Medical Romance December 2016 Books 1-6. Sue MacKay

another procedure that afternoon. She had already gone over her theatre equipment requirements, spoken to the anaesthesia team and nursing staff. All of the medical team involved in Georgina’s procedure, bar the one medical student and two interns on maternity rotation, were experienced with TTTS laser surgery, although none on more than two babies. Four was outside everyone’s experience. Including Juliet’s. And she did not hide that fact from the team.

      ‘While I have performed fetoscopic laser surgery on triplets, I will not deny that on quadruplets it will be a slightly more challenging procedure. However, the direct visualisation through the fetoscope will allow us to successfully perform a targeted and focused laser termination of the vascular communications directly responsible for the TTTS and effectively separate the placenta into two components, one for each foetus. With each baby having its own placental mass, and the removal of this communication, there will be an interruption to the transfusion process and we should stabilise the situation so we can advance to a gestational age where the four babies in this situation all have a greater chance of survival. Does anyone have any further questions?’

      ‘If the parents of the quads did not agree to the surgery, what would the risk be to the other three babies if the recipient baby went into stage five heart failure and died?’

      Juliet could see the question came from one of the interns. ‘That’s a very good question. If one foetus was to become non-viable through cardiovascular complication arising from the TTTS, then it would put all three remaining babies at high risk of death, injury or disability. Essentially the fetoscopic laser procedure has taken what was until relatively recently a lethal placental disease and turned it into a manageable condition if detected early.’

      The specialist team were all silent. Each nodded their understanding.

      ‘Just one more question. If the outcome of moving forward with this intervention is pre-term delivery, are you certain that you’re sufficiently prepared for the arrival of four twenty-nine-week gestational babies with a current average weight of less than three pounds?’

      Even without hearing the voice or seeing the man, Juliet knew the question had to come from Charlie, who was standing with folded arms at the back of the room. She took a deep breath. But instead of feeling resentment or interference, she appreciated the question. It was fair and one he had every right to ask in that arena and one that others might have been wondering about.

      ‘Yes, Dr Warren, that’s why we have assembled a multidisciplinary team who can deal with all potential outcomes including pre-term delivery. In addition to Ella, who is Georgina’s midwife, and two anaesthetists, Mr Darrington has already approved the four neonatal intensive care nurses and two neonatologists who are here with us today, and a senior paediatrician, paediatric resident and a paediatric cardiologist, all of whom I assume you will recognise on the day but can’t be at this briefing. In all we will have sixteen in the medical team, three observing and four incubators in Theatre. All of which, God willing, will be under-utilised on the day.’

      Surrounded by Theatre staff, many in scrubs, Juliet suspected the imminent laser surgery for his patient became more real in Charlie’s mind, giving rise to his ongoing concerns.

      ‘Good, I’m not surprised you have it under control, Dr Turner. Let’s hope we don’t need any of it,’ he said, then turned and walked away leaving a tiny grain of doubt in Juliet’s mind.

      Juliet never operated with doubt over anything. She needed to manage it immediately.

       CHAPTER TEN

      ‘CHARLIE, MAY I see you for a minute?’ Juliet asked at the same time as she knocked on his open door. She had excused herself from the pre-operative meeting with the medical team and followed him back to his office. ‘I need to ask your advice with regard to a question hanging over Friday’s procedure.’

      ‘What would that be at the eleventh hour?’

      ‘It’s hardly the eleventh hour.’

      Charlie rolled his eyes as Juliet stepped inside his office and closed the door behind her. Normally she would have shown professional courtesy by involving him in her plans earlier but his initial reservations had ensured that did not happen. She stepped closer to his desk and looked him directly in the eyes. ‘I should have asked for your input around the team. I realise it may have come across as if I’ve gone behind your back and made arrangements with your Assistant Head of Obstetrics with no input from you as the quads’ consulting OBGYN.’

      ‘What’s done is done,’ he said as he continued rifling through the paperwork on his desk.

      Juliet pulled out the chair opposite and sat down. ‘I am sorry about the way I’ve handled this. I’ve been a bit like a bulldozer.’

      His gaze lifted from the paperwork and met hers. ‘Perhaps a mini dozer.’

      She smiled. ‘I really do appreciate you agreeing to be there in the surgery with me. Not for protocol...just because I need you there.’ As the words slipped over her lips she surprised herself. Juliet never admitted needing anyone. And it wasn’t just to make up for what she had done. She meant it. She actually needed Charlie.

      He said nothing for the longest moment, leaving Juliet wondering what he was thinking.

      ‘Let’s just hope the procedure doesn’t induce an early delivery because all four are too small for my liking.’

      ‘I agree, that’s why I need your advice around my contingency plan for that occurrence. Do I have everything in place? You’ve delivered more babies at this hospital than I’ve seen in my life and I’m not afraid to say that I feel a little like a fish out of water and I want your advice on how we can best prepare for the worst.’

      Over the days since she had arrived, despite their disagreements, she knew Charlie was a great OBGYN. It was his passion for what he believed to be best for his patient that fuelled his stubbornness. Juliet knew he cared over and above and, while she conceded he was not one to take risks, perhaps that would make their collaboration perfect. He could temper her risks, mitigate the strategies and together they could find the best way forward.

      ‘What is it you want to know?’

      ‘I want to know if we have sufficient staff on board for starters. And if we don’t, I need you to tell me who’s missing. Oliver has left it up to me, and I would like your input.’

      Finally he looked up and spoke earnestly. ‘I think you’re fine with the surgical team. Each and every one is the best that Teddy’s has to offer and I don’t think you want to further crowd the operating room. My concerns would be around the anaesthesia.’

      ‘Why would that be?’ she asked with her curiosity piqued as she shifted to the edge of her chair.

      ‘If the laser procedure was to be the catalyst for pre-term delivery of the quads you would be looking at a Caesarean if the babies were to have any chance of surviving. They would be barely twenty-nine weeks’ gestation, and babies that premature would not survive the birth canal. There would not be sufficient time for an epidural to be administered so you’d be forced to use a general.’

      ‘So we’ll have that option on hand?’

      Charlie stood and walked around to the front of the desk, crossed his legs and looked directly at Juliet. ‘I think you should try to avoid general anaesthesia.’

      With a frown, Juliet continued the questions. ‘How can we though? You just said yourself that our only option if labour was to commence as a result of the laser surgery was a GA.’

      ‘No, I said that it would be the only option if we weren’t fully prepared.’

      ‘So you think we should have an epidural in place for the procedure rather than the local anaesthetic and conscious sedation?’

      ‘Yes, that way we’ll have both bases covered. It would meet your needs during the fetoscopic procedure, but allow a Caesarean to