The Italian Doctor's Perfect Family
‘Sorry. I think ED’s trying to contact me.’
‘Feel free to use the phone on the desk if you wish.’
‘Thanks.’ Pip was embarrassed to interrupt the examination but she couldn’t not take the call. What if her Mr Symes was busy having a cardiac arrest in a side room or something?
Suzie sounded apologetic as well. ‘I’m sure it’s nothing, but Mr Symes is complaining of chest pain now. Says it’s a crushing, central pain that’s radiating to his left arm.’
Classic symptoms. Almost too classic. ‘Any associated symptoms?’
‘Not really. He’s been complaining of nausea since he came in, along with all those aches and pains, but he’s not vomiting or sweating or anything. He reckons this came on suddenly.’
‘I don’t suppose he gave you a pain score without being asked, did he?’
Suzie laughed. ‘Ten out of ten. Do you think he’s been reading the right textbooks?’
‘We can’t afford to make assumptions. Can you do a twelve-lead ECG and put him on telemetry?’
‘Sure.’
‘What’s his blood pressure?’
‘One-fifty over ninety.’
‘Safe to try a dose of GTN, then. Put him on oxygen as well. Six litres a minute.’
‘OK.’
‘We’ll do some more bloods, too, and add in cardiac enzymes. I can do that when I come down. I shouldn’t be much longer.’
In fact, Toni was sitting down to share his findings with her as she hung up the phone, and Pip was aware of a vague feeling of disappointment that the consultation was almost over.
‘Cardiac patient?’ he queried.
‘Probably not, but we’ll have to rule it out.’
‘I won’t keep you too long. Alice seems like a normal, healthy little girl on first impression. The only finding I can make is mild and rather non-specific abdominal tenderness.’
That feeling of disappointment grew. Were her instincts misplaced? And would there be no reason for Alice to see Dr Costa again?
‘Mind you, that’s not an unexpected result and it certainly doesn’t mean I don’t wish to make any further investigations.’
Pip nodded, listening intently.
‘I’d like to do some further blood tests and another urine culture and microscopy. I think a general abdominal ultrasound examination would be a good idea. Maybe even an MRI scan.’ Toni was ticking boxes and scribbling notes on request forms.
‘We might like to consider a carbon-labelled urea breath test and possibly endoscopy to rule out the gastritis and duodenal ulceration that Helicobacter pylori can cause.’
Pip nodded again. This was more than she had expected.
‘Alice hasn’t been hospitalised with any of these episodes, has she?’
‘No. I came close to bringing her in the first time because she was so miserable, but it only lasted about half an hour.’
‘It would be ideal if we could see her and get a blood sample while she was having the pain. To check liver function for elevated blood amylase levels.’
‘So you think pancreatitis is a possibility?’ Pip caught Toni’s gaze and held it. To voice the unthinkable—that Alice could have a tumour of some kind—was unnecessary. The eye contact told her that he already knew her deepest fear.
‘I’m not ruling anything out at this stage. We’ll find out what’s causing the problem and then we’ll deal with it, yes?’
‘Yes.’ Pip dropped her gaze, embarrassed to show how grateful she was. ‘Thank you.’
‘And you’ll bring her in if it happens again? And call me? I’d like to see her myself if it’s at all possible.’
The warm smile that curled around the words made Pip think that this consultant might even get out of bed and come into the hospital at 3 a.m. if that’s when the attack happened to occur.
And that he was really going to do whatever it took to make a diagnosis and then fix whatever was wrong with Alice.
Did all the relatives of his patients feel so cared about?
So…safe?
Pip was smiling back as Alice finished getting dressed and plopped into the chair beside her. She glanced from Toni to Pip and then back again.
‘OK,’ she said. ‘Where’s my bus off to, then?’
Alice was less than impressed with all the tests she might have to undergo.
‘Why can’t they just take an X-ray or something? You know I hate needles.’
‘An ultrasound test is completely painless and it’s better than an X-ray. And an MRI scan is even better. It’s like having photographs taken of what’s inside your tummy. It’s incredibly detailed.’
‘Ooh, gross! Can you see, like, what you had for breakfast?’
Pip laughed. ‘Almost, but I wouldn’t worry about any of it. You might have to wait for weeks to get an appointment for something like an ultrasound. We’ll do what Dr Costa suggests and bring you into hospital next time you get a sore tummy.’
