Scalpel (3 page)

4

11.55 am

The piercing double alarm signal went off in three separate areas at the same time.

Over a welcome cup of coffee and cigarette in the staff canteen, Dr Don O'Callaghan, consultant anaesthetist, was reading the
Irish Times
and its predictions for the next Ireland versus England soccer match.

'Bugger it,' he muttered as he threw the paper down and rushed to the nearest red phone to dial central information.

Down in the paediatrics section of West Wing, Dr Paddy Holland was inserting an IV line into the scalp of a three-day-old baby when he too heard the emergency signal on his bleep. He grunted with satisfaction as he saw blood flow back along the line, confirming he had struck a vein.

'Strap that IV down securely, would you Nurse?' he murmured, holding the butterfly needle in place all the time lest the struggling baby would dislodge his best effort. As soon as a tape was secured he rushed to the nearest red phone and dialled.

Dean Lynch was writing an X-ray request when the alarm sounded on his bleep. Without stopping he lifted the phone beside him and contacted central information.

For all three men the details were the same, exactly as June Morrison had called them to the nurse in charge of central information when they reached theatre.

A twenty-eight-year-old primagravida, Sandra O'Brien, already in established labour needed an urgent Caesarean
section for foetal distress. Her vital signs gave no cause for alarm, the blood pressure holding at one twenty over seventy, pulse rate up to one hundred and ten beats per minute, but this was put down to the panic she was now experiencing with the sudden change of events. Her urine had been consistently clear throughout the pregnancy and labour and she had shown no signs of toxaemia at any stage. There was only mild oedema of the hands and ankles, consistent with the usual fluid retention of many pregnancies.

By contrast her baby was distressed, in definite risk of imminent death. There had been dips in the foetal heart rate over the previous three hours but it had always recovered to normal. The CTG scan had started to show irregularities over the previous forty minutes only. However, at exactly 11.32 am, she had spontaneously ruptured her membranes, with heavy, dark-stained meconium draining. The baby's heart rate had also dipped at that point and was now hovering around sixty to sixty-six beats per minutes. There hadn't been time to clip an electrode to the foetal scalp to measure pH levels.

The consultant obstetrician in charge of this pregnancy and delivery could not be located.

For all three men this was all the information they needed to act on and act quickly. An unborn baby was in danger and only swift intervention would save his life. The speed of that intervention was vital, even a minute's delay might prove fatal.

Don O'Callaghan sprinted from the canteen, passed startled onlookers, and along the corridors that would take him to the theatre where Sandra O'Brien was now stationed. He almost knocked over an elderly nun shuffling along directly in his path and shouted a rushed 'sorry' over his shoulder.

Paddy Holland was in the Emergency Only lift within seconds, punching in the level he required on the dials. He knew if he was in the lift at that point no one could interrupt its steady passage upwards, the security code would not
allow it to stop until the exact level requested had been reached.

Dean Lynch cursed all the way as he took the steps from his outpatients two at a time. For the fourth time in as many months he was on his way to the North Wing, the exclusively private section of the hospital and so different from the world he inhabited, East Wing with its grubby theatres, tatty corridors and shoddy paintwork. As Dean Lynch ran, he cursed silently but deeply, anger building up inside with every step.

At the same time as the three men converged on the operating theatre of North Wing a mobile phone clicked into action further down the corridor from the room into which Sandra O'Brien had just been whisked. Theo Dempsey, ex-Irish army sergeant and Harry O'Brien's minder, was beaming his message through the satellite directly to his boss at his North Wicklow mansion.

Big Harry had chosen to stay there while he awaited news of his wife's progress, no longer able to cope with the hospital atmosphere. He hated the smell of disinfectant, the muffled moans of women in labour and the incessant crying of newborn babies. He'd had to spend so much time there at the beginning of the IVF programme that the very sight of the front door made his stomach knot. Harry O'Brien was a man who liked to be in control and was most uneasy in any setting where he had to rely on someone else's judgement. When Sandra had suggested that he wait at home until it was closer to the time the baby was due, Big Harry readily agreed but still despatched Theo Dempsey to keep an eye on all developments, instructing him to make immediate contact when Tom Morgan or June Morrison gave the nod.

