Unknown (9 page)

'Antibiotics and IV fluids,' he told Merrin, after they'd seen the second patient together. 'Nil by mouth to rest the gut. Pethidine and a non-steroidal for pain relief. For antibiotics you should use cefuroxime IV eight-hourly plus rectal metronidazole. Usual bloods plus a clotting screen and liver-function tests. Talk to one of the radiologists and see if you can organise an ultrasound scan for tomorrow morning. She's only had one day of pain and Prof prefers to operate acutely before the inflammation gets too bad. If we can get the scan tomorrow he may do her on Thursday's list.'

'OK.' Merrin wrote it all down quickly. 'Orange Ward?'

'If they've any beds left.'

They did have. But Merrin was still learning where to find everything in Casualty. The place was busy and she had to wait for one of the computers to become free before she could organise her patients' blood tests and X-rays so it took longer than she'd expected to finish her admission. By the time her patient with cholecystitis was ready to go to the ward, Merrin had to rush straight up to Theatre to help Douglas with the little boy's appendix.

Assisting with an appendicectomy, she discovered, largely involved holding a small retractor and cutting the occasional thread. But, like the Professor had that morning, the registrar let her close the wound. This time, though, she was instructed to close each layer below the skin separately instead of all at once. Once again she used staples for the skin, using four single staples to close.

She remembered that their appendicectomy patient on Orange Ward had had his operation done using the laparoscope and asked him about it.

'We still do all the children open,' he explained. 'Prof doesn't feel there's enough evidence yet that laparoscopic work offers any benefit in the young. That might change in the next year or two but for the moment with children he's very cautious.'

Douglas bleeped their boss from Theatres once they'd finished to say that they were free to go around the wards if he was ready. Apparently he was because he met them on Orange Ward ten minutes later.

'Lindsay's not coming back tonight,' he told them briskly. 'Ben's got mumps, according to the GP. Lindsay's organised for her mother to look; after him from tomorrow but she wanted to stay with him today. Let's go. Any problems downstairs?'

'That twelve-year-old with appendicitis whom we've just done, and a lady with cholecystitis who should be up here by now,' Douglas told him quickly, helping Merrin with the notes trolley as they hurtled after their boss.

Their new admission was in the first side-room and they stopped there first. The Professor took a brief history, examined her, then confirmed Douglas's diagnosis. 'It
looks
like your gall bladder's inflamed,' he told her. 'The most likely cause is gallstones. Treatment for the moment is
rest
and pain relief and antibiotics. Dr Ryan will request an ultrasound scan for you and if that confirms stones then the easiest thing is to take out the gall bladder.'

'The
scan's
booked for nine-thirty tomorrow morning,' Merrin said quickly.

'Good.' The Professor sent her a brief look. 'Well done, Merrin. That's very quick.' He turned back to their patient. 'Depending on what we see on the scan, the best time to operate is either going to be Thursday morning or after six weeks. What do you think?'

'Thursday sounds good,' their patient said weakly. 'You know a doctor told me years ago that I had gallstones. He saw them on an X-ray they did when I thought I'd swallowed a safety pin out of my daughter's nappies. He said if they weren't giving me any trouble then I should leave them alone.'

'My. thinking is that he was right,' the Prof said. 'But now that they're giving you trouble, it's time they were out. We'll know more after the scan tomorrow. I'll come and talk to you then.'

They went through the rest of their adult patients quickly then the Prof was called away to a phone call and Douglas was bleeped away to see a Casualty patient. 'Chronic abdominal pain,' he told Merrin, explaining that that there was nothing to be gained by her coming down with him. 'He'll need outpatient investigations rather than admission so I'll sort things out while you go with Prof to the children's ward. I'll catch up with you when I'm free.'

When the professor returned from his call, Merrin explained Douglas's absence, but he didn't seem perturbed and instead simply hurried her off downstairs. 'How was that appendix you just did?'

'Definite appendicitis,' she told him, jumping steps two at a time in her determination not to slow him down. 'It was bright red and there was pus around it and loads of fluid.'

