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‘Gauze. Big one. Gamgee.’
Just as measured, just as calm as before, Geoff said, ‘Pressure’s going.’
‘Thanks, Geoff.’ Ange had wrapped the gauze around her fist, and now plunged it deep into the boy’s belly. Her eyes fixed in the middle distance, she slid her fist up the boy’s spine, feeling his aorta – the main blood vessel of the body – fluttering feebly beneath. Then she went further up, as high as she could go, until she could feel the diaphragm pressing down against her with each inhalation. Taking a deep breath, she placed her fist over the aorta and leaned down with straight arms, her whole bodyweight pressing below. The pulse was weakening. ‘Another gelo stat, please, Geoff.’
‘Already running.’
Kash glanced to his left. The clear cylinder to which his suction tube was connected already held a litre. Behind it, Jan appeared.
‘O-neg. Six units.’
Geoff glanced at her. They were meant to check each one, but there was just no time. ‘First one up, please, Jan.’ He glanced again at the blood pressure monitor. ‘We aren’t picking up. Ange – head down?’
‘Head down.’
Geoff kneeled and grabbed the silver handle on the side of the table, turning it fast. The operating table rose at the boy’s feet, forcing the blood to flow back into his heart, his brain.
The boy’s heart rate was slowing. 160. 140. 80. 50.
‘Atropine! Straight in, Jan!’
It took seconds for Jan to bring the syringe to the boy’s arm. As she did so, Geoff disconnected one empty blood bag, connected another and squeezed it with both hands, wrestling it by force into the boy’s empty body.
As one, they turned to the monitor. ‘Got it.’ It was Jan. ‘Fifty-five systolic. Better than nothing.’ They waited, Ange still leaning forward with all her strength, Geoff discarding another empty blood bag and attaching a third unit. ‘Seventy. And pulse back up to one-sixty.’
Angela clenched her teeth. ‘The fucking A-team,’ she whispered. But there were no smiles, no false bravado. This boy wasn’t out of trouble yet.
Kash looked at Ange. ‘Any ideas?’
Angela looked back across at him. ‘Whatever it is, it’s high. Got to be his spleen,’ she said. ‘EBV? Glandular fever can cause the spleen to rupture spontaneously . . .’
‘Yes. It can,’ he said uncertainly.
‘It’d fit with the one-week history and sore throat.’
‘Rare,’ interjected Geoff.
Ange pressed firmly on the boy’s aorta, the warmth of his body enveloping her forearm. ‘Well, that’s all right then. He’ll be OK, because it’s rare. How stupid of us!’ She rolled her eyes. ‘Bloody anaesthetists.’
‘One-oh-two on sixty-two,’ said Geoff, eyes still on the monitors.
‘Movin’ on up. Nothin’ can stop us now . . .’
Angela maintained the pressure while the last two units of O-neg went in. ‘Where’s the cross-matched blood?’ she breathed.
*
‘Still twenty minutes away,’ said Kash, ‘but we’ve got colloid to keep us going . . .’
‘Rate’s down to one-twenty,’ said Geoff. ‘We’re catching up.’
Ange nodded, caught Kash with a steely glare. This was it. Time to take a look. ‘Jan,’ he said, ‘can you move the lights? We’ll need them pointing in and up, if it really is the spleen . . .’
Once the operating lights were in place, Ange looked back at Kash. ‘I need you to occlude the aorta,’ she said. ‘Can you manage it?’
Could he? Only one way to find out.
‘One fist,’ Ange said as she prepared for Kash to take over. ‘One fist, but all your weight. Fuck up and he’ll bleed to death.’ She smiled. ‘And then so will you.’
‘Sounds fair,’ said Kash, with a lightness he no longer felt.
The switch-over happened in a second. He slipped his hand, holding a large swab, over and above hers. Then he made a fist, leaned in and down. Slowly, Ange released her pressure . . . Perhaps this was their one moment of divine intervention because, by some strange mercy, no more blood erupted. Kash concentrated on forcing his weight through his knuckles and nothing else.
