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The Road of Bones
by J Baillier
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CHAPTER 2/9 - Veins of glass
Chapter summary: References to his past drug use annoy and embarrass Sherlock, John gets to show off his medical skills and devastating news is received.
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Be faith, I need it
Pray I believe it
- Lykke Li
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A mere thirty minutes later they arrive at King's College Hospital's A&E department, despite Sherlock's protests that St Bartholomew's is much closer. John shuts him up by telling him that King's College has MRI facilities open around the clock and a more prestigious neurological department.
Mycroft texts John as Sherlock is being triaged. John is only slightly irritated to realize Mycroft is monitoring emergency dispatches in case emergency services get sent to 221b Baker street. He's too worried about Sherlock to properly 's reply is short, merely stating that there's no immediate danger and that he would get back to Mycroft later when they had some answers.
To both their relief the motor function of Sherlock's righ hand seems to have recovered by the time the neurologist on-call is making her initial status assessment. Nevertheless, there is a CT with contrast dye ordered promptly.
Sherlock is currently grimacing, because a stern-looking ER nurse is in the midst of her seventh attempt at cannulating a vein in the bend of his arm.
John huffs, feeling impatient. "Can't you place one on the back of his hand?"
The nurse looks frustrated. "They need a good-sized IV for the contrast dye and if we place it more distally radiology always complains. They've calculated the circulation times with the IV in the antecubital fossa. Not much I can do here, frankly. His veins are basically shot."
There's a strange mix of annoyance and embarrassment on Sherlock's face John can't say he has often witnessed. He has noticed that Sherlock has never happy to hear his past substance abuse discussed in front of people whose existence he has chosen to tolerate.
"Look," John offers disarmingly, "If you've got some sort of an ultrasound here, I could try and get one in using that. Easier than a PICC or central line and you won't need to page the on-call anesthetist."
The nurse crosses her arms. "I can't let you perform procedures without proper authorization."
John presents his driver's licence. "My NHS registry number is 61477. I've got admitting privileges here, at St Barts and King's Cross as well. You can easily clear it with the managing physician if need be."
"I will, Dr Watson. I'll be right back."
Sherlock looks somewhat impressed. "Ultrasound?"
John shrugs. "It's easier than it sounds. We used it all the time in Afghanistan - when you've got someone bleeding heavily their peripheral circulation sort of closes down and it can be tricky to find a good vein. We had this portable thing in the outpost I was stationed in - donated by some medical company, I guess, and in the slower hours I tried to get some practice in to get proficient. Did really come in handy a couple of times." John inches his chair closer to the gurney. "Let me have a look."
Sherlock bites his lip as John inspects him arms. There's considerable scarring in the more accessible major veins of both arms - as John gently runs his fingers over them they feel hardened and as though filled with pebbles. The veins on the backs of his hands look fine but they're of no use - it's not the first time John has been made aware of radiology's preference for the more peripheral ones in the upper extremity.
John finally lets go of the arm and Sherlock sits up on the gurney.
"You seem quiet," John remarks. "Penny for your thoughts?"
Sherlock seems contemplate this suggestion for a moment before opening his mouth. "Differential diagnoses?"
John takes a moment. He doesn't want to cause undue worry but knows Sherlock would not appreciate obfuscation either. "Some sort of circulation event seems most likely. You're pretty young for those, but considering your smoking, poor nutrition - -, " this earns him a glare, "And stress levels I don't think it would be out of the question."
"Still, stroke symptoms do not come and go."
"Stroke is not the only possibility," John remarks, secretly enjoying that for once he's the one with a better grasp of the big picture. It's not rare he gets to one-up Mr Know-it-all. "There's also TIA."
"Go on." Sherlock idly adjusts his backless gown.
"Transient ischaemic attack. It's sort of a warning before a proper stroke, a momentary block of an artery which resolves on its own. The thing is, the vessel often blocks again, more permanently. Visual auras are not a very common symptom of that, though, as far as I recall."
The nurse returns, with a portable ultrasound unit and an attempt of a smile, since John has offered to take a significant chore off her hands. John disappears into the hallway to desinfect his hands. When he returns, the nurse hands him a pair of gloves and leaves with a nod.
John sets to work locating a vein with the ultrasound probe and decides it's best to distract Sherlock with conversation. "There are other options, as well, but you have to promise me not to worry too much about them yet."
