[TW: Death, Cardiac Arrest, CPR, Defibrillation, Surgery, Anaesthesia, Internal Bleeding, Nudity, Blood, Graphic Medical Detail]
The pain had started at three in the morning. Low on the right side, below the navel, a grinding ache that woke Margot Cole from a dream she couldn't remember. She'd rolled over in bed, pressed her hand against her abdomen, and waited for it to pass. It didn't pass. By four it was a sharp, constant cramp. By five she was on the bathroom floor with her forehead against the tiles because the cold helped with the nausea. By six she'd called a cab because she didn't have anyone to drive her and the Uber surge pricing at six AM on a Sunday was criminal and she'd rather crawl to the ER than pay forty-two dollars for a seven-minute ride.
She was twenty-three. She lived alone in a studio apartment above a dry cleaner. She worked as a barista at a coffee shop that was trying very hard to be a wine bar. She had dark hair, thick, wavy, currently unwashed and pulled into a knot at the base of her skull. She had brown eyes and olive skin and a face that looked better with sleep than without it, which was a problem because she hadn't slept properly in three days because the pain had been building for three days, starting as a twinge on Thursday, becoming a cramp on Friday, becoming a grinding constant presence by Saturday night.
The ER was busy. A Sunday morning in a city hospital: the drunks from Saturday night overlapping with the early morning chest pains and the parents with feverish children. Margot sat in the waiting room for forty minutes with her arms wrapped around her abdomen and her knees drawn up on the plastic chair. She was wearing sweatpants and a hoodie she'd grabbed from the floor of her apartment. No makeup. No bra. The hoodie smelled like coffee from work. Her phone was at twelve percent.
When her name was called she walked to the triage desk slowly, bent slightly to the right, favouring the painful side. The triage nurse took her vitals: heart rate ninety-two, blood pressure one-eighteen over seventy-four, temperature thirty-seven point eight, sats ninety-seven. She described the pain. Right lower quadrant. Three days. Worse today. Nausea but no vomiting. No urinary symptoms. Last period two weeks ago. The nurse categorised her as urgent and put her in a bay.
The ER doctor ordered bloods and a CT scan. The bloods showed an elevated white cell count and a raised CRP. The CT showed what Margot had suspected and hoped wasn't true: a mass on her right ovary, five centimetres, complex, with features suggestive of a mature cystic teratoma β a dermoid cyst β that had torsed. The ovary had twisted on its stalk, cutting off its own blood supply. The pain was the ovary dying.
"You need surgery," the ER doctor said. "The ovary has twisted. If we can untwist it quickly and the blood flow returns, we might be able to save it. If not, the ovary will need to come out. The surgical team will come talk to you."
"Today. We're admitting you to the surgical ward and they'll operate as soon as there's a theatre slot. Probably this afternoon."
"I'm supposed to work at two."
"You're not working at two."
"Yeah, I figured." Margot texted her manager: "not coming in. in the ER. ovary situation. sorry." Her manager replied: "omg are you ok???" Margot typed: "tbd" and the phone died.
They moved her to the surgical ward at ten. Bed eleven, a four-bed bay. She was changed into a hospital gown, the dotted pattern, tied at the back. Two ties. The gown was loose on her frame, gaping at the neckline. A nurse put a nasal cannula in her nostrils, two liters, the oxygen hissing quietly, a precaution because of the tachycardia. She had a cannula placed in the back of her left hand for fluids and pain relief. She had electrode pads stuck to her chest under the gown, the leads trailing to the cardiac monitor. Beep. Beep. Beep. Heart rate eighty-eight, settling with the morphine they'd given her for the pain. Sats ninety-seven. Blood pressure one-fourteen over seventy. She had the blood pressure cuff on her right arm, set to auto-inflate every thirty minutes.
Margot lay in the bed. The gown was crumpled. The nasal cannula hissed. The pain was still there but the morphine had taken the sharp edges off, leaving a deep, constant ache on the right side that pulsed with each heartbeat. She was alone. No visitors. Her parents were in another state. Her friends were the kind you texted memes to, not the kind you called from a hospital bed at ten AM on a Sunday. She had a sister in Portland who she'd talk to eventually but not now because the sister would panic and the panic would be unhelpful. She was alone in a hospital bed in a gown with a tube in her nose, waiting for surgery, and the aloneness was not new. Margot had been alone for most of her adult life. She'd moved out at eighteen, worked since nineteen, lived alone since twenty. The aloneness was familiar. It just felt different in a hospital gown.
The morphine made her drowsy. She drifted, not quite sleeping, the monitor beeping, the oxygen hissing, the ward humming its mid-morning hum. Trays being wheeled. Nurses talking in the corridor. A phone ringing at the station. The sounds of a hospital that didn't know or care that Margot Cole was in bed eleven with a dying ovary, which was fine, because the hospital's job wasn't to care about her specifically. The hospital's job was to fix the ovary. The caring was someone else's department and the department was empty.
The surgical registrar came at eleven-thirty.
Margot heard him before she saw him. He was talking to the nurse at the station, his voice carrying down the corridor, and the voice was young and had the particular energy of someone who was on their third coffee and enjoying the caffeine. Then the curtain around her bed was pulled back, scrape-scrape, and he was standing there.
He was maybe twenty-six. Curly blonde hair, slightly chaotic, the kind that resisted any attempt at professionalism. Blue eyes. Blue scrubs. A surgical mask pulled down around his neck like a scarf. He had a lanyard with his ID on it: DR. ETHAN MARSH, ST4 SURGICAL REGISTRAR. He was holding a tablet in one hand and had a pen behind his ear that didn't match the rest of the look, a cheap biro with the cap chewed.
"Margot Cole?" He looked at the tablet, then at her. Then back at the tablet, then at her again, slightly longer the second time.
"I'm Ethan. I'm the surgical reg on today. I'm going to be doing your operation." He sat on the edge of the bed without asking, which was either confident or presumptuous depending on your perspective, and scrolled through her results on the tablet. "So. Dermoid cyst on the right ovary, five centimetres, torsed. Pain for three days. CT confirms it. How's the pain now?"
"The morphine helped. It's like a four. Before the morphine it was an eight."
"Four is manageable. We'll keep the morphine going until we take you down. The plan is laparoscopic detorsion β we go in through three small incisions, untwist the ovary, and see if the blood flow comes back. If it does, we leave the ovary and remove just the cyst. If the tissue is dead, the ovary comes out."
"What are the odds it's dead?"
"Three days of torsion is a long time. I'll be honest, the chances of saving it are maybe thirty percent. But we won't know until we look."
"Thirty percent." Margot looked at the ceiling. "Those aren't great odds."
"They're not. But they're not zero. And the other ovary is fine, so even if we take the right one, you've still got full function on the left. One ovary does the job of two. It's like having a spare."
"Your ovary is a reliable backup. I'm trying to be reassuring. Is it working?"
He smiled. It was a quick smile, slightly crooked, the kind that happened before the person decided whether to let it happen. Margot noticed it. She noticed it the way you notice things when you're in a hospital bed in a gown with a tube in your nose and someone young and alive walks in from the outside world smelling like coffee and scrub detergent instead of hand sanitiser and bleach.
"Any medical history?" he asked, scrolling. "Allergies? Previous surgeries?"
"No allergies. No surgeries. I had my tonsils out when I was eight if that counts."
"It counts but it's not relevant. Any family history of blood clots, heart problems, anaesthetic issues?"
"My dad had a heart attack at fifty-two. He's fine now. He does CrossFit. It's unbearable."
"CrossFit dads are a specific breed." He was writing on the tablet. "Do you smoke?"
"Socially. Which means more than I should but less than I could."
"No. Unless caffeine counts. I work in a coffee shop. I'm basically caffeinated at a molecular level."
He looked up from the tablet. The crooked smile again. "I'm on my third espresso today, so I'm not in a position to judge."
"It's eleven-thirty. That's aggressive."
"I've been here since six. The first espresso was survival. The second was maintenance. The third was ambition."
"Ambition espresso. Is that a medical term?"
"It should be. I'll write a paper." He put the tablet down. "Okay. I need to examine your abdomen. Is that alright?"
He pulled on gloves. He lifted the gown from the hem, folding it up to just below her ribcage, exposing her abdomen. Margot was aware of this. The lifting. The exposure. The gown bunched above her navel, the skin of her stomach bare under the fluorescent lights, the sweatpants still on below, the waistband visible. His gloved hands on her abdomen, pressing, systematic, quadrant by quadrant. Left side: soft, non-tender. Right side: she flinched when he pressed the right lower quadrant. The muscles tightened involuntarily, guarding.
"Sorry," he said. "I know it's sore. I need to check for peritoneal signs." He pressed deeper. Margot grabbed the bed rail. The pain was sharp, localized, exactly where the ovary was twisting on its blood supply. He let go. He pulled the gown down.
