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  When he got there, he could see it was getting busy. He crossed to the nurses’ desk.

  ‘Ange?’

  The nurse looked up. ‘Major resus. Bed four.’

  Kash nodded. A bed in the resus bay of the ‘major injury’ section: whatever it was, that meant it was bad. He pushed through the swing doors and slipped behind the curtains surrounding the fourth bed.

  Ahead of him lay a fourteen-year-old boy, as gangly and slight as Kash had been at that age. At first, Kash could not see his face – the bedside was crowded, another doctor – Marcus Something? – and Ange bent low over him. When he moved closer, he saw the boy was pale, his eyes fixed on the ceiling. His breathing was fast and shallow. A woman – his mother? – was mopping the sweat which beaded his forehead.

  Kash had seen some very sick people since he’d been at the Victory, but this boy looked like shit. He lay there completely still. A spider of intravenous lines sprouted from the back of one hand and from the forearm above it. Ange was running through two of gelo stat – and the monitor by the bedside showed his blood pressure at 60/40. His mother held on to the other line-free hand, consoling herself by repeatedly telling him he was going to be fine.

  Ange caught Kash’s eye. Ordinarily, Ange seemed to thrive on the intensity of the emergency department, but now she looked worried.

  The mother looked up.

  ‘I’m Kash. Another doctor.’ His voice was calm and measured. He smiled. The mother tried to reciprocate. Kash turned. ‘Angela?’

  Angela straightened. ‘This is Edmund. Edmund Chaloner.’ She gently stroked the boy’s arm. ‘Marcus here,’ she nodded to the casualty officer, ‘called at once because he was worried. Previously well. Bit of asthma. Has an inhaler which he rarely uses. Otherwise fit and well. One-week history of sore throat. Fevers. Worsening general malaise. Been off school. Missed football, which isn’t like him. Two hours of left hypochondrial pain followed by pain in the left shoulder. Pale. Mum put him in the car and rushed him here. BP fifty on thirty on arrival. One litre in so far, and those two.’ She flicked her eyes towards the gelofusine on the drip stands. ‘But it must be coming out somewhere. BP’s still low, pulse one-forty and thready.’

  Her examination had been brief. Edmund Chaloner was pale and clammy, his throat raw – but when she’d touched his abdomen, she’d found it hard as a board. No bowel sounds.

  Marcus looked up. ‘I’ll get two more gelo up after those ones.’

  ‘Bloods?’

  ‘Cooking now. Should phone them down in a moment.’

  Kash watched the imperceptible flicker on Ange’s face. ‘We’re going to have to move, Kash. But I need the boss in for this one. Can you get him for me? Now?’ She turned to Marcus. ‘Call theatres. Tell them to prepare for a laparotomy. Then you might as well call the porters, get them to send him straight up.’ She turned to the boy. ‘Young man, you’re going to need an operation. Your belly, it’s sore, isn’t it? Well, we’re going to make that better for you . . .’

  She walked from the bedspace, followed quickly by the mother, who grabbed her sleeve. ‘He’ll be OK, won’t he?’

  ‘I’m sure. I don’t know what the problem is, but we need to look inside to find out. Then we’ll put it right.’

  While Ange was getting the consent form signed, Kash made his way to the telephone on the wall nearby. Once, not so long ago, his heart would have pounded at moments like this; now it felt like work, what he did every day. He lifted the receiver, and dialled zero for the hospital switchboard.

  ‘Switch?’ he said. ‘Can you page Mr Trenchard for this number?’

  ‘Mr Trenchard for A and E resus?’

  ‘Yes please.’

  ‘Coming up.’

  Kash replaced the receiver and waited, his eyes fixed on the receiver, while the ordinary emergency room chaos somersaulted around him. He felt like the eye in its storm. One minute later, the phone was still silent. Two minutes later, and Trenchard had not rung. He snatched the receiver, and dialled again.

  ‘It’s Kash, in the ED. No news from Mr Trenchard?’

  ‘He hasn’t answered yet.’

  Kash looked over his shoulder. Marcus and Ange were standing back as the porters wheeled Edmund Chaloner out of his cubicle, his pale-faced mother still clutching his hand.

  ‘Can you put me through to St Philippa’s, please?’

  St Philippa’s was the private hospital up on the river, only a cab ride further east. Kash waited.

