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  Blythe concentrated on driving while she took this in. Janet Speares was a slim, lithe slip of a woman in her late twenties, always immaculately groomed. Imagining her bouncing around on the top of a bucking horse was impossible.

  Blythe glanced at her companion again, sure he must be pulling her leg, but he looked quite serious.

  Whitestone turned out to be a cattle property, not another small town, and, as they turned off the bitumen onto the drive that led to the homestead, clouds of dust rose and swirled behind them.

  ‘Bit dry out here. Means it will be dusty,’ Cal remarked, and though Blythe decided he must be more relaxed than usual as he rarely made that kind of purely conversational remark, she didn’t think more about it.

  Until the first horse and rider came out of the chute, and as the horse bucked, the dust in the makeshift ring rose in spiralling clouds. Fine as talcum powder, it hung in the air, insinuated itself into nostrils and settled on skin and clothing. Within minutes everyone had the same brown dusty-all-over look.

  ‘At the bigger rodeos they have a water truck that waters the ground a few times in between events, so the dust settles,’ Cal explained, but as Janet Speares was, at that moment, being thrown awkwardly through the air, Blythe couldn’t answer.

  She started from her seat, sure the woman must be badly injured, but Cal pulled her back.

  ‘She’s OK, and even if she wasn’t, the ambos would look at her first. They know we’re here if we’re needed, but don’t fuss. Rough riders and buck-jumpers hate people to think that they’re injured. I’ve seen a fellow with a broken pelvis walk out of the ring.’

  But the next rider wasn’t as lucky. Thrown off before the horse was properly in the ring, the young man was slow to roll away, and before the horse-mounted steward whose job it was to grab the horse’s halter and release the surcingle could grab the bucking animal, it had come down on top of the rider, lethal hooves plummeting into his abdomen.

  ‘This time we go,’ Blythe said, and Cal didn’t argue, following more slowly as she dashed around the ring towards the gate where ambulance officers were already jogging through.

  The young rider was curled up on the ground, his hands clenched and arms crossed protectively across his stomach.

  ‘Let’s have a look at you, mate,’ the older of the two attendants said, but the more he tried to ease the lad into a prone position, the tighter the legs curled.

  ‘He’s moving his limbs, which suggests there’s no spinal damage, so could we get him out of the dust?’ Blythe suggested.

  ‘It’s my shoulder, my left shoulder,’ the lad said, but Blythe was more worried about what damage the horse’s hooves might have done.

  One of the attendants left, returning seconds later with a light stretcher. By this time Cal had arrived, and it was he who supervised lifting the young man onto the stretcher.

  Blythe helped carry it towards the ambulance where they lowered the stretcher onto the collapsible frame of the trolley. The bright light from the cabin revealed the lad’s ashen face and the blue tinge around his lips. His pulse was fast and unsteady and he gulped at the air with a desperation that frightened Blythe.

  One of the ambos was talking to him, asking questions—name, age, any allergies—but the lad was having so much trouble breathing that answering any question was impossible.

  ‘Get an oxygen mask on him right away,’ she said, unsnapping studs on the man’s fancy shirt and peeling it back to reveal his chest, while the ambo put the mask in place and started the flow of oxygen.

  He dragged in a breath of oxygen as she watched but, instead of expanding, the right side of his chest deflated.

  ‘Rib damage, flail chest,’ she said, pointing to an area of his rib cage that was already carrying a red hoof mark and was obviously damaged, then glanced up at the ambulance attendant. ‘I need an endotracheal tube and a volume-controlled ventilator, or whatever type of ventilator you carry. I’ll give him a muscle relaxant if he fights it.’

  She took the youth’s hand.

  ‘You’ve broken a couple of ribs and they’re pressing on your lungs. I’m going to put a tube down your throat so we can get oxygen into you to stop that damaged lung collapsing. Once the tube’s in, we’ll give you something for the pain and check out the rest of you.’

  Blythe worked steadily, aware of her patient’s pain—aware also that he might have other serious injuries but knowing a reliable air supply was the first consideration.

