‘THAT SHOULDN’T HAVE HAPPENED. It was so unprofessional. I’m really sorry...’
Big blue eyes were filling with tears and Dr Matilda Dawson felt her heart sink another notch as she pulled a handful of tissues from the box and held them out. Night shift in a busy big city emergency department could be a challenge at any time. In the final run-up to Christmas, at the peak of silly season, it could be absolute chaos.
Everything had been under control until now—apart from having been unable to return a second missed call from her father, which was enough to make Tilly wonder if something had gone wrong with the plan for her to spend Christmas Day with her only family member. An opportunity to make a quick call had been ambushed, however, when Tilly had observed a junior nurse struggling to cope with the relatively simple task of taking an ECG on a patient who’d come in with chest pain.
Tilly had had no choice but to divert another nurse to do the ECG and whisk a clearly very unhappy young staff member into this office space to find out what the problem was. They couldn’t afford to have people on the front line who were distracted enough to be unable to function efficiently.
‘I’ll pull myself together.’ The nurse, Charlotte, blew her nose and then sniffed decisively. ‘Honestly, this is stupid. I’m twenty-one. It’s not as if I haven’t been dumped before but...’
Oh, no... Tilly could see someone over Charlotte’s shoulder, walking past the open door of this office. Someone who was smiling at her. The someone who’d apparently just broken Charlotte’s heart.
‘Merry almost Christmas,’ he said, in that adorable Irish accent that would have captured any woman’s attention if, inexplicably, the smile hadn’t already done the trick.
Tilly glared at him. This is your fault, was the silent message. You should be ashamed of yourself, Harry Doyle.
‘This is entirely my fault,’ Charlotte said, as if Tilly had spoken aloud. Her voice was wobbling as she turned her head to see Harry’s back. ‘He told me, right from the start. He said he’d go to the concert I had an extra ticket for but it would only be as a friend. It wasn’t a date or anything. But it felt like a date... And I really thought he might be the one...you know?’
‘Yeah...’ Tilly’s tone was a little grim. She knew. ‘Why did it feel like a date?’ she asked cautiously. ‘He didn’t try and—’
‘Oh, no,’ Charlotte said hurriedly, shaking her head. ‘Not at all. He didn’t even try to kiss me goodnight afterwards.’
She sounded deeply disappointed and Tilly felt suddenly weary. Was Charlotte so innocent she didn’t realise that making herself so available could have had a very different outcome? One that could haunt her for years to come?
‘You must have been aware that he’s been out with almost every single woman in this hospital, and that’s quite an achievement when he’s only been here for a few months.’
Okay, so that was a bit of an exaggeration, but Tilly had had him pegged from the moment she’d been introduced to him and had been the recipient of that smile, along with a gleam that could only be described as flirtatious in those distinctive, smoky grey-blue eyes. Harry Doyle might have come with very good professional references but, on a personal level, he was a player. A good-looking Irish rogue who could use his not inconsiderable charm to rule the world and everyone in it.
Apart from Tilly, of course.
‘I know. But then you think that it might be different this time. That you might be the one they’ve been looking for all along.’ Charlotte took a deep breath. ‘Sorry,’ she said again. ‘I’m fine, really. It won’t be a problem. I need to get back to my patients.’
Tilly could see her scanning the department as they walked towards the central hub. Bright red and green cardboard letters stuck to the front of the desk welcomed patients with the seasonal Maori greeting of Meri Kirihimete and there was a tiny, unobtrusive Christmas tree on one end of the counter, wrapped in silver tinsel with a star on top. There were two ambulance crews waiting for the triage nurse to decide where the new patients could go and some junior doctors and medical students were focused on computer screens to check past medical records or look for X-ray or laboratory results.
A cleaner, wearing a cheerful Santa hat, was mopping the floor nearby and a technician was humming a Christmas carol as he pushed a trolley past. Tilly could see that Harry was standing beside the patient who’d required the detailed ECG as part of the process of investigating whether his chest pain might be a symptom of a heart attack.
