John nodded to the paramedic bending over Sherlock and pulled himself up into the back of the ambulance. The rear door was shut rapidly behind him, and then there was the slamming of the driver's door and John barely had time to sit himself on the bench opposite Sherlock's stretcher before the ambulance moved off.
'I'm here,' he said quietly, reaching over to grasp Sherlock's hand, white and immobile on the red blanket, as the paramedic buckled himself into the jump seat next to Sherlock's head, but there was no response.
'Where are you taking him to?' he asked the paramedic.
'UCH is the closest.'
John shook his head. 'No, he needs to go back to The Royal London. He did a bunk from there this afternoon. That's where his cardio-thoracic surgeon is. He needs to get back there.'
'Sorry, mate - they can transfer later if they want. I'm not keeping him in the back of this ambulance any longer than I have to when he's doing that,' he indicated the monitor mounted on the wall of the ambulance. John had been so distracted, he hadn't even noticed it. It showed a heart rate that was dangerously fast at 170 beats per minute, with wide complexes.
John muttered an expletive under his breath. 'You medical?' The paramedic asked.
'GP and ex-army doctor. I spent fourteen years with the Royal Army Medical Corps.'.
The paramedic handed him the 12 lead ECG. The rhythm was unmistakable. Ventricular tachycardia. Sherlock's antics that afternoon and evening had pushed his already stressed heart into a potentially life-threatening arrhythmia. He was lucky that he hadn't had a cardiac arrest already, and the longer he stayed in that rhythm the more likely it was to deteriorate into ventricular fibrillation, at which point cardiac arrest was inevitable
'What's his blood pressure with that?' John asked.
'80/40. And I can't get a line in. His veins are all shot. That's why we're going to scoop and run.
John swore softly under his breath, as he unbuckled his seat belt and bent over Sherlock, instructing the paramedic to squeeze first one arm and then the other above the elbow to form a human tourniquet, always John's preferred device, but he was right. The veins that John could find were hard, inelastic, thrombosed from recent use, and John could find nothing that he could get a cannula into. Then his eyes slid to Sherlock's shirt collar, and a slight lump underneath it on the left. Had he -?
He pushed it to one side, and found himself grinning despite the grimness of the situation. 'Central line any good to you?' he asked the paramedic, showing him the triplet of clear tubing entering Sherlock's neck just above his left clavicle. Sherlock had obviously found it too difficult to remove, stitched in place as it was and so had simply left it where it was. It might just be about to save his life.
'You got amiodarone?' John asked, naming the drug of choice for kicking a heart back into its normal rhythm.
'In the arrest pack, but I'm not licensed to give it apart from in arrest.'
'I am,' John said crisply. 'You're not even going to get him to UCH at this rate. Where do you keep the drugs?'
...
The first dose of amiodarone hadn't done it, nor had the second. Sherlock's blood pressure had simply dropped even lower. John lent over and shook Sherlock's shoulder.T there was a low groan, but no other response.
'You got any anaesthetic drugs?' he asked. 'Propofol, ketamine, midazolam, anything we can sedate him with?'
The paramedic shook his head. 'Nothing,' he said.
'Then why don't you give him a bit more morphine and we'll shock him with that.'
The paramedic looked mildly horrified, 'You want to shock him while he's awake?'
'Well he's not exactly awake, is he,' John said, trying to keep the irritation out of his voice, 'and if we don't shock him now, we'll be shocking him in about -' he looked at his watch, 'Five minutes when his heart has stopped because he's gone into ventricular fibrillation. By which time we still won't be at UCH with this traffic. Which would you rather?'
'Your responsibility?'
'All mine,' John agreed with a nod.
The paramedic shouted to the technician to pull over, no shocking in a moving ambulance of course, too risky for all involved. Without waiting for him to stop, John braced himself on the side of the stretcher with one hand, and with the other flipped the monitor to defibrillate mode, and charged the pads already attached to Sherlock's chest, the characteristic beep of full charge sounding just as the ambulance pulled to a halt.
He started at 150 Joules, yelling to the paramedic to remove the oxygen and stand clear before he pressed the shock button. Sherlock's body jolted upwards and he cried out in pain as the shock was applied, but the cardiac rhythm remained stubbornly unchanged.
