Chapter 21
Alan's knees began to buckle. If it had not been for three fast moving staff members (the one who grabbed his coffee cups and the two who each took hold of an elbow) he would have ended up on the floor in a soggy mess.
Alan was led to the adjacent waiting area by the two elbow holders; who lowered him into a chair and then like bookends sat either side of him; each taking turns quietly talking to him.
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The voice in Don's head was ordering him to get over to his father. He just could not get his feet to move; afraid that if he did his struggling sibling would sense that Don was once again not where Charlie needed him to be.
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Alan eventually lost one of his hand holding bookends because she had to administer medication to several patients.
He lost his other bookend when a loud argument broke out between two family members in front of the vending machine at the far end of the hallway.
Alan slumped forward in his chair, hands clasped together, head bowed.
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Kaylee, having poured the hot coffee into a sink behind the nurses desk, now approached Don Eppes with a sense of purpose.
She understood the man's reluctance, but, that did little to stop the feeling of wanting to take hold of one of his arms and pull Don Eppes in the direction of the waiting area.
Kaylee stood in front of The Intimadator; leaving just enough space between them as to not have Don Eppes go off on her for crowding him.
"Right now, there are several staff members looking after Charlie." She informed the sad-eyed man. "Your father, however, is over there, sitting by himself." She pointed to the shell shocked Alan Eppes. "He needs you."
Even with the realization that what he had just been told him was the truth; Don still could not make himself move away from the doorway.
"I promise that I will come get you if there is a need." Kaylee stated truthfully. It was hard to believe that this lost looking man was the same strong willed personality that Kaylee had met at the very start of her double shift.
She was about to try one more time to reason with the immobile Don Eppes when without saying a word he walked around her.
The waiting area was just across the hall from Charlie's room. To Don, (once he reached his father), it felt like a mile.
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Alan, who had been staring at his folded hands, glanced up when a familiar pair of well-worn black thick soled shoes came into view.
"What happened?" Alan asked quietly. He was fighting like hell to not fall completely apart.
"I was going through my messages," Don slowly began. "Charlie woke up suddenly. He called for me and…" For the first time in a very long time, Don found himself struggling to recall precise details.
"I was just about to push the call button when Cosmos and Isabella arrived." He recalled.
"Was Charlie…" Alan tried to find the words. "Was he aware of what was happening?"
Don had no idea how to answer his father's question without causing the man further pain. He bought time by clearing his throat.
"Don?" Alan tried again. He needed his son to provide him with an answer.
A reluctant Don looked at everything around him, but his own father. He was weighing his options.
"What exactly am I supposed to do?" Don internally debated. "Be honest and tell him that he had never seen Charlie look so frightened (even taking into account the first time a bullet whizzed past Charlie's head). How the hell would knowing that Charlie had been terrified help his father?"
Don decided being honest was not in his father's best interest.
"No, Dad." Don finally answered. He saw a moment of relief in his father's eyes.
Alan's feeling of relief was soon replaced by one of confusion.
"I don't understand," He stated. "You said that Charlie called out for you. At that point he had to be…" The question died on Alan's lips when Andrew Cosmos emerged from his son's room.
Don, also noted the cardiologist approaching. He offered a hand to his struggling father and helped steady Alan as the shaken man got to his feet.
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Andrew Cosmos wished like hell that Alan Eppes had remained seated.
"Alan, Don, we need to have a conversation." Andrew Cosmos proposed.
A family of four had just settled into chairs directly behind Don and Alan.
"Let's find a more private setting." Andrew stated.
He swiftly shepherded the two men to a nearby conference room. It was a bad moment for Andrew; his first discussion (in regards to Charlie's health) with Alan and Don Eppes had taken place a mere five days ago and now Andrew had to inform the two men that their loved one's decline was occurring at a pace faster than Andrew had anticipated.
Andrew pulled the door open, poked his head inside, then stood holding the door.
Don guided his father the short distance with a firm grip on the older man's elbow. He could feel his father leaning into him for support.
Alan went into the room first. Don followed. Neither man addressed the looming cardiologist.
Andrew did not take offense: having learned eons ago that no one liked to acknowledge the bearer of bad news.
He asked each man if they would like a chair, both Don and Alan declined his offer and remained standing (the two in a mirror image folded arms stance).