'Did Douglas let you do much?'

'I closed.' She sent him a quick smile. 'Staples again. I'm becoming an expert.'

'Good.' To her delight he smiled back. 'Brush up on the anatomy and your knots over the weekend and perhaps he'll let you do one next week.'

'Do you think?' She felt her eyes widening at that. 'That would be amazing.'

'I'll have a word with him.'

'Thank you.' She'd slowed on the stairs and now he overtook her, but lightly, so lightly she decided that
he couldn't possibly notice, even though the closeness of him seemed to set her on fire, she let her hand touch his arm as he passed. 'Thank you.'

The children's unit seemed chaotic but thankfully it wasn't their patients causing trouble. The minor cases from the afternoon's list were due to go home and Professor McAlister saw them each in turn, taking time to explain his findings to their parents before discharging them.

While he talked, Merrin quickly scrawled discharge letters for their GPs, but she couldn't keep up and still had three to do when he was finished on the ward. When he held the ward door open for her to precede him out into the cold evening towards the main hospital, she lifted up the notes by way of explanation. 'I've still got to finish the letters,' she added. 'You go on. See you later.'

But he didn't go. 'I can help,' he said calmly, following her to the small doctors' office behind the main desk. 'What's there to do?'

'Just these letters.' She sent him a doubtful look but he appeared serious and so she sat at one desk while he sat at the other and she passed him a letter and a set of notes. 'Just fill it in. Date of admission, date of discharge, diagnosis and so on. It's all in the notes.'

While she worked on one, he did the other. 'What about, here?' he asked, pointing with his pen at the broad, clear space in the middle of the form. 'Do you put in the operation findings or do the GPs get a copy of my operation note?'

Merrin leaned towards him, inhaling the fresh tang of his skin appreciatively while she tried to pay attention to the notes he had open. 'Well, for your one I'd usually put something like, for instance, "At operation, posterior fissure diagnosed and treated with anal stretch, post-op treatment mild laxative, to be reviewed in Outpatients by Professor McAlister in six weeks",' she told him.

'You'd
usually
put something like that,' he said gently, watching her.

Merrin felt herself beginning to flush. 'Well, in the past two days that's the sort of thing I've usually written,' she qualified. 'I know I haven't been here very long but it feels like longer.'

'Yes, it does.'

Unsure how to take that, she blinked at him. 'Is that bad?'

'Bad?' He inclined his head, seeming to be considering that. 'No, not bad,' he said finally. 'Curious would be a better word.' He signed his name in a swift scrawl at the bottom of the form he'd completed. 'Are you finished?'

Merrin looked hurriedly away. 'One more to go,' she said, shuffling the papers as she looked for the next letter. 'You don't have to wait.'

'I do.' There was a heavy pause and when she glanced up he added, 'I'm taking you to supper.'

'What
?' Merrin gave Neil a breathless, startled look. 'But I'm on call. I can't leave the hospital.'

'I'm not suggesting a date,' he said dryly. 'McDonald's. There won't be anything edible at the canteen. You bought my lunch, I'll buy your supper.'

'OK.' Her spirits had sagged at his comment about the date but, telling herself that to have assumed anything else was ludicrous, she brightened again. The possibility of her refusing a chance to spend time with him was zero.
'OK,
that's great.'

'I'll bleep Douglas,' he said, reaching across her for the phone—proving that his offer hadn't been made because of any desire to spend time with her. 'He can meet us there,' he added.

Douglas came up behind them just as they arrived at the hamburger restaurant and he spent the meal in earnest discussion with the Professor about a research project in which they were both involved.

Merrin munched her burger and chips, interested in their discussion but for once determined to subdue her curiosity. She'd ask Douglas about the details later, she decided, letting the talk go over her head.

But it seemed that her boss had noted her diplomatic silence because when Douglas muttered something about an apple pie and left them to go back to the serving counter, the consultant lifted his eyebrows at her. 'Cat got your tongue?'

'Of course I'm interested,' she admitted, 'but I've asked you a lot of questions today. I thought you might be starting to get impatient with me.'