For the first time, Ange breathed. ‘Ring retractor, please.’ The scrub nurse pressed the notched metal ring into Ange’s hand. By attaching blades to the ring and slipping these inside the wound, the wound’s edges could be pulled apart, giving a clear space in which to operate. She was settling herself to insert it when a sudden thought occurred: to get it in place, whoever was holding the aorta would have to have their hands inside the ring. A hundred thoughts collided in her mind. They had switched over too soon. ‘Kash,’ she said, ‘we’re going to have to switch again. I’ll do the aorta. You’ll have to attach the blades. Are you up to it?’
Kash nodded. A single droplet of sweat was beading on his eyelashes, distorting his view of the boy splayed open underneath.
Ange moved without hesitation: her gauze-wrapped fist passing through the ring retractor, sliding down Kash’s forearm to the place where his knuckles clenched tight. Slowly, breathing in unison with her, Kash released the pressure. He looked at Ange, her face a rictus of concentration. All was fine so far. She could do this. He knew she could . . .
Everything changed in an instant. Kash was still fixed on Ange when the thick smoky blood welled up in the wound, over her knuckles, over her wrists, fountaining out of Edmund Chaloner’s belly like a burst water main. ‘You’ve come off the aorta!’ he breathed. ‘Ange, you’ve come off the . . .’ Words failed him. The blood was dark. It was not spurting. This was not aortic arterial blood. Venous, then? Was it the boy’s veins? Below the crimson surface, Ange moved her fist – but the bleeding only worsened. It cascaded down the boy’s sides now, pooling on the operating table. A waterfall onto the theatre floor.
‘Clamp!’ Ange called. ‘Clamp, now!’
Kash seized the clamp, plunged his hands in along Ange’s own. Beneath the surface, Angela fought to get it up to the aorta – but by now she was flying blind, groping unseen in the crimson surrounds. In a vain effort, she pushed the clamp as high as she could, squeezed it closed – and still the blood welled up.
‘Pressure’s going fast,’ Geoff cursed. ‘Jan – fast bleep the porters to get that blood. Group specific will do. Failing that, more O-neg.’
Ange plunged her remaining hand into the boy, right up to his spleen. Kash saw her face drain of all colour. ‘That’s it,’ she said. ‘It’s the spleen. It’s gone. It’s like . . . wet cardboard down here.’ Her face twitched once again. ‘It’s torn, Kash. There’s an inch-long tear. Clamp!’ She paused. ‘No pulse here. Geoff?’
Geoff reached for the carotid pulse, paused and shook his head. He glanced at the monitor. There was still an ECG trace. ‘EMD.’ Electromechanical dissociation. It meant the heart had electrical activity but was pumping no blood.
‘Crash trolley!’ called out Kash. ‘Jan, call triple three. We’re going to . . .’
Time slowed down. The world closed in. All that was left of it was these four theatre walls, the blood-soaked table between them and the boy who lay upon it, teetering on the edge between life and death. Out of the corner of his eye, Kash saw Geoff disconnecting the breathing machine, ventilating the boy by hand. Jan had already started the chest compressions. The theatre’s saloon doors were swinging open and a scrub nurse was hauling the crash trolley through, while another pulled the sterile green towels from the boy’s chest and slapped conducting pads onto his bare skin.
Soon, four more doctors and a nurse would crash into the theatre, but by then it would already be too late. The way she was standing now, Ange seemed to know it. The panic had left her, to be replaced with a cold realization.
They would carry on, working steadily, methodically, as they had been trained to do, but it was all pointless.
She seemed to be wat
ching herself from on high, as if her body were not her own, as if her actions, the actions of Kash, Geoff, Jan, were seen through a camera lens. Retractor, suction, swabs. Retractor, suction, swabs. Adrenaline. Chest compressions. Pulse check. Fluids. In that way, one minute passed. Two. Five. And all the while she knew. Twenty minutes in, she stepped back, almost unnoticed, and headed for the door, snapping off her gloves and flicking them to the floor.
9
Fifteen minutes later, Kash made his way to the female changing rooms. After knocking gently, he cautiously opened the door and peered round. Ange was sitting on a slatted wooden bench, her head in her hands. She was still wearing her blues. She didn’t look up.
‘They say you get used to it,’ she said, her voice a taut monotone. ‘I guess you largely do with time. I’ve seen a hundred people die, Kash, But . . .’ Kash understood. It hadn’t happened to him yet, but sooner or later you had to lose the sensitivity. Everyone – doctor, nurse, porter ferrying around the dead – must do, sooner or later. And most people who died were old, at the ends of their natural lives. The young ones were often ‘BID’– brought in dead – and you never got to feel for them. But this was different. Different, because . . . ‘He died at my hand, Kash.’