Andrew knew what Alan Eppes wanted from him: a direct approach (per the man's recent phone message). Alan did not want Andrew to "take it easy on him," even if it was what Don had decreed. Alan had ended his phone message by informing Andrew that despite both of his son's best intentions, he wanted Andrew to keep him completely informed.
Everything about Charlie's treatment up to this point had been a one-step forward/two-steps back frustrating process. However, with each setback the Eppes were able to regroup. Andrew sincerely hoped that the inner resilience that each man possessed would continue to carry them through this troubling journey.
Andrew was about to put Alan and Don Eppes through the grinder. Once more.
"Charlie experienced another V-Tach (ventricular tachycardia). However, unlike the previous VT this time his blood pressure dropped dramatically." Andrew said straightforwardly.
The cardiologist saw Don Eppes open his mouth. Andrew quickly pressed on.
He explained how Charlie received (IV) Procainamide an anti-arrhythmic agent, Tropol XL®, a stronger beta blocker, magnesium sulfate, more IV fluids, blood pressure support, all of which would require even closer monitoring.
That's what now… twenty medications?" Don wondered aloud.
"It sounds excessive, but that's where we are now." Andrew answered patiently. "Thankfully, we were not dealing with a monomorphic VT which would have required immediate electrical cardioversion."
Andrew Cosmos were never going to miss this part of his job.
"Electrical cardioversion," Alan slowly repeated. He could not believe he was actually having this discussion in regards to his youngest son.
Don turned a second too late in Andrew Cosmos' direction to indicate to the doctor that his father did not need further clarification; to let the discussion end.
"There are two versions of cardioversion: chemical and electrical cardioversion." The cardiologist stated. "Chemical involves using medication to convert unstable cardiac arrhythmia back to a normal sinus rhythm in a patient. Whereas, electrical cardioversion uses a shock to the chest to deliver…"
"Chemical." Alan said slowly. "This VT was treated with medication."
Don quickly snaked an arm around his father's back.
"Yes, Dad." Don said calmly. "It was treated with medication." He held eye contact with his father until he was sure the message was understood. The moment prevented Don from informing Andrew Cosmos that the man was an unthinking idiot.
"Today we got lucky." Andrew remarked. His off-the-cuff comment earned Andrew an even deeper displeased look from Charlie's older brother.
"It was the truth," Andrew sullenly mused, "they had gotten incredibly lucky today."
"What about an hour from now?" Alan questioned. "Six hours. Twelve hours. Tomorrow?" He did not want to hear about luck. He wanted to hear about ways to control the next VT.
Andrew chose his next words very carefully.
"In a heart failure patient faced with arrhythmias/VT's there are treatment options: an implantable ICD or catheter ablation. In Charlie's case, the GCM diagnosis changed the course of his treatment. At this point, Charlie's not an ideal prospect for either an ICD or a catheter ablation."
Don, tried to process the doctor's latest assessment, without any outward sign to his father how deeply the man's words had affected him.
Alan took his usually information seeking son's silence as a bad sign. He steeled himself to ask the question that Don seemed determined not to ask in front of Alan.
"Without the benefit of either one of those treatments am I right in presuming that the odds of the next VT being far more dangerous for Charlie go up substantially." Alan Eppes stated. The tremor in his voice gave away his inner fear.
"Yes," Andrew answered without hesitation.
He quickly explained (under the unrelenting stare of Don Eppes) that taking into account the arrhythmia Charlie had experienced in Dr. Van Acker's office and the fact that the latest VT's had occurred within a close time frame Andrew's concern now was that Charlie would experience a VTA; a dangerous combination of a ventricular tachycardia (VT) and ventricular fibrillation (VF).
"How bad would that combination be for my son?" Alan reluctantly inquired. In a just and fair world, it would be Don and Charlie standing here having this conversation with Andrew Cosmos.
Andrew looked down at the top of his old scuffed Dansko® shoes. He reminded himself that he made a promise to Alan Eppes.
The cardiologist's body language told Don that whatever Andrew Cosmos was about to tell them was going to be tough.
"How bad?" Don heard his father ask in a shaky voice.
"For 80% of patients VTA leads to sudden death." Andrew answered straightforwardly.
Alan swayed slightly and paled considerably.
Don grabbed a chair and helped his father into it. He was just as shocked by the news as his father, but anger helped him recover his voice.
"What the hell is wrong with you?" He growled at the cardiologist.
