Summer With Love: The Spanish Consultant

‘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 it is her spleen, will they try leaving it to heal by itself?’ Katy frowned, racking her brains to recall the detail of something she’d seen in a medical journal. ‘Didn’t I read something recently that suggested that removing the spleen can result in significant long-term health problems?’

‘That’s right.’ Jago nodded. ‘It’s very unusual to remove the spleen these days.’

Charlotte checked the child’s vital signs again. ‘I think she’s improving. That fluid is helping.’

At that moment the doors opened and the surgical team swarmed into Resus.

They conferred with Jago, checked the abdominal ultrasound and examined the child carefully.

‘I think you’re right,’ the consultant said finally, glancing at Jago with a slight smile. ‘I’d say she has a small tear in her spleen.’

Jago glanced at Katy and a slight smile touched his firm mouth. ‘It was Dr Westerling’s diagnosis,’ he said softly, and the consultant gave her an approving nod.

‘In that case, well done to you, Dr Westerling. We’ll get a CT scan and take it from there. If her signs continue to improve, we’ll manage it conservatively. Are the parents with her?’

‘The mother’s in the relatives’ room,’ Jago said, ripping off his gloves and dropping them in the bin. ‘I’m going to speak to her now. Katy, you can come with me as this seems to have turned into your case.’

Warmed by his approval, Katy blushed slightly. Despite his encouraging comments, she was well aware that it was he who had saved the child.

‘Do you think she’s going to live?’ Katy quickened her stride to keep pace with him as he strode out of Resus and made for the relatives’ room. She’d never been assigned the task of talking to relatives before, and was relieved that he was there to do it with her.

Jago pulled a face. ‘Because children are so small, a fall like that can cause multisystem injury. You have to assume that they have multiple injuries until proved otherwise. If it’s just a small tear to her spleen, she should recover fully.’

‘You were so calm.’

He cast her a wry smile that was thoroughly unexpected. ‘Not that calm.’ He paused for a moment, his dark eyes resting on her face. ‘I have feelings, too, you know.’

She looked at him, breathless, wondering whether he was just referring to Molly.

‘But you don’t show them.’

He lifted a broad shoulder in a shrug. ‘How would that help the child? The patient needs me to be detached and efficient. Emotion clouds judgement, Katy. Remember that.’

He gave a twisted smile and suddenly she knew what he was thinking.

That emotion had clouded his judgement eleven years ago when he’d seen those photographs.

And in a way, wasn’t it the same for her?