"Classic torsion presentation. I'm going to consent you for the operation. The anaesthetist will come see you separately. We're aiming for a two o'clock theatre slot."
He pulled out the consent form, a printed sheet on a clipboard. He went through it: the procedure, the risks, the alternatives. Risks included bleeding, infection, damage to surrounding structures, conversion to open surgery, loss of the ovary, anaesthetic risks, blood clots, and in rare cases, death. He said the word "death" the way all surgeons said it during consent, quickly, embedded in a list, not emphasised but not skipped. Margot signed.
"Any questions?" he asked, taking the clipboard back.
"Is this your first time doing this operation?"
"No. I've done about forty laparoscopic ovarian procedures. I'm supervised by the consultant, who's done hundreds. You're in good hands."
"Good hands. Another medical term?"
"That one's just a cliche. But it's true." He stood up. He clicked the pen β the chewed biro β and put it back behind his ear. "I'll see you in theatre. Try to rest. Nil by mouth from now."
"I haven't eaten since yesterday. Rest and starvation. Great Sunday."
"Better than a Tuesday. Nobody wants surgery on a Tuesday."
"Is that statistically supported?"
"No. It's vibes-based medicine. Very cutting edge." The crooked smile. He pulled the curtain back and walked away down the corridor, the scrubs, the curly hair, the pen behind the ear. Margot watched him go. The nasal cannula hissed. The monitor beeped. She was having surgery in two and a half hours and the surgeon had made her almost laugh and the almost was the most social interaction she'd had in three days and the gown was still warm where his hands had lifted it.
The anaesthetist came at twelve-thirty. A woman in her thirties, Dr. Yuen, precise and calm. She went through the anaesthetic plan: general anaesthesia, muscle relaxant, intubation, ventilation during the procedure. She checked Margot's airway β mouth opening, jaw movement, neck mobility β and said "straightforward" and wrote it down. She explained the process: Margot would be given oxygen through a mask before the anaesthetic, then the drugs would go through the IV, she'd fall asleep, the tube would go in, the machine would breathe for her. She'd wake up in recovery.
"The mask," Margot said. "Is it the rubber kind or the clear plastic kind?"
"Clear plastic. It fits over your nose and mouth. It delivers pure oxygen to fill your lungs before we put you under. It'll feel a bit claustrophobic but it's only for a minute or two."
"I'm mildly claustrophobic."
"Most people are with the mask. If it helps, you can hold it yourself rather than having me hold it. Some patients prefer that."
"I'll hold it. Control freak tendencies."
"Noted." Dr. Yuen smiled. She left.
Margot lay in the bed. The ward was bright with midday light. She had nothing to do. No phone β dead. No book. No visitor. Just the bed, the monitor, the oxygen, the gown, and the ceiling. She counted the tiles. Fourteen across, nine deep. A hundred and twenty-six ceiling tiles. She tried to think about something other than the surgery. She thought about the surgeon. The curly hair. The crooked smile. The pen behind the ear. Vibes-based medicine. She thought about how strange it was to flirt with someone who was going to cut you open in two hours. The intimacy of it. He'd pressed on her bare abdomen with his hands and she'd grabbed the bed rail from pain and from something else that wasn't pain and the something else was not appropriate and not relevant and she thought about it anyway because the ceiling had a hundred and twenty-six tiles and she'd already counted them twice.
At one-fifteen the pain changed.
The morphine was still running but the pain on the right side suddenly sharpened. Not gradually. A spike. Margot sat forward in the bed and pressed her hand to her right side and the pain was different from the grinding ache of the torsion. This was acute. Stabbing. It came in waves, each wave worse, each one making her grip the rail harder.
The monitor noticed before the nurse did. Heart rate climbing: ninety-two to a hundred to a hundred and eight to a hundred and fourteen. The alarm went off. Bip-bip-bip-bip. Sats ninety-five, dropping to ninety-three.
Margot was breathing fast. Shallow breaths. The nasal cannula wasn't enough. She could feel it β the air wasn't going deep enough. The pain was preventing full breaths. Each inhale was cut short by the stabbing on the right.
The nurse came running. She looked at the monitor, looked at Margot. "What's happening?"
"The pain spiked. Right side. It's different from before. Sharper. And I can't breathe properly."
The nurse pressed the emergency buzzer. She turned the oxygen up from two liters to six on the nasal prongs. She palpated Margot's abdomen gently. Margot cried out. The right side was rigid, board-like. The nurse pulled her hand away.
"I think the cyst may have ruptured," the nurse said. She was already paging the surgical team. "The pain change and the rigidity suggest the torsed ovary has burst or the cyst has leaked."
Ethan arrived in four minutes. He was slightly out of breath, the curly hair more chaotic than before. He pulled gloves on and examined Margot's abdomen quickly. His face changed when he felt the rigidity β the same rearrangement the ER doctor's face had done earlier, the adult-deciding-how-to-explain shift, but faster.
"The cyst has ruptured," he said. "The dermoid contents are leaking into the abdomen. Dermoid cysts contain hair, fat, sometimes teeth β it's a developmental thing β and when they rupture the contents cause a severe chemical peritonitis. The inflammation is intense. We need to move the surgery up. I'm calling theatre now."
"As soon as they can give me a room. The peritonitis will get worse the longer the contents sit in the abdomen. I need to wash it out." He was on the phone, walking, talking to the theatre coordinator. "I need an emergency slot. Ruptured dermoid with chemical peritonitis. She's deteriorating."
He came back. He sat on the edge of the bed again. The charm was different now. The flirtation was gone. He was a surgeon with a patient whose abdomen was full of dermoid contents and the urgency was genuine.
"We're going in thirty minutes. Theatre three. The anaesthetist is being called." He looked at her. "How's the pain?"
"Worse. A lot worse. The morphine isn't touching it."
"I'll get you more. And I'm going to switch you to a mask because your sats are dropping." He nodded to the nurse. The nurse replaced the nasal cannula with a non-rebreather mask, ten liters. The mask went over Margot's face, the elastic behind her ears, the reservoir bag inflating and deflating with each rapid breath. The hsssss was louder. The mask fogged with each exhale.
Margot's face was half-hidden behind the plastic. Her dark eyes looked at Ethan over the top of the mask. The fog came and went. He was sitting on her bed. He smelled like coffee and scrub detergent. Two hours ago he'd been making her laugh about vibes-based medicine. Now he was making phone calls about emergency theatre slots.
"Hey," he said. Quieter. "I know this is scary. The rupture makes it more urgent but it doesn't change the surgery itself. Same procedure. Same plan. I go in, clean out the dermoid contents, deal with the ovary. The only difference is we're doing it now instead of two o'clock."
"You said the odds of saving it were thirty percent."
"With the rupture, probably less. The chemical irritation damages the tissue further. I'll try."
He almost smiled. Almost. "Evidence-based trying. Different category." He stood up. "I'll see you in theatre. Thirty minutes."
He left. Margot lay in the bed with the mask on, the fog coming and going, the pain grinding on the right side, the monitor beeping fast, the morphine pump clicking, the ward moving around her. They were prepping her for theatre. The nurse removed her earrings, the small studs in her ears. She removed the rings from her fingers. She took the hair tie out and Margot's dark hair fell across the pillow. The nurse checked the consent form. She attached a wristband. She hung a bag of IV antibiotics alongside the fluids. Margot lay there being prepared, being processed, her body being made ready for a room she'd never been in and a knife she'd never felt, and the mask fogged and the monitor beeped and she was alone.
They wheeled her to theatre at one-fifty. The bed moved through the corridors, the IV pole swinging, the monitor on its portable stand trailing alongside. The fluorescent lights passed overhead in a steady rhythm. The mask fogged and cleared on her face. She watched the ceiling tiles change from ward tiles to corridor tiles to the double doors of the theatre suite, which opened automatically with a swoosh, and the air changed β cooler, cleaner, the smell of antiseptic sharper.
The anaesthetic room was small. White walls. Bright lights. A single narrow operating table with a thin mattress. Equipment everywhere β the anaesthetic machine with its monitors, the drug trolley, the airway trolley, cables and tubing coiling across the floor. Dr. Yuen was there, mask on, gloves on, drawing up syringes. A nurse in blue scrubs was laying out equipment on a metal tray.
Margot was transferred from the ward bed to the operating table. She moved herself, swinging her legs over, the gown riding up, the nurse guiding her. The table was narrow. Hard. Cold through the thin mattress. She lay on her back. The gown was the only thing between her skin and the room. The ties at the back pressed into her spine. The electrode pads from the ward monitor had been replaced with theatre ones, stuck to her chest and her side by a nurse who'd pulled the gown open at the front to place them. Margot felt the cool air on her bare skin, the cold gel of the pads, the nurse's hands quick and impersonal. The gown was pulled back into place.
