A/N: this chapter correlates to the story title 'Pain management' over on the main story. It's got some great BAMF doctor John Watson. Do enjoy...

Chapter 7: Damage limitation

John thought the cabbie might pass out himself when the older man opened the passenger door and noticed the blood soaking through the detective's shirt and scarf. It didn't help when the doctor pointed with his bloodied hand towards the emergency department and asked him to find a doctor.

"Okay dokey." The driver rushed off to find aid, leaving John to assess his friend as best he could.

"Sherlock?" John patted the younger man's cheek before placing two fingers on the detectives carotid pulse. "Hey, can you open your eyes for me?"

There was no attempt at any response from Sherlock, he was lax and lifeless, his pale face sent a small shot of dread into the doctor. How could John be so stupid to miss such a huge injury on his best friend.

Sherlock's pulse was racing and John pulled up his eye lid gently to check his pupils before noting the rapid shallow breaths exhaling onto his own cheeks. He bent a little lower to inspect the wound with care. This was a bit not good. The skin around the entry point was red and angry as expected, but redness, coupled with swelling was evident in the entirety of Sherlock's upper arm, an almost sure sign of a large bleed under the skin. If the external heamorrhage wasn't enough the detective was bleeding out internally.

John pulled his friends large coat off his lower arm and Sherlock let out a small whine but did not stir otherwise. He placed two fingers on his friend's radial pulse. There wasn't one. The doctor bit his lip in worry.

"Jesus mate." He whispered. The doctor in John knew this was now more than just a simple gunshot, not only was his friend potentially bleeding to death inside the wound but he also had compromised blood flow to his arm, this was bloody serious.

"Can I help you?" A young lady appeared by the cab doorway, John guessed she was a junior doctor, tired and drained looking, overworked as usual.

"This is Sherlock Holmes, gunshot wound to the right shoulder, laterally to medially, signs of heamatoma and active internal bleeding. Radial pulse is absent. He passed out on arrival here, not easily rousable, signs of hypovoleamia present."

"Right." The young women looked a little lost and flustered for a moment, "ah."

"Perhaps a trolley and some more help?" John commanded both calmly but firmly. "We'll need to carry him out the cab."

"Yes." The young lady rushed off.

"Let's get this off you shall we?" The doctor gently pulled Sherlock's coat from his left shoulder and arm to slip him out of it. It was then the detective managed to crack his eyes open.

"John?" He slurred, his voice carried an air of anxiety.

"It's alright, we're going to get you sorted okay." The doctor soothed, "just try to relax, we'll get you some pain relief and fluids and get you stitched up in no time."

John looked up to his friend's face but he was out again.

The gurney arrived only moments later, the young junior doctor had a more senior consultant in toe and John found himself repeating Sherlock's history, injury and clinical signs again but in more detail.

It took more than a little effort and cursing to move the detectives lax form from the back of the cab and onto the bed, and to John's rising worry he did not rouse for a second. Even when a nurse began to place pressure onto the oozing gunshot wound his face remained still and indifferent, not a single crease of discomfort passed across it. How much blood had he actually lost, why was he such a stubborn ass?

John barely had a second to thank and pay the cabbie double as the medical team began to spin into action, rushing the trolley from the roadside and into the entrance of accident and emergency department. In moments they were in a cubicle and nurses and doctors already attaching monitoring and lines to the detective. John only just managed to keep up with them and listened as the lead doctor now assigned to Sherlock's case began to reel off a list a orders and tests.

"I want three units cross matched, full bloods and radiographs of the arm and thorax, someone please page anaesthesia and both vascular and ortho surgeons. I want a line in, 10mg of morphine and co-amoxy IV. I know this is our forth GSW of the hour but you're all doing well team."

Forth? John zoned out momentarily, how could there be this many traumas in such a short space of time it wasn't a Saturday night in the east end? He actually almost kicked himself when he remembered the ambulance racing away from the deserted warehouse. His anger rose exponentially at the thought of the murderer, if he saw that bastard who had shot not only Sherlock but Lestrade and Donovan he was worried he might not be able to stop a revengeful outburst, he'd kill him if he had half a chance.

"Doctor Watson?" A voice snapped him out of his searing thoughts.

"Yes?" John looked up to the lead trauma doctor.

"Jack Michaels, senior consultant." The man shook John's hand.

"We're a little thin on the ground here." The senior man said, "seems the scuffle you all got into has caused quite a scene. I've already got press outside the door and I'm down three members of my team. Do you think you could give me a hand, I know you have extensive experience of gun shot injuries?"

"Of course." John didn't even think twice and accepted the pair of gloves donning them ready.