Charlotte had seen Harry as well and Tilly could almost feel her brushing off her earlier despair. She was smiling now. Almost beaming, in fact, as she caught Tilly’s gaze.
‘It’s Christmas,’ she said, as if she realised her dramatic mood change might need an explanation. ‘And you never know... Miracles can happen.’
Harry could see Charlotte coming towards him from the corner of his eye but he didn’t look away from his patient.
‘Can you describe this pain for me?’
‘It was like being kicked by a horse. Right here.’ The man put his hand over the left side of his chest.
‘So it came on suddenly? What were you doing?’
‘I had a crate of beer in the basement. Couple of dozen. I was bringing them in to put in the fridge because we’ve got a barbecue tomorrow, but I had to stop when I was only halfway up the steps. I couldn’t breathe, Doc, and then it hit me. Wham... My missus had to call an ambulance because I couldn’t move, the pain was so bad I felt sick and I got all sweaty, but they got there really fast.’
Harry nodded. Telling the emergency services that a middle-aged man had severe chest pain, nausea and sweating would get an ambulance on the way very quickly. The paramedics had taken an ECG that was normal, however, and a repeat one done when he’d arrived in the department didn’t show any abnormalities. The patient report form the paramedic team had completed stated no medical history of any cardiac or other major health problems either.
Charlotte came into the cubicle with an apologetic smile. ‘I’m so sorry I had to dash off like that, Gerald,’ she said. ‘But I’m back now and I’m going to take very good care of you.’
‘Thanks, darlin’.’ Gerald was grinning at the pretty blonde nurse. ‘I’m feeling better already.’
His smile vanished, however, when Harry put his hands on his chest wall to examine him. ‘Ouch...that really hurts.’
Harry could feel Charlotte’s gaze on him. She was poised to follow any direction he might give to administer painkillers. Or to deal with a cardiac arrest? She was so young and eager. And it was disconcertingly obvious that she had a bit of a crush on him.
‘Can you take a deep breath?’ he asked Gerald.
The intake of breath was interrupted by a sharp groan.
‘Too painful?’
Gerald nodded, his face still crumpled in agony. Charlotte put her hand on his shoulder. ‘It’s okay,’ she told him. ‘We’re going to look after you.’
‘It might not feel like it, but it’s good news that the pain gets worse with a deep breath,’ Harry said. ‘Along with your normal test results, we can be confident that you’re not having the heart attack you thought you were having. You’ve pulled one of your intercostal muscles—the ones that go between your ribs and make up the chest wall. It’ll be sore for a few days so you’ll need to avoid any strenuous activity. I’ll write you a script for some anti-inflammatories.’
He could feel Charlotte’s gaze following him as he went to print out a prescription and sign a discharge summary. ‘You were lucky enough to get the best doctor we’ve got,’ he heard her tell Gerald. ‘Isn’t he wonderful?’
Tilly Dawson didn’t think so. She was glaring at him as he paused by the central desk to deal with his paperwork. She hadn’t been that thrilled to see him when he’d greeted her earlier, come to think of it. Was it because he was filling in for a friend and she hadn’t expected to have to work with him? Or was it just that, for some reason, she really didn’t like him? He’d long since given up trying to charm this colleague and, given her cool, controlled demeanour, he hadn’t been surprised to discover she had the nickname of being the ‘Ice Queen’. They had managed to avoid working closely together so far but he’d been in this department at the same time often enough and he couldn’t remember ever seeing Matilda Dawson smile with any real warmth. Or hearing her laugh, come to think of it.
Somehow, her lack of friendliness seemed more undeserved tonight. It was only a couple of days until Christmas, for heaven’s sake—the universal time for goodwill and kindness—and they had the rest of a night shift to get through together. It was after midnight already and he could hear a very inebriated patient shouting from one end of the department, a small child shrieking from another corner and there was more than one phone ringing. A flashing light was a signal that a radio call needed to be answered from an incoming ambulance, which usually meant that a serious case was on the way. It was shaping up to be a long night and Harry did not need any extra tension from feeling like he’d done something wrong.
