LITMIR.BIZ

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and the paramedics rushed in with a small girl on the stretcher.

      ‘This is Molly Churchman. She’s two years old and she fell out of the bedroom window,’ the paramedic told them, his expression tense and anxious. ‘Bedroom on the first floor—the mother is hysterical.’

      Jago reached for the oxygen mask and positioned it carefully over the child’s mouth and nose. He watched carefully, nodding with satisfaction as he saw the mask fog.

      ‘Her airway is patent and she’s breathing by herself,’ he growled. ‘I want two lines in and I need an estimation of her weight.’

      Katy wondered whether it was the sick child or their earlier confrontation that was responsible for the grim expression on his handsome face and the tension in his broad shoulders.

      It was probably the child, she decided. Their relationship couldn’t possibly be that important to him.

      Charlotte looked up. ‘I asked the mother about her weight but she was too upset to give me a lucid answer.’

      ‘In that case, use the Oakley Paediatric Resuscitation chart on the wall,’ Jago instructed, and one of the other nurses hurried to do that while he carried on assessing the child. ‘Cervical spine injury is rare in a child of this age but we’ll keep the spine immobilised until we’ve ruled it out.’

      There was a flurry of action and Annie came back from examining the chart on the wall. ‘Estimated weight is about 12 kilograms.’

      ‘Right. Charlotte, make a note of that. Annie, go back to the mother,’ Jago ordered, ‘find out if the child cried immediately—I need to know whether she was unconscious for any time. And get me details of allergies, medications, past medical history and when she last ate or drank. And try and get a more precise account of the accident. What surface she landed on, how she was lying—that sort of thing.’

      Annie hurried off to do as he’d instructed and Jago spoke quietly to the little girl, reassuring her in a gentle voice as he worked.

      Charlotte was visibly upset as she undressed the child so that they could make a more accurate assessment of her injuries.

      ‘She’s so tiny. That poor mother.’

      ‘Lose the emotion,’ Jago said harshly. ‘We’ve got a job to do. Finish undressing her and get some overhead heaters and warming blankets—a fall in body temperature causes a rise in oxygen consumption.’

      Charlotte swallowed and looked at him, startled by the sharp reprimand.

      Katy felt a flash of empathy for her colleague but she knew that Jago was right.

      It wouldn’t help the child if they let emotions get in the way of their work. The child needed them to be professional.

      But there was no doubt that Jago was unusually tense.

      They removed all her clothes and then covered her in warm blankets and adjusted the heaters so that she wouldn’t become cold.

      With the minimum of fuss, Katy found a vein and slipped in the cannula.

      ‘Her blood pressure is slightly down,’ one of the nurses said, ‘but not dramatically.’

      ‘Check her capillary refill time,’ Jago ordered, and Katy finished taping the first IV in place and glanced up at him.

      ‘Is that significant?’

      He gave a brief nod. ‘A child can suffer considerable blood loss without a significant change to the vital signs,’ he told her, his eyes fixed on her fingers as she searched for another vein. ‘When we diagnose shock in children we rely on other signs, like capillary refill time, the appearance of the skin, the temperature of the extremities.’

      ‘Based on those criteria, this child is in shock,’ Katy murmured, pausing as she located what felt like a vein.

      Without hesitating, she inserted the cannula smoothly and watched as the blood flowed backwards.

      ‘Both lines are in,’ she said quickly, relieved that she’d managed what had proved to be a difficult task. Finding veins in a child that small was difficult at the best of times and sometimes they had to give an infusion directly into the bone.

      The child had barely protested, which was another indication of how ill she was.

      ‘That was a tricky job.’ Jago’s voice was gruff. ‘Well done.’

      For a brief moment their eyes met and he gave a slight smile. The tension in the room seemed to ease slightly but there was a hint of challenge in that smile that made Katy breathless.

       The subject of their relationship was obviously far from closed.

      She picked up a selection of blood bottles. ‘I’ll take bloods for group and cross-matching, blood-glucose estimation and request a full blood count and biochemistry. Anything else?’

      Jago shook his head. ‘No, but we need to get her some pain control.’

      ‘Her skin is very cold and clammy and her capillary refill time is prolonged,’ Charlotte said quietly, and Katy bit her lip as she took the bloods and administered the pain relief that Jago had ordered.

      ‘She’s very lethargic,’ Jago murmured, his eyes never leaving the child as he worked. ‘She’s showing all the features of class III shock. I want to give her 20 milligrams of crystalloid per kilogram. Do the calculation, Katy.’

      Katy did as he ordered and warmed the fluid before injecting it into the child’s vein.

      Jago carried on examining the limp, unresponsive body of the toddler. ‘She’s bleeding from somewhere and we need to find out where. Check her pulse and blood pressure again,’ he ordered, glancing at Charlotte as he spoke. ‘I’ve got a bad feeling about this. Bleep the surgeons and get me some blood up here fast. If her vital signs don’t improve in the next few minutes I’m going to transfuse her. Can we get a nasogastric tube down, please? And I want X-rays of her chest and pelvis.’

      Katy looked at the tiny body on the trolley and, despite Jago’s warnings about becoming emotional, she felt a lump in her throat.

      The little girl was so tiny and helpless. No wonder the mother was hysterical. She would have been hysterical if it had been her child who was lying there injured.

      They had to save the child. They just couldn’t let her die.

      A niggling suspicion entered her head and she opened her mouth to speak and then closed it again.

      ‘What?’ Jago’s tone was sharp. ‘You were going to say something.’

      Katy hesitated. ‘I was wondering whether it could be her spleen,’ she said quietly, ‘but there’s no clinical reason to imagine that it could be. Just a gut feeling.’

      ‘Never dismiss gut feelings.’ Jago looked at her and then returned his attention to the child, his expression thoughtful. ‘It would explain the degree of shock in the absence of visible injury.’

      Annie returned, having interviewed the mother in more depth, and she gave a full report to Jago who had examined the X-rays and now had his eyes fixed on the abdominal ultrasound.

      ‘She’s bleeding into her abdomen,’ he muttered, and Carl, one of the other junior doctors, looked at him questioningly.

      ‘But her abdominal wall is barely bruised.’

      ‘That isn’t a reliable sign in children.’ Jago didn’t look up. ‘She’s showing signs of abdominal injury. I think Katy is probably right. It’s her spleen.’

      Carl rubbed a hand over the back of his neck. ‘So we need to get her to Theatre urgently?’

      ‘Not necessarily.’ Jago shook his head. ‘We tend to avoid surgery and adopt a conservative approach where possible. The spleen is the most commonly injured organ following blunt trauma to the abdomen, then the liver and kidneys.’

      ‘If

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