Chapter 26

When John returned to the unit, he found Sherlock asleep; no longer sedated, no longer intubated, his face half hidden by an oxygen mask, the back of his bed raised.

Sherlock groaned slightly as he shifted his sleep, then opened his eyes, trying to push off the oxygen mask.

'Leave that, you need it,' John told him as he blinked, and tried to focus on John.

'John.'

'Welcome back,' John said.

Sherlock closed his eyes again, then opened them quickly, as if in doing so he could find himself in different surroundings. 'What happened?' he asked, his voice muffled by the mask.

'What happened when?' John asked, suddenly uneasy at the thought that Sherlock's brain might have been affected by the period of low blood pressure after his collapse.

'I was in Baker Street.'

'You collapsed,' John told him. 'You went into VT. Had to shock you in the back of the ambulance - yet another new experience that you've provided me with. And you poured a couple of litres of blood back into your chest from your right hilum. Earned yourself a trip back to theatre and another thoracotomy.'

Sherlock closed his eyes again. 'Hurts,' he murmured.

'Yeah, well that's what you get from having two thoracotomies in just over a week. James Macpherson says he wouldn't recommend a third, by the way, just in case you're thinking of doing any more escape acts. Sounds as if trying to out any more stitches in the hilum of your lung at the moment would be a bit like trying to weld an exhaust back on to the bottom of a car that's ninety percent rust.'

Sherlock blinked at him in confusion, then winced again.

'Yeah, I know, sorry. Probably a bit much to process at the moment,' John said, as he reached over and pressed the PCA button for Sherlock, watching the relief flood his face as the alfentanil took hold.

'Bad?'' he asked John eventually, and John noted the effort it was taking him to speak. His respiratory rate was high now that he was awake and he was wincing with each breath, despite the PCA. John pressed the button for him a second time, making a note to ask them to increase the infusion rate.

'You going to tell me what that was all about?' he asked when he was sure the opiate had taken hold. 'You could have just told me you know.'

'You wouldn't have believed me.'

'No, probably not. But still - did you really have to go that far?'

'It was important.'

'Important enough to risk your life for? You nearly died, Sherlock, again. Do you think you could please stop scaring me like that? Next time just talk to me, will you promise me that?'

You had to hear it from Mary herself.'

'Yes, well, you accomplished that. No more escape acts.'

'Magnussen.'

'What does he have to do with this?'

'Everything.'

But before John could ask him to explain further, the analgesia took hold and he was asleep again.

...

The next few days and nights blurred into each other as John held vigil by Sherlock's bedside, unwilling to leave him in case he made another bid for freedom. Mycroft's guards had miraculously melted away - whether because he was satisfied that Mary no longer represented a threat, or because he was aware that Sherlock wasn't in a fit state to go anywhere at the moment, John couldn't tell.

Sherlock remained on the High Dependence Unit, as complication after complication arose. On day 2 after surgery, he spiked a temperature, which was put down to a post-operative chest infection and treated with antibiotics. But despite the intravenous domestos that he was effectively being given, his fever refused to budge, and when John looked at his blood results, carefully documented twice a day on the charts at the end of his bed, he could see that the white cell count and C-reactive protein, both indications of bacterial infection, were climbing by the day. Wherever the infection was, whatever was causing it, the antibiotics that they were giving him weren't working. And more worryingly, the amount of oxygen that he was requiring to keep his arterial oxygen levels at a reasonable level was slowly creeping up.

James Macpherson and the constant stream of Intensivists looking after Sherlock were all reassuringly calm in the early days. Infection was not unexpected, they said, after two operations within a short duration of time, both of them emergencies. John just had to be patient and give the antibiotics a chance to work. But he couldn't brush off the uneasy feeling that there was something more sinister going on than a simple chest infection.

When John returned to the unit on the fourth morning, it was to find the ward round in progress, with five clinicians clustered round Sherlock's bed trying to work out the next step. His oxygen saturations had dropped overnight and they had started him on Optiflow, a system of humidified oxygen that delivered a small amount of positive pressure support. They were starting to talk about non-invasive ventilation if his respiratory rate remained elevated and his numbers didn't improve.

