‘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 with a twinkle in his eyes. ‘I didn’t see you at his welcome function last week.’
‘I was on nights,’ she explained, her mouth tightening a fraction.
Harry grinned at her sour expression. ‘So what gives, Allegra? You don’t like his … er … aura?’
She gave him a mock reproving look. ‘Don’t you start, Harry. He totally rubbished my project as if it was a load of pseudoscience. “Can’t afford alternative therapies in his science-based unit”, I think was how he put it.’
‘Yeah, well, I guess he’s under a lot of pressure to make this place work,’ he said. ‘There’s a lot of cash been poured into it, and there are a few irate unit directors who think they should have got the funds instead. If it doesn’t shape up fast, his head will roll.’ He grimaced as his pager went off. ‘I’m due in Theatre. I’ll see you around. Good work on Mr Munsfield, by the way. You and Joel Addison make quite an impressive team.’
She gave him another mock reproving glance but a small smile softened it. ‘Thanks, Harry.’
Allegra was using the staff restroom to freshen up when Kellie Wilton, one of her colleagues, came in.
‘I was hoping I’d run into you,’ Kellie said as she washed her hands at the basin. ‘I heard about your meeting with Dr Addison.’
Allegra frowned as she twisted her light brown hair back into its clip. ‘The hospital grapevine is running rampant again, I see,’ she said, turning to look at her friend. ‘Who told you about it?’
‘Louise mentioned it at morning tea,’ Kellie said, leaning back against the basin. ‘It certainly sounds as if you got off on the wrong foot. What’s his problem with your project? I thought Patrick Naylor was touting it as a unique study.’
‘He did, but apparently Dr Addison is under the impression that his decisions bear more weight than those of the chief executive officer. I hate men with overblown egos and closed minds.’
‘How is your relationship going with Patrick, by the way?’
Allegra put her hands on her hips and gave her friend a frustrated grimace. ‘Listen, Kellie, I had dinner with him—once. It wasn’t even in a posh restaurant and I ended up paying because his credit card wouldn’t swipe. We had pizza and a bottle of awful red wine, which I was still paying for with a headache the next morning. He spent the whole time complaining about his soon-to-be-ex-wife. Hardly what I’d call a date.’
‘Yeah, I’d heard his separation had hit him hard,’ Kellie reflected. ‘You do need to get out more, Allegra, with some fresh talent. Have you ever thought about using a dating service? My sister did and got a real honey.’
‘I don’t believe what I’m hearing, Kellie. What do you think—I’m desperate or something?’ Allegra gaped at her. ‘I can find my own dates without the help of a computer, thanks very much.’
‘One bad dinner in two years is not a good track record,’ Kellie pointed out.
‘Eighteen months,’ Allegra corrected her swiftly.
‘Look, Allegra, you’re twenty-eight years old. We’ve known each other a while now, and as far as I can tell the only fun you’ve had lately is sharing tubs of chocolate-chip ice cream with me while watching soppy movies at my place.’