Read the book: «The Surgeon's Perfect Match»

CHAPTER ONE

THE tremor was tiny.

So slight it could only be felt, not seen, but it was enough to threaten her confidence.

Could she manage this?

The smallest slip could be catastrophic. A tiny heart lay carefully exposed beneath her fingertips. The defect causing a three-year-old boy’s heart failure was visible and ready to be covered by the small teardrop-shaped patch of Dacron caught between the teeth of the forceps that surgical registrar Holly Williams was holding.

The tremor could be the result of first-time nerves, in which case Holly knew she could conquer it and succeed—as she had done countless times already on the totally focussed journey that had brought her to precisely this point in time.

But it could also be the result of fatigue and, no matter how much practice Holly had had in battling the physical effects of exhaustion, she knew there were times when she simply couldn’t win. And the notion of a three-year-old child sharing the repercussions of losing that battle was absolutely unacceptable.

Pushing herself this far might have been a huge mistake. What if…?

‘You can do this, Holly.’

The quiet, deep voice was so close that Holly could feel the vibration of air as clearly as she’d felt that embryonic tremor. And the confidence that had cloaked the words didn’t stop at her ears. It seeped instantaneously into her brain and then swept further. The ache in Holly’s calves subsided, the knot in her stomach unravelled just enough and her fingers felt rock steady.

She gave a single, decisive nod.

Of course she could do it. She had worked far too hard for far too long to pass up the opportunity of actually touching her dream.

Being more than an assistant, however vital that assistance might be.

So what if this procedure was an almost routine repair of one of the most common types of a ‘hole in the heart’—a ventricular septal defect? Or that all the skilled preparation had already been done by one of the country’s foremost paediatric cardiac surgeons? It was still Holly holding the suture needle and patch. Doing an actual repair herself and not just the final closure for the open heart surgery. There weren’t many consultants in any field that would trust their registrars enough to provide such an opportunity so soon.

She owed it to her mentor to justify that trust. As she had done on more than one occasion when Ryan Murphy’s confidence had deepened, if not actually engendered, an equal trust in herself.

‘Begin on the right side of the inferior rim.’ Ryan’s instruction was calm. ‘And carry it in a counter-clockwise direction to penetrate the septal leaflet.’

Tiny stitches. Through the cardiac tissue and then through the edge of the patch. Again. And again.

‘Perfect.’

The final suture was tied and cut. The rush of oxygen as Holly took a deep breath gave her momentary dizziness. How long had she been holding her breath?

‘Want to carry on?’

Holly glanced up to catch a pair of hazel eyes regarding her over the edge of a surgical mask. Ryan’s tone was as calm as ever but Holly could see a gleam of pride that was bright enough to more than replace an emotion she couldn’t afford to indulge in just yet.

‘Yes—thanks.’

‘Don’t thank me. I’m getting a holiday here.’

As if. Ryan was aware of every factor involved in this operation. Coaching and monitoring Holly’s work would require far more effort than doing it himself, and Ryan was also keeping tabs on all the parameters being measured on their small patient as the procedure was completed and preparation made to come off bypass.

‘Clamp coming off. Happy that you’ve removed all the air in the aorta, Holly?’

‘Yes.’ Holly moved to insert the needle into the largest chamber of the heart, the left ventricle.

‘Good.’ Ryan nodded. ‘You’ve got it right on the apex.’

The pause as the team watched for the heart to resume pumping stretched on longer than seemed normal and Holly felt a chill race up her spine. It was rare these days for defibrillation to be needed to restart the heart. Had something gone wrong?

Her gaze was riveted on the child’s heart, still lying motionless, but Holly was aware of a very subtle movement beside her. The tall figure that had already been standing close beside her seemed to sway an infinitesimal degree. Not enough for anyone to notice but Holly was aware of Ryan’s shoulder almost touching her own. The solid wave of reassurance the almost-touch provided coincided with the first movement of the tiny heart in her line of vision.

Just an uncoordinated wiggle to start with but it was enough for a collective, if inaudible, sigh of relief as the heart settled into a steady beat with reassuring swiftness. Then the whole chest moved as ventilation of the child’s lungs began again. Step by step, Holly continued the procedure, repairing the connection sites for the heart-lung machine, positioning drains and closing the small chest with fine wire to hold the edges of the breastbone together. She had used virtually all these skills previously but never continuously, and the strain was telling as the final layer of closure was reached.