'I told you, you've got a few weeks grace. Besides, I find your enthusiasm refreshing,' he added, rendering her dumbfounded. 'It reminds me of how I was at your age.'

He'd only half finished his burger but he pushed it aside and took the lid off his coffee. 'The study Doug mentioned is a university one which we're running in conjunction with a number of other hospitals. We're trying to perfect methods of detecting signs of rejection in patients who've had bowel transplants.'

'Can't you simply take biopsies?' she asked. 'Or tell clinically?'

'Biopsy changes tend to come too late,' he explained. 'Often too late for us to start treatment to save the transplant. Clinically, signs like weight loss and masses come even later.'

'So what are you looking for?'

'In early rejection the bowel becomes more permeable. We're investigating a method where our patients eat compounds which we've labelled with radioisotopes, then we measure the excretion of the compounds in the urine. In early rejection the percentage that gets through the bowel into the urine goes up.'

'And when you can detect early rejection...then more people will be able to have transplants?'

'In the long term that's the plan. Bowel transplantation is still in its relative infancy. If the problems with rejection are solved then there's a possibility of it becoming a frontline treatment for our patients with severe Crohn's disease. In particular for those who've had too much bowel removed to be able to absorb enough from their food to keep themselves alive. The field is advancing all the time. The future looks good.'

He finished his coffee, then checked his watch. 'Doug, I'll be over the road in the lab,' he said, standing when the younger man returned with an apple pie. 'Give me a call if you've any problems.'

There weren't any problems. Remembering the exhausting urgency of the weekend, Merrin was surprised to find herself with nothing obvious to do after about eleven that evening.

'Get some sleep,' Douglas told her, after saying that he was going to go to bed himself. 'I'll call you if there's anyone to see in Casualty and the wards will bleep you readily enough if they want anything.'

She had to get up once during the night to see a ward patient who'd fallen out of bed, but he didn't seem to have come to any harm and didn't need any X-rays and she was back in her room again within half an hour.

The next day she was too busy on the wards and admitting patients for the following day's theatre list to make it to Outpatients, but on Thursday morning she managed to get to Theatre in time to assist her boss and Douglas and Lindsay with Toby Wiseman's operation.

Sections of Toby's small bowel had become scarred and narrowed, meaning that he suffered terrible colic every time he tried to eat solid food. Despite supplementing his diet with high-calorie, nourishing drinks supplied by the hospital's dieticians, he'd lost over a stone in six weeks. It was weight he couldn't afford to lose.

He'd had several major operations over the past three years to overcome leaking and stuck bowel but this was the first for this problem.

'For six months I've been deliberately avoiding surgery,' the professor explained when she questioned him about why he'd not done anything sooner, 'but it's got to the stage where he's terrified to eat. The bowel's obstructed completely once in the past month, but although it relieved itself with conservative treatment the lumen's now so pinched that it's only a matter of a week or two before it blocks permanently.'

'But if you're just going to remove the damaged bit, then that's not such a bad procedure, is it?' she asked, still not understanding why he'd left things so long.

'He doesn't have enough bowel left to treat it that simply,' he told her, his head lowered to his work. 'That's why we're doing this.'

She watched as with Douglas's assistance he gently pulled a catheter with a balloon on the end through the lumen of the bowel. Each time the balloon stuck, he marked the spot with a blue stitch, then deflated the balloon, by using a syringe to remove the saline that was filling it, so that he could pull it through the obstruction, reinflate the balloon and move on to the next area of damage.

Merrin frowned as she watched his progress, not understanding. 'Are you marking each blockage so you know exactly which bits to remove?'

'So we know which bits to repair,' he answered quietly, obviously concentrating as he marked another narrowing. 'Cutting anything out is the last resort.'

When he'd marked the bowel through its entire length, he returned to his first marking suture. 'Cutting diathermy,' he ordered, and Merrin watched, fascinated, as he delicately cut along the damaged bowel to open the narrowed area. 'Now do you see?' he asked, as he took a stitch from the scrub nurse to close it again.