‘Will you come with me?’
‘Of course.’
‘What if you’re working?’
‘Then I’ll stop working to look after you. Like I did today to go to your appointment.’
‘Do you get into trouble for doing that?’
‘Of course not.’ Pip almost managed to convince herself as well as Alice. ‘I just have to make up for it later. Like now. Are you OK to sit in the staffroom and read magazines while I go and look after the patients I still have?’
‘Sure.’
‘You can get a hot chocolate out of the machine. You know how to work it, don’t you?’
‘Yeah.’
They bypassed the main area of the emergency department to reach the staffroom.
‘Hey, Pip?’
‘Yeah?’ When had she picked up Alice’s speech patterns that now came so automatically?
‘Dr Costa’s nice, isn’t he?’
‘Very nice.’ Her agreement was deliberately casual. What an understatement!
‘Is he married?’
‘I have no idea.’ Liar! Pip knew as well as most women on the staff of Christchurch General that Toni Costa was single.
‘Maybe you should find out.’
‘Why?’
‘’Cos it’s about time you got a boyfriend and I think Dr Costa’s hot.’
Pip wasn’t about to engage in that kind of ‘girl-talk’ with any twelve-year-old but most especially not her own daughter. ‘I’m way too busy to fit a boyfriend into my life.’
‘If you leave it too long, you’ll get old and crusty and no one will want you.’
‘Oh, cheers!’ But Pip was grinning. ‘For your information, kid, twenty-eight isn’t old!’
They had reached the staffroom now but, as usual, Alice had to have the last word.
‘Well, he likes you. I could tell.’
Toni sat back in his chair and sighed with relief as the shrieking toddler who had been the last patient in today’s clinic was removed from his consulting room.
He eyed the pile of manila folders and patient notes on his desk and pulled a pen from his pocket. While it would be nice to escape the hospital completely and revel in the peace and quiet of his home, he never left a clinic until he’d expanded his rushed notes to make a detailed summary of each visit. It wouldn’t take long.
When he got the Alice Murdoch’s file, however, he found himself simply staring into space, fiddling with the pen instead of writing efficiently.
How long would it be before he saw the Murdoch sisters again? Not that he’d wish an episode of acute abdominal pain on Alice, of course.
He could always find another reason to visit the emergency department, couldn’t he? A consult that he didn’t send a registrar to do, for example.
It wasn’t as though he intended to ask Pippa out or anything. Good grief, she was the relative of one of his patients.
Only the sister, though, not the mother. Did that somehow make it more acceptable?
But what would be the point of starting something that would go nowhere? He’d done that too many times already. And she was a doctor. A career-woman. Toni wasn’t about to break his number-one rule. However ready he might be to find his life partner, the mother of his children was going to have to be as devoted to them as he intended to be.
As devoted as his own parents had always failed to be.
But he was going to have a career, wasn’t he? Wouldn’t any intelligent woman also want a career—at least part time?
Maybe this Pippa Murdoch was planning to go into general practice some time.
Part time.
Toni tried to shake off his line of thought. Tried, and then failed, to complete the task waiting for him on his desk.
There was just something about the bond between those sisters that was very appealing. It was something special. Unusual.
Her family was clearly very important to her. She had left a patient who sounded as though he could be having a heart attack to accompany Alice to the appointment, and she was concerned enough to be determined to get a more definitive diagnosis than her family doctor had supplied.
He respected that.
And there was no getting away from the fact that she was a beautiful woman.
Different.
Stunning, in fact.
Toni reached for the phone and punched in an extension number.
‘Ultrasound Reception, Marie speaking.’
‘Hello, Marie. It’s Toni Costa here, Paediatrics.’
There was a small noise on the other end of the line. Almost a squeak.
‘You’ll be getting a request for an abdominal ultrasound on a twelve-year-old patient of mine, Alice Murdoch.’
‘Yes?’ Marie sounded keen to be helpful.
‘I’d like you to let me know when you schedule the examination. If I’m available, I’d like to come and watch.’
‘Really?’ Marie recovered from her surprise. ‘Of course, I’ll let you know as soon as it’s in the book. Is it urgent?’
Toni considered that for a moment. ‘It’s important rather than urgent,’ he decided aloud. ‘But it would be very nice if it could happen within the next week or two.’