For a split second he felt he was back on the battlefield again, treating endless wounded soldiers and civilians, the smell of disinfectant and white brought him back though. He glanced downwards, Sherlock's face was partially hidden behind an oxygen mask now strapped to his face, his closed eyes looked hollow and gaunt, could he even do this for his best friend?

"Are you sure this is a good idea?" He faltered.

"Think you can handle it? I could really do with a hand, I understand it's not normal protocol?"

John gulped back the rising panic, bit his cheek so hard it actually helped his thoughts clear and calmed somewhat.

"What do you need me to do?"

"The team are already getting some blood and fluids into him but his blood pressure is tanking, I think he's probably got a small arterial bleed in here." The consultant pointed gently to Sherlock's upper arm which had already been efficiently stripped of his shirt and jacket. The entry point wound had been bound with thick tight dressing to apply pressure.

How long had John been caught up in his own angered thoughts, things where moving so fast.

The senior doctor continued. "There's no exit wound meaning they'll be more internal damage. We'll take a couple of quick X-rays but it sounds like the surgeons are already caught up with your colleague and another surgery. Trouble is I don't think we have time to wait for them. We need to get this bleeding under control before we send him for reconstructive surgery, otherwise he's going to bleed to death."

John gulped again. "Agreed." He grimaced at the sight of the detectives upper arm, blooming and swelling with various shades of red and purple from the blood. "Do you want to tourniquet it?"

"Not yet, we don't know how far the bullet has travelled, we may be stemming the flow past the point of heamorrhage, let's get this radiograph."

John looked to see a nurse wearing a lead gown wheeling in mobile X-ray into the cubicle quickly.

"Thorax and right upper arm for now, we can do more as needed."

The nurse only nodded in reply, sorting out an X-ray plate and gently slipping it under Sherlock's injured appendage.

"Let's give her a moment."

John followed the doctor to behind a small screen and waited patiently, as every minute began to pass the heart beat in his ears only heightened his anxiety further. He could do this, he needed to do this, without him Sherlock was at risk of losing his arm or even worse potentially his life. Not worth thinking about right now. In a matter of minutes which to the blogger actually felt near a hour the X-rays were complete and he nearly ran back to the bedside of his friend, taking in the monitor readings and checking again to see if he had roused, but he hadn't.

"Doctor Watson?" Jack Michaels was before a computer screen which clearly had the radiographs on display already. John joined him quickly.

"Chest is clear."

John exhaled a little, thankful for small mercies.

"But the humerus is shattered, will need fixing." The doctor pointed to the screen as if John were a training doctor unable to see the comminuted break in Sherlock's upper arm bone, fragments were scattered around the clear path of the bullet which was lodged just in the edge of his clavicle, it was a mess.

"Shit." John rubbed his face. "There's a mirage of nerves and vessels running through here." The doctor felt the same, pointing out the obvious to the senior consultant. The path of the bullet suggested it travelled through the detective's upper arm bone, though his arm pit area where main vessels ran, then through the deep pectoral muscle and into the collar bone which had stopped it's trajectory.

"The bone fragments have probably nicked the brachial or axillary arteries. Or if we're unlucky then potentially both. We're bloodily lucky that bastard didn't take out the clavicle too!" The consultant pointed angrily at the bullet remains showing up like a shiny coin on the screen. "If it hadn't stopped it could have taken out the subclavian or even carotid artery, he would have been dead in minutes if so."

Typical trauma doctor, straight to the point, little time or need in talking around the subject.

John had to steady his composure for a moment. This wasn't the case, Sherlock was alive right now, despite a heavy bleed they were fighting for him and with some help he was going to be okay. Wasn't he?

"Nerve damage is highly likely." John swallowed back the nausea. This was a patient he needed to stop thinking this was his best friend, he needed to concentrate on being a doctor right now, there would be time to be a friend later.

"Yes but I think stemming the blood flow takes priority right now do you agree?"

John bowed his head and sighed. "And to be fair, we'd be risking compartment syndrome if we wait too long let alone worsening hypovoleamia. Are you sure the surgeons are not available to do this?"

"Inspector Lestrade is in surgery, he's requiring quite a team on him."

"Christ."

"Anaesthesia are here." The consultant pointed.

"I'm not sure..." John gulped. "I'm not sure I'm the best man for you? Do you think he would be better with a CT first?" His voice was shaking slightly.

"You're one of the best trauma surgeons we can get. Far superior on any of my work. I understand this is not normal protocol. We can't wait for a CT, his blood pressure is dropping by the minute."

In the back of John's mind he realised this was, probably somewhere along the lines, the workings of Mycroft Holmes. Very few doctors would be asking for this kind of involvement, it would not be a surprise that the older brother had already contacted the emergency department and already knew his brother had been shot. Bloody know it all.

"Fine." He took a long and shaky breath to compose himself.

