and I didn’t follow it up.’
‘Aspirin won’t have done this, though it might have made it worse,’ Leo said. ‘But if there’s a bleed it won’t help now. Carla, we’re going to have to have a look-see. Get a trolley, Maria. We’ll take her through for scans. Now.’
‘What can I do?’ Anna asked.
‘You’re a patient,’ Leo said roughly. ‘Thanks for your help, Anna. You should be right to go.’
The scan showed a bleed.
A big one.
The hairline skull fracture was bad enough. What was worse was the dark shadow underneath the fracture. A subdural haemorrhage. Blood vessels near the surface of the brain had obviously ruptured.
How the hell…?
But the cause of the injury was the least of his concerns. What was crucial was time. Blood had collected immediately beneath the three-layer protective covering of the brain. The brain was being compressed.
In young people a bleed like this was usually triggered by a significant impact. Older people could bleed after only a minor trauma.
Carla was hardly elderly but she’d been taking aspirin. The aspirin would have been thinning the blood.
The greater the pressure on the brain, the worse the bleeding would become. For her to lose consciousness so quickly…
‘I’m going in.’ He was talking to Carla, and to the nurse beside him. Maria was looking as terrified as he felt. ‘Carla, there’s a bleed under the surface. We need to get the pressure off.’ He needed to say no more. If Carla was aware enough to take it in then she’d know, and Maria had been a nurse long enough to realise the ramifications of a cranial bleed. Pressure on the brain caused brain damage, and it caused it fast. They had to get the pressure off now.
‘Leo, I’m asking again. What can I do?’
The voice came from the doorway. Anna still looked very much the patient. She was dressed in jeans and a T-shirt, but the white dressing showed starkly against her burnt-red hair.
‘You need to leave, Anna.’ It was an instinctive response.
‘I’m a doctor, Leo,’ she snapped. ‘Get over yourself. Let me help.’
‘You’re injured.’
‘I have stitches from a bump on my head. I imagine Carla’s haemorrhaging. Am I right?’
‘You’re not well. I can’t—’
‘Do you have another doctor on staff? An anaesthetist?’
He needed headspace and she was messing with it. He opened his mouth to snap back but sense prevailed.
His instinctive reaction to Anna had been that of a doctor to a patient. The internal war, how he was feeling about Carla’s illness, physician versus friend, could allow no other distractions.
Anna’s question, though, had cut through.
There was no other doctor within hours of travel. Carla collapsing so dramatically meant that the bleed was sudden and severe. The pool of blood under the dura must be causing damage.
Carla usually assumed the role of anaesthetist if he needed to operate. What now?
‘There’s no other doctor,’ he admitted.
‘Evacuation?’
‘It’ll take hours.’
‘Then she needs emergency craniotomy and drainage,’ Anna said. Her curt, professional tone helped. ‘If there’s no one else… Leo, can you operate if I do the anaesthetic? I’ve done additional anaesthetic training. The village where I work isn’t big enough to support medical specialists and there’s occasional urgent need.’
She had anaesthetic training? It was like a gift from the heavens. A colleague with anaesthetic skills…
‘You have a head injury yourself.’
‘I have stitches and bruising. I may also still suffer a bit of dizziness if I stand up fast, but I think I’m over it and I can cover it. I know it’s not ideal but given the circumstances… Give me a stool in Theatre and let’s move.’
He gazed down at Carla and saw no response. No glimmer of recognition. He looked again at Anna and she met his gaze with a determination that was almost steely. Treat me as a doctor, her gaze said. Get over your prejudices.
She was still a patient. He could hardly ask.
There was no choice.
‘Thank you,’ he said simply. ‘If you’re sure.’
‘I’m sure. Let’s move.’
The surgery sounded simple. Anyone with a decent handyman’s drill should be able to do it—in fact, Leo had heard of doctors in emergency situations using just such an implement.
Luckily he didn’t have to resort to such measures. Most of their of equipment was second-hand but it was functional. Leo had kept up with a lot of doctors he’d met during training, and when they had been purchasing shiny new medical toys they often remembered him and sent on usable older things. The X-ray department had been set up almost completely via donations from a friend he’d met in final year med school. For the rest they’d scraped and saved and cajoled the community, which meant the theatre he was working in was fully equipped.
And he had excellent staff. Maria, his chief nurse, was rigid about standards and ongoing training, and she ruled her nursing staff with a softly gloved fist of iron.
The only hole in the team was his lack of a trained anaesthetist and that hole had been plugged. In Anna he had an anaesthetist he could trust. From the moment he’d nodded his acceptance of her offer she’d turned almost instantly from patient, from heir to the powers of Castlavara, from his past lover—into a crisp, competent professional.
‘Do you have access to Carla’s medical history? I need to know what she’s taken, allergies… Family? Is someone on their way?’
‘Her husband died ten years back,’ he told her. ‘Her son’s in Italy. But we have her history. Maria…’
‘Onto it,’ Maria said, and so was Anna. Ten minutes later they were in Theatre.
‘Glasgow scale deteriorating,’ Anna told him. ‘I’m losing any eye response.’
He didn’t need telling. He knew the pressure would be building.
He needed to focus.
A handyman might be able to operate a drill but what was needed here was precision, care, knowledge. And confidence.
Confidence that Anna could keep Carla alive while he worked.
And strangely the trust was there.
If another doctor had walked in right now, someone he didn’t know… If they’d offered to help… Yes, he’d have had to accept their help but there’d be caution. He’d be checking all the time. He’d be torn, though, because the procedure he was performing was out of his comfort zone. He needed to work fast with skills he hardly knew he had.
Anna helped. Somehow just knowing she was here helped.
Carla was in the supine position, facing up. As soon as Anna had the IV line in, as soon as she was sure Carla was under, Maria did a quick shave.
Then it was over to Leo. Two small holes to expose the dura, then careful, painstakingly draining. Hell! The scan had showed a build-up but it shook him to see just how much fluid was in there.
He