"You're saying that a blood clot in the brain isn't enough to worry about?"
John pauses his work and meets Sherlock's gaze. "I don't need to tell you more if you don't want me to."
Sherlock looks apprehensive. "I can't function if I don't have all the facts." He tries to peer into the ultrasound screen and John turns it a bit so he can watch. "How do you know where to aim?"
"Basically it's like this: nerves look like chords, muscles look like cloth, blood is pitch black inside mostly oval or roundish vessels. Veins don't pulsate and can be compressed."
"So basically, you deduce which one is a vein and which one's an artery?" Sherlock enquires.
John nods and picks up an IV cannula. Sherlock watches him with his usual air of detachment when faced with pain or violence. John sometimes wonders if it's genuine or a carefully constructed act.
"Listen, I know you want all the facts but sometimes it's okay just to try and process one thing at a time. Arm still, please."
"Can we get one of these machines at home?" Sherlock inquires, pointing at the ultrasound and hissing as John plunges the cannula into the crook of his elbow and smiles when a drop of blood appearing in the guide chamber confirms that he has hit a vein on the first try.
John then secures the cannula in place with tape and leans back to admire his handiwork. "They cost about ten thousand pounds. And no, that's not the only reason. Lord knows what terrible things you would use it for."
"Why don't nurses use this equipment?" Sherlock enquires, "It doesn't seem to require much background knowledge or training."
John laughs. "I easily succeeded in what that nurse couldn't manage with Lord-knows-how many tries, and your take is that a trained monkey could have done it? Only you, Sherlock."
"I didn't mean to undervalue your efforts," Sherlock offers gingerly.
"Thanks, I guess," John replies and puts away the ultrasound.
"What about those differential diagnoses, then?" Sherlock reminds him.
"The other diagnostic options that come to mind are a mass lesion of some kind, although they tend to cause longer-lasting symptoms in general, or a malformed blood vessel."
"You mean a tumour or an aneurysm?" Sherlock sounds apprehensive.
"Aneurysm or an arterial-venous malformation. As I said, you need to promise not to get ahead of yourself. There doesn't seem to be any permanent damage done, which means that whatever this is, we've got a chance of fixing it before anything worse happens."
Sherlock leans back on the gurney, lost in thought. On the surface he looks quite calm and collected, but John notices the way in which he keeps tapping his fingers nervously on the edge of the gurney.
Two hours later John is trying hard to hang onto his professional demeanour. He's painfully aware that if he lets go of Dr Watson for a second, he won't be of much use to his friend. If he lets go he knows it'll hit him full force - the realization of what lies waiting in the barrel of the proverbial gun.
Words like "median cerebral artery aneurysm", "significant risk of rupture", "elective surgery", "luminal diameter exceeding endovascular treatment limits" and "genetic disposition" hang in the air after being spoken by Dr Berry, the consultant neurosurgeon assigned to Sherlock's case only an hour ago. John knows the poor man has been dragged back to the hospital from home in the middle of the night by the neurologist on-call but he doesn't feel any pity for his colleague. Not when this is clearly what Sherlock now needs.
John leans back in his chair as he listens to surgeon explain everything to Sherlock.
To an untrained observer Sherlock might look like he's listening - nodding in the right places and looking inquisitive enough - but John can read him. He knows the little things he is spotting are Sherlock's tells. The forefinger tapping on the coarse bedsheet. The occasional biting of his lower lip, which he never usually does, not even during the rare occasions when a case has him completely baffled. John fights the impulse to take a hold of his friend's hand.
The surgeon bids his farewell, passes Sherlock a calling card with an outpatient appointment time scribbled onto the back and leaves.
John stands up and grabs Sherlock's clothes from the hanger. Sherlock doesn't move a muscle. John drops the clothes in a heap on the bed - something the usually impeccably groomed Sherlock is likely to hate. "Hey," John says quietly, and finally Sherlock meets his gaze. "Let's go home."
Sherlock blinks. Twice. "What?"
"Didn't you hear the guy? Your surgery as scheduled a week from now. We can go home now."
"Shouldn't I be kept in for observation?"