It was then as he was about to ask for equipment that Sherlock's eyes snapped open. His gaze flitted around the room before he tried to sit up. John was on him in a second.

"Hey." The doctor bent over his friend and Sherlock looked at him with a glazed and vacant gaze. "Nice to see you with us. How you feeling?"

The detective didn't answer, he grimaced then moaned out against the pain in his arm and shoulder, trying to unsuccessfully sit upwards.

"Your a bloody idiot you know that right?" John said both in annoyance and friendly banter. "You've made a right mess of yourself." He gripped his friend's good shoulder and squeezed it firmly. "We'll get you sorted I promise."

He paused and Sherlock's brows tightened.

"Pain. Scale of one to ten, tell me?" He asked in a soldier like tone.

The detective still didn't answer, his eyes seemed to focus on his best friend and the look of misery passed through them. One single tear escaped down his cheek and John caught it with his thumb.

"Alright. I've got the message." He whispered.

He turned to the rest of the team. "He needs more analgesia, another 10mg of morphine and some benzodiazepines if you can."

"We'd prefer some ketamine if your looking for sedation."

"No." John shot. "No Ket, he doesn't react well." He was in full bad ass doctor mode now. "I'm his doctor." He added. "4mg of midazolam IV, if you can please?"

Sherlock let out a louder groan of pain and John noted a young medic had manoeuvred his broken arm up to begin cleaning it for emergency surgery.

"Hey!" John barked. "Leave it will you. Let's do that when he's had his morphine, better still once he's fully deeply sedated. He's in considerable amount of pain right now."

Doctor John bent down lower now, sitting briefly on the small stool beside the bed, he grasped his friend's hand, now complete with an intravenous line and pulse oximetry on his index finger. Sherlock's eyes slid weakly sideways, listening carefully to John's words.

"You've got a nasty bleed in your wound. The doctors are too busy with Lestrade so I've got to help the team out. I know you'll probably be much happier with this. But we are going to have to sedate you, it's going to be too painful."

"No." he whispered sluggishly in reply, "no sedation."

"Not negotiable I'm afraid."

John looked to the anaesthesia team, one was drawing up a large syringe of white liquid, unmistakable for propofol. It would put the detective out completely but safely enough for John and the consultant to stem the bleed surgically.

"Your going to need a proper operation to sort out your broken bones and soft tissue but right now it's just about stopping the bleeding. Damage limitation. Do you understand."

Sherlock didn't answer again, his eye lids dropped half closed, the second dose of opioids were trickling into his vein and he was drifting.

"Just hang tight mate." John clasped Sherlock's upper arm and then released it, turning back to the rest of the medical team.

"Right then. Anaesthetists what's the plan?"

"Propofol to effect, not planning for intubation but will be ready, placing a oropharyngeal airway to ensure it remains clear. Will be ready to tube if necessary."

John nodded. "Good." He said, barking to the nurses and junior doctors. "I need a general soft tissue kit, whatever you have, possibly vascular surgery instruments. Plenty of swabs for packing too. May need surgical loupes but will see. Once sedated I want the medial aspect and axilla scrubbed and the shoulder abducted up for access. No hanging around please we have an arterial bleed to stop."

Many different staff members pulled into action as John went to the sink, dousing his hands and arms in surgical scrub before starting his hand wash. He remained watching the team carefully, his nerves now all but gone and his mind solely on the one task at hand, medical diagrams of the shoulder joint coming to the forefront of his thoughts. He kept half an eye on the anaesthesia team by his friend's side, the propofol infusion beeping as the syringe driver began. Sherlock's eyes had long since slipped back closed, he hoped the sedation would be enough for the detective, he knew Sherlock's track record on fighting through drugs.

By the time John had finished his surgical scrub, donned a gown and sterile gloves the team had prepared Sherlock and all kit he needed. This was something he certainly didn't get the luxury of in field medicine. At times he'd struggle for even a sterile kit, it was sometimes a make do with what you have. But here he was in the middle of London at a leading hospital with some of the best trauma medics and nurses, he couldn't think of a better place for his best friend to be.

"Alright. Let's gets you sorted." He said with both conviction and assurance. John wasn't a good doctor, he was very good doctor, he knew what he was doing.

Sherlock was barely visible now, beneath a sea of sterile blue waterproof drapes John didn't forget his best friend was under them but switched entirely into trauma surgeon mode. Find the bleed, stop it and prevent further damage.

The detectives arm was swollen and misshapen and when the doctor sliced into it with his scalpel a large amount of blood spilled out onto the surrounding area and into the bed sheet below.