The fact that the doctor had just pulled Charlie through another frightening episode was, for Don, the sole reason why the man had not ended up in the hallway; pressed up against a wall.
"He's not doing anything I haven't asked him to do, Don." Alan said quietly but strongly to his angry son.
"Is there any way to predict the next VT?" Alan asked hopefully.
Andrew had learned of research recently started in Seoul, Korea on the subject of VT's and predictability. At this point, though, the study was in its infancy stage and not worth mentioning.
"No, Alan." The cardiologist answered honestly.
Alan could no longer pretend that GCM, a term he had never heard of before this week, was not incurable, not another vicious rampaging disease, certainly not one capable of taking Charlie from him.
"Granted," Andrew said to the two deeply shocked men. "We've hit a roadblock, but that does not mean we cannot try and go around it."
"What are you proposing?" Don cautiously replied. He had no doubt that it was going to be an extreme stop-gap measure.
"I'm going to ask Charlie for informed consent to place him on Venoarterial Extracorporeal Membrane Oxygenation (V-A ECMO) for a period of five days." Andrew stated. He looked at Don and then Alan.
Alan saw a wave of apprehension wash across his son's face.
Don, from the dazed look on his father's face, realized that Alan did not know what having Charlie placed on ECMO entailed.
Don, however, was all too familiar.
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Two years ago, a critically wounded colleague was placed on ECMO. The first time Don walked into the room to pay his respects to Agent Davis, he had to fight the urge to quickly turn back around. It was only the fact that Amelia Davis' parent's were flanking her bedside that kept Don moving forward.
The use of ECMO in Agent Davis' case had saved the critically wounded agent's life, but Don recalled that while still on the machine, there was a major incident which resulted in Amelia Davis suffering a stroke. The significant cognitive issues that resulted from the stroke led to her having to withdraw from her high-level position within the Division of Counterterriosm.
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If Charlie gives consent, then I will contact our ECMO team." Andrew said very carefully.
"Team? What exactly does placing Charlie on ECMO entail?" Alan questioned the doctor. He now stood next to Don.
"ECMO is comparable to the heart-lung bypass machines used during open-heart surgery." Andrew Cosmos explained.
The cardiologist proceeded to explain how the (V-A) ECMO machine would take over and allow Charlie's heart and lungs to rest.
Alan Eppes felt like he was trapped underwater and sinking.
"A heart-lung bypass machine. That's your idea of going around?" An emotional Don exclaimed.
He did not want what happened to Amelia Davis to happen to his brother. He knew in his heart that Charlie would never be able to cope with having significant cognitive issues. On the other hand, he sure as hell did not want Charlie dying suddenly from a VTA.
Don balled up his fist so tightly by his side; that his knuckles turned white, and his fingernails dug into the palm of his hand.
"What happened to the IABP/VAD/Transplant outline you described for Charlie before the IA was even put in place?" Alan suddenly questioned the doctor. He remembered the conversation; the IABP would be a bridge to the VAD (ventricular assist device) which in turn would lead to the transplant.
"That was the original game plan," An unruffled Andrew Cosmos volunteered. "At it stands today; Charlie's numbers are not where I would like them to be, he's battling arrhythmia, struggling with a heart that is no longer able to function on its own and his lungs are overworked. If he consents; this five day period will hopefully give us back the option of the VAD."
Don caught the word "hopefully" but his father had either missed it (seeing how Alan had not even flinched); or to keep his sanity chose to ignore it.
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Andrew would hold off on telling the men that the VAD would more than likely be the only option left once Charlie was weaned from the ECMO (after the allotted five day period) while the endless wait for a donor heart continued.
He could stretch the period on ECMO (he had read of patient's being supported on the machine for upwards to a month); but longer periods on ECMO increased a patient's risk for a bleed, transfusion problems, infections, small clots or air bubbles forming in the tubing, and stroke.
If Charlie accepted the five day schedule; Andrew would not then turn around later and try and push the issue of further days with Don Eppes (while the man served as his younger brother's legally appointed Decisionmaker).
This time it was Alan's turn to contemplate the tops of his shoes.
"Alan, do you need to take a break?" A concerned Andrew Cosmos inquired. He had adhered to the man's wishes, but could tell that the total honesty policy was beginning to take a toll on the man.
"No." Alan replied curtly. It was the only word he could manage to speak at the moment.