The tremor was clearly visible now.

Not that Ryan offered to take over. Not even when it took two attempts to knot and tie the final suture. His clipping of the excess length was perfunctory as his attention turned to the anaesthetist.

‘How’re we looking?’

‘All good. Blood pressure’s fine. Oxygen saturation is ninety-eight per cent.’

‘Probably the best it’s ever been for this wee chap. Happy to move, Holly?’

Holly finished covering the sutures with a clear plastic dressing and scanned the chest drains. There was no sign of any untoward blood loss from the field of surgery.

‘I’m happy if you are, Ryan.’

‘Oh, I’m more than happy.’ They could all hear the smile in Ryan’s words. ‘Well done, Holly.’

‘Yes, well done!’ The sentiment echoed amongst theatre staff who were quite aware of what a large step Holly had just taken towards her ultimate goal of being a paediatric cardiac surgeon. The congratulatory sounds stayed with her as they transferred their small patient to the intensive care unit where he would stay on a ventilator for the next twenty-four to forty-eight hours.

She had done well but her clumsiness at the end of the procedure couldn’t have gone unnoticed. How many of the staff were thinking, as Holly was, that it was just as well it hadn’t occurred earlier? Or that maybe Ryan was a little too trusting. Worse—that maybe Holly Williams wasn’t quite up to doing the job she had set her heart on.

Having directed them towards bed position one in the ICU, the charge nurse gave Holly a look that confirmed her fears.

‘You look dreadful, Holly! You’re as white as a sheet. Are you all right?’

‘I’m fine.’

‘Hmm.’ But the nurse’s attention was now on her new admission as they positioned the monitoring equipment and checked all the information made available. ‘Callum’s parents are in the relatives’ room,’ she told Ryan finally. ‘You can send them in to sit with him when you’ve had a talk.’ She raised her eyebrows. ‘I’m assuming everything went well?’

‘You’d better ask the surgeon.’

Holly smiled at the new level of respect she could detect in more than one face turning in her direction.

‘It went very well,’ she said modestly.

‘Textbook perfect, actually,’ Ryan added. ‘Let’s go and give Callum’s parents the good news, shall we, Holly? We might even have time for coffee before we do our rounds after that.’

‘Don’t bank on it,’ the nurse warned. ‘I’ve heard that the neonatal retrieval team have been sent out to collect a blue baby from one of the maternity hospitals.’

‘What’s the ETA?’

‘Thirty minutes or so, I’d guess.’

‘Cardiology up to speed?’

‘They’re standing by.’

Holly listened to the exchange with dismay. An afternoon of patient rounds evaluating their current case load had seemed manageable, but if she was already drained enough to have people commenting on her appearance, how could she hope to find the stamina to assist with what could be a very difficult procedure on a critical newborn baby?

‘In that case…’ Ryan’s tone belied any similar misgivings he might be having. ‘Coffee is imperative. Holly, would you go and put the jug on, please? I’ll talk to Callum’s parents.’

‘But—’

‘No “buts”,’ Ryan said sternly. ‘I need coffee stat!’

He could have been the one to go ahead to the staffroom while Holly spoke to the child’s family but they both knew why that wasn’t happening and it was with a heartfelt sigh, a few minutes later, that Holly sank into an armchair and closed her eyes.

Sometimes, this was just so hard.

His registrar was sound asleep.

Ryan Murphy shut the staffroom door quietly behind him when he arrived nearly an hour later. He’d spoken at length to Callum’s parents and then accompanied them to their son’s bedside, taking the opportunity for another check on his patient. He’d caught up with the cardiology team as their new admission had arrived via ambulance. The neonate was in trouble all right, with a level of cyanosis obvious enough to require urgent management. An X-ray and echocardiogram would be needed to make a definitive diagnosis, however, and that gave Ryan some breathing space.

It was time for coffee.

Maybe it was also time to have that talk with Holly.