And it would be very nice, albeit unlikely, if he happened to be free at the time of the appointment. That way, there was at least a chance he might see Pippa again in the not-so-distant future.
He went back to finishing his paperwork.
Quite oblivious to the half-smile that occasionally played at the corners of his mouth.
CHAPTER TWO
THE child looked sick.
Pip had gone past the mother, sitting with a boy aged about two on her lap, twice. They had been there for nearly half an hour and should have been seen before this, but a major trauma case had come in and a significant percentage of the senior emergency department staff were tied up with several badly injured patients in the main resus bays.
The department had been crazy all day. Pip currently had three patients under her care and they were all genuinely unwell. Seventy-five-year-old Elena was having an angina attack that was much worse than usual and could herald an imminent myocardial infarction. Her investigations were well under way and adequate pain relief had been achieved, but Pip was trying to keep an eye on her ECG trace as she waited for blood results to come back and the cardiology registrar to arrive.
Doris, in cubicle 3, was eighty-four and had slipped on her bathroom floor to present with a classic neck of femur fracture. The orderlies had just taken her away to X-Ray and then she would most likely need surgical referral for a total hip replacement.
Nine-year-old Jake had had an asthma attack that hadn’t responded well to his usual medications and his frightened mother had rushed him into Emergency just as the victims from the multi-vehicle pile-up on the motorway had started arriving. Judging the attack to be of moderate severity, Pip had started Jack on a continuous inhalation of salbutamol solution nebulised by oxygen. She had also placed a cannula in a forearm vein in case IV drug therapy was needed, but his oxygen saturation levels were creeping up and the anxiety levels dropping in both mother and child.
Pip was about to check on Jake again and consider whether he needed admission to the paediatric ward.
Toni Costa’s ward.
Seeing another child waiting for assessment made her think of Toni again, but Pip was getting quite used to that. It wasn’t just Alice’s fault for making that unwarranted but rather delicious suggestion that he’d been attracted to her. Pip preferred to think the explanation was because she’d been so impressed with the man as a paediatrician. How good he was with interacting with his young patients and what a good example he’d set in making such a thorough assessment of a new case. How he’d taken Pip’s unspoken concerns seriously and made her feel that her daughter was in safe hands.
Toni wouldn’t leave an obviously unwell child just sitting to one side of an emergency department and waiting too long for assessment because of pressure on resources, would he?
The small boy looked febrile. His face was flushed and appeared puffy. What bothered Pip more, however, was how quiet the child was. With the alien bustle of an overworked emergency department flowing past in what should have been a frightening environment, the boy was just lying limply in his mother’s arms and staring blankly.
Even from several metres away Pip could see that the little boy was in respiratory distress. A small chest was heaving under a thin T-shirt…way too fast.
Pip moved towards him, pausing for a moment beside the central triage desk.
‘Doris has gone to X-Ray so we’ve got an empty cubicle for a while. Could you find me a bed, please, Suzie? I think I should take a look at that little boy over there.’
‘Oh, would you?’ Suzie sounded relieved. ‘That would be great. I was just going to upgrade him for an urgent assessment. He’s looking a lot worse than he did when he came in.’ She sent a nurse aide to find a bed in the storage area off the main corridor to the hospital. ‘Put it in cubicle 3. Hopefully we’ll have another free space by the time Doris comes back.’
A stretcher was coming through the double doors from the ambulance bay. Another one was lined up behind that.
‘What’s the history?’ Pip queried briskly, before Suzie could get distracted by the new arrivals.
‘Just became unwell today. Running a temperature, off his food. Family’s new in town so they didn’t have a GP to go to.’
‘Cough? Runny nose?’
‘Apparently not. Temp’s well up, though—39.6 when we took it on arrival.’ Suzie was moving to intercept the first stretcher. ‘His name’s Dylan Harris. Turns two next month.’
Pip smiled at a mother who was probably her own age. What would life be like for herself, she wondered briefly, if she had a two-year-old instead of a twelve-year-old? She certainly wouldn’t be doing what she was doing now—a job she loved with a passion.
‘Mrs Harris?’
‘Yes…Jenny.’
‘I’m Dr Murdoch.’ The thrill of saying those words had never worn off. Worth all those long years of hard work and heartache. ‘Follow me. We’re just finding a bed so I can check Dylan for you.’