"Don?" The cardiologist turned to ask the youngest member of the circle. He had no doubts that whatever emotions were swirling inside Don Eppes, the man, was going to remain rock steady in order to support his family.
"Keep talking." Don replied abruptly. He knew if the doctor stopped his father would not be able to make it through a second go round and despite his outwardly appearance; Don was teetering on the edge.
Andrew gave a short overview of the ECMO. He would wait until his discussion with Charlie to get into more in depth details. Andrew owed it to his patient to not have Charlie feeling as if he was the least informed person in the room.
When Andrew finished his brief outline of the pros and cons of ECMO; it left Alan and Don Eppes reeling.
Don closed his eyes (in a futile effort to freeze out the image of Agent Davis on ECMO).
Alan threw an arm around his son's back, and pulled him close. Despite Don's determination to hold it together; Alan knew his kid was struggling.
It would be a full minute before Alan and Don would be able to look in Andrew Cosmos' direction.
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Andrew understood completely how difficult it was going to be for Alan and Don Eppes to see Charlie placed in such a vulnerable state.
Andrew would have to choose his words very carefully when he got around to discussing the numerous risk factors with Charlie. He wanted to avoid Charlie reacting negatively and making the wrong decision.
The sound of Don Eppes' voice interrupted Andrew's thought process.
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"Charlie's not going to go for it." An anxious sounding Don announced.
"Then you and I will help convince him." Alan responded with faked calmness. He tried to ignore the unconvinced look on his eldest son's face.
"I'm letting you know up front (he looked directly at Andrew Cosmos) that Charlie's not going to hear about this ECMO option alone." Don stated firmly.
"Don and I will both be there for the discussion." Alan added. He waited for the doctor's rebuttal.
"I would like nothing more than for Charlie to be surrounded by his family and have that reinforcement. Let's hope he feels the same…" The cardiologist's attention was diverted by a knock on the door.
Don and Alan had been all set to argue with Andrew Cosmos until they too heard the knock on the door.
Isabella poked her head into the room. She smiled at both Don and Alan.
"Charlie's awake." Isabella informed the three men. "He sent me in here to inform the three of you that and I quote "it was really rude to leave for Starbucks without asking him for his selection." The nurse hoped that she had achieved the right amount of Charlie Eppes sarcasm.
Isabella wisely chose not to volunteer that Charlie had also told her that "having a heart that wants to stop more than it wants to go should qualify him for an Espresso Machiato in order to keep it beating a little longer." He also told her that "it could be considered a holistic approach."
Despite being taken back by the second comment; Isabella laughed.
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She seriously did not think her enjoying his oddly-timed remarks meant all that much to Charlie; until he had aimed his big brown eyes at her and stated, "Thanks Izzy. You're the only one who still genuinely laughs when around me."
The usually unflappable nurse came close to losing her composure.
Isabella reassured Charlie that she would continue to be that person. She then made an excuse that she needed to see what was holding up Andrew Cosmos just so she could leave the room.
Out in the hallway, she gathered her emotions, and then began a real search for Andrew Cosmos.
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When Alan saw Isabella he smiled briefly. It was more for the nurse's benefit than his own.
Don, could not even fake a smile. Knowing all too well that his brother often made ill-timed statements in order to hide his anxiety. Don had a very strong sense that Charlie had said more to Isabella then the nurse was reporting.
He was not, however, going to push the issue because Don was sure that whatever it was that Charlie had brought up to Isabella would hurt like hell to learn.
The sound of voices brought Don out of his own head. He took note of Andrew and Isabella's conversation as they walked past him on their way to the office's door.
"How is he tolerating the Procainamide?" Andrew asked. "Any issues?"
"There is the start of a rash near the catheter." Isabella offered. "But no complaints of pain or itching."
"Let's treat it with a cortisone cream and keep an eye out for any swelling or coolness." Andrew stated. "Make sure our friend knows he is expected to let us know if there's any other issues."
"I have already drilled it into his head," Isabella only half-joking replied.
"A rash, I'll take any day." Andrew quietly addressed his trusted co-worker. "Let's keep all eyes on him for the next hour or so."
Don watched Isabella briefly pat the doctor's shoulder blade, in what could only be taken as an act of solidarity as they both prepared for whatever could come next.