James MacPherson nodded at John in greeting when he noticed him waiting in the doorway. They were discussing a central line change and a return to basic principles: remove and replace all lines, take a culture of everything that couldn't be removed and could be cultured, organise an ultrasound of his abdomen looking for bacteria cultures, order another chest x-ray.

'Empyema?' John asked, naming the collection of pus in the chest cavity that could occur following a traumatic injury or surgery.

James Macpherson shook his head. 'It's a bit early for that, and nothing showed up on the CT scan we did a couple of days ago. If he doesn't improve by tomorrow, then we'll rescan his chest and abdomen to look for a collection, but that's likely to require sedation and intubation as he drops his oxygen saturations when we lie him flat. I'd rather not go down that route if we can avoid it.'

'Everything else stable?' John asked, not wanting to hear the answer.

'His kidney function is dropping off a little, and he's still requiring inotropes to maintain his blood pressure.'

'Sepsis?'

'That's the working diagnosis. We just need to find the source, but all of the cultures are coming back negative.'

'Sherlock would work it out,' John couldn't help thinking. 'Sherlock would work out exactly what was going on, doctor or not. So why can't I?'

Sherlock himself seemed to be becoming weaker with each passing day, barely able to stay awake for more than five minutes, and John could get little conversation out of him.

Then that evening, as John sat reading the paper on his iPad, waiting for him to wake up, he looked up to see Sherlock looking at him.

'You okay?' he asked.

'I'm still here?'

'Yes, of course you're still here. Where else would you be?'

'Where's Mary?'

'At home, I would imagine.'

'You should be with her.'

'Why? What is this, Sherlock?'

'No John, listen to me, you should be with Mary, it's important.' Sherlock groped towards John with a hand, and John took it and held it. It was hot, and dry as a bone. His temperature must have shot up again.

'Sherlock, you're not talking sense, what are you -'

And then he realised. Sherlock really wasn't talking sense. He was staring at John, eyes wild with confusion, because that was what he was- delirious.

'Sherlock, where do you think that you are?'

'Baker Street, of course. Why are you here?'

'You're not in Baker Street, you're in hospital. You've been ill; that's all. You're in the HDU at The Royal London. You've been here for days.'

'Magnussen. Magnussen was here.'

'No, Sherlock. He wasn't here . You're just a little confused from the drugs they've been giving you'

'No, he was here, John. He was in the flat, I saw him. He was here with Mary, they were going to -'

And then he broke off, trying to pull the oxygen mask off his face, and John rang the bell for help.

'Leave that; you need it,' he told him, but Sherlock was frantic now, clawing at John's hands.

'Can't breathe,' Sherlock was panting, trying to push John's hands away.

'It's fine, you're just panicking, slow your breathing down, John said, and then he glanced up at the alarming oxygen saturations and realised that it wasn't fine at all. Sherlock's oxygen saturations had dropped precipitously, and he was gasping for breath, no longer fighting against the mask.

John didn't hesitate - he pulled the crash bell and turned the oxygen through the Optiflow machine up as high as it would go.

'Sherlock, are you in pain?' he asked, watching Sherlock's face twist into a grimace.

'Back,' Sherlock gasped, 'Back hurts. Hurts to breathe. Help me,' and then John was surrounded by people, dropping Sherlock flat, applying a bag and mask to his face, starting to ventilate him, calling for drugs and preparing to intubate him as his oxygen saturations dropped even further and his blood pressure dropped precipitously.

'He's having a massive P.E, you need to do something,' he shouted to anyone who would listen.

'We are doing something, John. You need to come and wait outside now,' the ward sister told him calmly, putting an arm round his shoulders and steering him away from the bed.

'I want to help. I'm a doctor, I-'

'John, listen to me. You need to leave him to us. You need to let us work, okay? Come this way.'

And John allowed himself to be led out of the unit and into the relatives room, where he sank onto the sofa, head in hands, and for the first time since this whole sorry business had begun, burst into tears.

...

It was James Macpherson who came to update John, after what felt like an eternity of waiting but in reality was probably less than half an hour. The ward staff had come in regularly to tell him that they were doing what they could, and to offer him cups of tea that he didn't want. 'We are doing everything that we can,' they told him. He knew what that meant. He had said it himself to too many relatives in the past. It meant that they thought that what they were doing wasn't enough. It meant that they thought Sherlock was going to die.

