Author's note: This covers the same scene as the Prologue, but seen from the perspective of the medical staff, rather than Sherlock. You may want to refresh your memory of how Sherlock experiences it, before seeing it from the other side.
Chapter 8: Waking Up
John crossed his arms and watched from the corner of the room. He was worried about the scene unfolding in front of him. And yet, he was finding it hard to explain why. So far, Toulson's approach had worked. Earlier this morning, they had started weaning him off the ventilator. Sherlock had passed a spontaneous breathing test, so they were now about to wake him up and remove the endotracheal tube. He'd been put on sedation hold, the propofol cut for a few hours. His fentanyl dosage had been cut by nearly a third, and he was now getting non-opiod analgesics, as well. Yet, something was just …setting off alarm bells, but John couldn't put his finger on a clear-cut clinical reason why. He'd learned a lot about his friend over the past twenty four hours, and he was still trying to digest what it all actually meant. He was tired, and his eyes were sore from reading the medical files for the past two hours. He'd scanned most of them, taking in the bare bones that Doctor Cohen had mentioned in passing.
Sherlock's records were crammed full of one-off examinations from doctors who came and went with depressing regularity. After release from the institution, he'd been cared for by a resident nurse and home schooled by a series of tutors brought in to prepare him for public school. Even so, his father was still conspicuously absent from the medical assessments and treatment plans. Between 12 and 15, there had been no fewer than five visits to casualty units for bruises, sprains and then the broken arm. One A&E doctor had written a query on the file, "possible abuse/self-harming- at next admission inform Social Services?" Then at 16 came the first drug use and rehab centre reports, intermixed with Doctor Cohen's records about growing concerns that her patient's treatment for anxiety, depression and addiction were being complicated by his hypersensitivity and autism. Over the past two years of living with his flatmate, John had realised Sherlock had an aversion to doctors and hospitals. Now he knew why- he'd seen more than his fair share during his life time.
Before the team had entered the room, John pulled Toulson and Cohen aside for one last try. "Look, I'm sorry, but I just feel things are being done too quickly here." He tried to address the physical issues to Doctor Toulson. "Changing Sherlock's medication to a NSAID is just going to increase his pain to the point where it interferes with his ability to cough- and surely that will make the pneumonia and pleural effusion worse. For Sherlock, paracetemol is like, I don't know, pouring a glass of water on a house fire. "
"I am sorry Doctor Watson, but I have to disagree, and I am responsible to his brother for Sherlock's care. His breathing is being compromised by the high dose of fetanyl, and we have no choice. His lungs' functional residual capacity is too low. He's been intubated for far too long, and weve been successful so far in re-training him to breathe on his own. We have to take the final step. He must start to come off the drug now, or risk his pneumonia getting worse. If the opiate is suppressing respiration to the point where the lung cannot properly re-inflate, the pleura won't re-seal, and the risk of infection will increase. There are already signs of growing pleural effusion, and we need to drain it."
He could tell from Toulson's set frown that he wasn't going to convince him, so he turned to Esther Cohen. "You're the one who has argued that treatment for physical injuries seldom deals with his psychological issues, aren't we in danger of doing that now, if we push him too far, too fast?"
Doctor Cohen gave John with a sympathetic but sad look. "I'm sorry, too, John, but on this occasion I have to agree with Doctor Toulson. Sherlock has just got to be weaned off the fentanyl as soon as possible. He is going to have to go through detox and withdrawal, and the longer he is on opiates the harder it will be. The drugs are going to complicate his recovery, both physical and mental. It's who he is, you know this as well as I do."
She put a comforting hand on John's arm. "He can't be wrapped in cotton wool. Time he woke up and faced the music. We have to find out how badly affected he is, both physically and mentally."
He considered her comment. Was it true? Was he afraid of Sherlock waking up, of what they would find when his friend recovered consciousness?
He made one last effort. "I'm worried that he's just going to freak about this." As soon as he said it, he regretted it; it sounded so medically unprofessional.
Dr Toulson frowned. "We have no reason to suppose that he's going to react badly, why would he be uncooperative, Doctor Watson? You seem to be over-reacting here. We're going to follow protocols here."
Reluctantly, John stood aside and then followed them into Sherlock's room.
Toulson wasted no time. "Nurse Saunders, please cut the fentanyl drip, and compensate with the IV paracetemol." As she complied, he turned to John and Esther. "Given how high a dose he has been receiving, I expect it will take some time for the drug to relinquish its hold before he wakes up enough to extubate."
But, Sherlock began showing signs of returning consciousness within fifteen minutes. His resistance to the opiate meant that he was only just being kept under. His heart rate increased and blood pressure rose. The ventilator was slowly tapered off and switched to on-demand, forcing Sherlock to breathe more on his own. His breathing became shallower and more uneven. John kept an eye on the oxygen saturation monitor. Once the CO2 levels climbed, the impulse to breathe on his own would take over and the tube could be unclipped from the ventilator machine.
The first sign of consciousness came when Sherlock's closed eyes winced as he swallowed. His breathing through the tube became more ragged and even shallower. His right hand flexed spasmodically. The tube was disconnected by Doctor Toulson who said "Sherlock, you need to wake up now. Come on, we need you to wake up so we can help you breathe." Nurse Compton worked the bed's controls so it raised his head and chest. She then lifted his shoulders and pushed another pillow behind his back. Sherlock gagged and his hand instinctively reached for the tube, as Doctor Toulson continued to speak. "We're going to remove the breathing tube now, Sherlock. I want you to take in a deep breath and blow it out on a count of three."
On the count of three, the tube was pulled out, and Sherlock gave the expected cough. Toulson said "That's good, well done Sherlock, that's just what we needed to hear." Nurse Compton then placed the pressurised oxygen mask over Sherlock's mouth and nose, pulling the straps tight to create a good seal. Sherlock shook his head and then his right hand jerked up to his face, colliding clumsily with the face mask. Nurse Saunders took his hand firmly, and pulled it away from the mask. Robert called out, "Sherlock, you need to leave the mask in place, and try to slow your breathing down. Try to hold each breath in for a count of four."
Sherlock's eyes were still closed, but he was trying to wrestle his hand away from the nurse. John kept an eye on the blood pressure monitor, now reading 140/90, and a pulse rate topping 108. He stepped up to the bed to look at Sherlock's face, and saw the first tell-tale signs- a fine sheen of sweat was forming on his forehead and eyelids. "Diaphoresis", he said pointedly to Toulson. With his right hand held captive by the nurse, Sherlock's left hand started to reach up to the mask. John took it in his own, feeling instantly how cold it was. "Vasoconstriction", he glared again at Toulson; "He's in a lot of pain, and not even fully conscious yet."
Sherlock took his first really deep breath in, and cried out as he came wide awake. The monitor showed his pulse rate jump up to 122 and the nurse confirmed it: "He's tachycardic, sir." His neck arched and his head went back reflexively, his eyes fluttering open. His pupils were blown wide open, John could hardly see the grey green irises. Sherlock began to thrash about on the bed, as John and Nurse Saunders tried to hold him down. They had to stop him from opening stitches, and shifting the broken bones.
"Come on, Toulson, you can see the evidence; he's in agony. How much more of this are you going to make him take?" Esther Cohen made a decision, and she took up a position on the side of the bed trying to stop Sherlock's legs from kicking. "We need to stop this now, doctor, or he's going to lose his airway again", as Sherlock's struggles intensified.
With a defeated sigh, Doctor Toulson reached up to the fentanyl drip and twisted it open again.
