Disclaimer: refer to chapter 1
NOTE TO READERS: First, thanks for the all of the reviews! I appreciate them all. Well, here is chapter 3 and I hope you enjoy it. I'm posting a day ahead of schedule. This chapter is around 18 pages long.
Side Note: The title of the chapterwas inspired from a Pablo Neruda poem of the same title. Also, the song lyrics utilized later in this story are from the Bing Crosby song, Don't Fence Me In.
DNR: stands for 'Do Not Resuscitate'
Chapter Three
Song of Despair
By Dawn Nyberg
"…my feet will want to march to where you are sleeping, but I shall go on living…" excerpt by Pablo Neruda, The Dead Woman
Two Days Later, ICU
"So, he has brain activity?" John clarified as he talked to Dr. Sadikov, Sam's main care physician and Dr. Keener, his neurologist.
"Yes, although it is indicative of a deep coma." Dr. Keener explained. "The clot impeded some blood flow to the brain, but your son luckily has a good vascular system and the impeded blood flow didn't cause a stroke in the sense you're thinking. It falls more under the general classification of a cerebral event."
"But, you said the coma is deep … when do you think he'll wake up?" Dr. Keener shared a look with Dr. Sadikov.
"John," Dr. Sadikov began. "It's possible that the coma may be irreversible because of the brain stem involvement."
"But, you said he's not brain dead and the other day you said Sam's MRI and PET scans were promising…"
"Yes, promising in terms we aren't finding any major damage that would indicate brain damage on a profound to mild scale. If Sam wakes up, it's very hopeful that he could have a full recovery, but when the brain stem suffers trauma, and well, I'll be frank, it's a miracle that Sam survived, as brain stem involvement often equates to either death or profound brain injury."
"When will he be off the ventilator," John looked at Sam's still face.
"Mr. Winchester," Dr. Keener stepped forward. "Sam has no spontaneous breathing efforts and no active gag reflex. Unless he regains consciousness I don't foresee him ever coming off the ventilator. As long as he remains in the coma we will have to maintain an airway for your son." John's eyes shifted from his son to the doctor's.
"But, he looks perfect," John replied absently. "A little pale, but…"
"I know it's difficult especially when you're dealing with an internal injury. You have no gauge to go by and it's easy to let yourself believe he's just sleeping," Dr. Sadikov spoke gently. "The surgical site is healing nicely and there is no sign of swelling or infection." John nodded at the small bit of good news.
"Sam is still very critical and he'll be in the ICU for a while yet, but his vitals are holding," Dr. Keener added. "The cath we used to evacuate the clot near his brain stem has had no side effects and he came through the procedure as I told you the other day extremely well."
"And, Dean?" John asked as he studied his youngest child's features.
"Dean remains in the coma, but he his vitals are stronger than they were and his urine output is regulating and his liver enzymes for his latest lab test are very good. His blood pressure is a little low, but we're keeping an eye on it. The jaundice is clearing up and is all but gone. I'm happy to report he began triggering the vent earlier this morning, but in order to give his body as much physical rest as possible I'm not weaning him off the ventilator yet."
"So, he's trying to breathe on his own again?"
"Yes."
"Does that mean he'll wake up soon?"
"Let's play it by ear John. Dean has been through major surgery and was in extremely grave condition when he went into the OR. His body needs rest and still has a long row to hoe."
"Can I just sit with my son alone for a while?" John's voice was tired. He was so tired of his children being poked and prodded. He just wanted his boys to be whole and healthy again.
"Certainly," Dr. Sadikov recognized John Winchester's request for what it was … a parent's plea to be alone with his child and for everyone to step back and give him to room to breathe and process the situation. "Dean's transplant surgeon will be stopping by to examine Dean's latest lab results and his incision later today." John nodded.
"I'll be there," he confirmed. Dr. Sadikov nodded and he and Dr. Keener left John alone with Sam.
"Hey, kiddo," John spoke gently as he stroked Sam's arm. "Listen Sammy, I know you're upset with me and I don't blame you," John offered honestly. "What I said to you about if you leave for school not to come back … I was a jack ass. Sam, I was just scared … scared you'd be vulnerable and alone, but I should have thought about what you wanted and needed. I'm sorry," his voice caught. "I need for you to come back to me … to come back to Dean. I need to make things okay between us. I'm so proud of you Sammy and I'm a damn fool for not saying it to you, I've always been proud of you, both my boys."