'What's happening?' he asked James Macpherson as soon as he came through the door.

'We're trying to get him stable enough for scan.'

'Why not just thrombolyse? It's barn-door surely? Post-operative, sudden onset shortness of breath, chest pain, hypoxia and hypotension. He's thrown a massive clot to his pulmonary artery. It can't be anything else.

But James Macpherson shook his head. 'It's too risky, John. That hilum is too damaged. He could well ex-sanguinate into his chest drain. Besides is not necessarily a P.E., it could be an aortic dissection or a suture seam that's given way. We need a diagnosis first.'

'So if it is a massive P.E. and you can't thrombolyse, then what's the alternative?'

'Embolectomy, if it comes to it.'

'But you said you didn't want to have to go in again.'

'They could do it with interventional radiology, but let's not jump the gun. We need a diagnosis first, then we can come up with a plan.'

John nodded slightly, then hesitated before asking. 'What are his chances, James? I mean realistically, it isn't looking good, I know that.'

'You know the drill, John. Statistics are all well and good for the lay person, but as medics we all know that a 70% chance of survival is great if you're in the 70%, but if you're in the unlucky 30% , then you're still 100% dead.'

'Give me an idea, James.'

'He's got a reasonable chance if we can work out what's going on and get him treated quickly. If we can't get to the bottom of this, and he continues to deteriorate, then we could be facing some very difficult decisions in the next twenty-four hours. That's the best answer that I can give you at the moment.'

'Fair enough,' John said quietly. 'I'd better let his brother know.'

...

'What the hell is that?' John breathed, as James MacPherson showed him the CT scan an hour later. Sherlock's lungs were full of small cavitating nodules, anything up to a few centimetres in diameter, and even the vessels showed evidence of them, cutting off flow in some places.

'Septic emboli,' James MacPherson told him. 'Foxed the Radiologists as well. They're rare, probably came from his central line. They grew staph from it, but we assumed it was a contaminant. At least, we know what we're treating him for now.'

'So what - clusters of bacteria have been growing in his central line and then shooting off through the circulation to lodge in his lungs?'

'Seems likely, yes. The line change earlier on might well have thrown off a whole shower of them which would explain why he suddenly deteriorated.'

'And treatment is - what – different antibiotics?'

'And ventilation until his respiratory function improves. Now that the line that was the source of the infection has been removed, he should start to pick up in the next twenty-four to forty-eight hours.

This chapter comes with huge thanks to sevenpercent for the betaing, and J_Baillier for med-picking and general advice on all things ITU related.

Explanatory Notes and Definitions

VT - Ventricular Tachycardia, a fast, broad complex heart rhythm arising from the ventricle that usually leads to low blood pressure, and if untreated to cardiac arrest.

PCA - Patient Controlled Analgesia. A mechanism by which post-operative patients can control their own pain by pressing a button to have intravenous analgesia delivered from a pump, rather than having to call a nurse to administer it.

Non- invasive ventilation - A way of delivering higher concentrations and pressures of oxygen to patients via a tight fitting mask which is strapped to the face. This effectively blows air into the lungs, improving ventilation and reducing the effort required to breathe. There are two types - CPAP, continuous positive airway pressure, used mainly when oxygen levels are low and BiPAP, bilevel positive airway pressure which is used when there is a problem with the mechanics of breathing and pressure is needed both on breathing in and breathing out.

P.E. - pulmonary embolus, a blood clot on the lungs, which if big enough impedes the flow of blood to the lungs and reduces the ability of the lung to oxygenate the blood. Big P.E.s present exactly like this - sudden onset shortness of breath and chest pain which is worse on breathing, and patients have low oxygen saturations, low blood pressure and look (and often feel) as if they're going to die. The gold standard for diagnosis is a CT scan, but the problem is the really big ones make patients too poorly to get to scan, so we tend to diagnose them by bedside echo, looking for a big right ventricle. Treatment is with thrombolysis, or clot-busting drugs, but post-surgery that's usually pretty risky.

Anything else you'd like defined, please let me know!