St Matthew's Passion

chapter Two



‘Mrs Reynolds?’

The tiny, stout lady struggled to her feet, her husband helping her. Melissa smiled and held the door open for the couple to shuffle through. Mrs Reynolds glanced curiously at her as they went in.

Melissa offered chairs for the two of them before seating herself at her desk. The elderly woman’s clinical records were on the computer screen before her but Melissa didn’t need to give them much more than an occasional glance. She’d studied the notes of all today’s outpatient clinic attenders the night before and familiarised herself with the histories and the treatment plans. They were all people whom Fin or his staff had treated for traumatic injury at some point, and most would attend for follow-up only until they were deemed either fully recovered or at least stable.

Mrs Reynolds had been in a car accident as a passenger two months earlier, and had sustained a deep laceration to her neck. The ambulance crew had kept her alive until she reached St Matthew’s, where Fin had operated in time to repair the carotid artery on the right-hand side. She’d had other injuries, including a broken leg which accounted for her limited mobility, but the neck wound was the one that would have proved fatal. Post-operatively she’d healed well, and all things being equal, Melissa was anticipating discharging Mrs Reynolds today.

After an initial exchange of pleasantries, Melissa was running through a standard checklist of questions – had there been any new swelling in the area, was there any lingering dizziness or lightheadedness – when she noticed Mrs Reynolds casting glances at her husband.

‘Is something wrong?’ Melissa asked.

‘It’s just…’ The older woman looked at her husband again, who shrugged slightly. Mrs Reynolds faced Melissa.

‘It’s nothing personal, dear. I’m sure you’re a lovely doctor, and a very good one. But… I really was hoping to see Mr Finmore-Gage.’

‘I know.’ Melissa smiled. It was a familiar request. Patients always wanted to see the most senior doctor, and who could blame them? Melissa herself would probably be the same if she needed medical help. ‘But I’m afraid he’s busy with his own clinic right now.’

The silence stretched out. Mr Reynolds coughed awkwardly, looking at his feet.

Mrs Reynolds said, ‘He is here, though. And he said to me that if he’s here when I come up, he’ll see me personally.’

Melissa kept her smile. ‘I’m really sorry, Mrs Reynolds. But I’m perfectly qualified to see you.’

Immediately she regretted saying it, thinking it must have come across as insufferably pompous. Mrs Reynolds tottered to her feet again, her husband jumping to help her.

‘I’m sorry, doctor,’ she said primly. ‘But I’d rather wait outside until Mr Finmore-Gage is free.’

Melissa rose, nonplussed. Mrs Reynolds’s husband gave her an apologetic grimace over his shoulder.

Melissa followed them out into the waiting room. At that moment Fin emerged several doors down, escorting a patient out. His face broke into a broad smile.

‘Mrs Reynolds! Good to see you.’ He frowned, peering down at the side of her neck. ‘It’s looking great.’

‘Mr Finmore-Gage, is there any chance I could see you, if you have a moment?’

Fin glanced across at Melissa, who stood helplessly outside the door of her examination room. He gave her a wink and said, ‘Yes, of course.’ Putting out an arm, he supported Mrs Reynolds into his room.

Melissa went back into her own room, closed the door, and slumped at her desk, glaring at the computer screen. Her face burned.

What was Fin doing? He must have realised what happened, that Mrs Reynolds had been seeing her, Melissa, and been unhappy about it. The very least he might have done was to express his full confidence in his registrar and urge Mrs Reynolds to consult her, even if he did have the time to see her himself.

She stared glumly at the display on the monitor. Had she displeased Fin in some way? She’d been in the post eight days, and had completely immersed herself, arriving at the crack of dawn and staying late, and even coming in on Sunday when she wasn’t scheduled to be at work. She had crammed several weeks’ worth of experience into that time, learning an immense amount assisting Fin in theatre and following his patients after surgery. He’d always been courteous towards her, acknowledging her contributions, and hadn’t criticised her or pointed out any obvious mistakes. So why was he undermining her like this?

Perhaps he was just another macho surgeon, part of the smug old boys’ club, who saw her very presence as a threat to his masculinity. Perhaps he genuinely believed she lacked the competence to carry out so routine a task as to evaluate the progress of a patient’s healing, two months after the operation.

