Dean forgot how loud and bright and generally disorienting emergency rooms could be – especially when you were still marginally tripping on morphine – and was more relieved than he would admit when Bobby joined him.
"Where's Sam?" Bobby asked, finally catching up with Dean; coming up behind him and taking over the pushing of the wheelchair.
Dean opened his mouth to answer but stopped when Stacy suddenly emerged from one of the side rooms; obviously looking for them as her gaze frantically scanned the hall.
"Hey..." Dean called, waving his arm.
Stacy jerked in the direction of the voice, looking slightly relieved. "In here," she said breathlessly and ducked back into the room.
Dean nodded and willed Bobby to walk faster, which must have worked.
Because in the next instant, they were there; framed by the room's doorway; watching a flurry of activity surround Sam as Marie, Stacy, and two other nurses worked together in chaotic tandem to stabilize their patient; to stabilize Sam.
One of the nurses clipped a pulse oximeter on Sam's finger and then adjusted a nasal cannula under Sam's nose and over his ears, tucking back his hair as she did so.
Stacy unbuckled the straps across Sam's chest, snatching off the blanket before cutting through Sam's t-shirt; while another nurse stood beside her, immediately attaching heart monitor electrodes as soon as Sam's bare chest was exposed.
Stacy nodded her approval before glancing at the blood pressure cuff on Sam's bicep and then turning to check the corresponding monitor.
Marie carefully peeled back the bandage on Sam's forehead, frowning at the amount of bruising and swelling but confirming that Sam had sustained a closed head wound, since the skin was still intact.
The nurse that had placed the nasal cannula was inserting an IV line and paused at the sight of Sam's gauze-wrapped hand.
"Um, doctor..."
Marie glanced at the nurse expectantly and then followed her gaze to Sam's hand.
"What happened?" the nurse wondered aloud, gently removing the bloodied, dirt-caked gauze to reveal inflamed skin puckered by a dark row of stitches.
"I don't know," Marie admitted since this particular injury had been hidden under the blanket until now. "We'll find out later. Just clean it for now, so we can see if any stitches need replacing."
The nurse nodded and turned to grab supplies from the nearby cart.
"Is his brother here yet?" Marie asked distractedly, pulling a penlight from the pocket of her scrubs and alternately shining it in Sam's eyes; not surprised to see his left pupil fixed and dilated, as the bandage on Sam's head indicated his left side had taken the impact.
"Yeah," Dean answered, surprised by how quiet and shaky his voice sounded.
Marie's attention darted to the door. "You were right about his vitals," she commented, continuing her examination.
In addition to Sam's dilated pupil – classically presenting only on the side of injury – Sam also showed signs of tachycardia, which in the presence of head trauma, unless due to some other injury, was a bad prognostic sign.
Not to mention Sam's decreased respiration, which was often a result of increasing intracranial pressure; his Glasgow Coma Scale score of three; and the alarming amount of heat radiating from his body. Elevated temperature was common in cerebral injury, and Marie suddenly felt overwhelmed with how critical her patient was.
"Did they run any tests at Sioux Falls?" Marie asked, reluctant to bring up that hospital but needing to know. "Does he have a chart or anything?"
Bobby nodded, grabbing the chart from beneath his arm and wordlessly handing it to the doctor.
Marie took the folder, frowning as she leafed through its meager contents. "No medical history, no blood panels..." She shook her head disgustedly and cut her eyes at Bobby. "What kind of facility are you running over there?"
"The kind that sucks ass," Dean responded angrily.
Marie nodded in agreement. "You're free to go," she told Bobby, not caring that her tone was bitchy. "We'll take care of them from here."
"Actually..." Bobby corrected. "I'm their uncle, so I'll be staying."
"Uncle?" Marie repeated and then looked at Dean.
Dean shrugged. "It's complicated," he replied, and Marie had the feeling that description would apply to just about everything in these men's lives.
"Okay..." Marie paused, pulling herself together as she found the results of the MRI. "Let's see...epidural hematoma..." she said aloud as she continued reading and sighed harshly.
