‘But you are here,’ she said quietly. The presence of the registrar in the room ceased to matter. ‘And I need you, Luke.’
They both followed her but it was Luke’s tall form striding beside her that gave Anna confidence. They moved fast enough for him to be limping by the time they reached the emergency department but they were still side by side.
A team.
The main resuscitation area in Emergency was crowded. Helicopter paramedics in their bright overalls and helmets were there with the medical staff, transferring their patient with great care. There was a bustle of activity and a buzz of urgent instructions.
‘Gently! Don’t bump him. Cardiac function is fragile.’
‘Is the Bair Hugger on?’
‘Dextrose, not saline. Get some more in the microwave to get warmed.’
‘Make sure that oxygen is warmed and humidified.’
‘Get some more dots on. We need a twelve-lead ECG.’
‘What’s his temperature now?’
‘Nineteen point five degrees Celsius.’ Luke whistled silently.
‘The lowest ever temperature that someone’s survived without neurological impairment was around thirteen degrees, wasn’t it?’ Anna kept her voice low. The boy’s mother was on the other side of the room, looking terrified.
Ben Carter was leading the resus team and he wasn’t happy with the oxygen saturation level of the boy’s blood.
‘I’m going to intubate,’ he decided. ‘Anyone who’s not directly involved step back a bit, please. It’s critical we do this with minimal movement.’
One of the paramedics stepped well back, close to where Anna and Luke were watching. Standing by.
‘What happened?’ Anna asked.
‘Kid got ice-skates for Christmas,’ the paramedic said quietly. ‘They live on a farm up north a bit and there’s a dam. He and his brother went skating and he hit some thin ice and went through. Took his brother about thirty minutes to find a branch big enough to get him out and another half an hour to run home and raise the alarm. Probably ninety minutes before we arrived on scene and the wind chill was significant. First temperature we got was eighteen degrees.’
‘Cardiac rhythm?’ Luke was watching Ben and his team securing the boy’s airway but he was listening to Anna’s conversation with the paramedic.
‘Slow atrial fibrillation. Marked J waves.’
Anything below a core temperature of thirty degrees was enough to put someone at risk of cardiac arrhythmias and arrest. This boy was dangerously cold but there was still hope. Anna remembered a lecturer at medical school talking about hypothermia.
‘You’re not dead until you’re warm and dead,’ he’d said.
The Bair Hugger was a blanket designed to force a current of hot air over the patient’s skin. Intravenous fluids were warmed to try and raise blood temperature but these methods might be too slow to help someone with such severe hypothermia.
‘Luke.’ Ben had finally stepped back from the initial flurry of making sure their patient was as stable as possible. ‘Didn’t think you were on today.’
‘I’m not.’ Luke flicked a sideways glance at Anna and there was a hint of a smile on his lips. He was here because she wanted him to be but it seemed like he wanted her to know he was happy to be here.
‘Well, I’m glad you’re here. Both of you.’
‘What’s the plan?’
Ben looked grim. ‘External exogenous rewarming is only going to achieve a rate of about a two point five degree increase per hour. He’s too cold to wait that long. With full cardiopulmonary bypass we could get a rewarming rate of seven point five degrees an hour.’
‘We can’t justify something as invasive as bypass unless he’s arrested. What about pleural lavage?’
The cardiothoracic registrar was looking bemused. Anna leaned closer. ‘That’s using an inter-costal catheter to pour large volumes of warmed water into the chest cavity.’
‘Still pretty invasive,’ Ben was saying. ‘And possibly less effective. Right now we’ll keep ventilator support going and monitor his rhythm. We should get results on the bloods we’ve drawn soon. I want to see what his acid-base status is. At least slow A fib isn’t a malignant rhythm.’
‘We need an arterial blood gas as well,’ Anna put in. She stepped forward to retrieve the sheet of paper emerging from the twelve-lead ECG machine but she didn’t get time to analyse the trace. An alarm sounded on one of the monitors at the head of the bed.
‘He’s in V tach,’ someone warned. ‘I can’t find a pulse.’
‘V fib now.’
‘Start CPR,’ Ben ordered, moving to the side of the bed. He looked back at Luke, who gave a terse nod.
‘One shock. If that doesn’t work, bring him up to Theatre under CPR.’
‘Theatre 3’s on standby. Bypass technician was paged when I called Anna.’
‘Charging,’ someone announced. ‘Stand clear.’
Luke gave another nod and touched Anna’s arm. ‘Let’s go. Better if we’re scrubbed and ready by the time they come up if we’re going to be needed.’
A cold, still heart.
This lad was technically dead and here they were thinking they could play God and bring him back to life.
Luke could see the lines of strain around Anna’s eyes. He knew that her lips beneath that mask would be pressed tightly together. And, despite how subtle it was, he saw the way she flinched when her hands touched the chilled flesh in the small chest they had just opened.
‘We need to work fast,’ he reminded her quietly. ‘Standard bypass. Arterial cannula in the ascending aorta. Right atrial cannulation with a single, two-stage cannula.’
Anna nodded. She was already placing a purse-string suture around the major vessel that took blood from the heart to the rest of the body.
Within minutes, with both surgeons working together in a tense atmosphere, the cannulae had been positioned and the boy’s blood was now being circulated through the heart-lung bypass machine instead of his frail-looking body. Circulated and being carefully warmed.
There was nothing more they needed to do surgically until it was time to take him off bypass and repair the vessels currently holding the thick tubes. Then they would—hopefully—restart his heart, close his chest and wait to see if he woke up. Wait to see whether his brain function had survived this terrible insult.
Hours later, Luke found Anna in her office. She had been pacing back and forth between the intensive care unit and the wards. Between the canteen, where she’d eaten nothing at all, and the ICU. Between her office and the ICU.
‘It’s taking too long,’ she said when Luke appeared through the door.
‘He’s in a good rhythm. Body temperature is within a normal range. The hyperglycaemia has been corrected. Renal function is looking good.’
‘I know, I know.’ But Anna was still pacing, her arms wrapped around her body as if for comfort. ‘Blood gases are fine, too, and I’m happy with cardiac pressures. But what about possible complications like thromboembolism? Or disseminated intravascular coagulation?’ She dragged in a breath. ‘Have you met his mum, Janet? Did you know his big brother is six years older and that she had two late miscarriages before Jamie came along? What … what if he doesn’t wake up?’
‘Anna …’ Luke stepped