Authors: Meredith Webber,Alison Roberts
But he was no longer standing beside Brendon. Hannah had been concentrating so hard on her task she had managed to block the sounds of the second patient’s arrival and the stretcher was now being swiftly manoeuvred to the other side of the trauma room.
‘Blunt chest trauma with tachycardia and hypotension. No sign of a tension pneumothorax.’ she heard Ryan stating. ‘We could be dealing with an acute pericardial tamponade.’
Would Ryan attempt a procedure to drain off the fluid inhibiting the function of the young mother’s heart? It would be a very impressive coup as far as patient treatment if it was successful. Hannah couldn’t help casting frequent glances towards his side of the room as she worked with the anaesthetist to get Brendon’s ventilator setting right, supervised the amount of IV fluid that was being administered, started an infusion of mannitol, which could help reduce intracranial pressure, and arranged transfer for an urgent CT scan of the boy’s head and neck.
Sure enough, Ryan was preparing to intubate his patient, cardiac monitoring was established and kits requested for both pericardiocentesis and chest drainage. Ryan looked determined and confident but less than happy about the
challenge he was about to face. And no wonder. From what Hannah could see, the woman’s condition was deteriorating rapidly.
Ominous extra beats were disrupting the line of the ECG trace on the screen of the monitor.
There was time for one more, rapid secondary survey on Brendon before he was taken to the CT suite.
‘Some of these bruises look old,’ she commented.
‘Maybe he plays rugby,’ Jennifer suggested.
‘You reckon his mother does as well?’ Wayne had been helping Ryan’s team in the initial preparation of his patient. ‘She’s covered in bruises as well.’
Hannah eyed the clothing remnants Wayne was putting into a patient property bag. ‘Dressing-gown?’ she queried.
He nodded. ‘I don’t think their trip was planned.’
A police officer was standing well to one side of the now crowded area. ‘Have any relatives been contacted?’ Hannah asked him.
‘We didn’t need to. The car she was driving had just been reported stolen.’ The police officer’s face was grim. ‘By her husband.’
Hannah absorbed the information like a kind of physical blow. Was her patient an innocent young victim caught up in a situation involving domestic violence? Had his mother’s desperate bid to protect him ended in a disaster he might never recover from? Would he even still have a mother?
It seemed unlikely. Ryan was sounding uncharacteristically tense as Brendon’s stretcher was taken through the double doors on the way to CT.
‘We’ve got VF. She’s arrested. Charging to 200 joules. Stand clear!’ He looked up as he recharged the paddles. ‘Hannah, are you free?’
Hannah’s hesitation was only momentary. She had been
planning to follow protocol and accompany Brendon but he already had an expert medical escort in the anaesthetic registrar. She knew what Ryan would do if the roles were reversed and
she
asked for assistance. Hannah turned back.
‘I’m free,’ she said quietly. ‘What do you need?’
‘W
E
’
VE
got sinus rhythm.’
Ryan dropped the defibrillator paddles with relief. The same kind of relief he’d noted when Hannah had turned back to help before he’d delivered that last shock. Not that he’d doubted he could count on her in a professional capacity. He could see her pulling on gloves and positioning herself beside the tray containing the pericardiocentesis and chest drain kits as he reached to check his patient’s pulse.
‘Carotid is barely palpable,’ he reported grimly.
‘Systolic pressure is fifty-nine,’ Wayne confirmed.
‘Let’s shut down the IV. Just run it enough to keep the vein open,’ Ryan ordered. ‘There’s been no response to a fluid challenge and if we’re dealing with thoracic haemorrhage it’ll only be making things worse.’
‘Ventricular ectopics starting again.’ Hannah had an eye on the monitor screen. ‘And the systolic pressure is dropping. Down to fifty-five.’
The patient was threatening to arrest again. Ryan reached for a scalpel and Hannah had the forceps ready to hand him a moment later. Then the cannula for the chest drain. In less than a minute, blood was draining freely into the bottle. Too freely. All too soon, the bottle was almost full.