  ‘St Philippa’s Hospital switchboard. How may I help you?’

  Kash breathed deep. He had to be there. He knew Trenchard was on call for the Victory, so shouldn’t be operating elsewhere, but perhaps he’d just called in to see a postoperative patient from days before. ‘Hi, there. My name is Kash Devan. I’m a doctor at the Victory. Could you put me through to theatres, please?’

  ‘Connecting you . . .’

  The seconds stretched out. There was too much silence, silence on the other end of the phone, silence as the lift doors closed, even a strange, distant silence in the emergency room around him. Then, at last, a voice broke through the veil. ‘Theatres,’ it said.

  ‘Hi, theatres. Sorry to trouble you. I’m Kash Devan, Mr Trenchard’s house officer at the Victory. I need him urgently. Is he there?’

  And there was that stultifying silence again.

  ‘He was here earlier, doing a case. But he left a good two hours ago.’

  ‘Do you know where he went? He isn’t answering his pager.’

  ‘Sorry. Maybe he’s with you?’

  ‘OK. Thanks anyway.’

  He slammed the receiver down, grimacing. If Mr Trenchard was with him, he’d scarcely be calling them, would he?

  He took a breath and tried to think. If Mr Trenchard wasn’t at the Victory, and if he wasn’t at St Philippa’s, then he’d be at home. Perhaps he’d slept through his pager? Or it had run out of battery? He dialled the home number.

  ‘Hello?’ came a sleepy voice.

  ‘Mrs, er, Trenchard,’ Kash stammered. ‘It’s Kash Devan, from the Victory. I’m a doctor – I work with your husband . . .’

  He waited a moment while she seemed to be processing this. ‘Yes, of course. Dr Devan. He’s spoken about you. Just the other day he was—’

  Kash hated to interrupt her but he couldn’t wait for her to finish. ‘Mr Trenchard. I’m looking for Mr Trenchard . . . it’s an emergency . . .’

  Her voice soured. ‘I know. He called from St Philippa’s to tell me. He was heading straight to you.’ She sounded wide awake now.

  Kash was confused. Perhaps Angela’s message had reached him somehow? Maybe he’d seen the pager number and come straight over? Maybe he had gone straight to theatres? But, then, St Philippa’s had said that he’d left a good two hours ago. He should have been here by now.

  ‘Thank you,’ he said faintly.

  The phone went limp in his hand. Kash dropped it back into the receiver and, for a moment, froze. Mr Trenchard was not in the Victory, he was certain about that. He was not at St Philippa’s and he was not at home. And a young lad was about to hit the operating room, with Angela being left alone to manage him. He looked up. For a moment, he had felt as if he was trapped in a bubble, with the emergency room swirling outside. But as the room came back into focus, his thoughts did too. Angela Warner was the best young surgeon there was. She had coped before, and she would cope again. Hell, it was probably just another appendix. Kash had scrubbed up for three of those already and had observed plenty more; given the green light, he could probably fly solo. Or maybe not. The pain was in the wrong place. But common things were common . . .

  Angela would need his help. Kash wheeled around, rushed for the lifts. The flickering yellow lights showed them hovering three storeys above, but the adrenaline was already coursing through Kash’s veins. He took to the stairs, three at a time.

  8

  Theatres were private universes. They nestled in the contro
lled chaos of the hospital, moving to their own rhythms, keeping their own times. In an operating theatre, there was no day or night, just the slow ticking of the clock to mark the passing time. Even when they awoke, they were not the scenes of excitement or chaos depicted on television screens. More, they resembled a factory floor, a busy assembly line where everyone knew their role.

  The porters swung Edmund Chaloner’s trolley into the anaesthetic room, which connected the main corridor to theatre three. They exited briskly, shutting the two swing doors behind them. Inside stood Jan. She had been an operating department practitioner, or ODP, at the Victory for six years and reckoned she’d seen it all. This case wasn’t going to be any different. Most of these ‘query appendix’ cases were nothing – pelvic inflammatory disease in young women, nothing at all in young men. It was rare that she saw any appendix come out that wasn’t lily-white, and even the inflamed ones could usually have waited until morning. But one glance told her that this was not one of her usual cases. Edmund Chaloner was lying far too quiet, far too still. He grunted with each shallow breath. He was less pale than white. Beads of sweat freckled his forehead, coalescing to mat his hair and run in rivulets to soak his gown.