Sam did flinch, didn't move. The ventilator continued its methodical whoosh and click. The activity outside Sam's room increased suddenly and John casually looked up. It wasn't an uncommon thing, after all, it was an ICU and there were other patients clinging and fighting for life in here. But, he noticed a flurry of activity and there was no mistaking the room … it was Dean's. John stood up quickly. "Sammy, I'll be back." He said hurriedly as he ran toward Dean's room only to be held back by Jan, a unit nurse.
"No, Mr. Winchester, they need room to work."
"To work? He was doing better … Dean?" he called out as if he expected his son to answer him. "What's happening?" he turned anguished eyes toward Jan. Then he heard the tall tale word, Clear! and the distinctive clunk noise he associated with the use of a defibrillator. "No, please, God, no…"
"Please, Mr. Winchester let the doctors work on him," Jan tried to gently lead John back toward Sam's room rather than leave the distraught father to sit in the ICU waiting room alone.
"What happened?" his eyes searching Jan's for answers.
"He suddenly crashed," she offered. "I'm not his primary care nurse, so I'm not sure. The doctors are doing everything they can. Please, just sit with Sam … someone will come to you." John wanted to rebel against her gentle command, but he knew it was pointless. Dean needed help and he needed to let the medical staff save his son. He nodded without another word and sat back at Sam's bedside grasping his young son's hand as if were a life preserver in a storm tossed sea keeping him from drowning in the cresting and crashing waves. He bowed his head and did what he hadn't really done in years … John Winchester prayed.
One Hour Later, ICU
John raked a hand over his face as he stood outside Dean's room. "You say is blood pressure bottomed out …" John clarified as he looked at Dr. Sadikov.
"Yes, and it triggered a cardiac arrest. We've started him on an epinephrine drip to keep his hear rate and pressure elevated. We may have to play with the dosages as necessary to prevent another blood pressure episode."
"The transplant," John began. "Is he rejecting it?"
"No, we've run extra tests and so far everything is in the clear. You can sit with him now if you like … Dr. Jessup is done examining the surgical site and lab results. Dean's fighting as much as he's able John, but his body is weak and tired." John nodded.
He walked into Dean's room and sat heavily into the white plastic chair beside the bed. "Hey, Sport," his voice was gruff with emotion. "The doc says you're fighting Dean, please, just hold on," he begged. He grasped Dean's cool hand in his own and examined his son. Dean was still swollen from the steroids and his usually handsome features were hidden under the swelling. His complexion was pale and he was thankful there wasn't much yellow left to his skin tone at all. He could find some solace in the fact the liver was working.
One Hour Later, ICU
"Well, kiddo, I need to go check on Sammy, okay? I'll be right back." John wanted to run over and check on Sam. His room was across from Dean's and two doorways down, room 4B. If John arranged his chair just right from either son's room he could see into each room or at the least see when nurses and doctors were coming and going. Dean's room had been busy. They were having to adjust his epinephrine drip frequently in the last twenty minutes or so as they fought to keep his pressure and heart rate up. John reached down and ran a hand over Dean's hair. "I'll be right back."
John walked out the door only to stop suddenly as Dean's heart monitor began to beep wildly and then there was the horrible long wail indicating Dean's heart had stopped. John heard a nurse at the telemetry station call out Code Blue, Room 1C, Code Blue.
"We got another Code," an additional nurse from the telemetry station yelled out again. "We need two Code Teams, now!"
John stood paralyzed as he heard a doctor bark orders running into Dean's room and then it dawned on him that a Code Blue was announced for another patient, and then when he heard the room announced Code Blue, Room 4B, his heart clenched in his chest. In this moment he was losing both his boys.
"Dean? Sammy?" he whispered as he was escorted from the unit. He was provided a family liaison who sat with him in a private conference room. The floor knew the code blues were for his children and they thought it was best John be given a private room to wait on the news of his two young sons.
ICU, Dean's Room
"Charge to 360," Dr. Sadikov barked. "Clear!" Dean's chest convulsed upward in response to the electrical shock.
"No response. Still V-fib."
"Come on Dean … again at 360 … Clear!"
ICU, Sam's Room
"Christ!" Dr. Turner yelled. "Continue compressions," he barked to his young intern. He was on duty in the ICU tonight and was familiar with the Winchester boys and that Sam had donated part of his liver to save his brother and had had complications in surgery. "Push an amp of atropine." He glanced at Sam's saturated bandage. "Dammit, stop the heparin, he's bleeding out. Get a blood count on this kid," he yelled. "I think he may be hemorrhaging. His belly's hard as a rock … we got a bleed on our hands … a bad one."
"He's in V-Fib," the intern glanced at the heart monitor.
"Charge to 300," Dr. Turner called out. "Clear!"