Kash walked over and raised his palms. ‘Our hands, Ange. We are a team.’
She didn’t respond.
‘Look, Ange, I know it isn’t my place but . . . it wasn’t your fault.’
Ange hung her head. ‘Then whose fault was it? The boy? His mother? It was my call, Kash and . . .’ For the first time, Ange’s voice broke. ‘I wasn’t up to it.’
Kash took her by the shoulder, turned her around. ‘That’s nonsense, and you know it.’
He held on to her, not knowing what else to do. In the end, it was Ange who had to pull herself away.
‘People like you round here, Kash. You’ve settled in well. You’re going to be a good doctor. And you’re trying to say the right thing. But just . . . leave it, would you? Because . . .’ She paused, struggling with what to say. ‘Because – where was he, Kash? Trenchard’s supposed to be here, in the Victory. So where exactly was he? Where is he, even now? Why was it me – why was it us – in there, doing that, when Trenchard should have been . . .’
Kash heard it in her voice. It wasn’t just sorrow. It wasn’t just guilt. It wasn’t just the terror of knowing that she’d soon have to face the mother – the mother who didn’t yet know, false hope still burning in her heart as she paced the corridor nearby. No. There was anger.
Fury.
‘What do I tell her, out there? The surgeon who could have saved your boy was absent, so we killed him instead? Is that it? Is that what I tell her, Kash?’
She was about to step through the door when Kash surprised himself by almost shouting, ‘You need to stop thinking like that, Ange. You need to stop it now.’
He had never spoken to anyone like this, but he could see the adrenaline still pumping through Ange’s body, the almost imperceptible twitches in her temple that showed she was wrestling against herself, trying desperately not to break down or scream.
‘That mother through there, when she finds out her son’s dead, what does it matter if Mr Trenchard wasn’t here? It matters to you, but not to her, not now. She needs someone to hold her hand and look her in the eye and tell her we did everything we could. She needs it plain and simple, Ange. Because she deserves it. She needs us now, just like that boy through there needed us then.’
He stood back, surprised at the words he’d just spoken but even more astonished at the deep-seated conviction that seemed to underlie them without his ever having been aware of it until now. Kash kneeled and touched her shoulder, then wrapped his arms around her and, though she could not return the embrace, she did not resist. She made no sound, but he could feel hot tears soaking his chest.
Softly, he said, ‘Ange. I’ll do it. You go and stitch the boy up. Get him presentable for his mum. I’ll go and deal with her now.’ He gave her a gentle squeeze, then rose and walked to the door. ‘Mess in twenty?’
She nodded. ‘Mess in twenty.’
Before he stepped through the door, he looked back. Angela was sitting, staring at her outstretched hands. There was still blood on them.
*
Kash paused in the corridor outside the relatives’ room. Used mainly by the families of those on the intensive care unit nearby, it only had one occupant just now. Through the glass in the door, Kash could see the distorted shape of Anna Chaloner pacing the linoleum.
He tried to gather his thoughts. There were sentences you could fall back on. He didn’t suffer. Nothing can change this news. It can’t matter to you right now, but it may later, and it’s important that you know: we did everything within our power to keep him with you. They ran courses in breaking bad news. Kash had sat at the front of the classroom as he always did, diligently taking diligent notes, filling up his notebooks and repeating the words by rote until they were drilled into his mind. They’d practised with actors, too. But now, here he was, standing alone late at night, his hand hovering ahead of the door, and he knew that this was different. An actor would allow herself to be consoled. An actor stuck to the script. But there was no script for this moment. He took a deep breath and walked into the room.
As he closed the door behind him, Anna Chaloner stopped pacing, her head snapping towards him at once, a smile forming, her eyebrows raised. Kash met her gaze, and walked forward. ‘Mrs Chaloner? I’m Kash. Dr Devan. We met briefly earlier . . .’ And Anna Chaloner knew at once. Her smile dying as her face became suddenly pale. She sat down abruptly in one of the worn plastic-covered armchairs.
‘Mrs Chaloner,’ he began. ‘May I call you Anna?’