The non-rebreather mask was removed. The nasal cannula was removed. For a few seconds Margot was breathing room air, the cool theatre air, and the absence of the hissing oxygen was stark. Then Dr. Yuen placed a new mask over her face.
The anaesthetic mask was clear plastic, contoured, fitting over her nose and mouth with a soft silicone rim. It was connected to the anaesthetic machine by a corrugated tube, and when Dr. Yuen turned the dial, pure oxygen flowed through it. The mask filled with the rush of gas. Margot breathed in. The oxygen was cold, metallic-tasting, different from the ward oxygen. It came in volume. Each inhale filled her lungs completely, the pure oxygen washing through the alveoli, saturating the haemoglobin. The mask fogged with each exhale, the condensation forming on the inside of the clear plastic, then clearing on the inhale as the fresh oxygen displaced it.
"I'm going to hold this for a minute to get your oxygen levels up," Dr. Yuen said. "Then you can hold it yourself if you prefer."
Margot nodded behind the mask. The fog came and went. She could see the ceiling through the clear plastic. The lights. The metal arm of the operating lamp, not yet switched on. She could see Dr. Yuen's eyes above the surgical mask, calm, focused. She could hear the anaesthetic machine cycling: a rhythmic whoosh-click, whoosh-click, measuring each breath, the bellows inside the machine rising and falling with her ventilation.
Dr. Yuen placed the mask in Margot's hand. Margot held it against her face. The silicone rim pressed into the skin of her cheeks and the bridge of her nose. The seal was close but not airtight β small leaks around the edges let threads of cold oxygen escape across her face. Her hand was on the mask. The IV was in the other hand. The gown was on the table. The monitor beeped from the anaesthetic machine's screen: heart rate ninety-four, sats a hundred percent on the pure oxygen, blood pressure one-ten over sixty-four.
"The oxygen is going to make you feel a bit light-headed," Dr. Yuen said. "That's normal. When you're ready, I'll start the anaesthetic through your IV. You'll feel a cold sensation in your arm, then everything will go warm and heavy, and you'll fall asleep."
"About ten seconds after I push the drug."
"Ten seconds. Some people count. Some people try to fight it. Nobody wins."
"What do most people do?"
"Most people say 'oh' and then they're asleep."
Margot held the mask. The fog came and went. The lights were bright. The room was cold. The gown was thin. She was alone on an operating table with a mask on her face and a nurse at her shoulder and an anaesthetist at her head and a surgeon somewhere beyond the doors scrubbing in and the surgeon had curly hair and a crooked smile and she'd flirted with him two hours ago in a hospital bed while he pressed on her bare abdomen and now she was about to go under and he was going to cut her open while she slept and the sequence of events was so intimate and so impersonal at the same time that her brain couldn't categorise it.
The cold hit her arm first. The propofol going in through the IV, a sharp cold that spread from the back of her hand up her forearm. Then the cold turned warm. Then the warm turned heavy. Her eyelids dropped. The mask slipped in her grip and Dr. Yuen caught it and held it in place. The lights dimmed. The last thing Margot saw was the anaesthetic machine's screen, the numbers, the heart rate dropping as the propofol took effect β ninety-four, eighty-eight, eighty-two β and the trace crossing the screen, her heartbeat, slowing, steady, each spike further from the last, and then the lights went out.
Dr. Yuen removed the mask from Margot's slack hand. The anaesthetic nurse tilted Margot's head back, opened her jaw. Dr. Yuen picked up the laryngoscope, slid the blade in, lifted. The vocal cords were visible. She passed the tube through them, inflated the cuff, connected the circuit. The anaesthetic machine took over. Shhh-click. Shhh-click. Margot's chest rose and fell mechanically. The gown was pulled open fully now for the surgical prep. The nurse cleaned Margot's abdomen with brown iodine, the cold liquid pooling on the bare skin. The drapes went on, blue sterile sheets covering everything except the surgical field β the rectangle of iodine-stained skin between the ribcage and the pelvis. The gown was tucked up under the drapes. Margot was draped and prepped and unconscious and the operating lamp clicked on.
Ethan came through the theatre doors. Scrubbed. Gloved. Gowned. The curly hair was under a surgical cap. The pen behind the ear was gone. The mask was up. Only the blue eyes were visible. He stood at the table and looked at the surgical field and the monitors and the unconscious patient and the anaesthetist at the head and he said "let's go" and picked up the scalpel.
Margot woke up in the recovery room. She didn't know she was waking up. She knew she was somewhere different because the sounds were different β fewer beeps, more voices, a steady rhythmic whooshing that took her a moment to identify as the blood pressure cuff cycling automatically. Her throat was sore. Her mouth was dry. She tried to swallow and the swallow scraped. The tube had been in her throat for ninety minutes. It was out now but the memory of it was there, raw tissue, a bruised feeling deep in her trachea.
She opened her eyes. The recovery room was bright, white, a row of bays with curtains. She was in a bed, propped on pillows, the gown back on, the hospital blanket over her legs. The nasal cannula was back in her nostrils, three liters, the quiet hsssss. The monitor was beeping. Heart rate seventy-eight. Sats ninety-six. Blood pressure one-oh-eight over sixty-two. A nurse was sitting on a stool beside her, writing.
"You're awake," the nurse said. "You're in recovery. The surgery went well. How are you feeling?"
"The throat's from the breathing tube. It'll be sore for a day or two. I can give you some ice chips for the thirst. How's the pain in your tummy?"
Margot assessed. The right side was sore, deeply sore, but different from before. The grinding torsion pain was gone. In its place was the tender, bruised soreness of surgery β the port sites, three of them, small incisions dressed with waterproof plasters. The inside of her abdomen felt raw, cleaned out, like someone had pressure-washed a room that was never meant to be pressure-washed.
"Sore. But better than before. The twisting pain is gone."
"That's because the torsion's been dealt with. Dr. Marsh will come talk to you about what they found."
Ethan came to the recovery bay at three-thirty. He'd changed out of the surgical gown but was still in scrubs, the cap off, the curly hair back, slightly flattened from the cap. He pulled up a stool and sat down beside Margot's bed. The mask was off. The full face was visible. Young, flushed from the theatre, the blue eyes slightly tired.
"Hey. How are you feeling?"
"Like someone went inside me with a hoover."
"That's basically what happened. The dermoid had ruptured and the contents were all through the pelvis. Hair, sebaceous material, a tooth."
"A small one. Dermoid cysts develop from germ cells, so they can contain any tissue type. Hair, skin, teeth. It's the body's most cursed art project."
"My ovary grew a tooth. That's the worst thing I've ever heard."
"It's actually quite common. About forty percent of dermoids contain dental tissue. The uncommon part was the rupture. The chemical peritonitis was significant β the fatty material from the cyst was all through the abdomen. We washed it out with three liters of saline. It should settle but you might have some pretty intense inflammatory pain for a few days."
"We had to take it out. The torsion had been too long. The tissue was dead. I'm sorry."
"Thirty percent odds. Guess I was in the seventy."
"You were. But the left ovary looks completely healthy. Full function. One ovary is enough for everything β fertility, hormones, all of it."
"The reliable backup." He smiled. The crooked one. "You'll be on the ward for a couple of days for recovery. IV antibiotics for the peritonitis. Pain management. We'll keep the oxygen on until your sats are consistently above ninety-five. Any questions?"
"Did you keep the tooth?"
He laughed. A real laugh, surprised, the kind that escaped before it could be filtered into professional composure. "It went to pathology. I can try to get you a photo."
"I'd like a photo. For my dating profile. 'Fun fact about me: my ovary had a tooth.'"
"That would get matches."
"The wrong kind of matches."
"All matches are the wrong kind until they're not." He stood up. He was looking at her. Not at the monitor or the gown or the cannula. At her. The dark hair on the pillow. The brown eyes above the nasal cannula. The face that was pale and post-surgical and still making him laugh. "I'll check on you later. On the ward. Part of the job."
"Part of the job," she repeated.
"Mandatory post-operative review. Very official. There's a form."
"Is the form vibes-based?"
"Entirely. It's just a blank piece of paper with a smiley face." He clicked the chewed biro, put it behind his ear, and walked away. Margot watched him go. The nasal cannula hissed. The monitor beeped. Her abdomen was empty of a dermoid cyst and an ovary and a tooth and full of three liters of saline wash and the beginnings of post-operative inflammation and she was alive and she'd made a surgeon laugh in the recovery room and the laugh had been worth the tooth.
