covered Tom, the snow falling white against the silver blanket.
Tom’s respirations had worsened—loud, gurgly and noisy. Bubbles of blood formed in his mouth.
Will checked his air entry with the stethoscope. ‘Shallow resps, poor air entry.’
‘Pneumothorax from the joystick?’
He examined Tom’s face. ‘Possibly, but he’s got a severely fractured maxilla. The middle of his face has separated from the rest.’ He looked up at her. ‘All this bleeding and swelling isn’t helping his breathing.’
Understanding crossed her face. ‘Do you need to do a tracheostomy?’
‘Yes, we need to establish his airway if we’ve got any chance of keeping him alive.’
‘And risk paralysis if his spinal cord is damaged.’ She bit her lip. ‘I hate triage.’
‘You’re not alone there.’ They were between a rock and a hard place. The treatment to save Tom’s life could render his life changed for ever.
‘Do you have a wide-bore needle, a fourteen-gauge, in that pack?’
Meg frantically scanned the laminated sheet. ‘I can do better than that.’ She read out the instructions. ‘In large bottom pouch, tracheostomy tube.’ Her fingers, pink with cold, fumbled as she opened the pack.
‘That’s one hell of a kit.’ Will took off his coat, rolling it up under Tom’s shoulders to extend the pilot’s neck. He removed the soft brace. ‘Tom, we have to put a tube into your throat. You won’t be able to talk.’ He had no idea if Tom could hear him. He was pretty certain he was unconscious.
She handed him the scalpel and cleaned Tom’s throat with the antiseptic wipe. ‘How long since you’ve done a trachy?’
Will didn’t lie. ‘On an adult, it’s been a long time.’
‘Some things you never forget.’ She gave him an encouraging smile, her confidence in him almost palpable.
He found the cricoid cartilage. The trachea is generally two finger-breadths above the sternal notch. The words of his surgical professor pounded in his head. He made a horizontal cut through the skin, the muscle and down into the cartilage of the trachea.
Meg tried to keep the area free of blood so he could see.
He needed to find the third or fourth ring of cartilage. ‘Pass the tube.’
He pressed firmly on the tracheostomy tube, until the resistance disappeared and the tube was in situ.
‘You inflate the balloon to keep the tube in place and I’ll check his breathing.’
He lifted the space blanket and put the stethoscope on Tom’s chest. The pilot didn’t flinch at the cold. Not a good sign. ‘His air entry is better but his pulse is weak. Open facial fractures bleed like hell. He’s lost a bucket of blood.’
‘Do you want me to bag him?’
‘Yes. I’ll see if I can get an IV in. What have you got?’
‘One litre of Hartmann’s solution.’
An expletive rose to his lips. One thousand millilitres wouldn’t replace the circulating volume Tom had lost.
‘It’s better than nothing, Will.’
Meg’s voice of reason penetrated his fear and frustration. ‘You’re right—sorry.’
As she rhythmically squeezed the air bag he tried desperately to find a vein. Tom was in severe shock, his veins collapsed. Will tightened the tourniquet around Tom’s arm. His fingers desperately palpated for a raised vein. Nothing.
He moved the tourniquet three times, trying arms and legs. Still nothing. He sucked in a deep breath, forcing himself to concentrate and to ignore the dread that curled in his belly.
‘Do a venous cutdown.’ Meg’s desperate words echoed his thoughts. ‘We’ve got a scalpel.’
The natural light was almost gone. In the glow of his headlamp he saw her face streaked with blood and pain, yet there was a steely determination there. She wasn’t giving in without a hell of a fight.
Neither was he.
‘You keep bagging and I’ll do the cutdown.’ His fingers, now half-numb with cold, seemed clumsy but he managed to make a clean cut and locate the vein. The wide-bore cannula slid in and he attached the IV, turning it on full bore. He only hoped it wouldn’t be running straight out of Tom’s body.
‘Put your gloves on.’ Meg’s voice had a schoolteacher-like quality. ‘I don’t need you getting frostbite.’ Her voice cracked slightly on the last word.
Her concern touched him. ‘How are you doing?’
She bit her lip. ‘Fine.’
But he knew she was far from it. None of them were fine. Snow covered her hat and coat and her cheeks burned red from the cold.
An icy feeling crept through him. The temperature was dropping fast now the sun was down. Hypothermia was a real issue and they needed some sort of shelter, but attempting to get Tom stable had to come first. ‘You know, the cold might count in our favour.’
Meg shivered. ‘How?’
‘The cold slows down the heart rate and the metabolic process. Perhaps it will slow down Tom’s bleeding.’
‘Good, because his pulse is getting weaker.’ Her voice wobbled with alarm.
Will examined Tom’s abdomen and chest. Air was going in and his respirations were easier with the tracheostomy. But his abdomen was guarded, a sure sign of internal bleeding. He’d bet his bottom dollar Tom’s heart was pumping the lifesaving Hartmann’s solution straight into his peritoneum. It was no use to him there.
Worse still, there was nothing Will could do to stop it. Tom needed to be evacuated to a trauma centre urgently, only that wasn’t going to happen.
‘Are you sure there is only Hartmann’s?’ Will scrounged through the pack, praying for more IV fluids.
‘I’m O-negative.’ Meg gave him a knowing look. ‘We could do a direct blood transfusion.’
Again, the protective surge moved in him, strong and hard. ‘No way. It’s far too dangerous for you.’
‘Tom’s like a father to me.’ Her voice rose. ‘We have to do all we can.’
He respected her courage, her desire to do all at whatever cost. ‘We are doing all we can. But without surgery to stem his internal bleeding, your blood will just end up pooling in his abdomen. More importantly, you could get a blood-borne illness. You know direct blood transfusions stopped years ago.’
‘I’m fit. I can handle it.’ Her jaw jutted in defiance of the conditions, the situation. With her free hand she reached for an IV line.
But