  ‘In A and E we’d call in an anaesthetist to give him a thoracic epidural to stop the pain,’ she said, glancing up at Cal when she was satisfied the tube was in place and the ventilator working.

  ‘I can do it—or talk you through it—but we’re better tackling it back at the hospital in sterile surroundings. For now make do with local anaesthetic—an intercostal block where the ribs are damaged.’

  ‘Allergies—always the concern of allergic reactions,’ Blythe muttered to herself, looking at her patient whom she knew wasn’t going to be answering questions any time soon.

  ‘I’ve brought his contact details and health certificate,’ a new voice said, and Blythe turned to find someone she assumed was one of the officials standing at her elbow. ‘We get everyone to fill out these forms in case of accident. Who to notify, and so on. I’ll call his parents as soon as you know where he’s going.’

  Blythe passed the information to Cal, who read bits aloud while she injected the mild analgaesic, one ambulance attendant passing her what she needed while the other was checking the patient’s blood pressure and, at the same time, keeping a watchful eye on the ventilator.

  ‘His name’s Byron Clarke, parents live outside Creamunna. No known allergies, has had tetanus shot recently, and not allergic to penicillin.’

  ‘Well, that’s a start,’ Blythe said.

  ‘Let’s get him to hospital,’ Cal suggested, when she began to undo Byron’s belt to lower his trousers to check for more damage.

  ‘Blood pressure’s low, ninety over sixty.’

  ‘We’ll keep an eye on it,’ Cal said, then he turned to Blythe. ‘Normally, with minor injuries, we’d keep the patient here until the show is over, so there’s an ambulance on hand. But this lad needs attention now, so would you ride back to town with him? I’ll stay on and the second ambo can drive me back. We shouldn’t leave until the show finishes, but if you need me…’

  He paused, and Blythe guessed he was worrying about leaving her in charge.

  ‘I’ll stay in my car—you can talk to me on the radio. Call me if you have a problem or want to talk about anything at all.’

  Blythe nodded, pleased to have Cal sort out the logistics in a situation that was entirely new to her.

  ‘Anything,’ he repeated, and touched her lightly on the arm.

  The touch made her feel warm and cared-for, so much so she lifted her own hand and rested it on his for a moment.

  ‘I won’t let you down,’ she promised, and saw his sombre expression lighten as he flashed a smile at her.

  ‘I didn’t for a moment think you would. Valkyrie were the handmaidens of the god of war—I’m sure they never let anyone down!’ he said.

  ‘Except the people they chose to be slain,’ Blythe reminded him.

  She waited until the stretcher was secured in place, then climbed in.

  ‘’Ware fluids,’ Cal said, and she looked at him, smiled and nodded.

  Fluid resuscitation was a common emergency response, and a necessity for a patient in shock, but she’d considered the consequences of giving any fluid from the moment she’d seen the uneven chest expansion that was symptomatic of rib and lung damage. Lungs all too easily filled up with fluids, which then became breeding places for all kinds of deadly sepsis. Cal had been right to remind her, in case she hadn’t been thinking about it.

  Once Byron was in hospital, where he could be monitored, she’d feel easier about giving him fluids, but the BP was a worry. Byron was young—he might always have a low blood pressure
. She’d have to take it again, watch for any change in the pulse pressure—the difference between the two numbers. That was a better indication in any change of status.

  Strapped into a safety harness beside her patient, she continued her examination, seeing bruising coming out where the second hoof had struck just below the rib cage to the left of the other mark. Possible damage to the diaphragm—and the organs that lay close to it? Spleen and liver. Low BP? Haemorrhage from liver or spleen damage?

  What were the percentages?

  Her mind, trained to deal with emergencies, asked and answered questions.

  Blunt trauma to the upper abdomen or lower thoracic region could cause injury to the spleen in what? Forty-one per cent of cases. Something like that. Liver damage less likely—about twenty per cent possibility. Livers could be repaired, spleens removed, though current thinking was to repair them as well. But in an emergency—to save a life before the patient bled to death—you would remove it. She had good surgical skills, having done extra residency terms in surgery, but an emergency splenectomy in a hospital she barely knew?