The level of concern shown by Cosmos and Isabella over what probably amounted to a minor rash on Charlie's arm had Don worrying again about the sheer number of medications currently making their way into his brother's veins via an ever growing canopy of IV bags and lines.
As much as the doctor annoyed Don in so so many ways; he understood and appreciated the fact that Andrew Cosmos (along with his colleague Ana Vaidya) has been performing a daily juggling act in order to keep Charlie stabilized in order to justify keeping his brother's name on the National Transplant Registry.
It also amazed, Don, how both Rowan and Isabella kept track and safely administered the multiple medications that Charlie now depended on even when it seemed like Andrew Cosmos or Ana Vaidya altered them every other hour.
When they were all out in the hallway; Isabella gave Don and Alan a quick smile before heading back toward Charlie's room.
It was not Don's imagination; the nurses' smile looked strained.
Andrew Cosmos followed Don and Alan as they walked toward Charlie's room.
"He can't be serious," Don thought to himself. Judging by the upset look on his father's face; Don knew the man had the same thought.
Don and Alan stopped moving which lead Andrew Cosmos to nearly walk into two very unhappy looking men.
Alan was the first to address the doctor.
"You're not seriously planning on discussing the ECMO option with my son right now?" an incredulous Alan Eppes stated.
"Alan, I'm sorry, but I thought it was understood that the wait and see option went out the window with the third VT." Andrew replied pointedly.
"You're not dropping this news on Charlie like you and your partner did the GCM diagnosis."
"Or the need for the IABP," Alan added.
It was now a tag team effort to attempt to talk Andrew Cosmos out of his ill-advised plan of action.
"Charlie is going to shut you down if he feels that you are trying to steamroll him." Don stated. "And I'm telling you right now he sure as hell will not give you an answer at the end of your discussion."
"He has to process all the information he's given and then and only then will Charlie make his decision." Alan added.
Andrew Cosmos folded his arms, contemplated the information given to him, and then announced:
"I will be presenting to Charlie specific information that he is familiar with and so the need for any extended period for him to…"
"Look," Alan quickly interjected. "My son has a hell of a lot of doctorates to his name and Charlie could talk from here to the moon and back about operations, factorials, rational expressions, linear equations and a hundred other mathematical things, that I have no idea about, but one thing I do know is that my son does not possess a medical degree."
Andrew waited a beat.
"Charlie has a Macbook®." He stated.
Andrew could tell by the way the two men looked at each other that he did not need to add that Charlie had already read every research study on GCM and VT's.
"From what Isabella pried out of Charlie; he ordered it over the phone, arranged to have the package expressed delivered to the reception area, made it worth it for a still unnamed St. Vincent's employee, to wait for the package's arrival, and bring it to him."
"Dammit," Alan exclaimed. He should have known when Charlie stopped asking for his laptop that his resourceful kid had mapped out a Plan B.
"He probably paid this person a set up fee too." Don remarked.
"Dammit," Alan cursed again. With so much going on so quickly, Alan had forgotten to take home the bag that contained Charlie's clothes and personal effects (which no doubt included his son's wallet and bank card).
"Charlie managed to get into some heavily restricted medical research sites." Andrew revealed.
"Of course he did." Don responded. He had tried to sound annoyed, but there was just too much pride in his voice.
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Isabella suddenly appeared in front of the trio now having an impromptu discussion in the middle of the hallway.
"Charlie sent me out to remind everyone here that any discussion involving possible treatment plans legally has to include his input." Isabella stated. This time there was no smile.
She had watched her patient grow more and more anxious as the minutes continued to click off the wall clock.
At one point, Charlie grumbled,"they are aware that I know what they're up to, right?"
"This discussion should be taking place in Charlie's room." Isabella stated, without another word, she turned and walked back to her patient's room.
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For the first time since Charlie was admitted; neither Don nor Alan jumped at the chance to be at his side.
It's not going to get any easier." Andrew addressed the reluctant looking men.
A stern looking Isabella held open the door to Charlie's room as Don, Alan and then Andrew made their way into the room.
Don, noted right away two things about his brother: Charlie looked exhausted and Charlie looked upset.
Alan saw it too.
An exhausted and upset Charlie Eppes was a highly combustible item.
Poor, Andrew Cosmos happened to be the only member of the trio unaware of that fact.
Don briefly hesitated and almost smirked (his hesitating being on purpose) as Andrew Cosmos walked around him to become the first to reach the foot of Charlie's bed.