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Chapter Four

When the Silence Falls

By Dawn Nyberg

"Pray God you can cope … I know you have a little life in you yet. I know you have a lot of strength left … I should be crying, but I just can't let it show. I should be hoping, but I can't stop thinking of all the things I should've said, that I never said … All the things I should have given, but I didn't … Give me these moments back. Give them back to me … Just make it go away now." Lyrics excerpt from Kate Bush, This Woman's Work

Dean moved restlessly in sleep. His mind too busy weaving dreams, the stuff of nightmares about Sam. His subconscious was putting forth an scenario it could create that mimicked Dean's state of fear and loss.

"Hey, Dean!" Sam called out to him as he crossed the street holding two coffee cups. The car crossed the center line before Dean could even scream to Sam to watch out, and he watched as the moments that followed played out in slow motion. Sammy turning wide eyed at the car coming at him, the coffee cups slipping from his hands splashing brown liquid up into the air resembling a small park fountain spray. And, then the sickening thud as the car impacted against Sam sending him crashing up onto the hood and into the windshield leaving a bloody impact mark branching on into red spider web designs, as his momentum carried him over the roof, and off the back of the car. He landed with a cracking thud. And, all was silent.

"No!" Dean dropped to his brother's side. Sammy landed on his back as a pool of thick crimson spread beneath his head. His eyes blinked slowly, and his eyes were unfocused.

"Dean?" the word bubbled out of his mouth in blood and saliva.

"Shh, Sammy," Dean soothed. He ran a trembling hand along Sam's cold cheek. "Just hang on, please."

"Dean?" There was a distant sound to Sam's voice as if he were speaking across a widening gap between himself and Dean.

"I'm here, Sammy. Stay with me." Sam's eyes focused for one glorious moment and Dean saw his little brother appear behind those glassy, eyes, and he smiled at Sam. "There you go," he encouraged. "It'll be okay, Sammy." A barely perceivable smile teased at the edges of Sam's mouth and his eyes slid closed, and it was over.

"No!" Dean jerked awake as the nightmare ended. His heart monitor beeped a staccato rhythm to his racing heart that threatened to snap his sternum from the force of the pounding. Sue walked into the room with a determined stride.

"You okay?" She asked as she made eye contact with Dean while she looked at his monitor.

"Just a dream," Dean offered. Sue gave a knowing smile as she checked his vitals, and excused herself to allow him to regroup.

It was late morning when Dean's doctor had agreed to allow him to get in a wheelchair to visit Sam. While Sue had an orderly help her get Dean in a wheelchair he tried to resist grunting in pain. He was afraid Sue would throw a red flag and tell the doctor that he was in too much pain. The orderly left after Dean was safely seated. "You ready?" Sue lightly patted Dean's shoulder as she held his IV stand and pushed the wheelchair in unison with rolling the IV's.

Dean nodded not trusting his voice. "I should tell you what to expect Dean."

"It's Sam that's all that matters."

"I know you think that, but seeing him in this condition isn't something you're used to. There are a lot of machines and monitors. I'll explain them all once we get to his room. You do know the only reason the doctor agreed to let you out of bed was because he was afraid you try to get out on your own."

"And, he would have been right." Sue shook her head.

"You're not in great shape Dean."

"My brother is worse." Sue couldn't debate that issue. "How is he this morning?"

"Same as last night. No real change in his vitals."

"That's good, right?"

"Depends on how you look at it I guess," Sue offered plainly. "He's no worse and no better. I take his vitals every hour or two and check his ICP monitor."

"ICP?"

"Sorry, it's short for intracranial pressure."

"Oh, yeah, the doctor told me about that. He said it's some catheter thing inside Sam's brain measuring the pressure."

"I see you were listening to him."

"Mostly," Dean offered. Sue stopped right before they reached a doorway.

"You sure?"

"Yeah," Dean's voice was tight as his throat constricted. She pushed him forward and into Sam's room. Oh Sammy, went through his mind. Sam was surrounded by machines, IV's and monitors. His brother looked so small and young beneath all of the equipment. He fixated on the tube jutting from his brother's mouth that caused his chest to rise and fall mechanically as the ventilator whooshed in regularity.

Sue tried to gauge Dean's emotional state. But, he's a tough read this one, she thought quietly to herself. "Are you ready for me to explain the equipment, so you have a better grasp of what's going on in here?" Dean nodded. She went through explaining the ventilator, his IV's , the EEG monitor that displayed Sam's brain activity, and Sue pointed out the thin catheter of the ICP monitor that came out of his brother's skull. "And, this monitor shows the ICP of Sam's brain." Sue said as she patted Dean's shoulder trying to reassure him that he wasn't alone.