‘Have we got someone from Cardiothoracic on the way?’
‘No.’ Jennifer shook her head at Ryan’s terse query. ‘Sorry. They’re unavailable for fifteen to twenty minutes. They’re tied up in Theatre with a post-bypass complication.’
‘Have we got a thoracotomy kit?’ He could almost hear a collective intake of breath. ‘She’s exsanguinating from a chest injury and about to go into cardiac arrest again. A thoracotomy might be a long shot but it’s the only hope we’ve got.’ Ryan knew the statistics were not on his side but at least they would be doing something other than watching this woman bleed to death.
Hannah nodded once, as though she had gone through the same thought processes and was in agreement with him. ‘Want me to scrub as well?’
‘Yes. Thanks.’
Wayne was sent to find the rarely used sterile kit. Jennifer took over the task of manually ventilating their patient. Ryan scrubbed fast. Ideally he should have the chest opened in less than two minutes. Faster, if there was another cardiac arrest.
‘Have you done this before?’ Hannah squeezed soap into her hands beside him.
‘Yes. You?’
‘Never even seen it.’
‘Know the indications?’
‘Penetrating thoracic injury with traumatic arrest or unresponsive hypotension or blunt injury with unresponsive hypotension or exsanguination from the chest tube. Overall survival is between four and thirty-three per cent but higher for penetrating injury.’
‘We’ve got VF again,’ Jennifer warned. ‘No … it’s asystole.’
Speed was now critical. A flat-line ECG meant that the heart couldn’t be shocked into producing a rhythm again. Chest compressions on someone with blunt trauma were also contraindicated because it could worsen the injury. Opening the chest was the only option with any hope at all now.
It was good that Hannah had never seen the technique. Explaining things as he started this incredibly invasive procedure somehow eased the tension of a desperate measure to save a life.
‘We’ll make bilateral thoracotomies in the fifth intercostal space, mid-axillary line—same as for a chest drain.’ Ryan worked swiftly with a scalpel and then a heavy pair of scissors. ‘I’ll be ready for the Gigli saw in a sec.’
He showed her how to use the serrated wire saw, drawing a handle under the sternum with a pair of forceps and then joining the handles and using smooth, long strokes to cut through the sternum from the inside out.
Hannah was ready with the rib spreaders. For someone who hadn’t done this before, her calmness and ability to follow direction was a huge bonus.
‘You can see why this is called a “clam shell” thoracotomy,’ he said as he spread the ribs away from the anterior incisions. ‘Suction, thanks.’ Ryan sucked out blood and clots from the chest cavity, hoping it would be enough for the heart to start beating again spontaneously.
It wasn’t.
‘Where’s she bleeding from?’
‘Haven’t found it yet.’ Ryan placed both hands around the heart. ‘I’m starting internal cardiac massage. Can you find and compress the aorta against the spine, Hannah? We want to maximise coronary and cerebral perfusion. I’ll clamp it in a minute.’
She was totally out of her depth here. It was a huge relief when back-up from the cardiothoracic surgeons finally arrived. They were impressed with Ryan’s management of the case so far, which was hardly surprising. Hannah wouldn’t have had the confidence or skill to go further than the chest drain insertion.
The thought that Ryan might deserve the consultant’s position more than she did was not a pleasant one.
Edged out as people with far more experience than she had took over, Hannah could only watch. It was hard, feeling the tension and increasing frustration as they failed to get the young woman’s heart started again, having controlled the haemorrhage from the damaged aorta.
Maureen’s signal, with the message that Brendon was now in the paediatric ICU and an invitation to discuss the results of the CT scan with the consultant, was welcome. Hannah slipped, unnoticed, from the resuscitation area.
She couldn’t afford to stand around admiring Ryan’s skill and thinking how easily he might win the position she’d wanted for so long. Or to share his disappointment at the inevitable failure he was facing. Empathy would create a connection that was too personal. Even worse than laughing at one of his stupid jokes. It would only make it that much harder to maintain the necessary distance between them.