Or perhaps, Melissa thought, shamefully, she was reading far too much into the situation. There might be an innocuous explanation. Well, there was only one way to find out.

She’d have to bring the subject up with him.



***



Fin strode briskly down the corridor from theatre towards the wards, Deborah at his side. Deborah Lennox was the sister in charge of the trauma wards, a cool-headed bastion of efficiency who was at the same time a firebrand when it came to getting the best possible care for the patients under her charge. She was updating Fin on the latest developments with his post-traumatic pancreatitis patient when he felt somebody fall into step at his other flank.

He glanced round, and saw it was Melissa.

‘Fin, do you have a moment?’ she asked, slightly out of breath.

He slowed, nodded to Deborah. ‘I’ll catch up on the ward.’ Turning to Melissa he said, ‘What’s up?’

‘Is there somewhere we could talk in private? It’s not urgent, but there might not be a chance after the ward rounds.’

He’d wondered if she might want to talk. Their outpatient clinic had finished six hours earlier and it had been a long afternoon in theatre, where she’d assisted him with a bowel resection. Over the surgical mask her eyes had met his from time to time, even when he wasn’t addressing her. He’d sensed something was on her mind.

‘Yes, of course.’ They reached the door of a small seminar room not currently in use and Fin led the way in. He turned to face her. She looked slightly uneasy and yet defiant at the same time, her posture straight, her chin tilted up a little, her gaze direct. He felt drawn to move closer to her but kept his distance, respecting her personal space. He waited for her to speak.

‘Earlier today, in outpatients.’ She faltered, and he gave an encouraging nod, having no idea what she was leading up to. ‘I felt quite uncomfortable about something.’

‘Oh, really?What was that?’

‘Mrs Reynolds. The carotid injury patient. She said she preferred not to see me and insisted you see her instead.’

‘Yes. That worked out well, because I happened to be just in between patients.’

She spoke more confidently now, building up steam. ‘It’s the principle, Fin. With respect. I was perfectly capable of managing her, and I’d already told her it wasn’t possible for you to see her because you were with another patient.’ She hesitated, flushing deeply. The colour in her cheeks set off the blue of her eyes and he felt a slow warmth spread through his chest and belly. ‘I felt quite undermined, as though you agreed with her that I wasn’t up to the job of caring for her.’

He waited to see if there was more. She was a little breathless, as though she felt she’d gone too far. Fin tried to ignore the rise and fall of her breasts under her coat.

At last he said, ‘Fair enough. I can see how you might have felt, and I’m sorry. But if we’re talking principle, then consider this. The patient’s needs come first. Always, in every circumstance. Now, of course if I genuinely hadn’t been available then Mrs Reynolds would have to have seen you. And –’ he went on as she opened her mouth once more, ‘by that I don’t mean you were the second best option. Far from it. In fact, Mrs Reynolds was very complimentary about your manner when I saw her. But wherever possible, we accede to the patient’s request. I’m not saying we give in to the patient’s every whim and demand, not when we know it wouldn’t be in their interests. But in this case Mrs Reynolds had a reasonable request, and it all turned out fine.’

Melissa blinked, appearing lost for words for a moment. Then she sighed. ‘It just felt as if I was being belittled, that’s all.’

‘You disagree with what I just said?’ He watched her eyes carefully, aware that he was being deliberately provocative. Again she floundered for a second. Then her expression tightened and she looked defiant again.

‘Yes. I disagree. Not with the point about the patient’s needs taking priority, but about how that was applied in this case.’

‘Good.’

She looked utterly taken aback, as if she’d been preparing for his anger, his outrage that he was being challenged. ‘Good? I don’t –’

‘It’s good that you’re sticking to your guns. Being honest about how you feel. About what you believe.’

She tilted her head to one side a fraction, a smile touching her lips. ‘Then you accept I’m in the right.’

‘No,’ he said. He noticed that her smile died a little. Fin shrugged. ‘I’m right. As long as I’m in charge, as long as the ultimate responsibility for what goes on in this department falls on my shoulders, then I’m right. That’s not to say you can’t have your own opinions. As I just said, I encourage it. But my decision’s the final one. Always.’ He smiled broadly. ‘Anything else?’

‘No.’ He suspected her voice came out more quietly than she’d hoped, and she looked annoyed at herself.

‘Good. Now let’s hit those wards.’