She hadn’t stirred as Ryan had entered the small staff-room. Before long, the area would start being used by staff snatching a lunch-break, but for the moment it was peaceful and Ryan was reluctant to disturb Holly. Exhaustion was etched onto that pale face in the form of an uncharacteristic frown line between her eyes and bruised-looking skin beneath the fan of dark lashes.

He’d never seen her asleep like this before and for a long moment Ryan felt mesmerised. That aura of strength had deserted her and the sheer vulnerability of the woman in front of him caught and squeezed Ryan’s heart painfully. She was way too thin now. In another life, with Holly’s height and stunningly good looks, she could easily have been a model. But that was not what Holly had set her heart on being, was it?

Ryan sighed inaudibly and moved towards the bench. He shouldn’t have pushed her to go solo on that VSD repair. He’d seen that moment of hesitation—the self-doubt. He’d also felt the gathering of whatever internal resources had been needed to succeed, and he hadn’t realised how tense he’d been himself until Holly had moved to take that first stitch and he’d been able to breathe again.

Not that he’d doubted for a moment that she could do it. If sheer courage and determination were all it took to succeed, there would be no stopping Holly Williams. Sadly, that wasn’t all it took, though, was it? And Holly was getting just a shade too close to the wall now. Maybe others hadn’t noticed yet but Ryan had become so closely attuned to his registrar that he knew as well as she must how much more of a struggle it was all becoming.

Yes. Ryan quietly set two mugs onto the bench and reached for the jar of instant coffee.

It was definitely time for the talk.

‘Holly!’

Her eyes flew open at the sound of her name. Blinking, Holly focussed on the source of the sound. Shaggy, gold-streaked brown hair. A face too craggy to be conventionally good-looking but a pair of the kindest hazel eyes in existence. A wide mouth, more inclined to curve into a slow smile than a grin. The kind of smile she could see right now, in fact.

‘Feeling better?’

Holly nodded, sitting more upright as she noticed the steaming mug of coffee Ryan was holding out for her.

‘Thanks.’ Embarrassed at being found asleep, Holly avoided more than the briefest eye contact. Her gaze slid past Ryan’s face, catching the wall clock visible just behind his shoulder. Her exclamation was horrified.

‘Oh, my God! I’ve been asleep for an hour!’

‘You needed a rest.’

‘I thought you’d only be five minutes. I only sat down to wait for the jug to boil.’ Holly shook her head in disbelief, pushing a long, single braid of dark hair over her shoulder. ‘I’m so sorry, Ryan. This is awful!’

‘It’s no big deal. Don’t beat yourself up over it.’

‘Falling asleep on the job is a pretty big deal in my book.’ Holly tried to stamp on a fear that had been gnawing at her for days. The fear that things were getting worse far too rapidly to control now. That she was reaching a point when she would have to admit defeat. She could only hope that fear wasn’t showing in her eyes as she looked up at Ryan again. ‘Why on earth do you put up with me, Ryan?’

The gentle smile broadened into the closest he ever came to grinning as he sat down beside Holly.

‘What is it they say on the wrinkle-cream ads? “Because you’re worth it”?’

‘Ha!’ But Holly couldn’t help smiling back at Ryan. He’d always made her feel like that. Mind you, he made everybody feel like that. His small patients, their parents—even their siblings. Ryan was just one of those amazing people that made anyone they spoke to feel special. Holly had never known him to complain of any personal cost he suffered and she had to be running up a fair account by now. ‘You have to juggle on-call rosters because half the nights I’m unavailable. I have more time off work than any normal registrar would be allowed and now I’m falling asleep on the job, for heaven’s sake!’

‘You had a big morning.’ Ryan raised his coffee-mug in a salute. ‘Well done again, by the way. When I think back to what my first patch was like on a VSD, I’m impressed all over again. In fact, I think I was only allowed to do half of it before my consultant muttered darkly about having to call in a plumber to fix the leaks and then took over.’

‘I don’t believe that for a minute.’ Holly’s glance at Ryan was very direct. ‘Why did you let me do it?’

‘Because you could.’

‘You didn’t know that. I didn’t know that. I’ve never done it before.’

‘You have more than enough ability. You’ve got to stretch your wings some time.’

‘But something might have gone horribly wrong.’