  She wouldn’t think about that just yet.

  She felt Byron’s hands and knew she’d have to think about it. His skin was cold, pale and dry, indicating shock, and his radial pulse so faint she could barely feel it. She squeezed the tip of his forefinger and waited for pinkness to return to the skin. The slowness indicated delayed capillary refill, a symptom of second-phase hypovolaemic shock.

  No matter the risk to his lungs, she had to get some fluids into him. The ambulance was travelling smoothly, its springs cushioning the passengers from bumps. This would be easier than cannulations she’d done in helicopters during terms in A and E when she’d been on call for the emergency helicopter in the city. Ambulances were usually set up in the same way, their storage compartments well ordered. She should be able to find all she’d need.

  She inflated the blood-pressure cuff around Byron’s biceps and was relieved to see a vein come up. As shock progressed, these veins would lie flat, depleted of the blood that kept them healthily rounded.

  Ignoring the movement of the ambulance as it shot along the road towards Creamunna, Blythe inserted the cannula, checked the bag of crystalloid solution she’d chosen and connected it up.

  Then she watched her patient, but her mind was racing through all the possibilities that lay ahead.

  She could probably, at a pinch, do whatever surgery was required, but to perform surgery on a patient whose breathing was already compromised was a tricky business. But she couldn’t send a patient on an emergency flight if he was bleeding internally. He might not make the hospital.

  And if he was OK to travel, how would a plane flight affect him when his lungs were damaged?

  And would it be a plane?

  She and Cal had been picked up by a helicopter, but it had been a rescue craft, not an air ambulance. This man would need medical support on any journey.

  The questions tumbled in her head as she checked and rechecked the ventilation and the drip.

  ‘Cal Whitworth to EVA 27.’

  Cal’s voice erupted into the cabin of the ambulance.

  ‘That’s us,’ the driver said to Blythe, before pressing a button on his radio and replying to Cal.

  ‘Hear you loud and clear, Doc. What’s up? Another patient?’

  ‘No, and hopefully there won’t be, but could you tell Dr Jones that once she has him stabilised and she’s confident he can make the journey, she should call in an air ambulance or the RFDS to fly the patient to Brisbane. We can do a lot of emergency surgery—patching up stuff—on site, but with his lungs compromised, he needs sophisticated support equipment.’

  ‘I was thinking that myself,’ Blythe told the driver, who relayed the message to Cal.

  The driver radioed ahead to the hospital, explained the situation and asked the nurse on duty to request an urgent emergency airlift for the patient.

  She radioed back to them as they reached the edge of town.

  ‘No luck,’ she said. ‘Sunday afternoon, weekend of traffic accidents, all aircraft are either in service or grounded because the pilots have flown all the allowable hours. Tomorrow morning at the earliest, though they’re still checking other options. They might be able to divert a plane this way or find a standby pilot, but emergency services suggest it would be at least three hours before they can get anyone Creamunna. Then it’s close to a three-hour flight to Brisbane, plus ambulance transport to the hospital and however long A and E there take to admit him. How does that sound? Do you want to take him on to Derryville? I can call them to send an ambulance to meet you halfway.’

  ‘What do you think?’ the driver asked Blythe, who didn’t need to think about it. Fluid replacement wasn’t helping and the symptoms of shock were becoming more pronounced. The young man needed help now.

  ‘No,’ she said, ‘but radio Cal, explain the situation and ask him to head back to the hospital right now. He’ll have to get someone else to drive him, so he can leave your mate out there in case of another accident. You can drop us off and go straight back out.’

  Blythe could feel her knees shaking, but everything she’d ever learnt told her this young man had damaged something in his abdomen that was causing internal bleeding. It wasn’t a ruptured aorta, the most disastrous of scenarios, because he’d be in a far more fragile state—or dead—by now, but certainly something else was amiss inside him and, with no specialist on hand to do a laparoscopy, the only way to find out—and fix it—in a hurry was to open him up.

  They pulled up at the emergency entrance, doors opening as they arrived and a number of staff coming forward to help.