"That number is the pressure in his brain?" Dean questioned.

"Yes."

"What's normal?"

"The lower the better," Sue tried to hedge her response, but Dean's next words told her she wasn't getting away with that answer.

"Sue, what's normal?" She let out a sigh. She had been busted.

"1 to 15," is normal." She offered. Dean looked at Sam's number and frowned.

"His number is 23, that's not good, right?"

"No," Sue responded bluntly knowing that Dean wouldn't take sugar coating. "But," she added quickly when she saw the stricken look cross Dean's face. "It was 24 earlier, so it dropped a point, and that is good," she offered.

"What are they doing for it?" Dean's tone was all business while his eyes settled on his brother's still features.

"They have him on some IV meds."

"Which meds? Show me the IV's." Dean didn't know what the drugs were, but he wanted to make damn sure they were doing everything they could for Sam. Sue smiled warmly and walked over to one of the many IV poles with bags and IV syringes programmed to inject at certain intervals.

"This one is 20 percent Mannitol and this one has Decadron in it," Sue answered. "Both of these are for the brain swelling. They are to help reduce it or control it."

"There's a lot more IV bags beyond those two drugs," Dean commented.

"Well, we have to keep him hydrated with fluids, and they have him on lactated ringers, and dextrose to keep his electrolytes stable. I suspect they will start him on a TPN in another day or two depending on his coma status."

"TPN?"

"It's a short abbreviation for a long term, but in a nutshell, it will be his food since he won't be able to eat. It will supply him with the nutrients his body needs to survive, and the doctor may or may not prescribe lipids for Sam." She saw the look Dean gave her, and smiled again. "Lipids are just another dietary need, but not all patients require it." Dean nodded. Sue grabbed Sam's chart from the table by his bed, and proceeded to jot down his vitals she was gathering from the various monitors. She activated the blood pressure cuff perpetually attached to Sam's upper left arm, and wrote the numbers down. Dean saw her draw up a syringe and injected it into one of his brother's IV's after consulting his chart.

"What's wrong?" Dean's voice was blunt.

"The doctor left standing orders for an epi injection if Sam's blood pressure and heart rate were low. This will help to increase his cardiac output. And, this increased blood flow will help to circulate oxygen rich blood to Sam's brain. That's why it's important to keep a close watch on blood pressure and heart rates of head injury patients like Sam, especially with the brain swelling."

"What was his blood pressure and heart rate?"

"70/65", she replied. "And, his heart rate was 58."

"And, now?" Dean tried scanning the monitors to see some of the numbers that apparently his brother's life was hanging on. Damn so many numbers Sammy. Dammit, you're more than a number. Sue took another blood pressure and marked down the numbers.

"His pressure is now up to 100/68, and his heart rate is up to 71." She pointed to the heart monitor. "Here is where you can see his heart rate, and this one is his body temp." She pointed to one smaller monitor. "This one show's his oxygen levels, and that's what the clip on his right index finger is for. He's on a ventilator so his oxygen levels are being maintained. We like numbers around 98 to 100. And, Sam is at 100. I need to do one more thing, okay?" Dean nodded. Sue opened the chart one last time, and proceeded to pick up a pen light and lifted each of Sam's eyelids, and then glanced at a small reference chart attached to his file, and she jotted something down. And, then proceeded to rub Sam's sternum vigorously with her knuckles to elicit a response to pain stimuli, but Sam remained still. "Sam? Can you hear me? Open your eyes? Can you squeeze my hand?" Dean watched her and Sam with intense eyes.

"What was all that for?"

"I have to record his pupil responses every hour or two and check his response to deep pain stimuli and verbal commands. And, based on what I see when I shine the light in his eyes I compare his pupils to the chart and assign Sam a GCS number, or what they call a Glasgow Coma Scale."

"And, what number did he get?" Dean smiled fleetingly. "Sammy always did well on tests. He's the smart one in the family. He went to Stanford, you know?" He looked fondly at his brother. "His number?" He repeated his earlier question.

"There's been no change from his previous exam. I gave him a four on the scale."

"You said low numbers were good," Dean was hopeful. She gave him this knowing yet sympathetic smile, and he knew this time was different.

"No, not on this scale, Dean," she said softly.

"Then what does the number mean? What is this damn scale anyway?"

