Toby, who had been extubated yesterday after a few weeks of ventilation, appeared to be struggling again. And Ruby Wallace, a nine-year-old with a closed head injury thirty-six hours post-MVA, had a grumbling temp.
Billy had returned from CT. He’d warmed up, his heart rate had improved and he was reasonably stable. The CT showed global swelling but no specific areas of concern. Hopefully he was going to be one of the lucky ones.
No sooner had they got Billy settled back in when Linda entered the side room. ‘Nash, Ray needs you. Toby’s just not coping.’
Linda stayed to help Gwen get Billy sorted and Maggie went with Nash. The situation at bed three didn’t look good at all and one look at Toby had Maggie pulling the Resus trolley closer.
Toby, who usually beamed at anyone who came close to the bed, even with an endotracheal tube sticking out his nose, was looking exhausted, using all his accessory muscles in his chest again to help him breathe. He certainly had no energy left to smile. His oxygen sats were eighty-five on a hundred per cent rebreather mask and his arterial blood gas was abysmal.
‘Shall we trial him on mask c-pap?’ Maggie queried.
Nash nodded. ‘I think so.’ He popped his stethoscope in his ears and listened, not liking the decreased air sounds over his right chest. ‘Let’s get an X-ray too.’
Toby’s father, Brett, was staying overnight and seemed very relieved when Nash explained to him that Toby would need to go back on non-invasive ventilation. Maggie could tell that watching his son struggle to breathe was increasingly distressing for the father too.
Toby wasn’t having any of it, though, fighting the claustrophobic confines of the mask. The harder he fought, the more he taxed his respiratory system. He was also in a lather of sweat, which made maintaining a good seal on the mask very difficult.
The X-ray showed a marked deterioration from the morning’s picture but no pnemothorax, as Nash had suspected. It took several doses of sedation to finally settle the boy with another blood gas finally showing an improvement in his gaseous exchange.
With the imminent crisis averted at bed three Maggie was able to grab her first cup of coffee. Considering it was almost three a.m. she was hanging for one. She made one for Nash too and brought it out to the central nurses’ station, plonking it down beside him where he sat at the doctor’s computer, making an electronic entry into Toby’s chart.
Nash glanced up. He hadn’t had a chance tonight to think about their tryst but the smoulder in her fudge-brownie gaze put him straight back in her bed. ‘Thanks,’ he murmured.
Maggie’s breath stuttered to a halt at the heat in his loaded gaze. Watching him in action tonight should have helped to put him firmly in the colleague category, but his calm capability, his decisive authority, his dedication to his job made him even more desirable.
She nodded and turned away. The night had been crazy and there was much to catch up on. She didn’t have time to moon over his blond good looks. She sat at the computer console furthest away from him, planning to review all the patients’ charts. She’d just clicked on the first one when Linda called her over to bed eight, where she was doing a meal relief.
‘I don’t like the look of her, Maggie.’
One look at Ruby Wallace and Maggie could understand Linda’s concern. She was tachycardic, hypotensive and febrile.
The little girl had been in a high-speed car accident two days ago. She’d been restrained but her head had still smashed sideways into the window, resulting in a large subdural haemorrhage. She’d had emergency neurosurgery to evacuate the blood but was still in a coma requiring ventilatory support.
‘She’s been grumbling along most of the day with this fever but just in the last twenty minutes she’s spiked her temp and her heart rate. Her oxygen requirement has increased. Her lactate on her blood gas is rising and her blood pressure’s bottoming out. I think she may be septic.’
Maggie nodded. ‘Nash?’ she called as she grabbed the Resus trolley again.
Nash wasn’t sure if it was because he was so attuned to her or whether it was the note of concern in Maggie’s voice but he stood immediately, joining her and Linda at bed eight. He listened to their concerns, more than a little alarmed at the deterioration in Ruby’s condition and the rising lactate.
‘Yes. I think she may be septic too. Let’s get some blood cultures and give her a ten per kilo bolus of colloid for her blood pressure to start with.’
Maggie accessed the arterial line for the blood while Linda hooked up the extra fluid.
‘Her abdo’s quite distended,’ Nash mused, palpating the tense dome. They’d been treating Ruby for an illeus since admission due to her lack of bowel sounds and bruising from the seat belt. Abdominal ultrasounds had shown no acute trauma but they’d kept her nil by mouth while her gut recovered from the impact.
‘Yes,’ Linda agreed, ‘I reckon it’s blown up just in the last hour.’
Maggie added the blood to the culture bottles, a heavy foreboding settling in her bones. She reached up to the monitor to adjust the alarm settings as Ruby’s heart rate climbed to one hundred and eighty. The little girl started to gag and cough and then vomited. Bilious liquid spilled from her mouth and nose, streaming down her face and over the sheets.
Maggie quickly whipped out the yankeur sucker and, turning Ruby’s head to the side to try to prevent aspiration, she suctioned the girl’s airway while Linda aspirated the nasogastric tube. Alarms trilled all around them as Ruby’s heart rate again breached the set limits.
‘I’ll call the surgical reg for a consult,’ Nash said, walking briskly to the nearest phone.
Maggie wiped Ruby’s face with a towel and used a couple more to sop up the excess stomach contents around her. Dr Hannah Oakland arrived fifteen minutes later as the second ten per kilo bolus was almost finished. Nash could see it was having no impact on the flagging blood pressure. ‘Let’s start some inotropes,’ he ordered.
Maggie and Kylie, Ruby’s nurse who had returned from her tea break, drew up some dopamine while Hannah and Nash consulted.
‘You want an ultrasound?’ Nash asked her
Hannah shook her head. ‘I think we need to go in and have a look. I’ll organise it. Where are her parents?’
‘Mother’s asleep in the parents’ lounge,’ Kylie volunteered.
Maggie, Nash, Linda and Kylie worked to stabilise Ruby for Theatre while Hannah talked to her tearful mother and gained consent for exploratory abdominal surgery. Maggie averted her eyes as Ruby’s mother stroked her daughter’s hair, tears trekking down her face.
‘It’s okay, Rube,’ she whispered, ‘you’re going to be okay.’
Even after fifteen years Maggie found it impossible not to become involved and she hoped desperately that Ruby’s mother was right and her gut feeling was wrong.
The sky was lightening when they finally wheeled Ruby into the operating theatre at the end of the corridor. Maggie and Linda, who hadn’t had a break yet, left Kylie to clean up the bed area confident that Ruby wouldn’t be back until the end of their shift, maybe even after that.
Nash joined them in the tearoom and they all sat round staring into their coffees still a little dazed by rapid-fire events of the night. Sure, these nights happened every now and then but they were both physically and emotionally draining.