They moved her back to the ward at five. Bed eleven. Same bay. The old familiar spot. The nurse reconnected the ward monitor. Beep. Beep. Beep. Heart rate seventy-four. Sats ninety-five on three liters of nasal prongs. Blood pressure one-oh-six over sixty. Temperature thirty-seven point six. The IV antibiotics were running. The morphine PCA was connected β a button she could press for a dose, with a lockout to prevent overdosing. The pump clicked when she pressed it. The morphine spread through the IV, warm, dulling the raw surgical pain.
The ward settled around her. The evening trays came. She managed three spoonfuls of soup before the nausea stopped her. The anaesthetic always left nausea. She'd been warned. She lay back on the pillows with the nasal cannula in and the gown on and the surgical dressings on her abdomen and the three small port site plasters visible at the gown's edge and the morphine blurring the edges of everything and the ward dimming as the evening came.
Ethan came at seven. The mandatory post-operative review. He'd changed into a fresh pair of scrubs. The curly hair was slightly damp, like he'd splashed water on his face between patients. The pen was behind the ear. The chewed cap. He pulled the curtain around the bed. Scrape-scrape.
"Better with the morphine. Maybe a three. The nausea's worse than the pain honestly."
"Post-anaesthetic nausea is normal. It should settle by morning. Have you eaten?"
"Three spoons of soup. Then my stomach said no."
"Three spoons is a start. Try crackers later. Bland things. Nothing ambitious."
"Nothing ambitious. That's my life motto generally."
He checked the dressings. He lifted the gown, the same motion as before, folding it up to the ribcage, the abdomen exposed. Three small port sites, each one covered with a waterproof plaster. The skin around them was pink, slightly bruised. No active bleeding. No swelling. No signs of infection. He pressed gently around each one. Margot flinched at the third, the one on the right lower quadrant where the ovary had been removed.
"That one's going to be the most sore. That's where we did the most work." He pulled the gown down. "Everything looks clean. The drain output is minimal, which is good. We might take the drain out tomorrow if it stays low."
"I didn't know I had a drain."
"Small tube, left flank, under the gown. It's draining any residual fluid from the washout. You might not have noticed because of the morphine."
Margot felt for it. A small tube emerging from her left side, taped to the skin, connected to a small drainage bag pinned to the sheet. She hadn't felt it until now. The morphine had made her body a blur, the edges soft, the details lost. Now she could feel it. The tube in her side. The tape pulling the skin.
"I'm collecting tubes," she said. "Nose tube. Hand tube. Side tube. I'm fully tubed."
"The nose tube comes off tomorrow if your sats stay up. The hand tube stays for the antibiotics. The side tube comes out when the drainage stops. Tube by tube, you're getting closer to freedom."
"Freedom. Also my life motto."
"I thought your motto was nothing ambitious."
"I have multiple mottos. I'm multifaceted."
He sat on the edge of the bed. The curtain was drawn. The bay was private. The monitor beeped on the other side of the curtain, the sound muffled by the fabric. He looked at her. She looked at him. The nasal cannula hissed between them. The gown was crumpled. The morphine was softening everything.
"You don't have anyone coming to visit?" he asked. Not as a doctor. As a person.
"No. My parents are in Virginia. My sister's in Portland. My friends are... I have work friends. Coffee shop friends. They're not hospital friends. Hospital friends are a different tier."
"I'm used to it. I've been on my own since eighteen. You get good at it. Or you get used to it, which is different from good but looks the same from the outside."
"It's not the same from the inside though."
"No. From the inside it's just quiet. Lots of quiet." She looked at the monitor through the curtain gap, the green trace visible. "The monitor is the most company I've had in a room in months. It beeps at me constantly. Very attentive. Best roommate I've ever had."
He was quiet for a second. The beeping filled the silence. Then he said: "I'll check on you in the morning. Before my shift starts. Off the record."
"The mandatory review is done. Anything after this is... extracurricular."
"Extracurricular. Is that a medical term?"
"It's a grey area term. Very cutting edge." The crooked smile. He stood up. He pulled the curtain back. Scrape-scrape. "Get some rest. Press the morphine button when you need it. Don't be a hero."
"I've never been a hero."
"Good. Heroes don't press the button and then they're in agony at three AM and the nurses are annoyed."
He left. Margot lay in the bed. The curtain was open. The ward was dim. The monitor beeped. The nasal cannula hissed. The drain drained. The morphine hummed in her veins. She pressed the PCA button. Click. The pump delivered. The warmth spread. She closed her eyes. She was alone in a hospital bed on a Sunday night after surgery and a surgeon with curly hair and a crooked smile had sat on her bed and called it extracurricular. The word sat in the room alongside the beeping. She held onto it. She fell asleep holding it.
The night was quiet. Observations at ten, midnight, two, four. Numbers stable each time. Heart rate seventy to seventy-six. Sats ninety-five on three liters. Temperature drifting up slightly β thirty-seven point eight at midnight, thirty-eight at two β but the antibiotics were running and a low-grade fever post-surgery with peritoneal contamination was expected. The drain output was twenty millilitres overnight. Normal.
Margot slept in stretches. The morphine helped. The PCA button was pressed at eleven, at one, at three. Each time the click, the pump whirring, the warmth spreading from her hand up her arm into her chest. Each time the pain eased from a four to a two. Between doses the pain crept back, a slow tidal return, the raw surgical sites announcing themselves.
At five AM she woke up properly. The ward was dark. The monitor glowed. She lay still, breathing, the nasal cannula hissing. She assessed her body the way you do in a hospital bed: the abdomen sore, the drain tube pulling slightly, the throat still raw, the mouth dry, the gown twisted. She shifted, carefully. The port sites protested. She found a position that was tolerable and stayed in it.
She thought about Ethan. The morning visit he'd promised. Off the record. Extracurricular. She thought about the crooked smile and the chewed pen and the blue eyes behind the surgical mask and the way his gloved hands had pressed on her bare abdomen twice β once in assessment, once in post-op check β and both times the touch had been clinical and both times she'd been aware of it beyond the clinical and the beyond was a place she didn't usually go because going there required someone to go there with and she hadn't had someone in a long time. The monitor beeped. The oxygen hissed. She lay in the dark and thought about a surgeon she'd known for less than a day and the thinking was warm and morphine-soft and probably ill-advised and she did it anyway.
Ethan came at six-thirty. Before his shift. He was in fresh scrubs with a coffee in each hand. He came through the bay and put one coffee on her overbed table.
"Flat white. I guessed. Barista's choice."
"You said you were caffeinated at a molecular level. I assumed you'd be in withdrawal by now."
"I am. The nasal cannula oxygen tastes like cold metal. It's not a substitute." She picked up the coffee. It was warm in her hands. She took a sip. It was good. Not as good as the shop where she worked, but good. "Thank you. This is above and beyond."
"It's a coffee. Don't make it a thing."
"I'm going to make it a thing. I'm in a hospital bed with no visitors and a surgeon brought me coffee at six-thirty in the morning before his shift. That's a thing."
"It's a gesture. I'm an expert on gestures. I work in hospitality. I know what it means when someone brings you something hot without being asked."
"It means you thought about me before you got here. You were somewhere, at a coffee shop, at a machine, and you thought: she might want coffee. And then you got two instead of one. That's a thought process. That's intention."
He was looking at her. The coffee in his hand. The crooked smile appearing and disappearing. "You're reading a lot into a flat white."
"I'm a barista with post-surgical insomnia. Overreading is all I have."
He sat in the visitor's chair. Not the bed this time. The chair. The professional distance restored. But the coffee was there, the two coffees, one on each side, and the professional distance had a hole in it shaped exactly like a flat white.
"Your obs overnight were stable," he said, switching modes. "Temperature's been creeping up, which we expected with the peritonitis. The antibiotics need a couple of days to really kick in. The drain output is low, which is good. I'll take the drain out this morning. And if your sats hold above ninety-five we can try you off the oxygen later today."
"Tube by tube." He sipped his coffee. "I've got a full theatre list today so I won't be around much. Ffion β the ward nurse β she'll be looking after you. Anything you need, she's the one."
"Extracurricular visits cancelled?"
"Postponed. I'll come by after my list. Probably around five."
"I'll be here. Not like I have anywhere else to be."
He stood up. He paused. "Margot."
"For what it's worth, the monitor isn't the best company you could have in a room."
"No. The monitor just measures. It doesn't bring coffee."
He left. Margot held the coffee. The warmth of the cup in her hands. The nasal cannula hissed. The monitor beeped. She took another sip. The coffee was good. The morning was good. She was alive and post-operative and drinking a flat white a surgeon had brought her at six-thirty AM and the morning light was coming through the window, pale and early, and for a few minutes the hospital bed was not the loneliest place she'd been.
