. And popularity. Without even trying.
Hannah lips pressed themselves into a thinner line as she made sure that the more serious gear that might be needed for a surgical airway was at hand. No, it wasn’t just the professional competition that irked her. It was the fact that she had been as attracted to Ryan as every other woman who’d set eyes on him from the moment he’d arrived in this department three months ago.
It had been so unexpected. He was the epitome of the type of man she had always steered very well clear of. Despised, even, thanks to the collateral damage she had seen them produce in the lives of women she cared about. One of life’s golden people. She had probably been the first woman ever to freeze out an advance from him. Was that why he was persevering for so long? Did she represent some kind of challenge?
‘She
still
didn’t win,’ Ryan was continuing. ‘She’s down on her knees, pleading and this time God speaks to her.’ His voice dropped to a deep rumble that Hannah could actually feel in her bones. ‘And he says, “Work with me here, Cindy.
Buy a ticket!
’”
Sure enough, there was a wave of laughter. A wave that faded with dramatic swiftness, drowned out by the faint wail of a siren. Then the sound of the approaching siren died as it sped onto the hospital grounds with just its
beacons flashing. Seconds later, the stretcher appeared. A third crew member was moving rapidly beside the stretcher, a bag-mask unit over the face of the child, trying to keep oxygen levels up on the short journey between the ambulance and the trauma bay.
The team went into action as a unit. The transfer of the small body was smooth—made easier by the fact he was strapped to a backboard with a collar to protect his neck. And although this team was well used to seeing victims of major trauma, it was a shock to get their first close-up view of this little boy.
Waiting at the head of the bed to manage the airway, Hannah sucked in a quick breath that was almost a gasp. No wonder he hadn’t been intubated and it would have been far too dangerous to attempt a nasopharyngeal airway. His nose and mouth were almost lost beneath swollen and lacerated tissue. There were obvious facial fractures and the eyelids were so swollen it was impossible to open them enough to assess the pupils with a torch.
‘Do we know his name?’
‘Brendon,’ one of the paramedics supplied. ‘His mother was initially conscious enough to be calling for him.’
He was wearing pyjamas, Hannah noticed as she leaned forward. Bright red racing cars on a blue background. ‘Brendon, can you hear me?’ She reached over his shoulder. Why had he been in a car in pyjamas instead of safely asleep in his bed? ‘Squeeze my hand if you can hear me, sweetheart.’
A response hadn’t really been expected and Hannah moved swiftly to take the tip of the suction unit Jennifer was holding. The child was moving air but there was a nasty bubbling sound and the probe on his finger revealed an oxygen saturation level that was far too low to be acceptable.
‘Rapid sequence intubation?’
‘If it’s possible.’ Hannah’s gaze flicked up, relieved to find one of the senior anaesthetic registrars now standing right beside her.
Ryan was on the other side of the bed and farther down, moving in to assess IV access and flow and to look for other potential injuries as the pyjamas were cut clear of the small body.
ECG electrodes were being attached. Jennifer was using a bag mask to assist the delivery of oxygen. Hannah suctioned as much blood as she could from Brendon’s mouth and nose.
‘I can’t see anything that clearly looks like CSF,’ she said. Not that that discounted the possibility of skull fractures or spinal damage.
‘Saturation’s down to ninety per cent. Let’s go for the intubation,’ the anaesthetist advised. He took the bag mask from Jennifer and began to squeeze it rapidly, increasing the amount of oxygen reserves to cover the down time for trying to get a tube into Brendon’s throat. He was clearly prepared to provide back-up rather than taking over the procedure.
Hannah drew in a slow breath to dispel any nerves. She heard herself issue instructions for the drugs needed, like suxamethonium to relax muscles and atropine to prevent the heart slowing dangerously. The formula for determining the size of the endotracheal tube was there instantly—the diameter equalled the age of the child divided by four, plus four.
‘I’ll need a 6 millimetre, uncuffed tube,’ she informed Jennifer. ‘And I want you to hold his head while we ease this collar off.’
It was a challenge, easing the blade of the laryngoscope past the swollen lips, broken teeth and a badly lacerated tongue, and Hannah had to use the suction unit more than
once. It was an unexpectedly easy victory to visualise the vocal cords and slip the tube into place.
‘I’m in.’ The tone was one of satisfaction rather than triumph, however. There was still a long way to go but at least they were on the way to stabilising a critically ill patient.
‘Well done.’
With her stethoscope now on Brendon’s chest to check for correct tube placement and equal air entry, the quiet words of praise were muted and, for a moment, Hannah thought they might have come from Ryan.