Within seconds of Dempsey's call, O'Brien was running through the house and out to his waiting chartered helicopter. The journey from North Wicklow to the improvised helipad in the hospital car park would take only thirty minutes.

5

12.01 pm

Theatre Suite Two, North Wing

Dean Lynch was scrubbing up alongside June Morrison who was going to assist at the operation. While she was at least three inches taller than Lynch and not easily intimidated, Morrison could barely bring herself to look at him.

'I'm sorry to call you, Dr Lynch,' she said through her face mask, trying to make herself heard above the running water and the noise of scrubbing brushes. She knew by the way Lynch had entered the theatre he was livid.

Lynch continued scrubbing, his eyes fixed on the brush as it swept across his nails, first one hand and then the next.

'She's one of Tom Morgan's patients but he wasn't in the house when the crisis arose. That's why we had to page you.'

Lynch still said nothing, not even acknowledging Morrison's presence. He spun around on his heels, still scrubbing, and observed the frantic scene.

Sandra O'Brien was lying on the operating table of Theatre Two, her eyes darting about like a frightened rabbit. All around her was activity.

Don O'Callaghan, the anaesthetist, already had an IV drip inserted into the back of her right hand and was checking his anaesthetic gases. His heavy paunch stretched his shirt to its limits and he had to hoist up his trousers every now and then to keep comfortable. He made a quick note in a chart clipped to the anaesthetic trolley beside the operating table, then took out his endotracheal tubes and sized them. He glanced quickly at Sandra O'Brien and selected one. With
a spare syringe he injected air into a narrow tube connected to the endotracheal tube and grunted with satisfaction as the sides expanded. As soon as he had Sandra O'Brien asleep this would be inserted down her throat and into her windpipe, then insufflated so that a tight and full connection existed. That way the anaesthetic gases went straight to the lungs and did not seep around the edges of the tube that drove them there.

Breda Mullan was busying herself for the operation, now only minutes away. Already scrubbed up, she was counting sterile gauze swabs with a nurse assistant so that the number used during surgery would match exactly the number counted back again when everything was over. A different nurse passed by quickly, clutching two packs of blood. She hung them off the same rail that already held the saline IV.

Lynch spun back again and rinsed his hands thoroughly under the running water before knocking off the flow with an elbow. He reached for the sterile towel offered by another nurse without looking at her. As he dried his hands he tried to control his breathing, fighting to contain the rage building up. His throat was feeling especially uncomfortable and he swilled some saliva in his mouth and swallowed to try and lubricate the raw dryness.

'The patient is Sandra O'Brien,' interrupted Morrison again, hoping desperately to get him onside before the operation began. She didn't want him near Sandra O'Brien with the anger she sensed. The rapid breathing, the rage filled eyes and agitated hand movements warned her to tread carefully. She glanced around quickly to see if Tom Morgan had turned up but there was still no sign of him. 'You know the one I mean? Married to Harry O'Brien? O'Brien Corporation?'

Lynch threw the towel at the feet of the nurse who had offered it and took the sterile gloves she now peeled out. He slipped one on, then the other, and turned to look up at Morrison for the first time. She thought her heart would stop as his fierce eyes centred on her own.

'Sister Morrison,' he hissed through his mask, 'I don't give
a fuck who she is. Why don't you just shut up and let's do it?' He walked away from the stainless steel wash sinks and stood slightly to the side of the operating table, eyes fixed on the swollen belly of Sandra O'Brien.

June Morrison and the nurse aide exchanged glances as the younger woman offered another set of sterile gloves. Their looks said it all. This was going to be an ordeal for everyone concerned.

It was now 12.06 pm.

Inside his helicopter Harry O'Brien was barking into a mobile phone, trying desperately to make out the faint signal coming back down the line. 'Jesus, Jesus Christ!' he screamed into the mouthpiece. 'What's going on?' But the roll of the chopper blades was too strong and drowned out the reply.