The drain came out at nine. Ffion did it. She clamped the tube, cut the suture, and pulled. The sensation was strange β a deep tugging in Margot's side, a burning slide, then the tube was out and a dressing was pressed over the site. Twenty seconds. Margot exhaled.
"One less tube," Ffion said.
The nasal cannula came off at noon. Her sats held at ninety-five on room air for an hour. Ninety-five was the threshold. The cannula was removed. The hissing stopped. Margot's face was free of tubing for the first time in twenty-four hours. The red marks behind her ears where the cannula had rubbed were visible, two small indentations. She touched them. The skin was tender.
Without the cannula, the room was quieter. The monitor still beeped. The IV still dripped. But the constant hissing was gone. Margot noticed the absence the way you notice the absence of a sound you'd stopped hearing β by the space it left. The room was bigger without the hissing. Emptier.
She ate half a piece of toast at one. She drank water. She walked to the bathroom with the nurse's help, the IV pole wheeled alongside, the gown swishing. The walk was hard. Her abdomen protested each step, the port sites pulling, the internal surgical trauma making itself known. She used the bathroom. She washed her hands. She looked at herself in the mirror: dark hair loose, tangled, unwashed. Pale face. Dark circles. The gown neckline showing the edge of an electrode pad. She looked like someone who'd been in a hospital for twenty-four hours, which she had. She looked like someone who was alone, which she was.
The afternoon was uneventful. Observations stable. Temperature thirty-eight point two, still febrile, but the antibiotics were working. The surgical sites were clean. The blood work showed improving inflammatory markers. Everything was going in the right direction.
At three-forty-eight, Margot was lying in bed reading a magazine someone had left on the overbed table. It was three months old and was about celebrity kitchens and she didn't care about any of it but it was something to look at that wasn't the ceiling.
Not the post-surgical pain she'd been managing with the PCA. Something different. Deep. Sudden. A cramping pressure in her lower abdomen that built over about thirty seconds from zero to seven. She dropped the magazine. She pressed her hand to her abdomen. The cramping intensified. Her face went from pale to white.
She pressed the PCA button. Click. The morphine delivered. The cramping didn't respond. It was the wrong kind of pain. The morphine worked on the surgical sites, the port site pain. This was deeper. Internal. Something happening inside the abdomen that the morphine couldn't reach.
The monitor showed it: heart rate climbing. Seventy-eight to eighty-six to ninety-four in sixty seconds. The blood pressure cuff inflated on its thirty-minute cycle. Whirr. Squeeze. Hiss. The number: ninety-two over fifty-four. Low. Lower than it had been all day. Lower than post-op. Lower than it should be.
Margot pressed the call bell. Bzzzt.
Ffion came. She looked at the numbers. She looked at Margot. She pressed on the abdomen gently. Margot cried out. The abdomen was distended, tense. Rigid on the right side. The drain site on the left was dry but the right lower quadrant was swelling visibly, the skin taut.
"Something's wrong internally," Ffion said. She was paging the surgical team. "Your blood pressure's dropped. The abdomen's tense. You may be bleeding internally."
"Possibly. A vessel that was cauterised during the operation may have started bleeding. It can happen in the first twenty-four to forty-eight hours. The clot forms during surgery but then dislodges."
The oxygen went back on. Not the nasal cannula. Ffion went straight to the non-rebreather mask, fifteen liters. The mask went over Margot's face. The elastic behind her ears, pressing into the raw marks from the cannula. The hsssss was back, loud, filling the mask, the reservoir bag inflating and deflating in rapid bursts. The fog on the plastic. The sudden compression of the world from open air to mask-sealed, the room visible through fogged clear plastic.
Heart rate: a hundred and six. Blood pressure: eighty-eight over fifty. Sats: ninety-two on fifteen liters. Dropping despite maximum mask oxygen. Something was bleeding inside her. The peritoneal cavity, washed clean of dermoid contents sixteen hours ago, was filling with blood.
Ethan arrived at four-oh-two. He'd been pulled from his theatre list. He came through the curtain in surgical scrubs, gloves on, and he looked at Margot on the bed with the mask on and the numbers dropping and his face did something she hadn't seen before. The charm fell away. The crooked smile was gone. The flirtation was gone. The surgeon was there. Just the surgeon.
"Margot, I think you're bleeding internally from one of the surgical sites. Your blood pressure is dropping. I need to examine you."
He lifted the gown. The abdomen was distended on the right, visibly swollen compared to the left. He pressed. Margot grabbed the bed rail. Her knuckles were white. The pain was a nine. He let go.
"I need to take you back to theatre. Right now. We need to find the bleeder and stop it."
"Right now. No waiting. We're going." He was on the phone. "I need theatre three back. Same patient, post-op haemorrhage, she's haemodynamically unstable, I need it now."
Blood was hung. O-negative through both IVs, squeezed through the rapid infuser. The cold blood went in. Margot could feel it, the cold spreading up her arms, into her chest. She was shaking. The mask fogged in frantic bursts. The heart rate was a hundred and sixteen. The blood pressure was eighty over forty-four.
"Ethan," she said through the mask. His name, not Dr. Marsh. The fog on the plastic. The brown eyes above the mask rim. "I'm scared."
He looked at her. The surgeon looked at her. "I know. I'm going to fix this. I fixed it yesterday and I'll fix it today. Same team. Same plan. We go in, we find the bleeder, we stop it. Okay?"
"Okay." He squeezed her hand. One second. Two. Then he let go and started moving the bed, wheeling it toward the theatre, the IV pole swinging, the monitor trailing, the mask hissing, the blood bags swinging, the corridor fluorescent lights passing overhead in their steady rhythm.
In the anaesthetic room, Dr. Yuen was waiting. Same room. Same table. Same equipment. The transfer was fast. Margot was on the operating table. The gown was open. The mask was switched from the non-rebreather to the anaesthetic mask, the clear plastic, the silicone rim, the corrugated tube. Pure oxygen. The mask fogged and cleared, fogged and cleared.
"Same as yesterday," Dr. Yuen said. "Ten seconds. Count if you want."
Margot held the mask. The clear plastic against her face. The oxygen cold and metallic. The propofol went in. The cold. The warm. The heavy. She counted: "Ten. Nine. Eight β"
The surgery took ninety minutes. They found the bleeder: the ovarian pedicle, the stump where the right ovary had been removed, had a vessel that the surgical clip had slipped from. The clip, placed yesterday, had dislodged. The vessel had been oozing into the pelvis for hours. By the time they opened, there was eight hundred millilitres of blood in the abdomen. They found the vessel, clipped it again, double-clipped it, cauterised the area, washed out the blood, and closed.
Margot woke up in recovery at six PM. The same room. The same brightness. The same sore throat, worse this time, the second intubation in twenty-four hours bruising the already-bruised trachea. The nasal cannula was in. Four liters. The monitor beeped. Heart rate eighty-eight. Sats ninety-three. Blood pressure ninety-six over fifty-six. Lower than yesterday's recovery numbers. The blood loss had depleted her, even with the transfusion.
She was cold. Very cold. The blood they'd given was cold and her body temperature was low from the theatre, thirty-five point eight, and the blankets weren't enough. A nurse brought a warming blanket, the kind that inflated with hot air. It went over her like a balloon, warm, humming. The shaking eased.
Ethan came to the recovery bay at six-thirty. He was still in theatre scrubs. The surgical cap was off. The curly hair was flat, sweaty. He looked tired. He sat on the stool.
"Found it," he said. "The clip had slipped off the ovarian pedicle. The vessel was oozing. We've double-clipped and cauterised. The bleeding's stopped."
"Eight hundred mils. You've had three units of packed cells to replace it. Your blood count will need rechecking but you should stabilise."
"Eight hundred mils. That's a lot."
"It's significant. But you're young and your heart is strong. You'll recover." He paused. "How are you feeling?"
"Cold. Sore. Tired. Scared." She listed them plainly, without the jokes, without the banter. The mask of charm she wore, the one that was thinner than the oxygen mask but served the same purpose, was off. She was too tired for it.
"The scared is reasonable. You've had two surgeries in twenty-four hours. That's a lot for anyone."
"Is it over? The bleeding. Is it actually over this time?"
"The vessel is secured. Double-clipped. Cauterised. It should be over. But I'm going to keep you on close monitoring tonight. Hourly obs. And I've asked the team to keep the rapid infuser at the bedside as a precaution."
"A precaution or a preparation?"
"Someone once told me those are the same thing."
"They're not. A precaution is an umbrella. A preparation is β"
"A life raft. I remember." He looked at her. The blue eyes. The tired face. "This is a precaution. An umbrella. Okay?"
"Okay." She wanted to reach for his hand. She didn't. The IV was in one hand and the PCA button was in the other and the nurse was two feet away and the reaching would have been a line crossed and the line was already blurred and blurring it further in a recovery room with a nurse present was not the move.