While she had suspected as much, reading the diagnosis in black-and-white only made Marie more pissed. Patients in Sam's condition had to be monitored carefully, and although she did not doubt that it was in Sam's best interest to be transferred to the county hospital, in doing so, they had potentially lost crucial time in saving his life.
"Okay," Marie sighed, forcing herself to focus; because what was done was done.
But Sam was her patient now, and she was confident she could make a difference from this point onward.
"I'm ordering a CT scan," she stated, both informing Dean and Bobby and ordering the medical staff.
Stacy nodded and crossed to the phone on the far wall while the other two nurses prepared Sam for transport upstairs to radiology.
Marie watched with approval and then directed her attention back to Dean. "An MRI is fine," she allowed, "but a CT scan is better in viewing blood and bone. It will help pinpoint the exact size and location of the hematoma and also any associated skull fracture."
Dean swallowed against the urge to throw up at the phrase "skull fracture" being used in relation to Sam and managed to nod instead.
"I want a complete trauma panel, too," Marie added, since there was literally nothing more than the MRI film and cover sheet in Sam's folder.
Stacy nodded that she had heard as she and the other two nurses began to move toward the door.
Bobby grasped the wheelchair handles and pulled Dean out of the way as the nurses crossed the room's threshold, hurriedly pushing Sam down the hall toward the elevators.
Dean watched as Sam once again disappeared from his view, feeling strangely detached and aware of Bobby's worried gaze. "I'm fine," he stated flatly.
Bobby rolled his eyes, but it was Marie who verbally responded.
"You sure about that?" she asked skeptically, motioning for Bobby to bring Dean into the room and focusing on Dean's casted leg as he entered. "Looks like you had quite a break there..."
Bobby nodded. "Open compound tibia fracture," he supplied, releasing the wheelchair's handles and rolling over one of the stools from the corner.
Dean narrowed his eyes. "I'm fine," he growled, staring meaningfully at Bobby as the older hunter sat beside him on the stool.
Marie smiled briefly. She knew Dean's type all too well. "Fine, tough guy," she agreed. "But if you start feeling 'not fine', I'd appreciate it if you let me know. One brother is about all I can handle right now."
Bobby snorted. He knew that feeling.
Dean sighed, cutting his eyes at Bobby, but nodded.
There was a beat of silence.
"Enough about me," Dean said, his tone allowing no room for argument. "What about Sam?"
"We'll know more after the CT scan and blood panels," Marie stalled, setting the chart on the side counter to take notes. "But I think you know he's in pretty bad shape."
Dean clenched his jaw; knowing "pretty bad shape" was a euphemism for "dangerously close to death" and swearing to himself they would find a way to kill every single one of those fucking leviathans.
Marie shifted under the intensity of Dean's gaze. "While we're waiting for Sam to come back, let's go over his medical history," she suggested, eager to distract the older brother; surprised that even though he was obviously exhausted and currently crippled, he still conveyed a degree of lethality.
It was fascinating and unnerving, and Marie was thankful she had not been the one to piss him off; was committed to taking the absolute best care of Sam to avoid being on Dean's shit list.
"What do you want to know?" Dean asked, his expression and tone guarded.
"Well, first things first..." Marie began. "What happened to him?"
"Some asshole monster whacked him in the head with a tire iron," Dean responded bitterly, hands gripping the arms of the wheelchair in barely restrained anger.
Bobby's expression hardened. "Them?" he asked quietly.
Dean nodded.
Marie cringed at the visual Dean's words conjured, vaguely remembering his use of the word "monster" when he had described the Sioux Falls hospital staff and wondering if there was a connection.
And although she had not originally pegged these guys to be the type who would brawl in the street with tire irons, if her past 16 years in the ER had taught her anything, it was that people were unpredictable.
"Was there a fight, or..." Marie shrugged, waiting for Dean to clarify.
"Something like that," Dean replied, his response classic evasion.
Marie nodded, knowing she would get no further explanation but needing one more detail. "Close range?"