He flicked off the phone and stared ahead, stony faced, as the helicopter pulled off to the east and its descent towards the maternity hospital. If anything happens to this child, I'll kill. I swear I'll kill.

It was now 12.07 pm.

Inside Sandra O'Brien's womb her unborn son was struggling to survive. His heart rate was barely sixty beats a minute, his limbs were weakening. He was getting tired. The threshing movements had stopped and only the foetal monitor showed life still existed. Everyone in Operating Room Two kept checking that monitor and everyone was becoming more and more concerned. Time was running out. Dean Lynch looked to Don O'Callaghan and nodded he was ready. O'Callaghan, a man nearing retirement and glad of that, nodded back. Lynch looked towards Paddy Holland who was standing by the paediatric resuscitation trolley. To his immediate right stood his senior registrar, a young female doctor with over six years' paediatric intensive care training, and to her right again a paediatric intensive care nurse. Holland acknowledged Lynch's nod. The team was ready.

Lynch turned to Don O'Callaghan. 'Let's do it,' he said.

All eyes focused on him as he stepped up onto a small foot stool beside the operating table to get a higher position. No one else needed such a lift, the stool usually reserved for some of the smaller nurses assisting at operations. As he swabbed and draped, June Morrison noticed his breathing settle, become much slower. His hand movements also relaxed. She looked up in time to see his eyes narrow to slits as he picked up the scalpel in readiness to carve into Sandra O'Brien's pregnant stomach.

The staff of Theatre Two braced themselves.

It was now 12.09 pm.

6

12.11 pm

The blade entered her body in one decisive hand movement. From somewhere deep inside her almost totally anaesthetised brain, Sandra O'Brien screamed. The blade continued its downward sweep, from navel to pubis, opening up her belly and exposing the bulging muscle layers underneath. Dean Lynch felt her buckle with pain underneath the green drapes. Behind his face mask a smile flickered.

Don O'Callaghan noted her chewing on the endotracheal tube, head rocking slightly, and squirted extra pethidine down the IV line. He had barely had enough time to get Sandra O'Brien anaesthetised before Dean Lynch started his one stroke incision. O'Callaghan hated working with Lynch and always tried to keep one step ahead with adequate anaesthesia before the scalpel was used. But today Lynch was in total control, the urgency of the operation taking priority. Feeling the sweat run down his back, O'Callaghan began conferring with his anaesthetic nurse who was already checking Sandra O'Brien's pulse and blood pressure. He slipped a fresh plug of nicotine chewing gum into his mouth. Out of the corner of one eye he kept a close watch on the operation, noting the speed of the surgeon's hand movements.

Within one minute Lynch was through the outer and inner muscle layers and had exposed the thin lining of peritoneum covering the swollen womb beneath. He cut into and divided the peritoneum with a pair of blunt scissors and pushed it
out of the way with a gauze swab. Two warm moist cloth packs were used to keep the exposed bowel at bay. Then, with careful but precise strokes of scalpel, he began cutting into the lower segment of Sandra O'Brien's womb.

By now, mercifully, she was totally anaesthetised, her writhing had ceased. With a grunt of satisfaction Lynch noted his scalpel finally paring through the womb muscle and exposing the membranes surrounding the baby inside.

'Suction,' he barked and June Morrison quickly had the stainless steel suction tube ready for the next stage.

It was now 12.16 pm.

Again using blunt scissors, Lynch ruptured the membranes. June Morrison sucked away the liquor that seeped out, careful not to block the operating view with her hand. Lynch dropped the scalpel onto a sterile tray, then turned to manoeuvre the baby inside the womb so that his face appeared through the artificial incision.

'Wrigley's forceps,' he barked again and they were in his hands within seconds. He inserted one blade through the gaping incision so that it slipped behind the baby's head and then, pressing slowly but firmly on the upper part of the womb, Lynch eased Gordon O'Brien's small but perfectly formed head into view and out through the opening.

Carefully and skilfully, he took the baby's head in both hands and started to lift him so that one shoulder, then the next became exposed and born. Within seconds Gordon O'Brien's body was taken from inside his mother and considered fully born into the outside world.