"I'll come check on you later," he said. "On the ward. When things are quieter."
"Mandatory. The form says so." He stood. The crooked smile. Tired but there. "Get some rest, Margot."
She was moved back to the ward at eight. Bed eleven. The faithful spot. The monitor reconnected. The nasal cannula swapped from four liters to three as the sats improved. Ninety-four. The ward was settling into its nighttime rhythm. Margot lay in the bed, the warming blanket gone now, the hospital blanket and her own from home pulled up to her chin. She was still cold but less. The morphine was running. The antibiotics were running. The blood count was rechecked: haemoglobin nine point two, low but stable. The heart rate was eighty-four. The blood pressure was a hundred over fifty-eight. Improving.
Ethan came at ten. Off the record. The ward was dark. He pulled the curtain, scrape-scrape, and sat in the visitor's chair. He had a chocolate bar. He put it on the overbed table.
"I can't bring you coffee at ten PM. So chocolate."
"You're going to get in trouble for this."
"For bringing a patient chocolate?"
"For sitting in a patient's bay at ten PM bringing chocolate and calling it mandatory."
"It is mandatory. The form β"
"There's no form, Ethan."
"There could be a form. I could create a form. 'Post-operative chocolate delivery assessment.' I'd sign it."
Margot opened the chocolate. She broke off a piece and ate it slowly. The sweetness was sharp after hours of nothing but water and morphine. She broke off another piece and held it out. Ethan took it. They ate chocolate in the dark of a hospital ward at ten PM and the monitor beeped and the nasal cannula hissed and the curtain was drawn and it was the strangest, most specific, most improbable version of a date that either of them had ever been on.
"When I get out of here," Margot said, "you should buy me an actual coffee. In an actual coffee shop. Where I'm not wearing a gown with electrode pads on my chest."
"It's a flat white. Don't make it a thing."
He laughed. Quiet, in the dark, the sound contained by the curtain. "I'd like that."
"Good." She ate another piece of chocolate. The morphine was soft in her veins. The monitor beeped. He was sitting in the chair three feet from her bed and the three feet was the width of a professional boundary that was not holding and they both knew it wasn't holding and neither of them was doing anything about it because the not-holding was the thing that was keeping Margot company in the loneliest room she'd ever been in.
He left at ten-thirty. He stood up, put the chewed biro behind his ear, looked at her one more time, and said: "Sleep. Real sleep. Not morphine-drift. Close your eyes and sleep."
"Good." He pulled the curtain open. Scrape-scrape. He walked away. His scrubs. His curly hair. The corridor swallowing him. Margot lay in the bed. The chocolate wrapper was on the table. The morphine was warm. The monitor beeped. She closed her eyes. She slept.
At two-fourteen AM the monitor woke the nurse.
The alarm was the cardiac alarm, not the standard observation alert. High priority. The tone was different, sharper, more insistent. The nurse at the station looked at the central telemetry screen. Bed eleven. The heart rate, which had been eighty-four at midnight, was climbing. Ninety-six. A hundred and four. A hundred and twelve. And the trace was changing. The narrow regular complexes were becoming irregular, widening, the rhythm losing its shape.
She walked quickly to bed eleven. The curtain was open. Margot was in the bed, on her back, the gown on, the nasal cannula in, the blanket pulled to her chin. Her eyes were closed. She was breathing, but the breathing was fast and shallow, thirty breaths a minute. Her skin was pale. Not sleep-pale. Grey-pale.
The nurse shook her shoulder. "Margot? Margot, can you hear me?"
Margot's eyes opened. They were unfocused. She blinked. She looked at the nurse. "What... I feel..." Her voice trailed off. Her hand went to her chest. "My heart feels weird. Fast. And wrong. Like it's tripping over itself."
The nurse looked at the monitor. Heart rate a hundred and eighteen. Irregular. Wide complexes interspersed with narrow ones. Ventricular ectopics. Couplets. A three-beat run of VT. Then sinus. Then another couplet. The blood pressure cuff cycled. Eighty-two over forty. Low. Dangerously low for someone who should have been stable.
"Something's happening to your heart rhythm. I'm going to increase your oxygen and call the team."
She switched the nasal prongs to a non-rebreather mask, fifteen liters. The mask went over Margot's face. The elastic. The hsssss. The fog. She pressed the emergency buzzer on the wall.
Margot was awake. She could feel it. The heart doing something wrong. Not the clean, steady, metronomic beating that the monitor had been showing for twenty-four hours. This was chaotic. A beat, a beat, a pause, a hard thump, a fluttering sensation, a run of rapid beats that made her vision grey at the edges. She gripped the bed rail. The mask fogged in rapid, uneven bursts.
"The bleeding," Margot said through the mask. "Is this from the bleeding? The blood loss?"
"It could be. The blood loss can cause electrolyte changes that affect the heart. The team is coming."
The on-call registrar arrived at two-twenty. Not Ethan. A different registrar, the night cover. She looked at the monitor, looked at the blood pressure, ordered an urgent ECG and bloods. The ECG showed frequent ventricular ectopics with runs of non-sustained VT. The bloods showed what the registrar suspected: potassium two point six, magnesium critically low. The massive blood transfusion and the surgical blood loss had depleted the electrolytes. The heart was misfiring because the electrical system didn't have the minerals it needed to conduct properly.
"IV potassium and magnesium. Stat. Through the big-bore IV, fast as we can push it. And page the surgical reg β tell Dr. Marsh his patient is deteriorating."
The potassium went in. The magnesium went in. The correction was urgent. The heart needed the electrolytes to stabilise. But the infusion took time β twenty minutes for the potassium to reach therapeutic levels, ten for the magnesium. The heart didn't have twenty minutes of stability left.
At two-twenty-eight, the VT became sustained.
The wide complexes took over the trace. The rate climbed: a hundred and thirty. A hundred and forty. A hundred and fifty. Margot could feel it. The pounding. The racing. The blood pressure cratering. Seventy over thirty-two. The room going dark at the edges. The mask fogging in frantic bursts that she could barely see through.
"I'm losing it," she said through the mask. Her voice was thin, distant. "The edges are going dark. My blood pressure β it's dropping. I can feel it dropping. Everything's going grey."
"Margot, stay with me. Keep talking. Keep your eyes open."
"I'm trying. The grey is getting bigger. There's less room. Less room to be awake in." Her words were slurring. The blood pressure was sixty-two over twenty-eight. The brain was losing perfusion. The heart was beating at a hundred and fifty-six but not pumping effectively, the VT producing a fraction of the normal cardiac output.
The crash team was paged. The resus trolley was pulled to the bedside. The defibrillator was opened, powered on. The nurse untied the gown at the back and pulled it open at the front, spreading it flat on either side of Margot's body, exposing her chest and abdomen completely. The electrode pads were already on her chest from the ward monitor. The defibrillator pads were pulled from their packaging, the backing peeled, the large adhesive ovals stuck to Margot's bare skin β one below the right collarbone above her right breast, one on the left side below her left breast. The pads were cold. The gel was cold. The adhesive pulled at her skin. Her bare chest was fully exposed under the fluorescent light, the gown bunched at her sides, the surgical dressings on her abdomen visible. The leads connected to the defibrillator.
Margot was still conscious. Barely. She could see the nurse's hands on her bare chest, placing the pads. She could feel the open gown, the air on her bare skin, the cold gel on her sternum. She was exposed from the neck to the waist, the gown splayed open, and she didn't care because the caring part of her brain was shutting down with the blood pressure. She could hear the defibrillator powering up, the hum of the machine. She could see the screen, her own heart trace, the wide chaotic VT scrawling across it.
"Amiodarone three hundred milligrams. Push it."
The drug went in through the IV. The VT continued. A hundred and fifty-eight. A hundred and sixty. The blood pressure was fifty-four over twenty-four. Margot's eyes were closing. The grey was taking over. The last thing she saw was the fluorescent light above her, the same light she'd watched from the operating table fourteen hours ago, and then the light went out.
"She's lost output. No pulse. V-fib."
The trace had degenerated from VT to ventricular fibrillation. The organised wide rhythm broke apart into the chaotic scrawl, the heart no longer beating in any pattern, just quivering, the electrical activity random and useless.
The nurse positioned her hands on Margot's sternum, between the defibrillator pads. She interlocked her fingers. She leaned over the bed, her arms straight, her shoulders directly above her hands. She pushed.