Any reduction in that distance could only make her vulnerable.
And Hannah Jackson did not do vulnerable.
She’d always been the strong one. Ever since she was ten years old and her father’s sudden death had made her small family almost fall apart. Hannah had been strong for her mother. For Susie. For herself.
The lesson had been hard but valuable. Strength was
protection. The only way to get through life without being scarred too deeply.
Being too tired didn’t help when it came to being strong.
When Hannah entered the staffroom nearly an hour later, she could feel Ryan’s dejection all too easily. He had his back to her as he made coffee but his body language said it all. Slumped shoulders. Bent head. The way he was stirring his mug so slowly. If it had been any other colleague she wouldn’t have hesitated in offering commiseration. A comforting touch or even a hug. But this was Ryan. Distance was obligatory.
‘No go, huh?’
‘Nah.’ Ryan straightened his back. ‘Didn’t really expect to win that one but it was worth a try. Want coffee?’
‘Sure, but I’ll make it.’
Ryan was already spooning coffee into a second mug. ‘You take sugar?’
‘No.’
‘Milk?’
‘No.’
He’d been in the department for three months and didn’t know how she took her coffee but she was willing to bet he’d know the preferences of all the female staff who responded to his flirting. And that was every one of them.
Except her.
‘So how’s your little guy, then?’
‘Not flash. He’s in paediatric ICU but the scan was horrible. Multi-focal bleeds. If he does survive, he’ll be badly brain damaged.’
‘Might be better if he doesn’t, then. You saw the father?’
‘Yeah.’ There was no need for further comment. The glance Ryan gave Hannah as he handed her the mug of black
coffee told her he shared her opinion that the man she’d had to talk to about the serious condition of his child was an uncaring brute. Responsible for the death of his wife and quite likely his son, not to mention the admittedly less serious injuries sustained by the other drivers involved, and he hadn’t given the impression of being overly perturbed about any of it. ‘And they can’t even charge him for anything.’
‘No.’ Ryan went and sat down on one of the comfortable armchairs dotted around the edge of the room.
The silence was heavy. Too heavy.
Ryan cleared his throat. ‘Hey, have you heard the one about the blonde who didn’t like blonde jokes?’
Hannah sighed. She sat down at the central table, deliberately putting Ryan out of sight behind her right shoulder. Maybe it wasn’t good to sit in a depressed silence but this was going a bit too far in the other direction, wasn’t it? She sipped her coffee without saying anything but Ryan clearly ignored the signals of disinterest.
‘She went to this show where a ventriloquist was using his dummy to tell blonde jokes. You know, like, how do you change a blonde’s mind?’ He raised his voice and sounded as though he was trying to speak without moving his lips. “Blow in her ear!” And what do you do if a blonde throws a pin at you? “Run, she’s still holding the grenade.”’
‘Yeah, yeah.’ Hannah allowed herself to sound annoyed. ‘I know.’
‘Well, so did this blonde in the audience. She was furious. She jumps to her feet. “I’ve had enough of this”, she shouts. “How dare you stereotype women this way? What does the colour of someone’s hair have to do with her worth as a human being? It’s people like you that keep women like me from reaching my full potential. You and
your kind continue to perpetrate discrimination against not only blondes but women in general and it’s
not
funny!”’
‘Mmm.’ Despite herself, Hannah was listening to the joke. So Ryan was actually aware of why someone like herself might take offence at his humour? Interesting. Did that mean he was intentionally trying to get under her skin? That his charm with her was as fake as it had been with Doris Matheson and he actually disliked her type as much as she did his?
Ryan’s tone was deadpan. ‘The ventriloquist was highly embarrassed. He goes red and starts apologising profusely but the blonde yells at him again. “Stay out of this, mister. I’m talking to that little jerk on your knee!”’