"No response. Still V-Fib."
"Charge to 360," the doctor commanded. "Clear!"
ICU, Dean's Room
"We got him back," a nurse called out as she looked at the monitor. The doctor glanced up to confirm the heartbeat and watched as the rhythm dropped.
"Dammit, he's decompensating. Lost his pulse again. Start compressions. Charge to 400." The activity around Dean was at a fever pitch. "Clear!"
"No response."
"Dean," the doctor's voice commanded. "You're not doin' this kid. Come on," he ordered. "We're going again at 400 … Clear!"
ICU, Sam's Room
"Hold compressions," Dr. Turner ordered and looked at the monitor. "Page, Dr. Broden, now!"
"Still V-Fib," the intern called out.
"Charge to 400 … come on kid … Clear!"
ICU, Dean's Room
"Got a pulse," a nurse called out. "He's back." Dr. Sadikov looked at the monitor and watched … the heart rate was holding. He let out a breath. "Increase his drip another 2 cc's."
"Dr. Sadikov," a nurse looked at one of Dean's monitors.
"Yes?"
"He's spiked a low grade fever … 101." Dr. Sadikov rubbed his eyes. "Page Dr. Jessup and run a blood work up."
"You think he's in rejection?"
"I hope not," Dr. Sadikov replied as he listened to Dean's chest with a stethoscope and frowned. "Why you're at it call x-ray and get a portable chest x-ray on him. His lungs sound wet and I think I heard some crackles."
"You thinking pneumonia?"
"Sounds like it, as if this kid needs one more thing to deal with."
ICU, Sam's Room
"Got a pulse," the intern called out as he glanced at Sam's heart monitor.
"You're kidding me," Dr. Turner looked at the monitor. "40? Start supplemental compressions before he code's again and let's get this kid to the OR. Push 4 cc's of epi." They urgently rolled Sam's bed out of his room as one staff member continued to ventilate Sam while the intern straddled Sam on his bed and continued compressions as the rest of the staff whisked them down the hallway toward the OR.
"Dr. Broden is meeting you in the OR," a nurse called out to the fleeing group. Dr. Turner waved his hand in reply.
One Hour Later, ICU Private Conference Room
John's stomach was in knots as he waited on word of his boys. The liaison had told him that Dr. Sadikov was on his way to provide news on Dean and Sam. There was a brief knock at the door before it opened. John stood up. The doctor offered a thin smile, "No, John please sit." He encouraged as he slid into a seat across from the worried father.
"My boys," John's voice wavered despite his best efforts to sound strong. "What's happening?" Dr. Sadikov took a breath and began.
"Dean is stabilizing. His blood pressure appears to be holding. We are trying to wean him off the epinephrine drip but we're playing it as we go. The drop in pressure precipitated an arrhythmia that caused Dean to arrest. We were able to reestablish a pulse. However, Dean has developed pneumonia which isn't an unexpected possible complication especially with a patient that is on immunosuppressants and has undergone recent major surgery…"
"Pneumonia? What are you doing for him?"
"I've started him on a course of IV antibiotics that should target the pneumonia. He has bilateral pneumonia, which means he has it in both lungs, but I'm confident that the new meds will work. He's running a low grade fever that we're keeping tabs on."
"Fever? Is he in rejection?" John had read the brochures and listened to the doctors and fevers were always a concern.
"Currently he isn't showing signs of rejection and Dr. Jessup was pleased with Dean's new blood work up, so for right now we just need to watch his pressure and get his pneumonia under control."
"But, he's so weak now … how can his body cope with the infection?"
"I won't sugar coat things John," the doctor hedged. "Dean's in bad shape and this infection is just one more thing his body has had to deal with. He's holding on and we're trying to give his body as much support as we can to get him over this hump."
"What about Sammy?" John needed to shift his focus but it was merely shifting from one waking nightmare to another.
"I spoke with Dr. Broden in the OR … Sam …" his voice was hesitant.
"Dammit," John replied under his breath. "Just tell me about my son."
"Sam has been on a drug called heparin since his procedures for the clots. They wanted to keep his blood thin to prevent other clots. Dr. Broden said that Sam had a bleed occur at an internal suture and then the suture ruptured and Sam began to hemorrhage quite heavily. His abdomen became distended and firm very quickly and he went into cardiac arrest due to the rapid blood loss and the dangerous drop in blood pressure that occurred as a result of the hemorrhage."
"He's bleeding internally? Because of a damn drug?"