"Yeah," Dean confirmed; his gaze faraway and haunted, as though he was reliving it.
Marie glanced at Bobby and then back at Dean. "And is that how he hurt his hand? Trying to block the attack?"
Dean frowned. "No," he responded as though she should have already known that. "He fell on some glass a few weeks back."
"Well, yes," Marie agreed. "I saw the stitches, but the wound was somewhat open and actively bleeding like he had somehow reinjured it."
Dean said nothing, remembering how Sam had savagely gouged his own wound and noticing Bobby's confused expression since the older hunter had not been with them at the warehouse.
Dean cleared his throat, aware the doctor was waiting for an answer. "Yeah, something like that."
Marie resisted the urge to sigh at yet another evasive reply. "And then after the attack...Sam was unconscious?"
Dean nodded. "And he had blood coming from his nose and ears."
Marie's attention flickered from where she was writing in the chart to Dean, alarmed at that detail. "How much?"
"Enough," Dean responded, his tone sharp.
Marie nodded, having her answer. A lot.
"But he woke up in the ambulance on the way to Sioux Falls," Dean continued, remembering Sam's unfocused gaze as his brother had turned to look at him when Dean had called his name.
"How long was he awake?" Marie asked, shuffling papers to find the MRI film.
"Not long," Dean replied. "Maybe a few seconds before he started seizing."
Marie remained quiet, eyes narrowed in concentration as she stared at the film. "Looks like Sam has a history of seizures."
Dean exchanged glances with Bobby. "What makes you say that?"
Marie held the film so that it faced the two men. "Here," she said, pointing to a mass of white in the middle of greys and blacks. "This is scar tissue, which most likely resulted from a previous brain injury. Although by the looks of this, it doesn't seem like the injury took place all that long ago...maybe a few months? And since the scar tissue is primarily in the left temporal lobe, I'm assuming Sam experiences problems with memory, too. I've just never seen scar tissue quite so linear in formation, almost like a – "
"Wall," Dean blurted, surprising himself at answering aloud and glancing again at Bobby.
Because was she serious? She could literally see the crumbled wall in Sam's head? That was what she was showing them on the MRI film – a shattered wall presenting as scar tissue in the portion of the brain responsible for memory?
Marie paused, considering Dean's description. "Yeah, I guess it does resemble a wall. It's certainly a barrier of some sort," she agreed. "And as scar tissue sometimes does, it's acting as an irritant in Sam's brain, causing the seizures. Has he sustained previous head injuries?"
Dean snorted disgustedly. "Yeah. Kinda goes with the job..."
"And what is the job?"
"That's classified," Dean responded, his expression unreadable.
Marie laughed lightly, the mystery of these brothers growing even more.
"I see," she remarked and turned her attention back to the MRI film. "Well, it seems Sam healed just fine from the previous head injury, but there was scar tissue left behind in the left temporal lobe. At first the scars were probably soft and didn't cause any trouble. But as time progressed – like I said, I'm guessing maybe a few months – they started to harden like you see here. And when they started to harden, they started interfering with the mechanics of Sam's brain – impacting neurons and so forth – which in turn led to Sam having seizures." She paused, staring meaningfully at Dean. "Am I right?"
Dean glanced again at Bobby.
Bobby held his gaze, nodding his agreement in telling the doctor the truth about this particular detail.
Dean sighed. "Yeah," he confirmed and then cleared his throat. "Yeah, you're right."
Marie nodded. "Thank you," she replied genuinely. "I know there's sometimes a stigma associated with epilepsy, but – "
Dean frowned and shook his head. "Sam doesn't have epilepsy."
"Has he had two or more seizures that were unprovoked by external stimuli?"
"Two?" Dean repeated and then laughed humorlessly. "More like two dozen, if not more. I've lost count," he confessed, remembering the numerous times over the past few months when Sam would just fall to the floor with no warning and proceed to seize for at least a minute, sometimes longer.
"That's the definition of epilepsy," Marie patiently explained. "'Two or more seizures that are unprovoked.' So, if that description fits Sam, then Sam is epileptic."