'Come on, Sherlock,' John whispered, as he turned the charge up to 200 joules. Once again, Sherlock's body jolted as the charge was applied, but this time, mercifully, it worked. The ECG trace when it returned after the spike of the charge was back in a normal rhythm, fast but no longer in the potentially deadly ventricular tachycardia. The pulse under John's fingers when he dropped his hand to Sherlock's wrist felt stronger, less thready, and Sherlock's eyelids were already fluttering as if he was trying to wake up.'
'Change of plan, we're going to The London,' he shouted to the technician in the drivers seat.
'UCH is closer,' the paramedic protested.
'Yes it is, but we're going to the London,' John told him firmly as he removed the stethoscope from round the paramedics neck and used it to listen to Sherlock's chest before adding, 'His haemothorax has come back. He needs James Macpherson's services. He's the best in London and I'm not having anyone else delving around in this man's chest.'
...
James Macpherson had sounded unsurprised when John had phoned him to tell him Sherlock was on his way to A&E by ambulance.. 'Mycroft Holmes has had me on standby ever since Sherlock was found missing,' he told him. 'What's your ETA?'
'Ten minutes,' John told him, after checking with the paramedic.
'I'll have a team standing by in the Trauma Bay. Does he need blood?'
'Probably,' John said. 'He's white as a sheet and hypotensive. Sounds as if he's got a good couple of litres in the right side of his chest.
'I'll get the ER set up as well then. Any possibility of new injuries?'
'No, he's just ripped a hole back in his lung, by the sound of it, or possibly the IVC has gone again, although I think it came on too slowly for that. Difficult to tell in the back of an ambulance.'
'Sats?'
'92% on 15 litres oxygen, heart rate is 135, blood pressure 84/40. We've got fluid running but the only access we've got is the central line so they're running slowly.'
'Kind of him to leave that in for us,' James Macpherson said dryly. 'The VT is a little concerning, but then I've never had a patient running round London five days after major cardiac surgery before. Irritated post-operative myocardium doesn't tend to take kindly to that. I'll activate the Trauma Team and make sure we're set up for you.'
...
John recognised several of the faces in the ED Resuscitation room and felt the irrational need to apologise for his friend requiring their services for the second time in less than a week.
Once again, the mechanics of the trauma team took over, and Sherlock was swiftly moved across to the resuscitation room trolley, and then disappeared from John's view between a sea of brightly coloured tabards.
James Macpherson was there waiting, still in his blue scrubs from theatre, or perhaps he had donned then ready for the inevitable trip there with Sherlock. He left the ED Consultant to lead the Trauma Team, but directed his registrar to insert the chest drain into the right side of Sherlock's thorax once the presence of another massive haemothorax had been confirmed by ultrasound.
Venous access had been tricky, and the blood had flowed painfully slowly into the central line before they had managed to place a cannula with ultrasound guidance. 'Short and thick does the trick,' thought John, watching how much faster the blood from the bag of red cells flowed into the short, wide cannula than it had into the long, thin central line. Poiseuilles law in action - Sherlock would have loved the science in that.
Sherlock himself was barely responsive, his face half hidden beneath the oxygen mask, beads of sweat standing out on his pale forehead.
Why had he done it? That was the question that John found himself entirely unable to answer. Why put his life in danger by doing a bunk from the hospital only days after major surgery just so that he could enable John to listen to Mary's story first hand? Why not wait, if he felt unable to tell him himself? What had been the urgency, and more to the point, why did he care so much about John understanding what Mary had done - no more, about him trusting Mary, that he would be prepared to risk his life for it?
'It's not the first time though is it?' said a voice in John's head, and the voice this time was, uncomfortably Mary's. 'It's not the first time that he's risked his life for you, John. The jump from the roof, the dive into the bonfire, concealing my identity from the police to protect you even though it meant I could potentially go back and finish the job, and now tonight. How many times does he have to risk his life to prove how much you mean to him?'
John swallowed hard, remembering Mary's words from earlier that evening. 'You don't have to choose between us.' Was it possible that his wife - his clever, lying, deceptive, secret services trained wife realised what he hadn't? That Sherlock's feelings for John went far beyond friendship. That they went deep enough for him to risk his life for John's time and again. What had he said about John at the wedding? 'The best man that I have ever known.' Had he meant that in ways that John had not even begun to suspect until now?
He headed for a chair in the corner of the resuscitation room and sat down hard, brushing off the concerned hand of one of the nurses. 'I'm fine,' he murmured.
But he wasn't, he wasn't fine at all. He looked at the immobile figure of Sherlock Holmes, hovering close to death yet again and all he could think was, 'What if he dies without me being able to tell him that I finally understand?'