‘Oh, thank goodness! I think he’s getting sicker.’
The bed wasn’t needed immediately. Pip carried the chair Jenny had been sitting on as she led the way to cubicle 3.
‘Keep Dylan sitting on your lap for the moment, Jenny. It’ll keep him happier and help his breathing as well.’
‘He’s started making funny noises.’
‘Mmm.’ Pip was listening to the soft stridor on expiration and a gurgle on inspiration with mounting alarm. ‘And how long has he been dribbling like that?’
‘Is he?’ Jenny looked down at her son. ‘I hadn’t noticed. It must have started just now.’
Something that could compromise a child’s airway this quickly was extremely serious and Pip already had a fair idea of what she might be dealing with. She signalled Suzie to indicate the need for assistance but the senior nurse was still occupied with a patient on an ambulance stretcher. Her apologetic wave and nod let Pip know she would do something as soon as she could. Pip reached for an oxygen mask.
‘Hold this as close as you can to Dylan’s face without upsetting him,’ she instructed Jenny.
Pip could see the way the skin at the base of his neck was being tugged in as Dylan struggled to breathe and the retraction of his rib-cage when she lifted his T-shirt to place the disc of her stethoscope on the small chest.
An empty bed was being pushed into the cubicle behind her.
‘Get me a nurse, please,’ Pip told the orderly. ‘Preferably Suzie, if she’s available.’ She took another glance at Dylan’s face. ‘You’re being such a good boy. You’re not feeling too good, are you, sweetheart?’
She got no response. Not even eye contact from the toddler. Pip looked up at Jenny.
‘Has he been talking much today?’
‘He hasn’t said anything since we got here. He’s not even crying, which is weird. He usually cries a lot. Does that mean it’s not that serious?’
‘Not necessarily.’ Pip wasn’t going to alarm Jenny by telling her that it was the quiet children that were usually most at risk. With the oxygen mask held close to his face, Dylan was leaning back on his mother’s shoulder, his chin raised. The ‘sniffing the air’ position that indicated an instinctive method of maximising airway calibre.
‘And he hasn’t been coughing at all?’
‘No. This came on really suddenly. He seemed fine except he wouldn’t eat his toast this morning. I wondered if he might have a sore throat.’ She cast a worried glance at her son. ‘It’s getting worse, isn’t it?’
It was. Dylan’s eyes drifted shut and his head drooped. Pip touched his face.
‘Dylan? Wake up, love. Open your eyes.’ She got a response but it wasn’t enough. ‘I’ll be back in a second,’ she told Jenny. Slipping through the curtain, Pip nearly collided with Suzie.
‘Any of the consultants free at the moment?’
The nurse shook her head. ‘One of the trauma cases has arrested. It’s a circus in Resus.’
‘I need a paediatric anaesthetist here,’ Pip said. ‘And we need to get Dylan to Theatre. I’m pretty sure he’s got epiglottitis and his level of consciousness is dropping.’
Suzie’s eyes widened. ‘I’ll find someone.’
‘Get me an airway trolley in the meantime?’
‘Sure.’
Pip could only hope that intervention could be avoided until Dylan was safely under the care of an expert anaesthetist.
‘I think Dylan has something called epiglottitis,’ she told Jenny a moment later. ‘It’s a nasty bacterial infection of the epiglottis, which is at the back of the throat. If it gets inflamed it can interfere with breathing, which is why Dylan has started making these noises.’
‘What will you do?’
‘We treat it with antibiotics but we have to protect the airway in the meantime. I’m going to get Dylan taken to an operating theatre if possible to have a tube put down his throat.’
‘He needs an operation? Oh, my God!’
‘Not an operation,’ Pip said reassuringly. ‘Not unless it’s difficult to get a tube in place. In that case, it might be necessary to create a temporary external airway by—’
Suzie was back with a trolley. ‘Someone’s on the way,’ she interrupted Pip. ‘Shouldn’t be long.’
It was going to be too long for Dylan. The small boy’s eyes suddenly rolled and then closed. Jenny felt him go even floppier and when she moved the oxygen mask to look at her son, they could all see the blue tinge to his lips.
‘Dylan?’ Pip rubbed his sternum. ‘Wake up!’