She didn’t quite stalk off, but she made sure she was a couple of paces ahead of him on their walk down the corridor, maintaining an actual as well as a symbolic distance between them. Again Fin felt the urge to gaze at her figure beneath the shapeless white coat, and again he fought it.

It was the first time he’d seen Melissa close to anger, and the first time he’d really seen her assert herself with him. He was pleased. Standing firm was as essential with colleagues as it was when making clinical decisions. Fin was bothered, though, by Melissa’s sensitivity about the whole issue. Patients always wanted to see the consultant, it was a fact of life, and there was little point in a registrar getting worked up about the matter. There was quite enough to be stressed about in the practice of medicine, especially a field as demanding as trauma surgery, and you needed to know what genuinely to fret over and what to simply let slide.

He watched Melissa disappear through the doors of the ward ahead, letting them swing closed behind her, and he thought: you’ve got a lot to learn, Ms Havers. Not just about surgery, but about toughening up too.



***



Melissa was on her way back from a follow-up visit to one of her patients on the general medical ward when her pager exploded into a blare of noise, and although the voice was so distorted by static as to be unintelligible she knew it meant one thing.

She began to hurry.

The Accident and Emergency Department was three floors down. She bypassed the lifts with their crowds of people milling before the doors and took the fire stairs two at a time. Barging through the doors to A&E she saw the usual Saturday afternoon scene: hobbling football players with sprained ankles being supported into seats by their teammates, amateur DIY enthusiasts clutching wrapped and bleeding hands, a few early pub casualties barely able to sit upright. All deserving of attention and care, but all small fry compared with what she was about to have to deal with.

The blue strobing of the ambulance’s flasher announced the vehicle’s arrival. A minute later a wheeled stretcher came through the doors, surrounded by three paramedics. One of them recognised Melissa and nodded.

‘Definitely one for you, doc.’

She moved into step beside the trolley as they wheeled it towards the ‘majors’ room, where the urgent cases were brought. Strapped securely to its metal frame was a burly man in workman’s overalls, an oxygen mask fastened over his nose and mouth and an intravenous line extending form one arm and attached to a saline drip. His right leg was held immobile by a series of blocks providing a temporary splint. The overalls were soaked with blood from torso to legs.

‘Sunil Khan, aged forty-three,’ the paramedic recited, with the terseness of someone who was used to packing as much information as possible into the fewest words. ‘Fell approximately fifty feet when the scaffolding collapsed under him. Multiple trauma to head, chest and right lower limb, which looks like a femoral fracture. GCS seven. Latest BP 115 over 63.’

GCS – the Glasgow Coma Scale – was a measure of a patient’s responsiveness after a head injury. Fifteen was normal. Seven wasn’t good at all. Melissa noticed another man hovering alongside the stretcher.

‘Are you a friend or relative?’ she asked.

He was in overalls too, his face streaked with grime and sweat, a man of about forty. ‘I work with Sunil,’ he said. ‘I was there when the scaffolding collapsed. Helped pull him out.’

‘Are you hurt?’ said Melissa.

He shook his head. ‘Nah. Just caught a light tap from one of the poles.’ He nodded at his friend. ‘Is he going to be all right?’

As a group of nurses helped the paramedics to transfer the patient on to the bed in one of the cubicles, Melissa snapped on a pair of latex gloves and set to work. She assigned tasks to two other nurses and requested that the portable CT scanner be brought across. Her gloved hands moved expertly across the patient, probing and tapping, examining for penetrating injuries, unusual percussion notes suggesting air or fluid where it shouldn’t be. With a tiny torch form her pocket she established that the man’s pupils were equal and reactive to light, a promising sign.

She became so absorbed in the activity that for a moment she wasn’t aware of somebody at her shoulder. Looking up and round from where she was listening to the patient’s chest with her stethoscope, she saw Fin, his broad chest inches from her face.

‘What have we got?’ he asked.

She gave him the summary. The CT scan revealed no intracranial abnormality, and there was no immediately obvious neurological deficit. The man’s right leg was a mess, fractured in several places. Of more immediate concern was the crush injury to his thorax, which had broken most of the ribs on the right hand side and had collapsed the underlying lung. He needed to go to theatre as soon as possible.

‘Okay, good,’ said Fin when she’d finished. ‘Care to assist me?’