"Observation for what? Your symptoms are gone, the aneurysm hasn't bled yet and it's still relatively small. We live ten minutes by ambulance from the nearest unit fit to handle neurosurgical emergencies. There's no reason why you couldn't spent the week at home."
Sherlock looks sceptical, but starts gathering his clothes in silence.
Sherlock hates hospitals, John reminds himself. He really does. And now he'd have agreed to stay in one without so much as an argument. "Are you alright?"
Sherlock ties his scarf around his neck, his movements automatic. "Quite, yes, of course, John."
"You've just been told you need surgery for a brain aneurysm. It's okay not to be, well, okay, you know," John offers but Sherlock is clearly having none of it.
"Baker street it is, then," John says.
Sherlock pulls on his coat and strides into the emergency room entrance foyer. To John it seems that the usual theatrical flourish is somewhat absent from his movements.
John jogs after Sherlock. Not much more he can do at this point than to see and observe.
The surgeon is holding up a skull. Judging by its yellowish hue and somewhat fragile-looking quality John deduces it's a genuine one. A trophy of sorts - not that it would in any likehood belong to any of Dr Berry's former patients. To John it just felt like something that a neurosurgeon might logically want to have in their office. It's very similar to the one on their mantelpiece. He doesn't tell this to Dr Berry.
Sherlock is having his proper preoperative visit with the surgeon. It had been scheduled for the morning after their A&E visit. The surgeon had talked to Sherlock at length at the A&E department but John knows that when the initial shock of a diagnosis is delivered, patients rarely remember much else that had been discussed around that time. So a proper appointment during daylight hours was needed.
Sherlock seems to be listening intently as Dr Berry is explaining him the intricacies of aneurysm surgery while running his finger along the coronal suture of the skull. The sutures, even though completely natural, look like the result of a ghastly experiment, a road carved on the whitish bone by some instrument of torture. A road of bones.
John tries not to think about the surgery, which is difficult because it's the very thing they have been summoned to discuss.
Sherlock, on the other hand, doesn't seem to be the least bit bothered by the thought of someone sawing his head open, which of course is rather typical of Sherlock, but now that it's about his very own head, his precious brain, it feels more morbid than usual. Maybe it just hasn't properly sunk in yet, John reasons and straightens his spine on the uncomfortable chair.
Dr Berry sets the skull on the edge of his desk. Sherlock is still staring at it.
"Any questions?" the surgeon asks, glancing at John. Sherlock grabs the skull and peers into its eyesocket.
"Yeah, well, how long will he have to stay in?" John inquires.
"We can do the preoperative tests and studies on an outpatient basis. I see no need for Mr Holmes to be admitted until the morning of the surgery. It's been proven that avoiding excessive hospital stays unless absolutely necessary can lower the incidence of concomitant infections and deep venous thrombosis."
John nods. This is in line with some articles he has read recently. John glances at Sherlock. The man looks like he's retreated into his Mind Palace.
Dr Berry clears his throat and continues. "As I said, the aneurysm's location and size rule out endovascular coiling as a treatment option so we'll have to do it via an open operation. We are able to wean most of our patients from the ventilator and allow them to wake up right after surgery in the postanesthesia recovery unit where they will stay until the next morning. Transfer to a regular inpatient ward will usually happen the next day, complications notwithstanding. Most of our aneurysm patients discharge within five days."
"Unacceptable," replies Sherlock, who has shaken out of his reverie, and gingerly places the skull back on the table. "I have a live-in-doctor as you are well aware, so you will be able discharge me much sooner."
"I'm not a neurosurgeon, Sherlock. I don't know what to look for in terms of what is or is not normal during the recovery," John says apologetically.
"Your skills were perfectly adequate to discern what was happening to me. I don't see why you couldn't handle the aftermath."
Dr Berry smiles apologetically. "I'm sure Dr Watson is most capable. However, it would be quite stressful for him to be responsible for your well-being."
John's laughter sounds hollow. "I'm responsible for that most of the time anyway, since this idiot won't look after himself properly."
Dr Berry pats Sherlock's arm emphatically and Sherlock's gaze narrows which is usually a bit not good in John's experience. "Well, then, let's give John here a bit of a break, shall we?" the surgeon suggests.
Sherlock lets out a breath and luckily seems to have decided not to push the issue.
"Anything else you'd like to ask or wish for us to know?" Dr Berry asks, idly leafing through Sherlock's medical records.