Marie paused long enough for that realization to take hold.
Dean shifted in the wheelchair and glanced at Bobby.
He had never thought of Sam as being epileptic, and judging by the expression on Bobby's face, the older hunter never had, either. They had both always assumed that Sam's seizures were a physical manifestation of a supernatural problem – a Death-erected, hell-blocking wall that had crumbled and, according to Death himself, could not be fixed or replaced.
But if there was an actual medical reason – scar tissue – and a medical diagnosis – epilepsy – then maybe Sam was not as lost to them as Dean sometimes feared; maybe there was help for his brother after all.
"What kind of seizures does Sam have?" Marie asked, flipping back to the front of the chart to continue taking notes. "Grand mal, which is what most people think of when they hear the word 'seizure' – the person on the floor, physically shaking...or petite mal, where it might just look like he's zoned out for a few seconds...or hallucinations, which..."
"Whoa, whoa, whoa. Hallucinations?" Dean cut his eyes at Bobby.
Bobby looked just as surprised as Dean and shrugged.
Marie's attention flickered between the two men. "Yes, hallucinations," she confirmed. "What about them? Does Sam have that type?"
"I didn't know hallucinations was a type," Dean responded, his tone sharp.
"Well..." Marie sighed. "I guess hallucinations wouldn't really be considered a type of seizure so much as part of a seizure. When the hallucinations occur, we view them more as a sign of seizure activity. In fact during the seizure event, the patient may actually talk to the hallucination or otherwise interact with it in some way while also interacting with the real world. It's quite fascinating how just a few misfires in the brain can cause people to straddle the line between what's real and what's not."
"Huh," Bobby mused, remembering the way Sam had been yelling at Lucifer when Bobby had walked up on Sam at the house earlier; how Sam had also talked to Bobby, even though Bobby had gotten the unshakeable feeling that Lucifer had remained in the room.
"But although hallucinations may occur during simple partial seizures," Marie further explained, "they are differentiated from psychotic symptoms by the fact that the person is usually aware that the hallucinations are not real."
Dean shifted in the wheelchair, his leg beginning to throb in time with his heartbeat as he recalled the way Sam had looked when Dean had told him Lucifer was not real.
He says the same thing about you.
...which implied that Sam had been aware that one was real and one was not – either Dean or Lucifer – and had been trying to differentiate between the two.
Only Sam had seemed confused as to which was which.
But he had also seemed extremely upset by his confusion and inability to decide, which would again imply a level of awareness.
And while crazy people exhibited a lot of things, "level of awareness" was not usually on the list; they were in their world and were content to be so; could give a rat's ass about anyone else's world.
But Sam obviously wanted to be in Dean's world; had only followed Lucifer to that warehouse because he had thought he was following Dean; had instantly snapped out of the hallucination as soon as Dean had made physical – albeit painful – contact with him.
So, that meant...what? That all of this time what they had thought were hallucinations indicative of an impending psychotic break were really hallucinations indicative of seizures occurring below the surface right before their eyes?
Marie shifted from where she stood, leaning against the counter at the side of the small room. "Dean..."
Dean blinked.
"I know all of this is a little overwhelming, but we need to wrap this up. Sam will be back soon, and the more I know about his history of seizures, the better I'll be able to treat him."
Dean nodded, beginning to fully feel the pain in his leg as stress and exhaustion overpowered whatever traces of morphine were left in his system.
Bobby narrowed his eyes and opened his mouth to speak.
"I'm fine," Dean interrupted before the older hunter spoke and then directed his attention to Marie.
"You're a liar," Marie corrected, smiling. "And as soon as we're done here, I'm giving you something for pain. But in the meantime, let's get back to my original question – what kind of seizures does Sam have?"
"Every kind you mentioned," Dean responded tiredly. "He usually has the grand mal, but we've seen him space out, too. And then over the past few weeks, he's been having hallucinations."
"Huh," Marie commented, writing in the chart.
Dean arched at eyebrow. "What?"