There was no movement to be seen. Including the chest wall. The toddler was in respiratory arrest. Pip plucked him from his mother’s arms and laid him on the bed.
‘Oh….God,’ Jenny gasped. ‘He’s not breathing, is he?’
‘No.’ Pip was pulling on gloves and hoping she sounded much calmer than she felt. Where on earth was that consultant? ‘We’re going to have to put the tube in here. Could you hyperventilate him, please, Suzie?’
While the nurse used the bag mask to try and pre-oxygenate Dylan, Pip pulled the tubing from the suction kit and switched the unit on. She clipped a straight blade to the laryngoscope and picked out the smallest, uncuffed endotracheal tube from the sterile drape she had opened on the trolley.
‘Hold his head for me, Suzie.’ Pip peered over the blade of the laryngoscope moments later. ‘Can’t see a thing,’ she muttered.
‘Secretions?’ Suzie asked.
‘Yes. And the epiglottis is very swollen.’
‘I’ll give you some cricoid pressure.’ Suzie pressed on Dylan’s neck and Pip tried to take a deep breath and banish her mounting alarm. She knew how critical it was to get this airway secured and it was not going to be easy.
Jenny was sobbing loudly enough for another nurse to put her head around the curtain.
‘I can’t bear to watch,’ the young mother gulped.
‘Come with me for a moment, then,’ the nurse said. ‘I’ll look after you while the doctors look after your little boy.’
Pip was barely aware of Dylan’s mother being led from the cubicle due to her intense concentration on the urgent task, but even with the pressure on the neck, the secretions sucked away as much as possible and her best efforts, there was no way to get the tube past the obstruction of swollen tissue.
‘It’s no go,’ Pip said tersely.
Suzie sounded just as tense. ‘What do you want to do?’
Pip had to think fast. She couldn’t rely on a senior doctor arriving in time to take over. If she didn’t do something herself, now, this little boy could die.
‘Ventilate him again for me, Suzie.’ She ripped open another kit on the trolley. ‘I’m going to do a cricothyrotomy.’
Stripping off her gloves and reaching for a fresh pair, Pip had to fight a moment of pure panic as the consequences of not succeeding with this next procedure forced themselves into her mind.
Then, for some strange reason, she thought of Toni Costa.
Well, not so strange, really, because Dylan would probably end up being the paediatrician’s patient.
And she had been thinking of Toni at rather disconcertingly frequent intervals over the last week anyway.
For whatever reason, Pip could almost sense his presence in the cubicle right now, and it brought an underlying confidence to her determination to succeed. So that Dr Costa would be impressed at the emergency care a patient of his had received.
Her fingers were as steady as a rock as she palpated the cricothyroid membrane on Dylan’s neck. There was no need for local anaesthetic as the child was deeply unconscious, and there was no time in any case. Pip stabilised the ring of cartilage with one hand and made a single, decisive incision with the scalpel.
Part of her brain registered the movement of the cubicle curtain and the fact that someone had entered the space and was now standing behind her. A large figure. Maybe it was Brian Jones, one of the emergency department consultants, answering her plea for back-up. She couldn’t look up at this point, however, or hand over to anyone else, even if they were far more experienced.
Reversing her hold on the surgical instrument, Pip inserted the handle of the scalpel and rotated it ninety degrees to open the airway. Then she slid the tube into the incision, removing the introducer and replacing it with the tip of the suction apparatus tubing.
She attached the bag mask to ventilate Dylan and listened with her stethoscope to make sure both lungs were filling adequately with air. Then she checked for a pulse and looked up just as the curtain twitched back for the second time, allowing herself an audible sigh of relief.
A sigh that was abruptly terminated. It was Brian Jones who had just entered the cubicle, so who had been watching over her shoulder for the last few minutes? Pip’s head swivelled for a second to find Toni Costa standing behind her.
‘What’s been happening?’ Brian queried.
‘Epiglottitis,’ Pip informed her senior colleague succinctly. ‘Respiratory arrest. Intubation failed due to the amount of inflammation.’
Dylan was making a good effort to breathe on his own now and was stirring. He would need sedation and the assistance of a ventilator urgently, but the consultant took a moment to nod with satisfaction.
‘Well done, Pip’ was high praise from a doctor known for being taciturn. ‘Let’s get him on a ventilator. Where’s his family?’