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'His condition didn't appear too bad at first,' the paramedic said, 'but now he's having difficulty breathing, and I'm wondering if the damage is worse than it looks. He has some cracked ribs, and it looks as though he has a penetrating chest wound, perhaps from some twisted metal.'

Sarah climbed into the passenger seat and looked at the injured man. 'I'm Dr Mitchell,' she said. 'Can you tell me your name?'

The man tried to turn his head. His lips moved, and she strained to hear his words. Looking at him closely, she suddenly began to feel very cold. Shivers ran down the length of her spine and she sucked in a shocked breath.

'Ryan?' she whispered. 'What happened? What are you doing here?' Another, more terrible thought occurred to her. 'Was Hannah with you?'

He made a faint nod. 'The paramedic.. .got her out.' He struggled to form the words. 'They...were worried. . .about fire.' The effort was too much for him and he closed his eyes.

Sarah guessed that they hadn't been able to move Ryan because of the mangled wreckage. He was partially trapped, although the firemen had managed to remove some of the metal that was confining him.

She looked around. Where was her sister? Then she heard Ryan making rasping sounds and her attention swivelled back to him. She knew that she had to attend to him. His neck veins were distended, and she was worried that he, too, had suffered a collapsed lung.

As she worked to restore his breathing and to stem the flow of blood from his chest wound, she looked up and said urgently to the paramedic, 'My sister was with him in the car. Will you find her? Let me know what's happened to her?'

The paramedic nodded. He looked concerned, immediately on the alert. 'What's her name?'

'Hannah.'

He hurried away. It was all Sarah could do for the moment. She wanted to go and find her sister, but she had to take care of Ryan. It was her job, and she would be failing in her duty if she left him. She was torn. This couldn't be happening.

One of the ambulances started to move away. She heard it leave, and she wondered whether Hannah had been one of its passengers. The paramedic hadn't returned to give her any news.

Sarah managed to stabilise Ryan's condition, giving him oxygen and intravenous fluids, and after some time they were finally able to remove him from the car and carefully wheel him into the waiting ambulance.

Mark had finished working on his patient and now he called Sarah to join him.

'That's everyone accounted for,' he said. 'We need to get back to the hospital.' He studied her cautiously.

'But Hannah was here,' Sarah said in desperation. 'I need to find her. I don't know what has happened to her.'

'She's in the other ambulance,' Mark said. 'I spoke to her just a moment ago.'

Sarah clutched at his sleeve. 'How is she? What happened to her?'

'She's alive. She's conscious, but she's suffered an injury to her back, and we don't yet know how serious it is.'

Sarah felt dizzy all at once. 'Are you saying that she might have a spinal injury?'

He nodded, looking sombre. 'It's possible. Without X-rays and MRI it's too soon to say anything more than that.'

Sarah felt the ground giving way beneath her feet. She began to sway and Mark quickly put his arms out to her and caught her in his arms. 'I've got you,' he said. 'Just take a moment. Don't imagine the worst. We're doing everything we can for her.'

'I know.' Sarah struggled to regain her balance and prayed for the world to right itself. After a while, she said, 'I'm all right. I need to go to her.'

'Good girl.' Mark turned her towards the ambulance and supported her as she stepped onto the ramp. 'In you go. Take a few deep breaths. I need you to try to hold it together. We have patients who need us.'

Sarah did as he said, pulling air into her lungs and making an effort to gather her thoughts. She had to be strong, for Hannah's sake.

Ryan was still conscious, but she was worried about his rapid breathing and the signs of respiratory distress, despite the attempts she had made to restore his lung function. There was a faint blueness around his mouth, and she was afraid that his condition was deteriorating. He was her patient and she was responsible for him.

They were still some way from the hospital when it became clear that something was badly wrong. Ryan's neck veins were distended, his blood pressure had lowered to a worrying level and his heart sounds were muffled.

She looked around to ask Mark for help, but his patient had suffered a relapse, too, and he had his hands full.

She was worried about Ryan's cardiac output. The ambulance started to pull into the hospital bay, and as the team came out to meet her she realised that the doctor with them was even more inexperienced than she was.