"Partially, yes, but the drug was necessary John. They have taken him off the heparin and have given him a small dose of a clotting factor. They are using the rapid infuser in the OR trying to get Sam's blood volume up and Dr. Broden is suturing the new bleeds." The doctor was about to continue when the phone rang. The liaison stood and answered it, her face flitted to both men and she motioned for the doctor.
"Dr. Sadikov you need to take this."
John tensed. He knew something was wrong with one of his boys. He watched the doctor's expression which remained strained and his shoulders were tense. He couldn't make out the hushed responses. The doctor hung up the phone and sat back down.
"John," he began hesitantly, "it's Sam…"
"Please," John choked out. "No…" his mind already playing out the scenario in his head. His baby boy was gone. Lost to him forever.
"No, no …" the doctor tried to assure. "He's alive for now, but…"
"But, what?" John barked.
"Sam's heart stopped in the OR again. They put him on bypass while they try to get the bleeders under control and transfuse him. They're hoping the dose of clotting factor kicks in to help Dr. Broden."
"And, if it doesn't…" John felt like the room was swinging side to side.
"John, if they can't get his volume up and the bleeding to stop, so that his heart can properly fill and be restarted … they'll arrange for you to see Sam before they remove him from bypass…" John turned stricken eyes to the doctor.
"See him? Before they remove him from bypass… for what," he bellowed. "To say goodbye?" his voice ended on an agonized whisper.
"Yes." The doctor's reply was quiet and it filled John's soul with a cold and hollowness he had never felt before, not even at the loss of his beloved Mary. Sam was his child, his youngest, this was Sammy.
One Hour Later, ICU, Dean's Room
John sat at his son's bedside stroking his forehead and right flushed cheek with a thumb. "You keep fighting Dean. Everything is going to be okay," John's heart was split in two. One half was with Sam in the OR and the other was here with his firstborn. "Hey," John looked at Dean and a soft smile crept across his face. "You remember that song you used to love for me to sing to you when you were little? You always asked for it on the nights it was my turn to put you down instead of your mom." John leaned close to Dean's head as he sat in a chair. He stroked Dean's forehead in a regular pattern. "You loved that song," he said with a smile. He leaned closer to his son's ear, so that father and son had as much privacy as a busy ICU would allow them. John began to hum and then he started to sing softly to Dean.
"Oh, give me land, lots of land under starry skies above, Don't fence me in," he continued to stroke Dean's forehead as he sang. His eyes misting with unshed tears. "Let me ride through the wide open country that I love, don't fence me in," John choked back a quiet sob as he looked down on his child … swollen from steroids and pale except for the flushed cheeks reminding him that his son was battling an infection. The breathing tube rose up from Dean's mouth and the rhythmic click and whoosh sounded in the background reminding John that a machine was helping his boy breathe and it made him ache with the reality that his child actually needed help to breathe. "I'm here Dean," he spoke softly. He cleared his throat and started singing softly again as he leaned in close once again and stroked his son's hair.
"Let me be myself in the evenin' breeze, and listen to the murmur of the cottonwood trees, send me off forever, but I ask you please, don't fence me in …" Silent tears cascaded down his cheeks as his strength began to weaken and the tears fell freely. He fought to finish Dean's favorite part of the song, so he skipped ahead. "I want to ride to the ridge where the west commences and gaze at the moon til I lose my senses, and I can't look at hobbles and I can't stand fences," his voice shook. "Don't fence me in … No …" John leaned forward and kissed Dean's temple as his mouth hovered near his child's ear. He took a shaky breath and said the final line, "Poppa, don't fence me in …" his voice cracked inside his throat and his face crumbled as it fell forward into his hands and he cried.
Two Hours Later, ICU
John woke with a start. He hadn't realized he'd fallen asleep. "Mr. Winchester," Jan spoke softly. "I didn't mean to startle you, but Dr. Sadikov and Dr. Broden are in Sam's room and would like to speak with you."
"Sam? He's out of surgery?"
"Yes, and he was just resettled a short while ago." John looked at Dean and touched his son's head gently before walking across the unit floor to Sam's room.
The doctor's looked up from charts and machines as John walked into his son's room. "My God," he breathed as he took in Sam's appearance. He was stark white almost, bloodless. His chest was exposed and the blanket and sheet were folded down at his waist. John could see gauze and surgical coverings on Sam's abdomen, wires running from his chest to the heart monitor. There were small coverings near his neck, as well.
"I know he looks like hell," Dr. Sadikov relented. "The coverings near his neck will be removed in the morning. They are from the bypass procedure."
"How is my son?" John asked with a voice far stronger than he felt.
"I was able to get the bleeders under control and the clotting factor started to work. We had a little trouble getting him off bypass, but he rallied," Dr. Broden answered.