"It measures level of brain injury," she responded. "Typically a GCS of 13-15 is a mild brain injury, 9-12 moderate, and anything under 8 is usually considered severe brain injury." Dean looked defeated. "I'm sorry sweetie, I know this has to be rough."

Dean only nodded because he couldn't find any words. Sue could tell that he had just about reached his quota of medical information overload. "Look, how about I give you some time alone, but not more than ten minutes, okay. You need to be back in bed. If you need anything before I come back here's the call button."

"Thanks."

"Sure thing," Sue offered a warm smile in an effort to provide some kind of comfort.

"Hey Sammy," Dean cleared his throat after his brother's name came out sounding choked. "Well, kiddo, you just had to up stage your big brother, huh? Had to prove you could be sicker. Not fair," Dean attempted humor. "Sam," Dean's voice was serious. "I said some things yesterday that I shouldn't have. I don't even know why I said them," he scrubbed a hand over his tired face. "I didn't mean any of it." Dean studied his brother silent features as his hearing was bombarded with the whooshing of the ventilator, and the beeping of the heart monitor. "If you'd just wake your lazy ass up I could apologize. Now, that has to have got you interested Sammy. You know that an apology from Dean Winchester is a rare event. Come on," he urged. "Open your eyes Sammy." He stared at his brother's face, but nothing happened.

"Okay, I get it," Dean replied with a small smile. "You're going to force one of your chick flick moments on me, huh? Cause you think I can't hack it, eh? That I can't do chick flick." Dean reached up with both hands taking his little brother's cool, lax hand and enveloped between both of his warm hands. "See what you've reduced me to," Dean commented as he gave Sam's hand a light squeeze. "How about this," Dean suggested. "Just squeeze my hand, okay? Or twitch a finger? Sammy?" Dean could feel the desperation growing inside his chest and weighing down his very soul. He stared at Sam's face and felt panic knowing his little brother was lost in the dark, and had gone somewhere he couldn't follow. "Please, Sammy," his voice broke despite his best efforts to contain his emotions.

Dean glanced at the monitors playing the number game again. He looked at the ICP monitor and it was back up to 24. Dean growled. "Dammit Sammy, you gotta fight this, you hear me? Fuck," he hissed in anger. "All this damn medicine is good for nothing," he spat. He glanced at the other monitors. Sam's heart rate was 65. He wondered what his blood pressure was, but Sue wasn't here to activate the cuff. Dean made a mental note to watch her the next time, so he could cheat and keep track when he wanted to know a current reading. He glanced again at the ICP monitor and saw 25. He felt a sense of urgency growing in his gut. He looked at Sam's heart rate again and saw 62. It was almost a reflex reaction as he picked up the call button even before his mind processed the desire to pick it up. He began frantically pushing it. Sue came running in from the nurse's station.

"Dean! What's wrong?"

"His numbers," Dean barked. He urgently pointed to the ICP and heart monitors. He watched Sue consult Sam's chart, and proceeded to increase drip rates on the mannitol. He remembered that was Sam's brain swelling. He watched her activate the blood pressure cuff and memorized what she did. The numbers came up on a digital display, 70/64. "That's too low, right? You said they should be higher to get the blood to his brain." He felt his world was exploding. He felt like his brother was being pulled away from by some invisible force he couldn't fight or put himself between it and Sammy.

"I'm increasing his drip rates the doctor wrote down should his numbers climb, and I'm giving him a dose of epi to increase his heart rate and blood pressure. Dean," she tried to reassure. "Sam's numbers will go up and down, and until he stabilizes we'll have to keep addressing the up's and down's of his vitals, okay? It'll be all right. See," she pointed to the heart monitor, and Dean saw that his heart rate was up to 84, "that's actually very good." She tried to give Dean something positive to hold onto the young man looked positively desperate and lost. "And, his new blood pressure is 105/70, that's excellent."

"You sure?"

"Yes," she smiled, and glanced at the ICP monitor. "Well, would you look at that," she pointed to the dreaded monitor that Dean hated the most. His eyes darted toward it expectedly. And they both saw the number 20.

"That's down 5 points," Dean said with a confident smile. "That's good isn't it?"

"Very good," she assured. "Dean, I should get you back to your room." She could see he was on the ragged edge, and needed to rest before he collapsed.

"It's too soon," he complained.

"Five more minutes, okay? And, then you go back with me … we have a deal?" Dean couldn't help, but smile.

"Yeah."

"All right then."