‘Of course it could. Something could have gone horribly wrong for me as well. That fear is always there.’ Ryan’s expression was quizzical. ‘You’ve had your heart set on a surgical consultancy for as long as I’ve known you, Holly. And that’s, what…two years now?’

She nodded. ‘Off and on.’

‘And as a consultant, you take that risk and responsibility on board and do the best you can. Your best is more than good enough.’

‘I’m not talking about the risk of complications or error.’ Holly stared into the depths of her coffee-mug. ‘I’m talking about the lack of physical ability. What if I’d blacked out or got the shakes badly enough to create a disaster?’

‘You didn’t.’

‘You took a hell of a risk, though, Ryan.’ Holly swallowed hard. ‘And while I’m enormously grateful, I don’t think you should do it again.’

‘That’s my call.’

Holly shook her head sadly. ‘I’m not so sure about that. Not any more.’

‘What do you mean?’

‘Maybe it’s time I faced reality here. The odds are stacked pretty high against me getting where I want to go.’ Holly took a deep breath. This was hard to say. To admit that her fiercely defended independence wasn’t as great as she’d believed. ‘Maybe it’s just not fair that people like you have to keep propping me up.’

Ryan was giving her an oddly wary look. ‘You’ve been battling those odds for as long as I’ve known you and I’ve never heard you come even within spitting distance of admitting defeat. What’s changed?’ He frowned. ‘Did I put too much pressure on you this morning? If I did, I’m sorry, Holly. I never meant to—’

Holly shook her head again, interrupting any apology. ‘It’s not that. You’ve never put too much pressure on, Ryan.’ She smiled. ‘You seem to know how to put on just enough to push people into discovering what they’re capable of without destroying their confidence. You’re a brilliant teacher, you know.’

Ryan shrugged off the compliment. ‘So what is it? Are you just tired?’

‘I’m always tired.’

‘What’s changed, then?’ Ryan persisted. Hazel eyes seemed to darken with concern. ‘Are you needing dialysis more often?’

‘Probably. I’m due for blood tests today.’ Holly eyed the remains of her coffee. Should she use up that much of her daily fluid allowance now or save it for later? She took another small mouthful and then sighed. ‘I’m doing it four nights a week already, Ryan. Soon all I’m going to be doing is coming to work and going home to sleep with a machine.’ She tried to throw in some of the customary humour with which she had always lightened such conversations. ‘I really shouldn’t tick the single box on forms, should I? I’ve had a partner for years.’

Ryan didn’t appear amused. ‘It’s a temporary relationship. You know that a normal life will be entirely possible when you get a kidney transplant.’

‘Yeah.’ Impossible to keep her tone light now.

‘That’s it, isn’t it?’ Ryan looked as though he wanted to slap his forehead for being obtuse. ‘That’s what’s changed. I thought you brushed off that disappointment last month rather too easily.’

Holly couldn’t deny it. ‘It’s caught up with me now. To get that far…’ The disappointment cut more deeply than ever right now. ‘I kept telling myself it was better to have the plug pulled then than to go through the surgery and then have to wait to see if the transplant would work and then battling rejection and dealing with failure and the knowledge that another transplant would be that much more difficult, but I was kidding myself. To actually get prepped for surgery and then sent home was awful.’

‘The donor kidney was found to have kidney disease that hadn’t been diagnosed, hadn’t it?’

‘Yeah. Polycystic. Same as me. Ironic, eh?’

‘No.’ Ryan reached out to cover Holly’s hand with his own. He gave it a brief, gentle squeeze. ‘Incredibly disappointing. You’d waited so long.’

The empathetic touch would have been enough to generate tears in someone other than Holly, but Holly Williams had never cried about her illness. She had simply got on with the most important things in her life and refused to even consider letting it slow her down. Until now, anyway.

She touched the second pager she wore clipped to her pocket. The one that had only sounded once in all that waiting time. ‘It’s been more than two years,’ she said quietly. ‘I went on the waiting list as soon as I had to start regular dialysis.’

‘You haven’t fallen off the list,’ Ryan reminded her. ‘You’ll still be at the top. A compatible organ could come up any time.’

‘With my blood group? I’m O, Ryan—but in my case that’s not really O for ordinary.’