Marie shook her head. "Nothing. It's just unusual for a patient to have such a variety. It's not unheard of, but it's certainly not the norm."
Dean snorted. "That's Sammy," he remarked affectionately, and Bobby nodded his agreement.
"Well, if you ask me, normal is boring and entirely overrated." Marie smiled, reading over her notes. "So, does he take any medications to treat his seizures?"
"No." Dean shook his head. "They've only been happening for a few months, and we just kinda deal with them as they come and move on."
Marie nodded, not missing the way Dean looked at Bobby; feeling unexpectedly emotional at the obvious sense of solidarity they shared in their responsibility of taking care of Sam.
Because Marie could tell that Sam's condition was not a burden to them, was not something they blamed Sam for; it was just something else life had handed them, and they were coping and moving on as best they could. It was too bad all of her patients did not have such depth of love and support from their family.
Marie cleared her throat. "We'll put Sam on anticonvulsant meds as part of protocol with patients who have sustained significant head trauma. If he does well with them, we'll discuss leaving him on them. There's no point in letting him suffer multiple seizures a day – no matter what type they present as – if there's an effective way we can prevent them."
Dean nodded earnestly. "I completely agree. Sam's been through enough."
Marie paused, once again wondering about the story of these two brothers.
"I'm sure he has," she agreed softly, overwhelmed with the desire to make something finally go right in these boys' lives.
Dean held her gaze, seeming to appreciate her sincerity.
A clattering of wheels against tile echoed through the hall, heralding Sam's return to the room, and Marie knew whatever moment they had just shared was over as Dean broke eye contact and turned to look over his shoulder.
In the next instant, Stacy and the other two nurses appeared in the doorway, maneuvering the stretcher into the room as Bobby stood and rolled the stool he had been sitting on back to the corner before wheeling Dean out of the gurney's path.
Dean shifted in the wheelchair, trying unsuccessfully to see Sam around the nurses. "Dammit, Bobby," he growled in frustration. "Move me closer."
"Not yet," Bobby replied, watching the nurses continue to situate the stretcher and earning himself a heated Winchester glare.
Dean muttering something under his breath was the only warning Bobby got before the wheelchair handles were snatched from his grasp as Dean gripped the wheels on either side of the seat and propelled himself forward.
Bobby shook his head, irritated but not surprised by Dean's stubbornness, and smiled his apology to Stacy who audibly gasped at being forcibly nudged out of the way by a wheelchair.
Marie laughed softly at Stacy's shocked expression and motioned for the nurse to hand over the folder containing the results from radiology.
The other two nurses exchanged glances as they busied themselves around their patient, equally amused and touched by Dean's actions; because it was obvious Dean could not care less if he had offended, irritated, or inconvenienced anyone – Sam was his priority.
With Stacy out of his way, Dean positioned the wheelchair closer to the bed and reached through the bedrail, grasping Sam's wrist and squeezing it in greeting; knowing that was all his brother needed to know he was there; knowing he could keep Sam grounded and here with only his touch – just like he had done at the warehouse.
Sam remained motionless; his face pale, but his cheeks flushed; the bruise on his forehead looking even darker and more swollen than before; the monitors emitting a different cadence, indicating unstable vitals.
Dean sighed, squeezing his brother's wrist again; more for himself this time than for Sam.
There was a beat of silence.
"Well..."
Dean glanced over his shoulder at the sound of the doctor's voice. "Well, what?" he asked skeptically, unsure if he liked her tone.
Marie paused, reading the results again. "This was certainly not what I was expecting."
Dean swallowed, feeling his heart drop. "What the hell does that mean?" he demanded, worry and fear making his tone harsh.
Wordlessly, Bobby crossed to the bed; his glare demanding the same.
"It means our day just got better," Marie assured, realizing how her initial statement must have sounded to an already stressed family. "A lot better," she added, coming to stand beside Dean at Sam's bedside.
Dean looked up at her, narrowing his eyes; always suspicious of good news. "How so?"