Hannah snorted. Somehow she managed to disguise the reluctant laughter as a sound more like derision. She didn’t want to laugh, dammit! Not at one of Ryan’s jokes and not when she’d just been through a gruelling, heart-breaking and probably fruitless couple of hours’ work. She knew exactly why he was trying to make her laugh. It had to be the quickest way of defusing an overly emotional reaction to a case. But if she let him make her feel better, it would be worse than empathising with
him.
She could feel the connection there, waiting to happen. It needed dealing with. She had to push Ryan as far away as possible.
‘You just can’t help yourself, can you?’
‘I thought you might appreciate that one.’
‘What makes you think I’m in the mood for jokes right now?’ Hannah swivelled so that she could give Ryan a direct look. ‘Doesn’t anything dent your warped sense of humour? Even a battered wife who died trying to get her child to a safe place?’
‘That’s precisely why I thought a joke might be a good idea,’ Ryan said wearily. ‘Sorry, maybe I should have left
you to wallow in how awful it was. Maybe question your abilities and wonder endlessly what you might have been able to do better.’
‘It might be more appropriate than telling jokes.’
‘Really? What if another major case comes in in the next five minutes, Hannah? You going to be in a fit state to give that person the best you can?’
‘Of course I am.’
‘Well, lucky you. Some of us need to distract ourselves. Lift our spirits a bit. There’s always time for wallowing later.’
‘I don’t believe you ever wallow,’ Hannah snapped. She wasn’t going to admit that even that stifled snort of laughter
had
done something to ease the emotional downside of this job. She’d rather believe that it was being able to channel her frustration and anger into a confrontation that had been building for some time. ‘And you distract yourself often enough to be a liability in this department. You’ve been here, what, three months? And how many times have you taken time off to flit back to Australia? Four, five times? I should know—it’s usually me that does extra shifts to cover the gaps.’
This distraction was working wonderfully well. Hannah was really hitting her stride.
‘You know your problem, Ryan? You’re shallow. You’re so intent on having a fun life you can’t even spare the time to think about someone else.’
‘Oh?’ Ryan was staring at Hannah and she’d never heard him use such an icy tone. ‘Shallow, am I?’
‘You might find it more beneficial to your career to review cases like we’ve just had. You never know. Try having a professional discussion with a colleague next time instead of telling
stupid
jokes. You might learn something.’
‘From you?’ Ryan snorted. ‘I doubt it.’
‘Why?’ Hannah’s tone was waspish. ‘Because I’m blonde?’
‘No.’ Ryan stood up, abandoning his cup of coffee. ‘Because you’re less experienced professionally and far less competent when it comes to relationships between people. You’re judgmental, Dr Jackson, and you don’t even bother finding out the facts before you make those judgments.’
He stalked behind Hannah and she had to swivel her head to keep glaring at him as he made his parting shot. ‘And when I’m consultant, it might be nice if you made
me
coffee, babe. Not the other way round.’
‘Dream on, mate!’ What a pathetic rejoinder. Hannah could only hope Ryan would take it as she meant it—referring to the consultancy position and not the coffee-making.
Jennifer came in a few seconds after Ryan had left. Her eyebrows had disappeared under her fringe.
‘What on earth’s wrong with Ryan? I’ve never seen him look so grumpy!’
‘He’s a grumpy man.’
Jennifer laughed. ‘He is not and you know it. He’s a lovely man and if you weren’t trying so hard not to like him you would have realised that by now.’
‘I’m not trying hard,’ Hannah protested. ‘It’s easy. Besides, it was your friend in Sydney that told you what a reputation he had for breaking hearts. The man needs an emotional health warning attached.’
Jennifer shook her head, smiling. ‘Yeah … right.’ She took another glance at Hannah. ‘You look pretty grumpy yourself.’
‘It’s been a bad night. I hate cases like that—especially when they shouldn’t have happened in the first place.’ She sighed again. ‘And I’m tired. Roll on 7 a.m.’