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theatre in our emergency departments or out in the field. Burr-holes, tracheotomies, amputations, thoracotamies, Caesareans.’ Charlotte paused for effect. ‘Extreme measures in desperate circumstances. How many are justified? Does the weight of evidence suggest we’re performing miracles? Or guilty of performing mutilations?’

      Another pause. This was the moment that would make or break this talk.

      ‘I had a presentation that was full of statistics about these kinds of extreme procedures and graphics to show you the controversial relationship between patient outcomes and cost-effectiveness. Obviously it’s not possible to do those facts and figures justice from memory, so instead…’ The solution to this problem came to her in a flash of inspiration. ‘I’m going to present a case history.’

      Nico sat back in his chair.

      He could feel the surprise of the people around him. What was this? They were all intelligent people who were hungry for new knowledge. They wanted to be presented with the results of cutting-edge research that they could use to improve what they did for a career. But they were going to be told a story?

      ‘The man I’ll call Bernie was forty-three years old,’ Charlotte was saying. ‘He went to the corner shop very late one night, because his pregnant wife had a craving for chocolate ripple ice cream. The timing was unfortunate. The shop was held up and Bernie got stabbed. A small knife with a short blade was buried to its hilt in his chest, deflected by the sixth rib, maybe five or six inches to the left from the midline.’

      Nico could sense the interest picking up around him. The injury had been dangerously close to the man’s heart.

      ‘The ambulance crew knew not to remove an impaled object. Bernie’s still conscious when they arrive but his blood pressure’s dropping. Fortunately, this corner shop is only about two minutes’ drive from St Margaret’s hospital. They put a doughnut dressing around the knife to stabilise it, give Bernie some oxygen and load and go. They establish IV access en route.’

      The way Charlotte had changed to the present tense drew them all into the urgency of this case. Clever. Or were they all drawn in, as he was, by the sound of her voice? Soft, but as clear as a bell. As under control as her hair was again, all scraped back into that complicated knot thing.

      Nico had preferred it the way he’d seen it after that resuscitation scene, with enough loose wisps to suggest that the whole knot could be released if you buried your fingers in it, wiggled them and then dragged them gently through the length of the hair. How long was it when it was loose? he wondered. And then he sharply dismissed the errant speculation and concentrated again on what she was saying.

      ‘By the time Bernie comes through our doors, he’s lost consciousness. His BP’s unrecordable. His cardiac rhythm goes from SVT to VF to asystole within thirty seconds of my team getting him hooked up to the monitors.’

      Nico was really listening now. So this was a case that Charlotte herself had managed? He could imagine her there, in the emergency department of St Margaret’s. Wearing scrubs, probably, with a white coat over them. No…she’d been expecting a major trauma. She’d have a plastic apron on. And gloves. And a head covering that probably had a plastic face shield to protect her from blood spatter. She would have been in charge. In control. Her voice might have been louder than it was right now but just as clear.

      ‘We know our protocols inside out but how do we start CPR? This man’s got a knife in his chest that’s probably punctured his left ventricle. He’s bleeding out. We can pull the knife out and push fluids but there’s a hole in his heart so that would be futile.’

      Nico was holding his breath without realising it. Everybody here knew that the only option was to do one of the most invasive procedures that could ever be done out of an operating theatre. Cracking open this man’s chest and getting to the heart of the problem, so to speak.

      ‘He’s dead already unless we do something major and do it fast.’ Charlotte’s tone told them she agreed with the conclusion they’d all reached. ‘A thoracotomy is the only option but I know as well as everybody else in the team what the odds are for a successful result. Virtually nil. But, hey…we have to try, don’t we? This man is about to become a father. Right now, his pregnant wife is probably wondering why it’s taking him so long to get back with her ice cream.’

      Charlotte seemed to straighten her back. ‘I’m the one who has to make the call and, as far as I’m concerned, it’s a no-brainer. We take out the knife and I do a clam-shell thoracotomy. There’s a gaping hole in the left ventricle and I suture it shut while we deal with more blood in a thorax than I’ve ever seen before.’

      Nico closed his eyes for a heartbeat. He could picture it. A nightmare scene. The tissue of the myocardium would have been slippery. The visual field would have been impossible to keep clear with all that blood so you’d have to work almost blind.

      ‘We start pushing fluids and begin CPR. I’m riding that stretcher to Theatre with my hand inside Bernie’s chest, doing internal compressions and praying that my rough suturing is going to hold.’

      Oh, Nico could imagine that scene too. Charlotte would have had to have been astride the man’s legs, with one hand on the side rail to steady herself. Amongst the bank of monitoring and ventilation equipment that would have been in place. Speeding along with her team running to get them to Theatre as fast as possible.

      It felt like he was standing in one of the wide corridors of St Margaret’s right now, watching the dramatic spectacle rush past him. Opening his eyes again, he knew that he was looking at Charlotte with growing admiration. This was some woman.

      ‘The cardiac surgical team is waiting for us. They do a much better job than me in repairing the damage. They replace the blood volume and get Bernie’s heart started again. By this time his wife is at the hospital. Bernie’s taken to the intensive care unit. He’s still alive but what none of us know is whether we’ve done the right thing in saving him. Will he wake up? And, if he does, how much brain damage has been caused by the lack of oxygen? His wife is distraught and, just to add to the tension, she goes into labour three weeks before her due date.’

      A soft groan came from her audience. This might be nothing like what they’d expected as an opening talk but they were all invested in the story now. They had to know the outcome.

      ‘I’ve told you this story because it does, unlike so many, many others, have a happy ending. Bernie did have a degree of neurological compromise. His cognition and speech were affected and he had a unilateral weakness on his right side.’

      It was the first time Nico had seen Charlotte smile. He felt his own lips curve in an unconscious response.

      ‘But his weak arm didn’t stop him being able to cradle his newborn daughter a couple of days later. His difficulty in finding words didn’t dim the way he could communicate his joy to his wife.’

      Dammit. Was that a lump Nico could feel in his throat? He swallowed it away. His own career was full of success stories like this, wasn’t it?

      ‘The bottom line,’ Charlotte continued quietly, ‘is that our job is about the people who come under our care. Bernie was a miracle. But if he hadn’t made it, that resus scene in my ED could have been denounced as unnecessary mutilation. We couldn’t know how it would go before we started but is it just a coin toss?’

      Charlotte was looking around the room. Nico was waiting for her gaze to cross his. He was oddly disappointed when it didn’t.

      ‘No.’ She answered her own question. ‘That’s what our chosen specialty is all about. Working towards being the best we can be in our field of expertise. Knowing when there’s a choice that pulling out the big guns is going to make the difference between life and death.’

      Nico saw Charlotte take a deep breath. She was wrapping up now and the unusual introduction had clearly been a huge success. Everybody was leaning forward, totally engrossed and eager to participate in the programme that was about to start.

      He felt the same way so how on earth could he be distracted

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