He smiled. ‘I could have told you that.’

Holly’s smile in return was wry. ‘I’m a universal donor but I can only receive from another O. And that’s just the blood group. There’s tissue and cross-matching factors to complicate things as well. Which reminds me, I’m due to send in the monthly sample today. Could you draw some blood for me later?’

‘Sure.’ Ryan had finished his coffee but he made no move to get up. In fact, he had a rather determined look on his face. ‘I’m glad the subject’s come up, actually, Holly.’

‘Oh?’ He was going to agree with her, wasn’t he? Had Ryan just been waiting for an opportunity to ease her out of her senior registrar position?

‘Yes. I’ve been giving your situation quite a lot of thought recently. Ever since that hiccup with the transplant last month.’

Holly waited, her heart sinking. He did want her to give up trying to work full time. He’d supported her so much for so long and the ace up her sleeve had always been that it was worthwhile because when she got her transplant she would make up for any inconveniences she had caused. They would never have such a committed and hard-working registrar on their team. Now Ryan could see, as she did, that holding out for the miracle a transplant could provide might be just a dream. The odds of it happening before she deteriorated further or even died suddenly seemed much smaller.

Almost non-existent.

The door to the staffroom opening at that point to admit one of the ICU nurses was a reprieve that Holly grasped with alacrity.

‘Sue, hi! How’s Callum doing, do you know?’

‘He’s good.’ The nurse sat down and opened a packet of sandwiches. ‘What are you two doing in here? I heard there was a blue baby on its way in.’

Holly’s gaze swerved to Ryan. ‘That baby must have arrived ages ago. Why haven’t we heard anything?’

‘I popped down to see her before while you were…getting the coffee. Sorry, I should have told you.’

Holly could feel the muscles in her jaw tighten. No. She should have been there as well. ‘So what’s the story?’

Ryan stood up, taking Holly’s coffee-mug to the sink along with his own. ‘Full-term baby girl. Nothing abnormal noted on foetal ultrasound. No murmurs but a loud second heart sound and she was still cyanosed on a hundred per cent oxygen.’

‘Transposition of the great arteries?’

‘That’s our pick for the moment. They’ve probably done the echocardiogram by now. Shall we go and see what they’ve found?’

‘Cool.’

Back to business as usual was fine by Holly. She was regretting having let the conversation become so personal. Her warm smile at Sue as they left the staffroom was, in some part, thanks for interrupting before Ryan had been able to ease into the subject of firing her, and Holly made sure their communication was purely professional as they threaded their way through the busy corridors of the large children’s hospital.

‘We don’t get a transposition very often, do we?’

‘Fortunately, no.’

‘Surgery won‘t need to be immediate, will it?’ The physical demands of the rest of Holly’s day were suddenly looking rather more manageable.

‘No, but it’s usually done within the first week or two of life, before the left ventricle becomes unable to handle systemic pressure. If it’s severe enough, they’ll need an interim measure to improve the cyanosis.’

‘A Rashkind procedure?’ Holly had no difficulty in sounding more than interested.

‘Ever seen one?’

‘No.’ Any residual despair at having her own physical weakness demonstrated so recently was chased away by excitement. ‘I’d love to, though.’

‘How much do you know about it?’

‘It’s designed to allow the systemic and pulmonary circulations to mix, isn’t it? They thread a double lumen catheter into the left atrium via the umbilical vein. A balloon gets inflated with contrast medium and then pulled back through the atrial septum to create a tear.’

‘Mmm. Strange business, this, isn’t it? We spend half our morning repairing a septal defect and our cardiologist colleagues might well spend half their afternoon creating one.’ Ryan was smiling at Holly. ‘I take it you’d like to go and watch if it goes ahead?’

‘Oh, could I?’

‘Absolutely. Good learning experience for you. To be honest, I’d quite like to go and watch myself.’

‘What about rounds?’

‘We’ll fit them in. We’ve got a consult to do in the ward as well. Another VSD who’s developing pulmonary hypertension.’

‘How old?’

‘Eighteen months.’

‘Is that Leo?’

‘Don’t tell me you’ve seen him already?’