"While the MRI done at Sioux Falls suggested the presence of an epidural hematoma, the CT scan Sam just had indicates otherwise." Marie turned the film around to show the two men, pointing toward another cluster of white shadows. "On a CT, a cerebral contusion appears as an ill-defined hypodense area mixed with foci of hemorrhage, like you see here."
Bobby squinted at the image. "So, you're saying Sam has a cerebral contusion, not an epidural hematoma?"
"Yes." Marie nodded and moved her finger in a circular motion. "And there's also diffuse increased density suggesting widespread tiny hemorrhages."
Dean frowned, his hand still wrapped around Sam's wrist. "How is that good news?"
Marie smiled. "I know it doesn't sound good, but trust me...it is," she assured. "A contusion is a type of traumatic brain injury that causes bruising of the brain tissue. We usually see a fair amount of swelling but not as much bleeding. A hematoma, on the other hand, is heavy bleeding into or around the brain and often times must be treated with surgical intervention. So, given a choice between the two, a contusion is preferred because it usually is easier to treat, does not take as long to heal – only weeks or months, as opposed to months or years – and the patient bounces back quicker. Plus, there's no sign of skull fracture here."
Dean nodded his understanding of her logic. But if he was given a choice, he would choose for Sam to not have a head injury at all.
"So now what?" Bobby asked, crossing his arms over his chest.
"We move him to ICU and get him settled," Marie replied, glancing at Stacy to make sure she was listening to orders. "And since swelling is still a concern, we'll be placing an intracranial pressure monitor as well as administering medication that is considered a hyperosmotic agent to help reduce brain swelling."
"And the seizures?" Dean checked, haunted by how long and hard Sam had seized in the ambulance.
"Yes," Marie agreed. "We'll also administer the anticonvulsant medications we discussed to prevent seizures – or at the very least, control them – as we wait for the swelling to decrease. We'll also be monitoring his vitals, of course, and managing the infection."
Dean frowned, eyes sweeping Sam's body before cutting to the doctor. "Infection?
Marie nodded, shuffling through the papers she held. "Sam has a fever, which is not uncommon with brain injuries. But lab results show Sam's white count is abnormally high, and I'm guessing he has an infection in that wound."
Dean followed the doctor's gaze to the opposite side of the bed where Sam's left hand was curled in such a way that the injured palm was barely visible.
But Dean knew it was there. He had seen it happen; had cleaned and stitched it; had taken care of it for weeks only to watch as Sam had applied enough pressure to rip it open again.
Dean inwardly cringed, remembering the blood oozing up from the gauze and welling around Sam's thumb as his brother had pressed hard into the center of the wound.
There had been no time for first aid between leaving the warehouse and arriving at Bobby's, so the injury had been left unattended – bleeding and dirty – and Dean was not surprised that it was now infected.
"So..." Dean sighed, gently sweeping his thumb back and forth across the underside of Sam's wrist; a comforting gesture from childhood that always resurfaced during times like this. "Just broad-spectrum antibiotics?"
Marie nodded, continuing to write her orders in Sam's chart. "Yes, that should cover our bases without adversely interacting with the other medications."
There was silence.
"Any other questions?" Marie asked, arranging the papers and handing the chart to Stacy as the nurse stood at the foot of the stretcher.
"Not right now," Dean responded, exchanging glances with Bobby as the older hunter shook his head.
"Good." Marie smiled encouragingly. "We'll get the ICP monitor placed and then move Sam to ICU for the next 24 to 48 hours. Depending on how well he responds to treatment will determine how long he stays in ICU beyond that initial timeframe. Hopefully we'll be able to move him to a regular room in a couple days, but we'll just have to wait and see. The first 24 hours will be the most critical."
Dean nodded, aware that Bobby was moving away from the bed to allow space for the nurses to work and knowing he should move as well. But he was reluctant to leave his brother's side.
Having moved to the far side of the room, Bobby cleared his throat and stared at Dean meaningfully when the oldest Winchester looked at him.
Dean sighed, giving Sam's wrist one final squeeze – Sam...you stay with me, you hear? –before rolling himself away from the stretcher.
TBC