  ‘I didn’t know there were this many people on duty on a Sunday,’ Blythe said, as a wardsman and the ambulance attendant detached the stretcher from its anchors then, with the ventilator stashed beneath the patient, slowly lifted the wheeled conveyance out.

  ‘This is Byron Clarke,’ she told the staff. ‘Rib and lung damage, flail chest, hence the ventilator. He can’t talk to us while he’s on the ventilator, but we can talk to him, so tell him what you’re doing all the time.’

  Wanting someone to talk to herself—someone with whom she could share her concerns—she realised for the first time the true isolation of rural medicine. She was it! There was no back-up, even for discussion.

  Yes, there was! The flying surgeon! Wasn’t that what he was there for? Yet even as the thought occurred to her, she knew it was no good. He was based in Roma, more than an hour’s flight away, and even supposing she could get hold of him, and he could hustle up his anaesthetist and pilot, and they could all come immediately, further delay could be fatal for Byron.

  Her frustration with the system was so strong she wanted to rage at someone, but the patient needed her calm and steady, not fuming hysterically. Ah, the hospital had a radio…

  ‘Can you call up Cal on the radio?’ she asked one of the nurses. ‘Then show me how to talk on it?’ She was thinking about peritoneal lavage, a reasonably simple procedure that involved passing warmed sterile fluid through the abdominal cavity then retrieving it to see if there was blood in it.

  ‘Not necessary,’ Cal told her when, after explaining the deterioration in Byron’s condition and her fear he was going into haemorrhagic shock, she mentioned this to him. ‘You’ll need to go in. Take him to Theatre and prep him for abdominal surgery. We’re only fifteen minutes away. I’ll do the anaesthetic.’

  ‘I’m worried about his lungs,’ Blythe told him.

  ‘Me, too,’ Cal agreed. ‘But you’ve already got a ventilator breathing for him so there shouldn’t be a problem. And we can drain his lungs if fluid becomes a problem later. You’ll need a nasogastric tube in as well, to decompress his stomach. If you have to take out his spleen, he’ll need that post-op. Catheterise him to measure urine output, it’s a good guide to circulation. Put in a second large-bore cannula so we’re ready if we need to pump more fluid in. Take some blood, type it and make sure
you’ve both resus fluid and plasma on hand. We can’t always cross-match blood, but we can give type-specific.’

  Blythe handed the mike back to the nurse and headed back to her patient, telling herself this was what medicine was all about. She drew up some blood and took it to do a simple typing test, then ordered what she’d need for Theatre.

  As she prepared Byron for Theatre, she told him what was going on, explaining about the operation and how it might be something simple causing the blood loss inside him, but whatever it was, they needed to find it and stop it.

  He seemed to understand, nodding from time to time, but Blythe wondered how valid informed consent was when a patient was so ill, in so much pain and under the influence of analgesics.

  ‘Sue Warren’s theatre sister, I’ve called her in,’ one of the nurses said.

  ‘And she’s actually on her way?’’ Blythe said, amazed to have finally found one experienced person to help out.

  ‘Not on her way but here,’ a breezy voice declared, and, recognising the voice, Blythe looked up.

  ‘Sue Simpson! What on earth are you doing out here in the back blocks of civilisation?’

  Sue greeted her with equal delight.

  ‘Sue Warren it is now. Married a local,’ she explained, while Blythe prepared a pre-anaesthetic injection for her patient. ‘Three years ago. He was a patient at the Royal and we fell in love. I must admit I was a bit worried about the move from the city, but now I’m here, I love it. I was down home last week. Just got back this morning, or I’d have heard you were here. Don’t tell me you’ve given up your idea of being the top surgeon in Brisbane and come to the bush to help out instead.’

  Before Blythe could explain her position was strictly temporary, Cal walked in.

  ‘Sue, what a relief you’re here. I thought you’d gone home.’

  He greeted the nurse with a quick hug and a far too familiar—in Blythe’s eyes—kiss on the cheek.

  ‘I’m back,’ she said, ‘but later I want to know how you persuaded one of my favourite doctors to come to Creamunna.’