qualified in martial arts. ‘You know what I mean.’
‘Yeah, sugar. I know. Right, I’m going to do my reports. And then I’m going home to sleep, sleep, sleep.’
‘I should be so lucky.’ Holly smiled at him, then went over to her patient and introduced herself. ‘I’m just going to examine you, Peter. I’ll be as gentle as I can, but tell me if you need me to stop, OK?’
‘My chest hurts,’ he whispered. ‘Hurts all over.’
‘OK, Peter. I’ll give you something to help that.’ She inserted a couple of IV lines then gave him IV analgesics, noting as she did so that his breathing was a little faster than she would have liked and there were slight traces of blue round his lips, a condition known as cyanosis.
Which meant compromised respiration.
‘Hurts to breathe,’ he said.
It could be a tension pneumothorax, where air leaked into the space around the lungs and was trapped. The pressure caused one of the lungs to collapse and could rapidly lead to a cardiac arrest.
Then Holly noticed something she really, really hadn’t wanted to see. As Peter breathed in, part of his chest moved inwards too, and as he breathed out the same segment moved out again. Flail chest, she thought with a sinking heart. Where at least three ribs had broken, in two or more places, part of the chest wall could move independently—known as ‘flail chest’, it meant that there was likely to be significant damage to the lung underneath it. If he got through surgery, he’d be in Intensive Care for a while.
A quick check on the pulse oximeter showed her that Peter’s oxygen saturation was dropping. His blood pressure was low, too, so either it was a tension pneumothorax or there was a chance that the kicking he’d received had ruptured something, possibly his spleen.
‘I’m going to put you on an oxygen mask,’ she told him. ‘That’ll help you breathe more easily. Take it slowly—in and one and out and one,’ she counted as she slipped the mask over his head. ‘Miche, we need a chest X-ray and the usual bloods, cross-matching,’ she said. She slipped on the earpieces to her stethoscope. ‘Can you get David?’
David was at her side almost immediately. Holly turned away from Peter for a moment and gave David a quick rundown in a low voice. ‘There’s definitely flail chest but I don’t know how bad the damage is. I’m not happy with his blood pressure or his oxygen sats. I don’t think it’s a tension pneumothorax—I’ve checked and there’s no absence of breath sounds on one side, no tracheal deviation, and his neck veins aren’t distended. I think the low BP could be related to organ damage rather than a tension pneumothorax.’
‘Have you ordered a chest X-ray?’
‘Yes, and the usual bloods.’
‘OK. We’ll get Theatre on standby and warn the anaesthetist there’s a strong risk of pneumothorax,’ David said. ‘We need to find out if there’s any internal bleeding. Any obvious signs?’
‘No.’
‘DPL, then.’ Diagnostic peritoneal lavage, or DPL, was used in patients with multiple injuries to assess possible abdominal injuries. ‘Can you get the patient’s consent?’
Holly held Peter’s hand and explained what they wanted to do and why. ‘Can you sign a consent form for me, sweetheart?’
‘Yeah,’ he whispered.
The scrawl was barely decipherable but it was enough.
While David fitted a nasogastric tube, Holly inserted a catheter to decompress Peter’s bladder. Holly cleaned Peter’s skin while David draped sterile towels over the area, then gave Peter a local anaesthetic.
‘Ready?’ he said to Holly.
‘Ready.’ Strange how easily they’d gelled into a team, working together without getting in each other’s way or even needing to say much to the other. But then, she’d known him so well, all those years ago. She’d almost been able to read his thoughts.
Which was why his behaviour had hurt so very much when he’d let her down. Because it had been the last thing she’d expected.
David made a vertical incision in the skin, about three centimetres long. ‘Can you put pressure on the edges, Hol?’
To minimise bleeding. ‘OK.’
‘Dividing the linea alba,’ he said. To her relief, he was the type who said exactly what he was doing so she didn’t have to second-guess him. ‘I’ve got the peritoneum. Can I have clips, please?’
Holly was already passing them to him.
‘Thanks.’ David brought the peritoneum into the wound and felt the edge between his thumbs to check no bowel had been caught into the clips. When he was satisfied, he made a tiny incision and inserted a peritoneal dialysis catheter, made sure the seal was tight and aspirated the fluid.
‘Positive,’ Holly said very quietly as blood started to appear. ‘He needs a laparotomy.’
‘I’ll close. You get Theatre,’ David said.
While Peter was being whisked to Theatre, Holly and David cleared up in Resus.
‘Thanks for your help,’ Holly said. ‘It’s good to know I can rely on you…’
David frowned. Was it his imagination, or had she muttered ‘now’? Her face said it, too. ‘What do you mean, now?’ he demanded.
She smiled thinly. ‘You know exactly what I mean.’
‘I think,’ he said quietly, ‘we need to talk.’
‘The time for talking was twelve years ago. You weren’t interested then—and I’m not interested now.’
‘What?’ His frown deepened. ‘Hang on a minute. Twelve years ago you dumped me.’
She scoffed. ‘More like you abandoned me. Just when I needed you.’
His eyes narrowed. ‘I can’t be hearing you straight. I must be in caffeine withdrawal.’ He glanced at his watch. ‘Look, we’re both at the end of our shifts. It’s been a long night and we’re both tired. Come and have breakfast with me. I just want a bacon sandwich—preferably with a ton of tomato ketchup.’
She shook her head. ‘Forget it.’
‘Hol, we need to talk.’
‘I don’t think your wife will be very happy about that.’
‘I’m divorced. And, anyway, I’m only asking you to talk to me.’ He paused. ‘What about you? Anyone waiting at home who’d be worried if you were late?’
‘No.’
‘Then I think we owe it to each other to get this straightened out. If nothing else, it’s going to be easier to work together. That, or I’m going to have to ask for a transfer to the other team because I can’t work with you—not if there’s all this stuff bubbling under the surface. Everybody knows you went to school