'I think he must be haemorrhaging into the pericardial sac,' she said. 'We need a thoracotomy tray.'

The doctor looked anxious, dithering as though he was unsure what to do.

Sarah said, 'Jonathan, he's bleeding into the membranes surrounding his heart. If we don't do something about it, he's going to go into cardiac arrest.'

'I've never done a thoracotomy before.' The young doctor looked horrified.

Sarah guessed that the more experienced doctors were all busy working with patients. It was probable that the icy conditions on the roads had brought an overwhelming number of casualties into the hospital in the last hour or so and they were even more short-handed than usual.

'It's all right,' she said. 'I'll stay with him. Call for a cardiothoracic surgeon and arrange for a Theatre to be made ready. You had better order some blood for transfusion. Then come back because I'll need you to assist. We might not have time to wait.'

The doctor nodded. Sarah quickly donned gloves and a protective apron. She started to attempt aspiration of the pericardium, using a needle connected to a syringe and a three-way tap. If she could draw off some of the blood that was restricting the heart, she might be able to buy some time and improve the action of Ryan's heart.

It wasn't working. Despairing, Sarah debated what to do next. Ryan was getting oxygen via a tracheal tube, but all at once he wasn't breathing and she realised that he had gone into cardiac arrest.

She started to do external chest compressions, but that wasn't working either. The young doctor came back.

'The surgeon's busy with an emergency,' he said. 'What are we going to do?'

A nurse brought a thoracotomy tray, and Sarah stopped the chest compressions. 'I'll have to open his chest,' she said. 'It looks as though we're dealing with a cardiac tamponade. I don't have any other option.'

The young doctor looked panicked. 'Shouldn't you call Mark over?'

'He's working on another patient,' she said. 'I've already asked a nurse to call him in.'

She started her incision, and used rib retractors to enable her to open up Ryan's chest. Once she had gained access she attempted to evacuate the blood from the pericardial sac around the heart.

'Jonathan,' she said sharply to the young doctor, 'I need you to compress the aorta. I'm going to massage his heart.'

Using the flat of her hands, her fingers placed over the defects in Ryan's heart, she began the massage, willing life back into his body. It seemed hopeless, but she couldn't give up. This was Jamie's father, and how could she tell the little boy that she hadn't been able to save him? Whatever Ryan's faults, he loved the little boy, and when he was away from alcohol he could be gentle and kind, a different person.

The surgeon came at last. 'OK,' he said. 'What have we here?' He took in the situation at a glance and started to suture the defects in the myocardium. Once the sutures were in place, he said, 'We can stop the cardiac massage now. I'll check the cardiac rhythm and output.'

Exhausted from her efforts, Sarah stood back. She lifted her arm and wiped her damp brow with her elbow. She hoped that was the end of it, and that they had done everything that they needed to do to save Ryan's life, but the surgeon said, 'I'm going to have to shock the heart.'

The defibrillator was charged and he used the paddles internally on Ryan's heart. Sarah closed her eyes and prayed. None of this was real. It couldn't be real.

'I've found a pulse,' a nurse said.

'That's good.' There was relief all round. 'All right, I'm going to put in an arterial line and give him cefuroxime IV. We'll get him up to Theatre as soon as we can.'

Sarah was thankful to hand Ryan over to the surgeon. She had done everything she could think of and she was at a loss to know what more she could do. She said, 'He had a head injury, too. It didn't seem too severe, but I haven't been able to check up on that yet.'

'We'll do what we can for him,' the surgeon said.

Sarah pulled off her apron and gloves and tossed them into a bin. She started to walk away and the young doctor stopped her and said, 'Thank you for helping me out. You were terrific.'

Sarah didn't feel that way. She had worked on sheer instinct and necessity, and it wasn't over yet. Ryan's life was still in the balance, and she wasn't sure that she had done everything that she could for him. Part of her had been resenting the fact that he was keeping her from going to her sister. All the time that she had been working with Ryan she had been fearful for Hannah. What was happening to her? Why wasn't she able to do anything for her sister?