It was now 12.19 pm.

The baby lay for about five seconds in Lynch's gloved hands while his umbilical cord was clamped and cut.

'He's very flat,' grunted Lynch as he handed him over to Paddy Holland. 'Apgar of zero from where I stand.' The apgar score reflected the baby's dangerously poor condition. A healthy newborn baby, crying vigorously and moving all limbs, would ideally have an apgar score of eight to ten.

June Morrison felt her world crumbling as she watched. It looked like they had lost the baby. Her body trembled
and shook and she tried to steady herself by gripping tighter on the retractor she was holding.

The blue-grey colour of the baby was a poor sign, as was his total lack of movement and zero respirations.

'Apgar score of one,' shouted Paddy Holland as he listened through a paediatric stethoscope for the baby's heart beat. 'Blue-grey colour, no respiratory effort, no response to stimulation, poor muscle tone.' He looked quickly at the theatre clock. '12.20 pm, heart rate of approximately fifty beats per minute.'

The drama had now switched to the paediatric team. Holding a paediatric laryngoscope in one hand, Paddy Holland inspected the baby's throat and upper windpipe. He took a fine bore plastic suction tube with his free hand and sucked away any mucus and fluid he could see blocking air entry into the lungs. Then, through a small endotracheal tube, he sucked mucus from further down in the windpipe. His registrar stood by with a small face mask connected to an air bag which in turn was connected to an oxygen cylinder. As soon as Holland was happy that nothing was blocking the free passage of air into the baby's lungs, the mask was placed over his face and he was artificially ventilated.

'12.21,' Holland shouted, after a quick glance at the clock again. 'Apgar still one.'

Each detail was being meticulously recorded by the neonatal intensive care nurse. All eyes were fixed on the tiny, lifeless baby, now lying on an open incubator with overhead heater.

Don O'Callaghan, Breda Mullan, June Morrison, the assistant nurse and the rest of the theatre staff were transfixed as they watched Paddy Holland trying to breathe life into him. Only Dean Lynch showed no interest in the battle for survival.

'Sister Morrison,' he snapped, 'would you pay attention to your patient. I'm trying to close her up and I find it extremely hard to work with everyone's attention elsewhere.'

Morrison and Mullan turned back quickly and stared into the opening in Sandra O'Brien's body. There was a lot of work to be done to close her up. A lot of layers of tissue, muscle and skin to be pulled and sutured together before her side of the operation was concluded successfully.

'Sister Mullan,' continued Lynch, relishing the tension and discomfort he had placed the nurses in, 'would you reach me a one chromic catgut? I'd like to get home before midnight if you don't mind.' He was obviously enjoying the power trip. Mullan and Morrison exchanged angry glances. They could sense his triumphant glee.

Then a tiny, fleeting whimper was heard. At first it seemed no more than a squeak, the faintest of whispers.

'Apgar up to four,' shouted Paddy Holland. 'Some grimacing, heart rate up to one hundred. Feeble attempts at spontaneous respiration.'

His registrar pushed a small plastic cannula into Gordon O'Brien's elbow vein to establish an IV line. The child winced. Then, almost as if furious with everything that had gone before and the sudden pain he was now feeling, Gordon O'Brien took a few spontaneous breaths and tried to cry. His first attempts were no more than gurgles, grunts at respiration. Then he seemed to draw himself up to his full weight with a deep breath and let out a piercing cry of pain. All activity in the theatre stopped, apart from the movements of Dean Lynch's hands as he sutured tissue together.

'Apgar five at seven minutes,' shouted Holland. 'It's now 12.29 and his apgar is up to five.' There was a collective sigh of relief throughout the theatre. After two or three more convulsive gasps and grunts Gordon O'Brien finally let out a prolonged strong and healthy cry. Two of the nurses clapped with delight and June Morrison felt tears welling up. She blinked furiously to keep her field of vision clear. Breda Mullan gave her a reassuring smile. They both couldn't resist taking a peek at the tiny arms and legs now threshing on the resuscitation trolley. The deathly blue-grey
colour had been replaced with a pinkish glow as blood rich in oxygen flowed throughout his body.