‘Not as a patient. He’s been in the ward for a few days, though.’ Holly’s smile was a little embarrassed. ‘He was part of that hide-and-seek game you caught me playing yesterday—when I should have been writing up those discharge notes.’

‘You stayed far too late yesterday catching up on them. It’s no wonder you’re tired today.’ Ryan paused as they reached their destination of the neonatal intensive care unit. ‘And we’re giving ourselves a very busy afternoon.’ He held Holly’s gaze. ‘Are you up to it?’

‘I’m not about to fall asleep again, Ryan.’ Damn, this could provide another lead-in to that talk Holly really didn’t want to have. Her chin came up. ‘Of course I’m up to it.’

It was a struggle, anybody could see that, but there was no way Holly was going to admit defeat. She’d push herself until she fell over, Ryan observed with concern. No matter how hard it might be, she simply couldn’t help herself going the extra mile.

Like the way she sat with baby Grace’s shocked parents and drew them a diagram of what had gone wrong with the development of the arteries in their infant’s heart because they hadn’t been able to take it in the first time around with the cardiology team.

‘So the aorta, which takes the blood from the heart to the rest of the body, is attached to this part of the heart on the right side, do you see? And that’s where the pulmonary artery should be. So it means that the blood that’s getting the oxygen from Grace’s lungs isn’t getting to the rest of her body, which is why her lips and fingers look so blue.’

Grace’s father looked desperate to both understand and find a way to help his family. His tone was belligerent.

‘It can be fixed, though,’ he demanded. ‘That’s right, isn’t it?’

Holly’s smile both accepted the anger being directed at her and gave reassurance. ‘When we operate, what we’ll do is attach the arteries to the ventricles they should be attached to.’

‘Why can’t you do that right now, instead of that thing with the balloon they were talking about?’

‘It’s a major operation. We need to make sure Grace is strong enough and there are a few more tests we’ll need to do before surgery.’

The baby’s mother sat hunched in a wheelchair beside the incubator, her face pale. ‘Can I stay with her?’

‘Of course you can. The nurses will show you how you can help care for her. The procedure this afternoon shouldn’t take too long.’

‘Will you be there?’

‘Yes. Don’t worry, we’ll all take very good care of Grace.’

Donning a lead apron so that she could stand close enough to touch the baby during the procedure in the catheter laboratory instead of observing on the screens in the technicians’ area meant that Holly put ten times as much effort into that session than she needed to, but Ryan wouldn’t have dared suggest that she took things easier.

His registrar was already building a bond with both this tiny patient and her parents that would make the upcoming surgery less traumatic for everybody. That kind of bond was automatic when Holly was involved. The huge grin she got from Leo when they slotted that consultation in during their ward round was another example.

The toddler sat on his mother’s knee initially as they examined the child, which wasn’t all that easy because she was heavily pregnant. It was Holly who listened to his heart. She showed Leo the end of her stethoscope before approaching him. She wiggled it. ‘This is Silly Snake,’ she told Leo. ‘He likes tickling people and he wants to wiggle under your T-shirt. Shall we let him do that?’

Leo nodded, wide-eyed.

‘Wiggle, wiggle,’ Holly whispered. Leo giggled as she positioned the disc. She listened intently for a full minute and then nodded. ‘Wiggle, wiggle,’ she said again, and she must have tickled the small boy as she removed the instrument because Leo writhed in mirth. It made both his parents smile and suddenly the consultation was far more relaxed than it might have been.

‘What could you hear, Holly?’

‘There’s a harsh systolic murmur,’ she reported. ‘A pulmonary systolic ejection and a mitral mid-diastolic flow murmur. The pulmonary second sound is loud.’

‘What does that all mean?’ Leo’s father asked.

‘They’re abnormal heart sounds,’ Ryan explained, ‘which we’d expect after the results of the catheter test Leo had yesterday. As you already know, that hole in the ventricular septum hasn’t closed nearly as much as we would have hoped by this stage.’ He glanced up at the X-ray illuminated on the wall of the ward’s small consulting room. ‘Leo’s heart is increasing in size quite dramatically and so are his pulmonary arteries. We don’t want that to continue. He’s getting more symptoms now, too, isn’t he? Despite his medications being increased?’