Chapter 9: Reconsideration
Toulson looked like his nose was seriously out of joint. In a scathing tone, he confronted John in the corridor outside Sherlock's room . "So, Doctor Watson, what's your Plan B?" His emphasis on the title made his scepticism clear.
Esther Cohen decided to play peacemaker. "Robert, I know you have been thinking of John as the patient advocate here, but remember, he is a qualified trauma surgeon with battlefield experience. We owe him the professional courtesy to consider his advice."
John decided to be blunt. "I'd start by switching the analgesia. Start swapping sufentanil for the fentanyl progressively over the next five hours. Even though it's an opiate, it's more potent so you can use a significantly lower dose and that won't depress his respiration as much. Because he has such a high tolerance for opiods, I think he needs enough to get him conscious, but not in agony. Once he's awake, we can see whether he's willing to co-operate when you drain the pleural fluids, and then keep reducing the analgesia. If he's awake we can switch to patient administered, and let him set the level."
"When we can get his pain management under control, then we can think about detox. We wouldn't need to do this if he had just avoided the cocaine, but I didn't have eyes on him for more than about four hours between…uh.." the days were starting to blur together. Had it really only been two and half weeks ago that they had been standing beside a pool? "the 17th and when he turned up at the emergency department. So we don't know the real extent of the cocaine problem. We need to find that out, but my guess is that it was not a binge- more a way of helping him think his way through some tough problems. Stupid- but with hindsight, I suppose predictable given what we'd been through."
"So, now that he does have to deal with it, I recommend that we suggest he does it quickly- a rapid detox. Rather than the usual two to three weeks' worth of weaning him off fentanyl followed by withdrawal, and then having to cope with the effects of insomnia and depression for months, we can offer him something more radical – a really fast detox under anaesthesia that will last about four to six hours. He'll wake up to fewer withdrawal symptoms and be further along the detox process, After three days, he can take oral naltrexone, and then after another few days, we can inject a naltrexone pellet that will keep him clean for a month at a time- or three months, if he agrees to it. Instead of the usual 28 day in patient exercise, it takes 8 to 10 days max. And I know Sherlock, that will be what he wants to do, because it will mean he can get out of here faster. And that, in my view, is the best way to deal with both the anxiety and the depression that follow a normal detox."
"That rapid a procedure isn't done in the UK except in the private sector; the NHS is not happy with the risks involved. General anaesthesia will almost certainly lead to a loss of airway and re-intubation- wouldn't you say this is risky for a patient with pneumonia?" Toulson sounded incredulous.
John put on his best army doctor tone. "The procedure can be done on moderate to deep sedation- we can keep him at just the right level for him; he doesn't need to be all the way out of it through a general, so there's less risk of compromising his airway. At most he might need an oxygen mask like the one he's using now." He smiled.
"And what about contraindications for renal failure?"
"That's a red herring. His kidney function is improving by the hour. Once he's awake you can get him off the Foley, and remove the risk of a UTI. Give him a day or two awake on a lower dose of sufentanil to make sure both the pneumonia and the bruising are no longer a real issue, then go for detox aggressively, provided he wants to do it. If he is mentally prepared for it, then I think it will work, doctor."
Like two alpha males facing each other down, the pair had been trading medical prognoses like punches. It was Toulson who blinked first. "You seem to have thought this through, Watson."
Robert turned to Esther to see if he could find an ally there. "What's your view, Doctor Cohen? You've experience with him going through detox; if it worked the traditional way before, why change it to a rapid approach under anaesthetic?"
She looked first at him, then at John. Slowly, thinking carefully. She needed a good working relationship with both if she was to be effective for Sherlock. "I can't comment on the medical merits of the anaesthesia swap, but the idea of bringing Sherlock back to consciousness slowly has to be better, given what we've just seen. Based on past experience, once he's all there, he can cope with pain, despite his hypersensitivity- but it will be his choice. We just don't know what triggers the allydonia and hyperalgesia. But if we can give him a day or two to exercise his 'mind over matter' strategy, it generally works, provided that detox doesn't wreck him with anxiety and depression. So, in pinciple, I get the logic of stall at first and then push like hell. And John's right-if he thinks that it will get him out of here faster, then he might by-pass or at least lessen the depression that I've seen from him in the past when he's detoxed. So, yeah, I'd give him the choice, so long as he can demonstrate his competence to make that choice."
Toulson wasn't at all happy, but faced with two doctors who disagreed with him, he decided to stall. "I reserve judgement on the second half of your proposal. Let's wake him up the way you suggested, and then reconvene once we know how he is getting on with it."
John breathed a sigh of relief, not realising that he had been holding his breath while they talked. Progress! Let's just hope we can reach Sherlock this time.