'Apgar up to nine or ten,' shouted Holland triumphantly. 'Well done team. We've saved him.'

Only Dean Lynch kept his eyes firmly down, continuing his careful and painstaking closure of each layer of Sandra O'Brien's abdomen.

A figure suddenly appeared beside them, one hand holding a face mask over his mouth. 'What happened? What's going on? Is everything okay?' It was Tom Morgan.

At the sound of his voice Dean Lynch looked up sharply.

'Is she okay, Dean?' asked Morgan nervously.

Lynch turned back momentarily to his suturing. 'Cut,' he snapped and June Morrison snipped the catgut where Lynch had tied a firm knot. He dropped the needle handle onto the floor and kicked it to the far end of the theatre.

'This is the last fucking time I save your ass, Morgan!' he snarled. He turned on his heels and marched out of the theatre, leaving it in pandemonium.

Lynch didn't notice the burly figure of Harry O'Brien hurrying along the corridor towards theatre, nor that of Theo Dempsey, heart pounding with anxiety, following at his boss's heels. The only thing Dean Lynch was aware of was a dreadful pain in his head. His face was white with a barely suppressed fury as he changed out of his operating greens. Within minutes he had left the hospital buildings and was in his car, tyres scattering gravel in its wake as he swung out into Whitfield Square. The car sped along the narrow streets that led away from the hospital complex, finally joining the afternoon traffic along O'Connell Street. Lynch ignored the blaring horns and shaking fists as he cut across, switching lanes without warning. The clock on Trinity College chimed one thirty as he drove past on his way to Nassau Street and out towards Ballsbridge.

As he neared his flat, one of a group in a modern complex just off Baggot Street, Lynch made a conscious effort to control himself, drawing in deep breaths and letting the air
out slowly through pursed lips. He slipped quietly into the car park and glided to a halt in the numbered position reserved for flat twenty-three. After double checking the car alarm, he walked as casually as he could across the tarmac and into the building, hoping no one would notice him home so early in the day. Ignoring the open lift, he took the fire escape steps two at a time up to level three and was inside his flat within minutes.

He pulled back a rug that lay across the maple floor in his exercise room and inserted a kitchen knife into an edge that was barely visible between the boards. The board lifted in one short piece. Reaching his hand down into the opening, he groped for a few seconds before retrieving a green plastic bag. Lynch squeezed the bag twice, as if for comfort, before sitting down at the kitchen table and spilling out its contents onto the formica top.

'Fucking bastards,' he muttered as he tapped out white powder from a small clear plastic bag onto a stainless steel spoon. He flicked the top off an ampoule of sterile water before igniting a methylated spirits wick with a lighter. Drawing up the water with a fresh needle and syringe, he gently flushed it back onto the spoon and then heated it over the flame until all the powder dissolved. Then carefully, oh so carefully, he drew the mixture back up into the syringe. He was still cursing and muttering as he pulled a tourniquet across his left upper arm, slapping at the veins. Very slowly he inserted the twenty-three gauge needle into the proudest of the bulging veins and drew back slightly to make sure he had the point in accurately. He grunted with satisfaction as he watched his blood waft back into the syringe. Then he gently pressed down on the plunger and injected. This was the bit he enjoyed most and was careful never to rush in case he felt overwhelmingly sick and vomited. Just slowly and gently, every now and then drawing back to make sure he was still in the vein, Dean Lynch emptied the heroin into his arm. He had this timed to a fine art, finishing just before he felt the full rush to his brain. His mouth, lips and tongue felt heavy and he licked repeatedly to keep them moist. The
needle, syringe and plastic bags were carefully dropped into a kitchen drawer, to be dealt with in the morning, before he slumped down on his bed, watching the ceiling and room drift in and out of his vision. He felt relaxed again, contented. Clumsily, he stuck an Elastoplast across the entry point of the needle, fumbling to peel away the adhesive strip. Dean Lynch was at peace again.