She went to find out where Hannah had been taken, and discovered that Mark was at her bedside.

'He took over your sister's care,' the nurse told her. 'He's been with her for the last half-hour.'

Sarah was glad of that. More than anyone, she trusted Mark to do what was right for her sister.

He turned as she walked into the room. 'I've been monitoring her condition,' he said. 'I'm afraid she's in no shape to talk. We want to keep her as quiet and calm as we can, so she's been given medication. Your father's on his way.'

Sarah nodded acknowledgement and stared down at Hannah. She was being given oxygen via a tube in her throat and she was hooked up to an ECG machine. Monitors were bleeping, but her sister was very still, her eyes closed.

'How bad is it?' Sarah asked.

'She'll need surgery,' he said quietly. 'There's a spinal injury and we're uncertain yet whether we need to remove bone fragments or stabilise fractured vertebrae.'

'Is she going to walk again? Is her spinal cord intact?' She was shaking and hardly dared voice her anxieties, but she needed to know.

'I don't know the answer to that yet,' Mark said. His eyes were dark with sympathy, filled with compassion, and Sarah wanted to weep. How could this be happening to her bright, beautiful sister?

'What did the MRI show?' She paused, holding on to the metal bed head for support. 'You did do an MRI?'

'Yes, I did. It's hard to assess the level of damage at this stage. There's so much swelling and fluid accumulation. I've done a neurological examination, but that, too, is difficult to interpret. If the cord is intact, it may be that she'll recover some of her reflexes after the swelling has subsided.'

'What happens now?'

'I'm giving her steroid therapy, because that can help to improve function if it's given early on. In the meantime, we're waiting for the surgeon to come and take her up to Theatre.' He looked at her steadily. 'I'm so sorry, Sarah.'

His sympathy was her undoing. Her lips trembled and he hesitated for a fraction of a second and then came and put his arms around her, holding her close. She buried her cheek against his shoulder and sobbed into his shirt. He held her and comforted her, stroking his hand along her back, and she cried and wished that she would wake up and find that all this was just a bad dream.

It was only some time later when she realised that it had perhaps not been the most sensible thing to do, to allow herself to be comforted this way. Mark was her boss after all and, much as she might crave his support, she needed to learn to deal with her problems on her own. He wasn't going to be around to help her over every stumbling block, and showing him her vulnerable side had probably been unwise. He already had misgivings about her capabilities as a doctor. Wasn't she just giving him more ammunition to fire at her in the future?

She straightened up and carefully eased herself away from him. 'I'll be all right now,' she said huskily. 'I'm sorry if I've made a mess of your shirt.'

The fabric was damp with her tears, and he looked down at it and gave a slight shrug. 'Don't worry about it.' He looked uncomfortable, guarded, as though he, too, realised that their embrace had been a step too far.

He moved away from her, putting a little distance between them. 'I think you should go and talk to your father. He's in the waiting room.' He signalled a nurse to come and lead her away, and Sarah allowed herself to be ushered out of the room. She felt strangely isolated, as though she were utterly alone in the world.

Sarah
watched her father as he pulled up a chair and sat down beside Hannah's hospital bed. He was shaky, unsure of himself, and it troubled her because she had never seen him this way before. He had always been a rock, steadfastly confident and reliable, but now he was a shadow of himself.

It was only natural that he should be this way. What had happened was distressing for all of them, terrifying in its aftermath, and she was finding it all too much to take in. How was she going to cope?

Mark was with them in the room, but he stood apart from them, talking quietly to a nurse. He had taken on the responsibility for Hannah's care, and deep down Sarah was glad of that. She saw that he was checking that everything possible was being done for her sister.

'We have to think about taking care of Jamie.' Her father interrupted her thoughts and she turned her head towards him once more. 'Will you go and collect him from nursery school?'

She didn't answer. She couldn't get her head around the fact that Jamie's world had been turned upside
down, and now she simply stared at her father, not speaking, not moving.

Perhaps her stillness made him doubtful. He said softly, 'It might be better for him if you go, rather than me. He'll not think it unusual to have you go and meet him, since he's been living with you for a few days.'