‘Of course.’ Melissa hadn’t spoken to him since the day before, when there’d been the awkwardness about his seeing Mrs Reynolds. She’d spent the night in turmoil, her feelings swinging from a creeping shame that she’d overreacted to a minor issue, to hot anger at Fin for his arrogance. Yes, he was the boss… but that didn’t mean he was always right. Was he toying with her in some cruel way?

Now, though, she jumped at the chance both to re-establish the goodwill between them and to assist him in a complicated case. He said, ‘See you in theatre,’ and headed out.

Melissa cast a final glance at the patient’s vital signs – blood pressure, pulse and oxygen saturation all acceptable – and scribbled some notes in her quick, unusually neat hand. She gave instructions to the nurse to prepare Mr Khan for theatre and to alert the anaesthetist on duty, and stepped outside the cubicle.

Mr Khan’s friend, his fellow construction worker, was seated on one of the orange plastic chairs outside. He looked up anxiously.

‘How is he?’

‘He’s going to need surgery,’ said Melissa. She gave the man a quick layman’s account of his friend’s injuries. While she did so she saw him rise to his feet and grimace.

Melissa frowned. ‘Are you all right?’

‘Yeah.’ He winced. ‘Bit of pain in the shoulder, that’s all.’

His face was putty-coloured. Melissa took him by the arm and guided him into one of the adjoining cubicles.

‘You said you had a slight tap from one of the scaffolding poles?’

‘Yeah.’

‘Where?’

He allowed her to lay him on his back, though Melissa could see from the contortion of his face that it hurt him to do so. ‘Just here.’ He waved his hand over his abdomen. ‘Fell across one of the bars.’

‘From a height?’

‘Only ten feet or so. Not like Sunil.’

Melissa felt her pulse quicken. She called, ‘Deborah.’

Deborah Lennox, the trauma ward sister, was passing. Accident & Emergency wasn’t one of her usual haunts but she sometimes came down here to ‘majors’ to see who would be ending up under her care after surgery. She came over.

‘Could you get a BP on Mr – what was your name, sir?’

‘Barry Davis,’ he hissed between his teeth. ‘Call me Barry.’

‘Sure thing,’ said Deborah, and busied herself with the cuff. Melissa propped the man’s feet up to raise them above the level of his head, and felt his carotid pulses. His heart was going at over 120 beats per minute. She helped him out of his overalls and exposed his abdomen, then began to probe with flat hands. She pressed down gently and released, but Barry didn’t react. No rebound tenderness, then.

‘Where’s the pain?’ Melissa asked. ‘Still in your shoulder?’

‘Yeah,’ he groaned. ‘The left one. Getting worse.’

‘BP’s ninety-seven over fifty-two, Ms Havers,’ said Deborah.

That was low, and coupled with the rapid pulse the finding was ominous. Melissa said, ‘Barry, does the shoulder pain get worse when you breathe in?’

He inhaled, then gasped. ‘Oh yeah.’

Kehr’s sign. Pain in the left shoulder, aggravated by inhaling. It indicated blood in the abdominal cavity, most likely from a damaged spleen. A life-threatening injury.

‘Deborah’, said Melissa, ‘could you please bring the CT scanner over here?’

While she was waiting for the CT films to process, Melissa kept close watch over the injured man. He’d started to report pain in his abdomen, and this time when she palpated it there was a sharp moan of pain. She set up an intravenous drip but when his blood pressure failed to rise satisfactorily she asked Deborah for a central venous line kit. With practised skill Melissa inserted a large-bore cannula into the internal jugular vein in the side of Barry’s neck. It allowed a high volume of fluid to be infused rapidly into his system to counteract the blood loss that was occurring somewhere within his abdominal cavity.

Deborah handed her the CT films. Melissa clipped them into the backlit screen mounted on the wall. There it was: an extensive fluid collection in the right upper quadrant. The spleen was hard to see accurately, but looked far from intact.

At her shoulder Deborah said, ‘I’ll call Mr Finmore-Gage out of theatre.’

‘There’s no time,’ said Melissa. ‘That’s a stage five injury. A shattered spleen. He needs it out, and urgently.’

Deborah gazed into her eyes, as if gauging whether Melissa understood the implication of what she’d said. Melissa nodded silently: yes. I know.