So he smiled at Tilly. One of his best smiles. ‘How’s it going?’
She didn’t smile back. ‘It’s fine,’ she said. ‘Or it will be, if you don’t upset any more of our nurses.’
Harry’s smile evaporated. ‘I have no idea what you’re talking about.’
Except...she’d been talking to Charlotte when he’d walked past earlier and the young nurse had been clutching a handful of tissues. He’d wondered at the time if Charlotte had been upset by a patient death or that perhaps she was being reprimanded for a failure to follow a strict protocol that he could be sure Tilly would have spotted instantly, but maybe he’d been miles off the mark.
And maybe it had been a bad idea to go to that concert the other evening, but Charlotte had told him it was a departmental group outing that she just happened to have an extra ticket for. He’d thought it was odd they hadn’t come across anyone they knew in the mosh pit, but the music and dancing had been great fun and he’d made it crystal clear before he’d accepted that invitation and again at the end of the evening that it hadn’t been any kind of a date. Hadn’t he?
If Tilly could see his silent question, she wasn’t about to answer it. She simply turned away to speak to the nurse who had picked up the ambulance call.
‘Post cardiac arrest case en route,’ he heard the nurse say. ‘ETA three minutes. Fifty-six-year-old male who’s in sinus bradycardia but still being ventilated. I’ll get the catheter lab on standby.’
Harry looked at the growing list of patients that had been allocated to him. The sore throat in one of the curtained cubicles had been waiting a while now. He picked up the patient file from the desk as Tilly moved swiftly away towards a resuscitation area where she would be continuing treatment for someone lucky enough to have beaten the odds and survived a cardiac arrest. So far. Way more exciting than a sore throat, that was for sure.
Not that he was going to waste any mental energy feeling envious of others having a more interesting challenge. Or feeling hard done by because someone disliked him for no obvious reason. It reminded him of some of the more miserable moments of his childhood, when he’d had to change schools as his mother moved them yet again in search of a cheaper rental or a better job. He might have learned that making people laugh or feel good was a quick way to make friends but he’d also learned that there were some people who weren’t going to like you no matter how hard you tried and it didn’t really matter because you could just move on and make a fresh start.
Harry Doyle was thirty-six and he’d lost count of the number of fresh starts he’d made in his life so far. He’d been in New Zealand for a good three months now but, as much as he loved the country and its people, it felt increasingly as if there was something missing from his life. It might already be time to think about moving on again.
Somewhere a bit closer to home, he decided as he introduced himself to an eighteen-year-old who had come to the city to spend Christmas with friends. It looked as if Talia had come from a summer beach party with the shorts she was wearing along with an oversized singlet over a bikini top. Harry added a condition to that decision to move on before he pushed it aside to focus on his patient. His next destination needed to be back in the northern hemisphere. Celebrating Christmas in the middle of summer felt so wrong it might be a big part of the reason he was feeling as if something needed fixing in his life.
Something was also clearly wrong with the throat he found himself peering at moments later. The ominous spots on the red and swollen tissue of the throat and tonsils, combined with the fever and painfully enlarged lymph nodes of his patient suggested a strep infection and, with a young Pasifika patient, he knew the risk was greater of it becoming something more serious like rheumatic fever. Starting antibiotics had to be a priority.
‘We’ll do a rapid antigen test for strep throat, Talia. If it’s positive we’ll start you on a ten-day course of antibiotics. Are you allergic to any medications, like penicillin?’
Talia shook her head. ‘Don’t think so.’
‘Have you got a nurse looking after you?’
She nodded this time. ‘She went to find me an ice block. She said it might help make it easier to swallow.’
It was Charlotte who arrived with the fruit-flavoured frozen snack. Her face lit up when she saw Harry.
‘I was just looking for you,’ she exclaimed. ‘Gerald’s waiting for his discharge form so he can go home. Someone else was asking where you were too.’ She smiled at him. ‘You’re popular tonight.’