Meanwhile, John Winchester's Hospital Room

John stirred and groaned into awareness. Everything was fuzzy around the edges. He remembered waking briefly in the ER. He knew there had been a car accident. My Boys? Shot through his mind. And, then he remembered his brief meeting with Sam. Oh, Jesus, what did I say to him? His mind screamed. The damn medication had made him say things. He had hurt Sammy. He closed his eyes as he remembered Sam's face when he had seen his youngest son standing at the foot of his bed, "I don't want to see you, Sam. You could have ended it. I thought we saw eye to eye on this issue."

"But, Dad," Sam had pleaded. "I told you we still have the gun and the bullet. We'll just start over." His voice sounded so lost. "Dad, I just couldn't do what you wanted."

"And, look where it got us," his words were slurred and disjointed, but his point was getting across. "I don't want to see you now. I can't look at you." John turned his eyes from his baby son, but not before he saw the hurt, the pain his words and actions had caused. He also remembered seeing the bruises on his young son's face, and the tall-tale stitches indicating that Sam had been injured in the wreck. And, he had ranted at his son, you're a stupid bastard, John Winchester, he thought to himself.

"Sonofabitch" he complained to the empty room. "You damn fool," he chastised himself. You'll talk to him and make it right. Make him understand that you didn't mean the harsh words, not really. He pressed his call button. His nurse, Alexa, walked in the door.

"Hey, good to see you've decided to join the living," she said smiling. John offered her a slight bemused smile.

"My boys? Where are my boys?"

Meanwhile, Sam's ICU Room

"Sammy? They're going to take me away in a few minutes," Dean spoke softly while stroking the back of Sam's hand. "I'd stay, but they won't let me. Damn hospital rules. But, I'm only two doors down, okay," he spoke evenly. "So, if you decide to end your coma boy routine and wake up, just ask for me, all right? I'll be here, I promise." He looked at his brother hopefully waiting for some sign that Sam was coming back to him, but all was stillness. Dean looked over his shoulder to see if anyone was coming, and they weren't, so he struggled to his feet as he hung onto his IV pole for a little leverage as he pulled himself up. He leaned over Sam, and spoke into his ear. "Listen, little brother, I don't know where you are, but you're not alone, okay? Even if you can't see me, I'm there, all right," he encouraged. "I know you're in the dark Sammy, but if you can hear me follow my voice." He closed his eyes as his emotions threatened once again, as they rose up like a cresting wave, only to recede as he pushed them back down quelling them.

"You're not alone Sammy. Please…" his voice broke off.

"Dean!" Sue spoke authoritatively from her viewpoint from the opening to Sam's room. "You should not be up," she reprimanded. Her voice dropped low, as she pointed to the wheel chair. "Sit, your ass back down on that chair mister." Dean stared at her wide-eyed both at her words, and that this small stature, petite woman suddenly looked like a formidable opponent. Dean Winchester sat back down. He looked up at her from his newly seated vantage point.

"I just had something to say to him," he spoke quietly. "I…" Sue's eyes softened as she looked at Dean and heard the anguish buried beneath his words.

"I know," she cupped a hand reassuringly over one of his shoulders. "I'm sorry," she offered. "My temper is a slow burn, but when ignited I go off like an M-80 firecracker, I apologize. It's just I don't want you doing yourself more harm," she spoke softly. Dean nodded. "And, anyway, what good would you be to this brother of yours if you're not running on all eight cylinders, huh?" Dean smiled.

"Eight, huh?"

"Sure, you don't strike me as the 6-cylinder type of guy." Dean quirked an eye at her. "I have brothers," she filled in. Dean gave a knowing nod.

"When can I see Sam again?"

"How about we let you rest up a bit. See if we can get some breakfast in you, and I'll see about letting you have some time this afternoon. Deal?"

"Yeah, okay."

There conversation was ended as Alexa called over to Sue from the nurse's station. "One minute Dean."

"Okay." She could take all the time she wanted. It gave him more time to sit at his brother's side.

"Sue," Alexa began as she nodded her head in Dean's direction. "His Father's awake and wants to see his boys. I haven't told him about the youngest one condition."

"Oh, okay. Let me tell Dean. I really wanted to get him back in bed, but seeing his Father and talking to him may help."

And, she couldn't have been more wrong.

To Be Continued

Well, here we are once again, another chapter. How was it? I'm thankful for all of the reviews! Please, keep them coming as they are a wonderful way that I'm able to gauge how the story is going. Like it? Hate it? It's just okay?

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