  Jan slowed briefly to introduce herself to the boy, checking the name on his wristband against the notes that had come with him. ‘Edmund?’ The boy made no response, staring fixedly at the ceiling. ‘We are going to make you better. Don’t bother about me. I’m just going to attach a few wires, and then you can have a decent sleep. When you wake up, Mum will be there, and you’ll be fine.’ Her voice was relaxed and smooth, and she spoke deliberately slowly. But her hands now worked fast. She pulled the gown, connecting three electrodes to the boy’s chest, and then the three coloured wires which descended from the monitor on the anaesthetic machine. Next, she wrapped a blood pressure cuff firmly around Edmund’s upper right arm, and hit the automatic measurement button.

  As she did so, the doors behind her opened once more. Geoff Wright was the on-call emergency anaesthetist, his haystack bulk in stark contrast to his gentle manner and soft voice. Angela had called him. She had been brisk and to the point, and the lack of social niceties told him everything. Angela was quality. If she was worried, then he needed to be too. One glance at the boy, and his concerns were confirmed. Beside Jan, the blood pressure monitor flashed red and alarmed. Sixty on forty.

  ‘Hello young man,’ Geoff began. Perhaps his voice really did have a magical quality, because the boy’s breathing momentarily became less ragged. ‘Let’s sort you out then, shall we?’ He reached forward and stroked the boy’s left arm. It was icy cold. Seizing two rubber gloves, he knotted them together to make a tourniquet and wrapped it around the boy’s left arm. As he slapped it to bring up a vein, Jan handed him a cardboard kidney dish containing an orange intravenous cannula and an alcohol swab. The production line at work. But no vein was going to appear. The boy was just too shut down.

  Jan read his mind, and removed the makeshift tourniquet. ‘We’ve got a green and a blue line in on the right.’ She held out another pressed cardboard kidney dish containing some labelled syringes.

  ‘Thio, sux, tube, atracurium?’ he asked.

  ‘Vecuronium. Chart says he’s asthmatic. ET tube? Five or six?’

  ‘Five.’ Jan was good. She turned to select the right size of tube to pass down the boy’s airway to his lungs.

  Meanwhile, Geoff worked quickly and calmly. There were some doctors who would mess around all night. Not Geoff. Besides, time had run out some moments ago; you didn’t need a medical degree to see that this boy needed an operation now, not in twenty minutes. Cool and efficient, even polite – it was his way of keeping in control – Geoff slid a bag of fluid into a net casing, pumped up the bladder behind it to force the fluid in faster, and quickly checked that the trolley could tilt head-down, in case the kid vomited. Next, he switched on the suction, and put the connecting tube under the pillow. Now, if the boy vomited, he could clear his mouth and pharynx. Then, with a final word of promise to the boy, he turned on the oxygen, and placed the black rubber mask over his face.

  ‘Deep breaths, young man. A few moments and you’ll be fast asleep.’

  Jan slid past him, taking control of the mask. As she did so, Geoff moved to the drip-arm, connected a syringe, and injected the thiopentone. A barbiturate anaesthetic, thiopentone had the advantage of tending not to drop the blood pressure too much. Dropping this boy’s pressure would be near terminal. He breathed a little more rapidly, briefly moved his arms restlessly, then relaxed.

  As he did so, Geoff spoke firmly. ‘Sux, then cricoid.’

  Jan injected the contents of the 2 ml syringe – ‘Sux in!’– then turned and pressed firmly on the cricoid cartilage, at the lower part of the boy’s voicebox, thus compressing and blocking his oesophagus and preventing any regurgitation of stomach contents into the lungs.

  To open the belly of a sick child requires all of the muscles of the abdomen to be relaxed, and to do this requires paralysing the patient. Likewise, to pass a tube through the voicebox south towards the lungs. In an emergency, this has to be done as quickly as possible, and suxamethonium is the quickest agent available. It took only twenty seconds or so for the sux to work. The boy’s muscles twitched. His eyelids fluttered; his face winked and rippled. And then, nothing. He was sedated and paralysed. Quite literally; he couldn’t move a muscle.