Sherlock draws in a deep breath. "I wish for Dr Watson to assist in the surgery."
John stands up before even realizing he is doing so. "Sherlock, no! First of all, they won't let me and second of all, I can't bloody well be responsible for slicing into your brain. Don't you realize how that'd make me feel? Which part of "I'm not a neurosurgeon" didn't you register?!"
Sherlock's looks indignant. "How _you_ would feel, hm? How about me, John? Trusting my most important asset to strangers?"
"When have Mycroft's sources about these sorts of things ever failed? If they say that Dr Berry is the finest in the country then we should probably trust him."
Sherlock doesn't seem to buy into this theory. "What about the rest of the team, then? The anesthetist? The scrub nurse? Who will guarantee that I won't be stuck with some Shipley-wannabe or someone hung over enough to have shaky hands?"
"I assure you, I work with a team who I've had a long and fruitful working relationship with. They have all the skills required to handle this type of surgery," Dr Berry replies.
"No trainees?"
"No trainees", Dr Berry assures him.
Sherlock nods tentatively. "Nevertheless, I wish to have a recording of the operation."
"Sherlock, again, no," John sighs. Dr Berry looks apologetic.
"You're saying that after going through all of this ordeal I won't get anything tangible of scientific interest for further reference?" Sherlock is glaring daggers at both doctors.
John gently lays his palm on Sherlock's shoulder. "Sherlock - - I wish you'd just focus on this thing itself. On getting better."
"I am not currently poorly, so there is nothing to get better from. If I need to be inconvenienced, I wish to dictate the terms."
"You can't dictate how the NHS works, Sherlock," John points out. Why did he ever think Sherlock would not get difficult? Was he really that naive after all this time? Barely three months had passed since he'd sat in the dining room of that inn in Dartmoor, listening to a panic-stricken, manic, trembling Sherlock bellow how bloody allright and fine he was, despite all the evidence to the contrary.
Sherlock stands up, extends his hand to Dr Berry and after a hasty handshake, he walks out without a word, John trailing behind.
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Author's notes: I don't work for the NHS but I assume certain principles can be generalized when it comes to European medical practice. In general, letting doctors observe or participate in the procedures or other kind of treatment of their loved ones usually never happens (apart from small things like writing prescriptions for minor ailments or giving the occasional advice, which we do all the time and doesn't usually bother us). It's not only because of patient might be nervous or the doctor's role might be difficult to maintain in that situation - it's because being responsible for the health and life of someone you is incredibly stressful for a doctor in a very particular way because people who know you see past your professional role.
Ultrasound is slowly revolutionizing many fields of medicine. The so-called difficult-to-cannulate-patients no longer pose the problems they used to, because if we can't see the veins, we can locate them by ultrasound and cannulate them while visualizing the needle going through the tissues. In reality it's quite unlikely that John would have had a portable ultrasound available in Afghanistan but hey, for the purposes of this story, why not?
If aneurysms are big enough or located in a critical area, they might cause symptoms even without rupturing. Unfortunately, for many patients, the very first symptoms of an aneurysm is a so-called SAH (sub-arachnoid hemorrhage), a specific type of brain bleed, the effects of which are commonly devastating and often lethal. Sherlock can therefore actually consider himself kind of lucky here (not that he'd see it that way, of course!). Cerebrovascular problems (which is a fancy name for stroke, TIA and other pathological states of brain vessels) can be difficult for patients to come to terms with because many patients might be asymptomatic and still require urgent hospitalization or major surgery. Sherlock is usually described as a terrible patient who tends to be in denial even about major injuries, but I think if there was something threatening his mental capacities - his precious brain - he'd agree to fix the problem instead of trying to sweep the whole thing under the rug. But yes, he would still not be the most agreeable to patients. Poor John.
Many aneurysms nowadays can be treated by endovascular coiling, where a radiologist passes a small guidewire into the aneurysm sac and fills it with a metal wire coil. This causes the body's natural blood clotting system to form a clot inside the aneurysm, effectively filling it so that blood will no longer circulate inside the aneurysm. However, not all aneurysms are eligible for coiling - it might be because of type or size, or that the neck of the aneurysm if too wide for the coil to work satisfactorily. That leaves open surgery the only option.