"Jesus mate." John packed the new wound with swabs. "No wonder your blood pressure is so crap." He looked to the monitors, reading his friend's vitals, stable, but pressures still dropping slowly. He tried to clear the surgical site but even as he wiped away the crimson, more of it welled up, blocking his view. He took a deep breath to compose himself. "Suction." He asked firmly. A small suction tip magically appeared in his view to remove the flow of blood.

"Right where are you?" John dug into the wound, exploring the inside of his friend's arm both quickly and as carefully as he could, something in there was bleeding profusely.

He took several minutes, opening the wound up and trying to see further inside but with no luck.

Suddenly though, just as he probed deeper, his forceps must have come into contact with nerves because Sherlock's arm twitched and somewhere deep in his throat he groaned.

"Christ!" John turned to look at both the anaesthetists and his friend's face. "He's not sedated enough."

Sherlock coughed and the team quickly removed his airway tube before pushing in a bolus of propofol through his line. His eyes were still closed but his brows furrowed tightly into a grimace and a stifled moan left his lips.

"Get him under!" John shot. "I don't care if he's fully under anaesthesia, I can't have him awake." A small air of angry undertone changed the atmosphere of the room.

Within a minute or so the detectives face relaxed back into slack and emotionless features. The doctor by his head gently placed a laryngeal mask into his mouth and down into throat to protect his airway again and he then made no attempts at rousing.

John nodded in thanks and continued his job.

It took a good 10 minutes for him and the senior trauma doctor to locate the source of the heavy bleeding. The axillary artery, it had been ruptured by a small shard of bone from the bullet's path and it took a large amount of cursing on both sides to repair it. Without repair then they were risking the blood flow to Sherlock's lower arm and hand. John couldn't tell how much nerve damage there was, the wound was a mess but it would have to wait for the experts to sort it. Right now they had repaired what they needed to and it was time to get out and suture.

Five minutes later both doctors looked up from their work.

"Thank you." John said, placing the final tacking stitch before pulling off his gloves.

The nursing team jumped into action the moment he stepped away and once the wound was cleaned it was soon dressed and bound to protect it prior to surgery later on.

"Good job." Doctor Michaels said, patting the younger doctor on the back.

"Thanks." John swilled his hands under the two but then turned sharply when he heard his friend's choked gasp. He was by the bed in a flash.

"Easy." He grasped Sherlock's good shoulder.

"John?"

"Jeez mate, how can you wake up like that, you're unbelievable. Though nice to see your blood pressures rising." John planted himself in the seat which was still surprising next to the gurney. "You alright, how you feeling?"

"Like a shark ripped my right arm off and ate it. Is it still there?" The detectives voice was slurred and slow, he pulled the oxygen mask off his face to his neck but the doctor didn't have the heart to move it back right now.

"Yep, still there. But it's quite a mess, you're going to need some proper surgery on it to repair the bone and all the damage the bullet has inflicted."

"Thought you were doing that?" He mumbled.

"Ah no." John smiled. "I'm not a orthopaedic or vascular surgeon. I just fixed you up so you wouldn't bleed to death or hopefully lose the limb. You've got some of the best doctors in the country to sort the rest out."

"Oh." Sherlock finally managed to let his head turn to face his friend. He frowned deeply and a bewildered look passed over his features. "But I thought you were the best doctor in the country?" He slurred.

John couldn't help but laugh slightly. "I'm an army medic Sherlock, a trauma surgeon and doctor. I'm all about damage limitation and salvage what you can. I think I'll leave the proper work to the proper doctors, that is if you want a working limb."

"Huh." The detective's eyes narrowed and he blinked a few times to try to clear his thoughts.

"Enjoying that morphine?"

"Hmm." He smiled lopsidedly. "Quite a bit actually, though it doesn't seem to do a thing for the pain."

"Sorry." John frowned. "Maybe we can switch to something stronger."

A pause.

"John?" Sherlock stirred, but his eyes were now half lidded again.

"Yes?"

"Thank you." And he slipped back into oblivion.

Laterally to medially - laterally is the outer side of the body or limb and medial is the inner side for example your inner leg if this makes sense. It's a way of describing points or directions on the body in medicine (both human and veterinary)

Heamatoma - blood accumulation under the skin - a blood blister is a typical example but they can be extreme.

Co-amoxy - Amoxicillin/clavulanic acid, also known as co-amoxiclav, a penicillin antibiotic

Hypovoleamia - low circulating volume of blood casing shock

Oropharyngeal airway - a type of tube which is inserted into the mouth in down into the oropharynx to stop the tongue from blocking the airway

Laryngeal mask - a tube/mask which is placed over the opening of the trachea (larynx) to protect and ensure a patent airway during minor or short procedures - used more often in hospitals these days

Surgical loupes - those fancy glasses surgeons wear which are like microscopes for the eyes for doing very delicate surgery

Axilla - your arm pit basically