Popularity wasn’t Harry’s goal. He would be happy to settle for being able to keep all the balls he was juggling up in the air without dropping any of them. He had a patient with severe abdominal pain that could be appendicitis. Or a kidney stone. Or possibly a urinary tract infection, but she’d been unable to provide a sample for analysis. She was due back from a CT scan but Harry needed to find the swab for Talia’s rapid antigen test and check on the diabetic patient from earlier in the night who was being observed as he recovered from a hypoglycaemic episode. When Talia’s test result was positive for strep throat, he went back to let her know.
‘You can have a one-off injection of penicillin,’ he told her. ‘If that’s preferable to taking a ten-day course of pills twice a day. It’s very important that you don’t miss any doses with the pills or stop them in a few days because you’re feeling better. This bug can come back or hang around and cause other problems down the track. It can even damage the valves in your heart, which can be very serious.’
‘I’m going camping for Christmas with my friends.’ Talia bit her lip. ‘So it might be difficult to remember to take pills. Is the injection really painful?’
‘It’s got local anaesthetic in with it, so it’s not too bad,’ Harry promised. ‘Then you just need to wait here for twenty minutes or so to make sure you don’t have any kind of allergic reaction.’
Harry was thinking about Talia’s planned trip as he headed for the drug room to prepare her medication. It was another weird thing about this side of the world, wasn’t it? He’d heard that some New Zealand camping grounds were magnets to celebrate Christmas or see in the New Year in the sun, preferably beside a beach or a lake, but he could remember how excited he’d been as a kid when it started snowing in time for the big day. He still had a photograph somewhere of him and his mother standing beside the best snowman in the world that they’d created.
‘Are your friends going to take you home?’ he asked Talia.
‘Yes. They got sick of waiting so they went to get hamburgers.’
‘I’d like to talk to them before you go. About being careful with sharing food and drinks while you’re camping and that they’ll need to see a doctor if they get any symptoms themselves.’
When Harry came out of Talia’s cubicle having administered the injection, he saw a patient being wheeled out of Resus with a medical team surrounding the bed that included the senior consultant on duty. If it was the same one who’d been rushed in, the change was astonishing. He wasn’t being ventilated any longer. He wasn’t unconscious. Propped up on pillows, the middle-aged man was awake. Smiling, even.
Harry veered towards Resus as Tilly emerged. ‘Is that the post-cardiac arrest guy?’
Tilly nodded. ‘He’s finally stable enough to be on his way to the cath lab for angioplasty.’
Managing the critically ill patient had obviously been a challenge. Tilly’s cheeks were pink and there was a strand of long dark hair that had managed to work itself loose from the tight braid she always wore. He could sense her satisfaction in the case and he knew what that felt like. He could feel a corner of his mouth lift in a wry smile. Dr Matilda might not like him very much but they had something quite significant in common, didn’t they?
‘Well done,’ he said quietly. ‘He’s a lucky man.’
‘He’s had a massive left anterior STEMI so he’s not out of the woods yet.’ Tilly was scanning the department as if she was trying to decide where she might be most needed next. An ambulance stretcher was being rushed into the second resuscitation area beside them, where the trauma team being led by the HOD was waiting. That could mean there were other patients who’d been temporarily abandoned so that the incoming emergency could be dealt with. The whole department was on a knife-edge that could tip them into chaos at any moment.
And Tilly was frowning. ‘Oh, no...’ she muttered. ‘What’s wrong this time?’
Harry followed her line of sight to see Charlotte rushing out of the cubicle he’d been in only minutes ago, to administer Talia’s injection. And something was very clearly wrong. Charlotte looked absolutely terrified.
‘Help!’ she called. ‘Someone? I need help...’
Tilly followed Harry.
She’d been about to confirm she wasn’t needed by the trauma team before focusing on whatever priority was deemed most urgent elsewhere in the department but Harry’s reaction to spotting Charlotte trumped any other option. He knew something bad was happening—she could feel it by the sudden tension in his body language. No, it was more than tension. It felt like fear...