Over her shoulder, already on the move, Deborah called: ‘I’ll alert theatre.’

Heart hammering in her throat at the realisation of what she was going to have to do, Melissa spoke rapidly to the injured man, explaining the procedure, trying to keep a tone of calmness in her voice. He took the proffered pen and consent form from her and signed, and she assured him that his wife would be notified immediately.

On the way to theatre, as a nurse and a porter steered the trolley deftly through the corridors with Melissa at its head, Deborah appeared beside her. ‘Theatre’s ready,’ she murmured. ‘There are complications with Mr Finmore-Gage’s case and he’s tied up there, so he says you’ll have to do this one. I’ve arranged an assistant for you and an anaesthetist.’

In the scrub room, her hands sheathed in sterile latex gloves and a nurse tying her surgical gown behind her back, Melissa stared at her reflection in the mirror over the basin. Her eyes were calm, her mouth set. To all appearances she was relaxed, confident, the very model of a cool and collected surgeon. Inside, she was terrified. She was about to perform a laparotomy and splenectomy on her own for the first time ever. The patient’s life depended on her.

The nurse put on Melissa’s face mask for her, leaving only her eyes exposed. Melissa used her back to push open the door and stepped into the theatre, where amongst the beep of the monitoring equipment and the clatter of the instrument trolley as it was moved into place, her patient lay supine on the operating table, draped in green apart from his exposed abdomen, yellow in the harsh light from above.

The next hour would linger in Melissa’s memory as one of the most intense of her life, in which her senses – sight, smell, hearing – were heightened to an almost animal level. She made the incision in the upper abdomen at the midline and opened the abdominal wall. As she’d predicted, and as the scan had confirmed, the cavity was filled with blood. In short order, while the junior doctor assisting her held the retractors to keep the cavity exposed, Melissa used suction to visualise the internal organs, detached the anchoring ligaments of the spleen, clamped off and cauterised the vessels connecting the organ to the vascular system, and lifted the spleen free. It was a wreck, fragmented beyond salvage. After that the process was straightforward: examine the rest of the organs including the pancreas for damage, clear out all remaining fluid from the cavity, check for bleeding vessels, and, at last, suture the abdominal wall closed.

Melissa emerged into the scrub room and fired her gloves at the waste container with a loud snap. She felt delirious, light-headed, and fifteen feet tall. For the first time she’d taken charge completely, suspecting a problem and following her instincts to make the correct diagnosis, then operating to solve the problem, without any outside advice or supervision. There was still a lot that could go wrong, of course, and the patient would have to adjust to life without a spleen which would render him more susceptible to infection. But he was alive now, all because of Melissa; his wife still had a husband and his children a father. Nothing Melissa had ever experienced before came close to the bursting joy she felt now.

One by one people filtered into the scrub room to slap her on the back and offer their congratulations: her junior assistant, the theatre nurse, even the anaesthetist, who’d perched through most of the operation on a stool reading a newspaper, as nonchalant as members of his specialty usually were. Melissa basked in the praise, all the while knowing there was someone else whose admiration would matter so much more.

Fin emerged nearly two hours later from the adjacent theatre, his gown painted with blood, the sweat matting his hair to his forehead. Melissa helped with the post-operative write-up of his case – the severely injured construction worker, Mr Khan, would live, though it would be a long time before he’d walk again – and found Fin as he was coming off the phone.

‘How did the laparotomy go?’ he said, as if he’d only just remembered it.

‘Not badly,’ she said as neutrally as she could. Quickly she described her approach. He listened, nodding slightly.

When she’d finished he nodded and asked, ‘Mind if I take a look?’

She led him into the post-op room where Barry, her patient, was still unconscious and being tended by a nurse. Fin uncovered him and gently peeled away the dressing, inspecting the incision she’d made in his belly.

Melissa watched Fin’s face, her body taut with tension. At last Fin smoothed the dressing back in place.

‘It’s okay,’ he said. ‘Spacing of the sutures could be a little more even.’

With that, he turned and left.

Melissa slumped into a chair, closing her eyes. She felt like a tyre which had suddenly had all the air let out of it. The adrenaline, the exuberance she’d been coasting on for the last few hours had dissipated like smoke in a storm.

What was his problem? Why was nothing she did ever good enough for this unreadable, infuriating man?