The first compression was deep. Five centimetres into Margot's chest. The sternum flexed under the force. Margot's body moved on the bed, her head rocking, her arms flopping at her sides. A nurse pulled the gown out from under her completely, lifting her shoulders to slide it free, and dropped it on the floor. Margot was naked from the waist up. The hospital blanket was pushed down to her thighs. Her body was exposed under the bright lights β the defibrillator pads on her chest, one above the right breast, one below the left, the electrode pads between them, the pale skin of her sternum where the nurse's hands were pushing. Her ribs were visible with each compression, the chest wall flexing. The port site dressings sat on her abdomen, three small plasters in a line. The drain site dressing was on her left flank. Her collarbones stood out sharply. Her dark hair was spread across the pillow, tangled, unwashed. Her face was slack, the mouth slightly open. The mask had been pulled off. The non-rebreather was on the overbed table. Nobody covered her. Nobody thought about covering her. The body on the bed was not a person with modesty. It was a chest that needed compressing and a heart that needed restarting and the nakedness was as clinical as the drugs and the electricity.
The compressions continued. One hundred and ten per minute. Deep, rhythmic, relentless. The nurse's body rocked with each push. The bed moved. The IV pole swayed. The monitor displayed the compressions as artefact on the trace, regular, mechanical spikes that weren't heartbeats but looked like them on the screen.
A second nurse was at the head of the bed. She tilted Margot's head back, opened the jaw, and placed an oropharyngeal airway β a curved plastic tube β into Margot's mouth. It held the tongue forward, keeping the airway clear. She placed the bag-valve-mask over Margot's face. The clear plastic dome sealed over her nose and mouth. She squeezed the bag. Whoosh. Margot's chest rose under the compressions. The air went in, filling the lungs while the compressions circulated the blood. Whoosh. Again. The ratio was thirty compressions to two breaths.
"Charging defibrillator. Two hundred joules."
The defibrillator charged. The sound. The sound that fills every resuscitation room in every hospital. A high-pitched electronic whine that started low and built, climbing in pitch and volume, rising to a peak, a sustained tone that hung in the air for two seconds while the capacitor reached its charge.
"Everyone clear. I'm going to shock."
The compressions stopped. The nurse lifted her hands from Margot's chest. The other nurse lifted the BVM from Margot's face. For two seconds nobody was touching the patient. Margot lay on the bed, naked from the waist up, still, her arms at her sides, the defibrillator pads on her bare skin, the wires trailing to the machine. The bruise on her sternum from the compressions was already forming, a red flush between the pads. Her chest was motionless. The trace showed VF.
The registrar pressed the button.
Ka-chunk. The electrical current passed through the pads, through the chest wall, through the heart. Margot's body jumped on the bed. Her bare chest lifted off the mattress, her back arching. Her arms jerked outward, her hands opening. Her breasts shifted with the force of the jolt, the defib pads pulling at the skin. Her head snapped back. The current passed in milliseconds. She fell back onto the mattress, limp, her body settling, the momentum rocking the bed frame. The blanket at her thighs slipped further down.
Everyone looked at the monitor. VF. Still. The shock hadn't converted it.
"Resume CPR. Adrenaline one milligram IV."
Compressions restarted. The nurse's hands found the same spot on the sternum. Push. Release. Push. Release. A hundred and ten times a minute. The bed rocked. The BVM was replaced over Margot's face. Whoosh. Chest rose. Whoosh. The adrenaline went in through the large-bore IV, one milligram, a syringe of clear liquid pushed directly into the vein, flushed with saline. The adrenaline hit the circulation β what was left of the circulation, the compressions generating twenty to thirty percent of normal blood flow β and spread through the body, reaching the heart in the compressed trickle of blood the CPR was producing.
Two minutes of CPR. The timer on the defibrillator counted. Two minutes exactly. The algorithm demanded precision.
"Hold compressions. Rhythm check."
The compressions stopped. The trace appeared. VF. Finer now. The amplitude of the fibrillation waveform was decreasing. The heart was losing energy. The quivering was becoming weaker.
"Still VF. Charging. Two hundred joules."
Ka-chunk. Margot's body jumped. Higher this time, the current stronger through the decreasing resistance of the chest wall. She fell back. The bed rails rattled.
The monitor: VF. Still. But different. The trace was degenerating toward asystole. The waveform was flattening.
"Resume CPR. Amiodarone three hundred milligrams."
Compressions. Bagging. The amiodarone went in through the IV, three hundred milligrams in twenty millilitres, pushed slowly. The drug was supposed to stabilise the cardiac membrane, make the cells less excitable, give the shock a rhythm to reset to. The potassium infusion was still running. The magnesium was still running. The electrolytes were being replaced while the heart was being compressed and shocked and drugged.
The compressing nurse was tiring. Five minutes of continuous CPR was physically demanding. Her arms ached. Her back ached. Her hands were cramping.
"I need to swap out," she said.
A fresh nurse stepped in. She positioned her hands on the sternum, finding the landmark between the defib pads on Margot's bare chest. She began pressing. The depth was the same. The rate was the same. The rhythm continued without interruption. The changeover took three seconds β one pair of hands lifting off the naked skin, another pair landing in the same place. Margot's body continued to rock with each push, her head lolling, her arms shifting at her sides. The bruise on her sternum was deepening, spreading outward from the compression point. Sweat from the nurse's arms dripped onto Margot's bare stomach.
"Hold compressions. Rhythm check."
The trace: asystole. Flat line. The VF had deteriorated to nothing. No electrical activity. No quivering. Nothing.
"Asystole. Continue CPR. Adrenaline."
The adrenaline went in. Second dose. The compressions continued. The bagging continued. Margot's chest rose and fell with each squeeze of the bag, the air going in and out of lungs that were not exchanging oxygen effectively because the heart was not pumping blood through them. The compressions moved the blood. Each push on the sternum compressed the heart between the sternum and the spine, squeezing blood out of the ventricles and into the arteries, a mechanical heartbeat generated by someone else's arms.
Two minutes. Rhythm check. The trace showed a blip. Then nothing. Then two blips close together. Then nothing. Then a narrow complex. Weak. Slow. Another one. Another.
"I see something. Hold." The registrar watched. The complexes were coming. Slow, narrow, regular-ish. Thirty per minute. Then forty. "Pulse check."
The nurse felt Margot's neck. The carotid. One second. Two. Three. "I've got something. Weak. Thready. But present."
"Hold compressions. Keep bagging. What's the pressure?"
The cuff cycled. The number appeared: fifty-eight over thirty. Barely a blood pressure. But a blood pressure. The sats climbed from unmeasurable to forty-two to fifty-six. The heart was beating on its own. Badly. Weakly. But on its own.
"Keep the potassium running. Keep the magnesium running. Keep bagging. Let's see if this holds."
It held. For four minutes. The heart rate climbed. Forty. Fifty. Fifty-eight. Sinus rhythm, slow, narrow complexes. The blood pressure climbed. Sixty-two over thirty-four. Sixty-eight over thirty-eight. The sats climbed. Sixty. Sixty-eight. Seventy-four. The team watched. The compressions had stopped. The bagging continued. The drugs continued. The monitor beeped its slow, fragile rhythm. Beep. Beep. Beep. Each beep a beat. Each beat a life.
At the four-minute mark, the rhythm broke.
Sinus to VT in one beat. The narrow complexes widened. The rate jumped. Sixty to a hundred and forty in two seconds. No transition. No warning. The potassium had climbed to three point one during the arrest but the magnesium was still critically low and the myocardium was ischaemic from twelve minutes of cardiac arrest and the cells couldn't hold a stable rhythm. The VT lasted four beats before degenerating into VF.
The hands went back on. The compressions resumed. Push. Release. Push. Release. Margot's body rocked on the bed. Her dark hair was across her face now, pushed there by the BVM, strands sticking to the sweat on her skin. The nurse brushed them back. The compressions continued.
Ka-chunk. Third shock. The body jumped. The trace showed VF. Still.
"Adrenaline. Continue CPR. And someone page Dr. Marsh. Tell him his patient has arrested."
Ethan was paged at two-thirty-eight. He was in the on-call room, asleep. He hadn't been deeply asleep β the chocolate with Margot at ten, the worry, the operating list, the second surgery β none of it had let him sleep deeply. The pager went off. He looked at the message: CARDIAC ARREST BED 11 MARGOT COLE. He was on his feet before the message finished displaying. He was running down the corridor in scrubs and socks, no shoes, the corridor cold under his feet.
He arrived at the bay at two-forty. The curtain was around the bed. He could hear the compressions before he got there, the rhythmic thudding, the bed rocking. He pulled the curtain aside.