Any opinion that his reaction was a bit over the top vanished as Tilly stepped into the cubicle. A young girl was sitting bolt upright on the bed looking even more frightened than Charlotte. Her eyes were puffy and a rash was making the skin on her arms look oddly lumpy. More alarmingly, the high-pitched sound she was making as she sucked in each breath told them that there was a potentially life-threatening problem with her airway.
‘Talia had intramuscular penicillin about five minutes ago,’ Harry said tersely. He stomped on the brake at the end of the bed and started pushing it. Charlotte leapt out of the way, pulling the curtain open at the same time. ‘Resus One’s clear, isn’t it?’
Harry didn’t wait for Tilly’s affirmative response. The area might not have been cleaned yet, with the last critically ill patient having only just been transferred, but it would have everything they could need in the way of equipment and drugs available for a respiratory emergency.
Everything except perhaps assistance at the level of skill that could be required. Tilly could see more staff rushing into Resus Two and caught a glimpse of what looked like a traumatic cardiac arrest being managed in there. The bedside space was already crowded so it was a no-brainer for Tilly to stay with Harry. She might have heard good things about his professional abilities, but she’d never worked closely with him personally and there could be a young girl’s life hanging in the balance with what appeared to be an anaphylactic reaction to antibiotics unfolding in front of them.
Harry went straight to the drug cupboard in Resus One to draw up adrenaline.
‘Can you get some high-flow oxygen on, please, Charlotte?’ he directed. ‘And we’ll need the IV trolley. Tilly, could you get some ECG dots on and a set of vital signs?’
Tilly worked fast, sticking electrodes onto Talia’s shoulders and abdomen so that they could monitor her heart rate and rhythm. She wrapped a blood pressure cuff around her upper arm to enable automatic measurements and clipped a pulse oximeter to her finger. She could feel her own heart rate increasing as the figures started appearing on the screen of the monitoring equipment.
‘Heart rate’s one thirty-two,’ she relayed to Harry. ‘Blood pressure’s eighty-six on fifty, respirations twenty-eight and pulse ox ninety-four percent.’
In other words, her heart rate was too high, the blood pressure was too low and, despite rapid breathing, there was not enough oxygen circulating in Talia’s blood, but Harry’s words to their patient were as calm and reassuring as if this was nothing to be overly concerned about.
‘I’m going to give you an injection in your leg,’ he told her. ‘It should start to help your breathing very soon. I know this is scary, Talia, but hang in there. We’ve got this, okay?’
Talia nodded. Charlotte, her hands shaking, was trying to fit an oxygen mask over Talia’s face at the same time Harry was injecting the adrenaline into the muscle of her thigh.
‘Let’s find a non-rebreather mask instead of this one,’ Tilly said calmly, taking the mask from Charlotte’s hands. ‘And we need to turn the rate up as high as possible.’ She caught Harry’s glance and the flash of appreciation that she was here and he wasn’t having to deal with an emergency with an inexperienced and extremely nervous young nurse.
‘Could you set up for a fluid challenge?’ he asked. ‘I’ll get some IV access.’
Tilly found and checked a bag of IV fluid, hung it up and then opened a set of tubing and flow control to get it ready to attach to both the bag and an IV cannula. There was also a pressure infusion cuff that needed to be wrapped around the bag to enable rapid delivery to counteract the hypovolaemia that anaphylactic shock could cause. She was watching what Harry was doing from the corner of her eye at the same time. The combination of urticaria, dark skin and low blood pressure would make it a challenge to find a vein, let alone slip a wide-bore plastic cannula into place but, again, Harry gave the impression of being calm and confident, so Tilly wasn’t surprised that he completed the procedure within seconds. She was, however, impressed enough to nod at him.
‘Well done,’ she murmured.
The few minutes it took to accomplish these first steps meant that it was time for a second dose of adrenaline. Judging by how little response there had been to the first dose, Tilly wondered if Harry was thinking of starting an IV infusion of the drug. He was certainly on top of his plan of action.