Her hands, which had been kneading each other, suddenly stopped. A stillness had come over her, as if she’d summoned up some last reserve of inner strength. She looked up, and it was then that Kash, incongruously, noticed what a striking woman she was. She had soft green eyes, like Claire’s, and for a moment his carefully prepared thoughts scattered. She was still wearing her scarf, as if at any moment her son might come skipping out of surgery and demand to be taken home. Sweat beaded her brow, where the widow’s peak of chestnut hair met her skin.
He crossed the room, sitting opposite her on the low coffee table strewn with TV guides, puzzle magazines and celebrity gossip rags.
He reached for her hands but, instead, she grasped his, her thumb stroking the skin at its back. Even now, he thought suddenly, she was the mother, consoling the young boy.
And so Kash began. He tried to follow advice a lecturer had once given him. ‘Speak with only half your brain. Let one half be compassion. The other has to observe, to edit, to stay detached. Let them have the emotion, not you.’ But those things were easier said than done. The trick was to look into her eyes and yet look past them, to some distant place on the other side where all this was just another part of a normal day.
He began with the simple truth. ‘Anna, I’m sorry. We did everything we could, but Edmund didn’t make it through the surgery.’ He paused for her to respond, but Anna said nothing, her silence encouraging him to say more. ‘We believe he’d been suffering from glandular fever. It’s rare, but in some cases, it reaches the spleen – and Edmund’s had ruptured. That’s why he got the pain. He needed surgery fast. We called Mr Trenchard, the consultant, but he . . .’ Only now did Kash find himself faltering, for the things he didn’t say were even more important now than the things he did. ‘ . . . wasn’t going to get here quickly enough. Dr Warner knew that every second mattered, so we took Edmund straight into theatre.’ It was all true, all of it, everything except the inference that Mr Trenchard had agreed. ‘We couldn’t stop the bleeding, Mrs Chaloner. Edmund had already lost so much. I’m so sorry, Anna.’
Kash sensed that, like him, one half of her brain was also computing, comparing the account she was hearing to everything she’d seen in the eme
rgency department, those precious last minutes she had been with her son.
Face turned away, Mrs Anna Chaloner seemed to be concentrating only on her breathing. Her skin was bleached and drained. Then, as Kash watched, a deep frown set in across her face, the lines spreading and setting like shattering glass. So, he thought, her body was finally absorbing the news. He sensed her breathing changing, alternately peaceful and ragged, as her mind caught up.
In medical school they taught you about Kubler-Ross and their stages of bereavement. Drummed into his head in some long-ago lecture, now he could see them so clearly. Stage one: denial and isolation. OK, he thought, seeing her shrinking into herself, that fitted. Then came bargaining, depression – and, finally, acceptance.
Kash paused. He had missed out a stage. Bargaining was stage three. Something came before it.
What was it?
He saw her turn rigid. The way her eyes, which had seemed so distant, were suddenly brighter. The way her hands, which had been clasping each other, had become claws, digging into her thighs.
Ah, he thought, that’s right. Before bargaining comes . . . anger.
Quietly, Kash got to his feet and left Anna Chaloner to her pain.
10
The days following Edmund Chaloner’s death were frantic, and this was actually a blessing. There was no time to ruminate or to feel sorry for yourself – or anyone else. You had to move on to the next thing, or you’d fall off the rollercoaster and never get back on. If you spent any time thinking about the last emergency, you wouldn’t be able to focus properly on the present one. And he could feel himself toughening in a way he didn’t like. There was going to be a narrow line between protecting his humanity and losing it. Only now, he’d had to break bad news again.
You could often tell the age of a patient by their name. Pretty much every Violet, Rose or Ivy was over ninety, and every Kylie under nine. This Rose had been eighty-two and a church organist. At least that had made life simpler when he’d had to tell her family the truth. They’d had to ‘open and close’: as soon as the abdomen had been opened up, it was clear that it was choked with cancer. There was nothing to be done other than close it at once, and start some morphine for the pain. He’d faced the daughter, leaning forward and holding her hands, as a small silver crucifix had swung hypnotically from a thin silver chain around her neck. She’d tried not to cry, but to smile. She had nodded. ‘I guess Jesus just wants her now,’ was all she would say. But he could hear the sobs now, as he walked from the room.