  Geoff flicked the grey steel blade of the laryngoscope into Edmund’s mouth and, peering in, held out his right hand. ‘Tube.’ Jan placed it in his hand, and Geoff slid it through the larynx and into the trachea, inflating the small balloon at its tip. ‘Cuff up!’ He connected the black rubber bag to the tube, and squeezed, listening for air entry into the lungs on both sides. It was there. ‘Cric off!’ Jan released her pressure on the boy’s throat and began to connect the endotracheal tube to the ventilator, as Geoff injected the Vecuronium. Sux was good and quick, but it didn’t last long. Vecuronium would last a good deal longer.

  The whole business had taken less than a minute.

  Kash, meanwhile, had changed rapidly into blue surgical scrubs and white vinyl clogs. As he pushed back out into the corridor, he glanced at Trenchard’s locker. Its door was open. It was empty.

  Inside the operating theatre itself, Angela was already scrubbed, standing in one corner with gloved hands clasped. She raised her eyebrows as Kash walked in and made his way to the steel trough to wash his own hands.

  ‘He wasn’t anywhere, Ange. No answer on the pager. St P’s last saw him a couple of hours ago. He’s not at home. His wife thinks he’s here.’ The nursing staff, busying themselves with preparations, paused for a beat. Angela didn’t move. Kash continued to wash his hands. ‘But . . . ta-dah! You have me!’ He assumed a sonorous tone, reminiscent of Trenchard. ‘I am a very experienced surgeon, you know. The best. I’m sure that you know my reputation? I have seen three appendectomies. Three, I tell you.’ He turned to one of the staff nurses. ‘Gloves please. Size eight . . .’

  Angela allowed herself a half-smile. Kash’s cheesy routine was exactly what she needed.

  Behind them, the doors from the anaesthetic room opened and the trolley was wheeled in. Jan pushed it to one side of the operating table, and locked the wheels with a flick of her heel. ‘On slide. Ready . . . steady . . . slide!’ Together with the staff nurse, they slid the patient from trolley to table. Geoff reconnected him to a second anaesthetic machine and hung another litre IV bag to the drip stand. Meanwhile, Jan removed the boy’s gown, and swung the theatre’s operating lights to focus on his abdomen, another scrub nurse wheeling her trolley of sterile instruments into place.

  Geoff looked at the monitors. The boy’s heart rate was at 160 – far too fast. His blood pressure was at 64/35, despite that litre going straight in, but at least its oxygen saturation was 99 per cent.

  Ange moved into place beside the theatre sister and scrub nurse, as Kash snapped his gloves on and took up position opp
osite her. She glanced up at Geoff. ‘Ready?’

  ‘As we’ll ever be. His pressure’s crap. He’s empty. Jan just went for the blood.’

  At the same moment Jan crashed back into the theatre. ‘No blood. Lab says no one phoned the sample through. They’re doing it now, but it’s going to take forty minutes . . .’

  Kash felt the gut-punch. Shit. Marcus must have forgotten. He watched as Ange’s jaw clenched beneath her surgical mask. ‘Call them back, please,’ said Geoff. ‘Explain the urgency. Ask them for ten units ASAP.’ Then he turned to the nurse. ‘Grab the six O-neg from the fridge. Ange, we can start with those.’

  Ange nodded. It was best to give cross-matched blood, but you could give O-negative to most people in an emergency.

  She stepped swiftly to the patient’s side, picked up the scalpel from where it had been left. Beneath her, the belly was tense and swollen – but there was no point in messing about. No point debating the whys or wherefores, no point even thinking about what might have happened to Michael Trenchard to stop him from being there. While Kash watched, she placed the tip of the scalpel just below the ribcage and drew the blade all the way down to the line of Edmund’s shaved pubic hair, only deviating to curve around his umbilicus. A swab soaked up the blood that appeared in the cut. Then in went the diathermy forceps to fry any little bleeding points of the skin. A second sweep took her deeper again, through the thin white layer of subcutaneous fat. Again the diathermy. And now another sweep, this time through the muscle layer and the peritoneum, and into the abdomen itself.

  Blood welled up through the wound, a slick red wave which spilled across her hands, cascading across the sterile drapes and flooding the floor. Ange stared at the wound and held out a hand, saying quietly, ‘Suction, please.’

  She pushed the hard plastic suction tip deep into the abdomen, the clear tubing to which it was connected bucking and slurping in response. ‘Kash?’