‘I’ll draw up an antihistamine and steroids too,’ he told Tilly. ‘We’ll get a twelve lead ECG, chest X-ray, an arterial blood gas and some bloods off to check her urea and electrolyte levels. Could you set up a racemic adrenaline nebuliser, please?’ His gaze slid sideways. ‘Talia?’ He was focused on her face beneath the oxygen mask. ‘How’s your breathing feeling now? Is it getting any easier?’
But Talia didn’t nod. Or shake her head. Her mouth was opening and closing beneath the mask and her eyes were wide and terrified. Then her eyelids fluttered and closed.
‘Talia?’ Harry was at the end of the bed in a single step. He lowered the end of the bed, pushed the pillows off and tilted her head to open her airway.
‘She crashing,’ Tilly said quietly. ‘Blood pressure and heart rate are dropping.’ She turned to pull the airway trolley closer. ‘SPO2s under ninety.’
Talia’s level of consciousness was also dropping fast and she was clearly struggling to breathe.
‘We’re losing the airway.’ Harry’s words were quiet but he was dropping a verbal bombshell.
Charlotte made a distressed sound and stepped back, her fingers pressed to her mouth. This time Harry’s gaze caught and held Tilly’s for a heartbeat. And then another. The decisions they had to make in this space of time were huge but could mean the difference between life and death for a young woman. A normal intubation via the mouth or even the nose was highly unlikely to be possible due to the swelling of the tissues at the back of the tongue and in the larynx, which left only one alternative to secure an airway in time—to go in through the front of the neck.
There was no time to summon extra help, like the anaesthetist who was currently busy anyway in Resus Two, dealing with the major trauma case. Charlotte was too overwhelmed to be useful, so this was down to Harry and Tilly and part of their swift, silent communication was deciding who was going to perform this invasive procedure. In the end, that decision was as much of a no-brainer as having come to assist Harry in the first place because Tilly thought she saw Harry’s confidence falter. Just for a nanosecond, but it was enough.
‘I’ll do it,’ she said.
Oh, man...
Tilly couldn’t possibly know what was going through Harry’s mind in that instant—a flashback to a scene that had started in an almost identical fashion to this and ended in catastrophe—but she saw enough to take the lead and...and it felt like a lifeline. He could—and would—have stepped up to this challenge with every expectation of success but, for this young girl’s sake, it was much better for it to be done by someone who didn’t have a demon to fight.
He could step back. Not as far as Charlotte had, of course. He could provide the skilled assistance that Tilly needed with drawing up drugs needed and having all the equipment available. He arranged the scalpel, artery forceps, bougie and the endotracheal tube on the sterile drape and made sure he had an ambu bag with an end tidal CO2 detector attached. He helped position Talia by hyperextending her neck when the drugs took effect but he didn’t have the responsibility of identifying exactly where to make that incision through the cricothyroid membrane and then open it, insert a guidewire and then slide the hollow tube over the top to create a patent airway.
He just needed to hold his breath and hope like hell that Tilly really knew what she was doing.
She certainly seemed to. Her focus was intense enough to suggest that failure wasn’t allowed to be an option, the movements of her hands suggested that this wasn’t the first time she’d performed this procedure and within a commendably short space of time the bag mask was attached to the tube and oxygen was flowing to where it needed to go. There was still a lot to do to ensure this patient’s condition was stable but, as Tilly’s gaze snagged on Harry’s as she looked up to check the readings on the monitor, it was an acknowledgment that they were already well on track to a successful outcome in an unexpected crisis. And that they’d done it together, as a team.
He could see something else in her eyes he’d never seen before.
Respect? He knew she’d been impressed at the speed with which he’d managed that tricky IV cannulation but there was an edge of something else in that brush of eye contact and it looked like curiosity. Had she guessed that when a surgical airway had to be done he’d been facing a personal challenge of a scenario he’d never wanted to see repeated? If so, she wasn’t judging him for it but rather wondering what it had been about. Maybe he’d tell her about that case at a more appropriate time.
For now, it was enough to know that that ghost had been laid, so he was unlikely to feel that frisson of doubt that could potentially affect his performance if he was ever faced with this situation again.
Which meant that he was most definitely in Dr Matilda Dawson’s debt.
Big-time.