Margot was on the bed. Naked from the waist up. The defib pads on her chest. The electrode pads. The surgical dressings on her abdomen. The blanket had been pushed to her ankles during the compressions. Her body was completely exposed under the overhead light, the pale skin, the bruising on her sternum spreading like a stain, the ribs flexing with each compression. Her dark hair was across her face. The BVM was over her nose and mouth, the nurse squeezing it. The compressions going, steady, deep, a nurse he didn't recognise doing them, her hands between Margot's breasts, pushing hard, the chest compressing five centimetres with each push. The defibrillator beside the bed, the screen showing VF. The drug trays open. The syringes on the overbed table. The adrenaline vials. The amiodarone. The potassium. The gown was on the floor, crumpled, the dotted fabric that had been the only thing covering her for thirty-six hours discarded and stepped on. The whole machinery of resuscitation deployed around the bare body of the woman he'd brought coffee to that morning and eaten chocolate with that evening.
"What happened?" he said. His voice was different. Not the surgeon voice. Something underneath.
"VT deteriorating to VF at zero-two-fourteen. Electrolyte-driven β potassium two point six, mag critically low. Three shocks so far. ROSC for four minutes after the second shock then re-arrested into VF. Potassium and magnesium running. Third adrenaline going in now."
Ethan looked at the monitor. VF. He looked at Margot. The compressions rocking her body. The BVM inflating her chest. The dark hair. The face behind the mask. The face he'd seen laugh about vibes-based medicine and ovary teeth and flat whites. The face that was slack now, grey, the mouth slightly open under the BVM.
"Continue the protocol," he said. "Keep the potassium running. Check the level now β if it's correcting, the next shock might hold."
A nurse drew blood from the arterial line that had been placed during the arrest. The bedside blood gas analyser gave the potassium in ninety seconds. Three point two. Climbing. Not there yet but climbing.
Ka-chunk. Fourth shock. VF became asystole. Three seconds. Then a complex. Then another. Then VF again.
"She's flickering. The potassium is getting there. Keep going."
Compressions. Bagging. The rotation happened. Fresh arms. The new nurse's compressions were slightly faster, adjusted down to rate by the registrar. The adrenaline went in. Fourth dose. The compressions continued. Margot's chest bore the deepening purple of sustained CPR, the bruise spreading from the centre of the sternum outward across her bare skin, the discolouration visible between the defib pads. Her ribs, compressed thousands of times, cracked at the eighteen-minute mark. The nurse felt the give under her palms, the cartilage separating from the bone with a gristly crunch. The chest wall became softer, less resistant, the compressions sinking deeper into the broken ribcage. The nurse kept pushing. The cracked ribs were an expected consequence. Margot's body was slick with sweat now, the skin of her bare chest and abdomen glistening under the lights, the defib pads peeling slightly at the edges from the moisture. A nurse pressed the pads back down, her hand flat against Margot's bare skin.
Ka-chunk. Fifth shock. VF. The amplitude was decreasing. The fibrillation was becoming finer, weaker. The heart was losing the energy to even fibrillate.
"She's going fine VF. If the next shock doesn't convert we need to consider whether we're going to get her back."
Ethan was standing at the foot of the bed. He was watching the compressions. He was watching the monitor. He was watching the face behind the BVM. Twenty minutes. The potassium was three point four now. Almost there. Almost in the range where the heart might respond.
"One more round," he said. "The potassium is nearly corrected. Give it one more cycle."
Compressions. Adrenaline. Fifth dose. Two minutes. The timer counted. The compressions continued. Push. Release. Push. Release. The bed rocked. The IV pole swayed. The drugs dripped. The bag whooshed.
The compressions stopped. The trace appeared. Fine VF. Barely distinguishable from asystole. The waveform was a tremor.
The trace went flat. Asystole. One second. Two. Three. Four. Then a complex. Narrow. Then another. Then another. A rhythm. Sinus. Slow. Forty-two per minute. Forty-six. Fifty.
The nurse felt the carotid. "Pulse present. Stronger than last time."
"Hold compressions. Keep bagging. Check the pressure."
Blood pressure: sixty-four over thirty-six. Low. But there. Sats climbing: fifty. Sixty-two. Seventy-one. The heart was beating. The potassium was three point six. The correction was taking effect.
Ethan watched the monitor. The rhythm held. Fifty-two beats per minute. Fifty-six. Sixty. Narrow. Regular. The blood pressure climbed. Seventy. Seventy-four. Eighty. The sats climbed. Seventy-six. Eighty. Eighty-two.
"Holding," the registrar said. "It's holding."
The room exhaled. Not literally. But the tension that had been in every body in the room for twenty-two minutes released fractionally. The compressions were stopped. The bagging continued. The drugs continued. The monitor beeped. Beep. Beep. Beep. Sixty-two beats per minute. Sinus.
Ethan was at the bedside. He was looking at the monitor. The trace. The number. Sixty-four. Sixty-six. Climbing. Stabilising. The potassium was in range. The magnesium was correcting. The rhythm was holding.
"Come on," he said. Not to anyone. To the monitor. To the trace. To the heart. "Stay."
The rhythm held for two minutes. Two minutes and fourteen seconds. The blood pressure was eighty-six over forty-eight. The sats were eighty-eight. The heart was beating. The blood was flowing. The oxygen was reaching.
Not VT. Not VF. The complexes widened slowly, spreading, the conduction time increasing. The heart was slowing. Sixty-two. Fifty-six. Fifty. Forty-four. Bradycardia. The damaged myocardium, ischaemic from twenty-four minutes of arrest, was failing not from electrical chaos but from exhaustion. The muscle cells, starved of oxygen for too long, were stopping. Not fibrillating. Just stopping.
"She's going brady. Push atropine. Five hundred mics."
The atropine went in. The rate didn't respond. Forty. Thirty-six. Thirty. The complexes widened further. The blood pressure dropped. Seventy-two. Sixty. The sats dropped. Eighty-four. Seventy-eight.
"She's losing output again. Resume compressions."
Compressions restarted. The hands on the bruised, cracked sternum. The bed rocking. The bagging continuing. Adrenaline. Sixth dose. The trace showed the compressions artefact overlaying the fading native rhythm, the mechanical spikes superimposed on the dying electrical signals.
Two minutes. Rhythm check. The native rhythm was gone. Asystole. Flat. The heart had stopped producing electrical activity entirely. The muscle was dead. Not fibrillating. Not conducting. Dead.
"Adrenaline. Continue CPR."
Two more minutes. Rhythm check. Asystole. Adrenaline. Two minutes. Asystole. The flat line persisted. The end-tidal CO2 on the capnography was below five. The pupils, checked between cycles, were fixed and dilated. Six millimetres. Both sides.
Ethan was at the foot of the bed. He was looking at the monitor. The flat line. The silence where the beeping had been, filled now only by the mechanical sounds of CPR. He looked at Margot. The bare chest, bruised purple-black. The cracked ribs visible as depressions in the sternum. The defib pads, sweat-loosened, peeling at the edges. The electrode pads. The dark hair across the pillow. The face behind the BVM. Her body exposed on the hospital bed, the gown on the floor, the blanket at her ankles, the nakedness that nobody had thought to address because nakedness was irrelevant in a resuscitation and would only matter again if there was someone alive to cover.
The registrar looked at Ethan. She didn't say anything. She didn't need to.
The compressions stopped. The bagging stopped. The nurse's hands lifted from Margot's chest. The BVM was lifted from her face. The room was quiet. The defibrillator was silent. The IV pumps continued their clicking but the clicking was the only sound.
Margot was on the bed. Naked from the waist up, the gown on the floor where it had been dropped twenty-eight minutes ago. The defib pads on her bare chest, the adhesive loosened by sweat. The bruised sternum, purple-black, the skin broken in two places from the compressions. The cracked ribs. The surgical dressings on her abdomen, the three small port sites from the first surgery, the drain site from the second. The blanket bunched at her ankles. Her body was still under the fluorescent light, exposed, the pale skin marked by the bruise and the pads and the electrode stickers and the IV sites. Her dark hair was across the pillow, unwashed, tangled, the same hair she'd had in a knot when she'd walked into the ER thirty-six hours ago. Her face was slack. Her eyes were half-open. Brown eyes. The nasal cannula was on the overbed table. The non-rebreather mask was on the overbed table. The chocolate wrapper was on the overbed table.
Ethan stood at the foot of the bed. He was in scrubs and socks. No shoes. His curly hair was flat from the pillow. The chewed biro was not behind his ear. The crooked smile was not on his face. He was a twenty-six-year-old surgical registrar standing at the foot of a bed looking at a twenty-three-year-old woman he had operated on twice and brought coffee to and eaten chocolate with and called extracurricular. She had asked him for a coffee in an actual coffee shop where she wasn't wearing a gown with electrode pads on her chest. He had said he'd like that.
He picked up the chocolate wrapper from the overbed table. He looked at it. He put it in his pocket. He didn't know why. He turned and walked out of the bay, through the ward, down the corridor, the linoleum cold under his socks, the corridor lights buzzing, the ward behind him quiet, the monitor in bed eleven off, the screen dark.
