Once Upon a Christmas

And it was going to happen on Saturday. She was going to invite him in for coffee and she was going to kiss him.

The next day was incredibly busy.

‘It’s the roads,’ Sean said wearily as they snatched a five-minute coffee-break in the middle of a long and intensive shift. ‘They’re so icy and people drive too fast. I predict a nasty pile-up before the end of the evening.’

His prediction proved correct.

At seven o’clock the ambulance hotline rang. Bryony answered it and when she finally put the phone down both Sean and Jack were watching her expectantly.

‘Are you clairvoyant?’ She looked at Sean who shrugged.

‘Black ice. It was inevitable. What are the details?’

‘Twenty-two-year-old female, conscious but shocked and complaining of chest pains.’

She’d barely finished repeating what Ambulance Control had told her when the doors slammed open and the paramedics hurried in with the trolley.

‘Straight into Resus,’ Jack ordered and they transferred the woman onto the trolley as smoothly as possible. While the rest of the team moved quickly into action he questioned the paramedics about the accident.

‘It was a side impact,’ the paramedic told him. ‘She was driving and the other vehicle went straight into her side. Her passenger walked away virtually unharmed. He’s giving her details to Reception now.’

Jack nodded and turned his attention back to the young woman, a frown on his face. ‘She has a neck haematoma. I want a chest X-ray, fast,’ he murmured, and looked at Bryony. ‘Have you got a line in?’

She nodded. ‘One.’

‘Put in another one,’ he ordered, ‘but hold the fluid. And cross-match ten units of blood.’

Bryony’s eyes widened. ‘Why?’

‘Just a feeling. Nicky, I want a BP from both arms,’ he said, gesturing to the staff to stand back while the radiographer took the chest film.

‘Her blood pressure is different in each arm,’ Nicky said quickly, and Jack nodded.

‘I thought it might be. She’s only slightly hypotensive so I want minimal fluid replacement for now.’

Bryony looked at him, waiting for a blonde joke or one of his usual quips that would ease the tension, but this time his eyes were fixed on the patient.

‘Fast-bleep the surgeons,’ he ordered, ‘and let’s take a look at that chest X-ray.’

They walked across to look at the chest X-ray and Bryony looked at him, able to talk now that they were away from the patient. ‘Why did you cross-match so much blood?’

‘Because I think she’s ruptured her aorta.’

Bryony’s eyes widened. ‘But a ruptured aorta has a 90 per cent mortality rate. She’d be dead.’

He squinted at the X-ray. ‘Unless the bleed is contained by the aortic adventitia. Then she’d be alive. But at risk of haemorrhage.’

Bryony stared at the X-ray, too, and Jack lifted an eyebrow.

‘OK, Blondie—impress me. What do you see?’

‘The mediastinum is widened.’

‘And is that significant?’

Bryony chewed her lip and delved into her brain. ‘On its own, possibly not,’ she said, remembering something she’d read, ‘but taken with other factors …’

‘Such as?’

Bryony looked again, determined not to miss anything. ‘The trachea is deviated to the right. The aortic outline is blurred and the aortic knuckle is obliterated.’

‘What else?’

‘It’s cloudy.’ She peered closer at the X-ray. ‘I haven’t seen that before. Is it a haemothorax?’

‘Full marks.’ He gave her a lazy smile but his eyes glittered with admiration. ‘She has a right-sided haemothorax caused by a traumatic rupture of the thoracic aorta, which is currently contained. In this case we can see it clearly on the X-ray, but not always.’

Bryony looked at him and felt her heart thud harder. The patient was lucky to be alive. ‘So what happens now?’

‘She needs urgent surgical repair. In the meantime, we need to give fluid cautiously, otherwise the adventitia could rupture and she’ll have a fatal haemorrhage.’

‘So presumably we also need to give her good pain relief so that her blood pressure doesn’t go up?’

His eyes rested on her shiny blonde hair and he shook his head solemnly. ‘Amazing.’

She poked her tongue out discreetly and he gave her a sexy smile that made her knees wobble.

Fortunately, at that moment the surgeons walked into the room and provided a distraction. They all conferred, agreeing to take the woman to Theatre right away for surgical repair.

‘So what exactly do they do?’ Bryony asked Jack after the woman had been safely handed over to the surgeons and they were left to deal with the debris in Resus.

‘Depends.’ He ripped off his gloves and dropped them into the bin. ‘They’ll attempt a surgical repair.’

‘And if they can’t repair it?’

‘Then they’ll do a vascular graft.’

Bryony helped Nicky to clean the trolley. ‘But what made you suspect an aortic rupture? I always thought patients died at the scene of the accident.’

‘Well, if they’re alive it basically suggests a partial injury,’ he told her. ‘It’s often hard to diagnose on X-ray. A widened mediastinum doesn’t necessarily indicate an abnormality. But in her case there were other classic chest X-ray signs and she had clinical signs too. The neck haematoma, asymmetric BP and chest pain.’

‘And if the X-ray hadn’t been clear?’

‘I would have talked to the consultant radiologist and we would have done a multi-slice CT scan. It’s worth finding out as much as you can about the details of the accident. The paramedic told us her car had been hit on the driver’s side. A significant number of blunt traumatic aortic ruptures are caused by side impact.’

Bryony stared at him in fascination. ‘What’s the pathology?’

‘Basically a sudden deceleration such as a fall from a height or an RTA allows the mobile parts of the aorta to keep moving. It usually tears where the aorta is tethered to the pulmonary vein—’