as the current was applied.
‘He’s in sinus rhythm,’ Allegra noted, looking at the monitor. ‘What drugs do you want up?’ she asked the registrar.
‘He’s had an infarct is my guess. There’s a few VEBs. I’ll start a lignocaine infusion, but we need to get him round to ICTU and keep him well oxygenated. I’ll contact my boss and bring him round to ICTU for a consult.’
‘You look as if you could do with a bit of oxygen yourself,’ Allegra said, taking in Peter’s flushed features. ‘Are you OK?’
He gave her sheepish look. ‘The lifts were busy. I had to run up two flights of stairs. I guess I’m not as fit as I thought.’
‘Lucky you,’ she said as she moved aside for the trolley men who had come to do the transfer. ‘I had to run up six.’ She gave him a smile and added, ‘Go and have a glass of water. I’m going back to ICTU anyway so I’ll hand the patient over.’
Allegra accompanied the patient, Gareth Fisher, to ICTU and had not long informed the surgeon, Bruce Crickton, of his patient’s condition when the ICTU registrar Danielle Capper approached.
‘Dr Tallis, can you help me on bed five?’ she asked. ‘It’s Mr Munsfield, the Whipple procedure. He was extubated yesterday and was doing OK, but his sats have gone down in the last hour and he’s on 60 per cent oxygen. He’s become febrile and has abdo pain.’
‘Sure.’ Allegra began walking with Danielle to the far end of ICTU, where bed five was situated. ‘Have you had any bloods done?’
‘They should be on the fax now in the office. I’ll grab them and see you there,’ Danielle said.
Allegra reached bed five and after greeting Fiona Clark, the nurse in charge of beds four and five, took a look at the patient, who was pale, slightly cyanosed and very breathless. His sats monitor showed 80 per cent, BP 100 and pulse 110.
‘Deep breaths, Mr Munsfield,’ Fiona instructed the patient. ‘I’ve just given you some IV morphine for the pain.’
‘What was the last temperature, Fiona?’ Allegra asked.
‘Thirty-nine. It’s been up all morning,’ Fiona answered.
‘Where’s the pain, Mr Munsfield?’ Allegra addressed the patient gently.
‘In … my stomach, and in my back …’ he gasped and puffed. ‘In the middle of my back … like a knife …’
Danielle arrived with the printouts, accompanied by Joel Addison, who had been collecting pathology reports from the printer. ‘Hb is 80, white cell count 25 with neutrophilia, and his amylase and lipase are through the roof, Dr Tallis,’ he said, looking intently through the sheath of figures before he met her eyes briefly. ‘What do you feel is the problem?’
‘Looks like we’ve got pancreatitis, maybe pancreatic sepsis. Could have an anastomotic leak,’ Allegra said.
‘I agree. We should also consider an anastomotic leak as the precipitating problem,’ he suggested.
‘Danielle, get the surgeon down here now. We need an urgent surgical review, and get X-ray up here, too—we need a chest X-ray. Those sats are worse. My guess is adult respiratory distress syndrome.’
‘ARDS is almost certain, Dr Tallis. We’ll need to intubate pretty much straight away but it’s your call,’ Joel said, giving her an unreadable look.
Allegra explained to the patient that there was a problem in his abdomen and that it was affecting his lungs, making it hard for him to breathe. She explained the procedure of intubation to him before instructing Fiona to obtain drugs and airway equipment.
‘His Hb has dropped too, Dr Tallis,’ Joel said, when she’d turned back from the patient. ‘There are a couple of cross-matched units left over from surgery.’ He turned to address Danielle. ‘Can you retrieve those from the blood fridge while I help Dr Tallis here?’
After pre-oxygenating as much as possible, Allegra got Joel to inject 10mg suxamethonium and 10mg diazepam and applied a mask and bag.
‘He’s hard to inflate. His lungs are stiff with pulmonary oedema,’ she said. ‘I’ll have to intubate him—he’s too hard to keep bagging. Hand me the laryngoscope and tube, Dr Addison.’
Allegra introduced the laryngoscope and attempted intubation but the patient had only been extubated forty-eight hours before and the larynx was red and swollen. To make matters worse, he had a short, bullish neck. She couldn’t see the cords and reverted to bag and mask, but could hardly keep a seal on the face with the mask because the insufflation pressure needed was so high.
She muttered a curse under her breath, conscious of Joel watching her every move. ‘I’ll have to try again. We’re in real trouble here.’
‘I can see that, but you’re the most skilled here at airway management,’ Joel said calmly. ‘Just tell me how you want me to assist.’
Allegra threw him a quick grateful glance and tried the laryngoscope again but still could not intubate the patient. Mr Munsfield’s sats were now 70 per cent and he was looking deeply cyanosed.
‘We need to get an airway, Dr Tallis. He’s badly hypoxic and throwing off VEBs,’ Joel said.
‘I can’t get a tube in,’ she said, her brow beading with perspiration. ‘I’ll have to do a surgical airway. Open the tray, Dr Addison, stat.’
Joel opened the surgical airway pack on the top of the trolley. Allegra put on sterile gloves and made a transverse incision over the cricothyroid membrane with a disposable scalpel. Taking a pair of artery forceps, she widened the hole, and passed in a cuffed tracheostomy tube and inflated the cuff, then connected the tube to the oxygen bag. The chest rose and fell with each pump on the bag, though the insufflation pressure was high.
Allegra flicked her gaze to the sats monitor, which showed the patient’s sats coming up into the 90s. She connected the ventilator and set the dials to cope with the high pressure and poor oxygen exchange.
‘Well done, Dr Tallis,’ Joel said, briefly placing a hand on her shoulder to steady her. ‘That was a top-notch surgical airway under pressure. Things look back under control here. I’ll leave you to fill Harry in—he’s just arrived.’
He moved off towards the A and E area before Allegra could thank him for his help. She frowned as he went through the swing doors, her feelings towards him undergoing a confusing change which she couldn’t quite explain.
The surgical registrar arrived with the consultant, Harry Upton, and was briefed by Allegra.
‘He needs to be opened, I agree. The pancreatic anastomosis has probably leaked, and on top of that he’s got pancreatitis. Thanks for salvaging the situation, Allegra.’
Danielle filled Harry in on the rest of the patient’s details before he turned back to speak to Allegra. ‘You look like you could do with a break.’
Allegra blew a wisp of damp hair off her face. ‘I’m off for a break right now. It’s been one of those mornings.’
‘So you’ve finally met our new director,’ Harry said