"Trouble?" John studied the physician's face.
"Well, Sam is incredibly weak and his heart took a few minutes to respond and begin spontaneous profusion." John looked up at his child's heart monitor and saw that his heart rate was 58. Not great but considering what his child had been through at least it was beating.
"He's okay now? The bleeding is stopped?"
"The bleeding is stopped and we were able to transfuse him. The coma remains very deep. He took six units of blood and we'll watch his counts. I may have them hang a bag of platelets, but I'll play it by ear. I've stopped the anti-coagulants he was on."
"You mean the heparin?" John clarified.
"Yes." Dr. Broden answered.
"John, Sam is holding on," Dr. Sadikov assured. "He's fighting very hard." John nodded. The doctors talked to John about a few other details, but all he wanted was to sit with his son and touch him to assure himself that his baby son was still among the living, although judging by his appearance that could be debatable. John was finally alone with Sam and he held his limp hand in his own. He chaffed the cold hand between both of his own trying to infuse his son with warmth.
"Hey, Sammy," John's voice was soft and hesitant. "The doc says you're fighting. I'm proud of you kiddo. I know you have to be tired, but just hold on, okay?" He stared at his child and found it hard to believe that only two days ago the transplant surgery had happened … it felt like an eternity to John Winchester.
Four Days Later, ICU
"What is this procedure again?" John was bone tired and stressed to his breaking point. He stared at a pile of daunting consent forms.
"It's called ECMO, John," Dr. Sadikov began. "Here I'll let Dr. Castle who is our ECMO specialist fill you in on the details once again.
"Mr. Winchester, Dean's pneumonia is clearing up, but as we discussed earlier his lungs are over taxed and his oxygenation has been becoming poorer despite the increase in vent settings and he is receiving 100 percent oxygen. Basically, Dean's lungs are heading for failure and they need a rest, and ECMO will provide that break." John sat and listened.
"ECMO stands for extracorporeal membrane oxygenation. It's similar to a heart-lung bypass machine … ECMO is literally a temporary artificial lung and heart for your son, however, his heart doesn't need support, so we'll only be utilizing the ECMO to take the place of Dean's lungs. I will … provided you give consent start Dean on the type of ECMO called VV or veno venous … where a single catheter is placed in a vein in his neck and this will provide support for his lungs. I'll be using his jugular vein. It will oxygenate the blood for him and return it to his body, so his lungs will get a break. His vent will be dialed back a great deal, as the ECMO is taking over for his lungs."
"And, he needs this?" John hated putting Dean through another procedure.
"Mr. Winchester, Dean's lungs will fail and it's my belief that ECMO is what he needs right now."
"John, Dr. Castle's right," Dr. Sadiokov responded. "His oxygen levels are decreasing every hour and his heart is working overtime to compensate for the strain. If we don't act now … Dean's lungs will fail and he'll go into cardiac arrest … there won't be anything we can do if his lungs won't work."
"How long will he have to be on it?"
"7 to 10 days most likely, but depending on his response to ECMO and his physical condition it could be needed a bit longer." Dr. Castle answered.
"Does he need to go back into surgery?"
"No, we administer a small anesthetic and this procedure can be done in his room."
"What are the risks?"
"We will have to give Dean heparin to thin his blood, so that it can go through the ECMO machine easily without clotting and there is a chance that it could lead to bleeding problems, there have been some neurological, such as bleeding in the brain, but I assure you Mr. Winchester ECMO is used as a last resort and it is a procedure where the potential benefit outweighs the risks."
"But, heparin is what put my other son back in the OR for hemorrhaging," John's eyes were hard.
"Sir, I understand your hesitation, but in my three years of being strictly involved with ECMO I haven't run across a massive bleed in an adult. I have seen a few brain bleeds, but even then mostly I have seen them in babies that have been on ECMO. Dean needs this procedure … it's his best chance at survival right now." Dr. Castle spoke with confidence.
"How soon before you do this?"
"I'd like to get him on ECMO within the next hour or two. I'll have the room closed off to keep the field sterile and myself and a specialized ECMO nurse will complete the procedure and once it is complete you'll be allowed in and can sit with him. He'll be constantly monitored by an ECMO profusionist who will be in his room most of the time monitoring the equipment and your son. There will be a shift change, but he will always be monitored while on the ECMO. I will see him more than once a day and aside from the profusionist he'll also have an ECMO nurse that will take over his primary care while on ECMO."
John nodded. His hand slid over to the paperwork and he scribbled his name across multiple forms giving permission to have Dean put on ECMO. The doctor gave John a detailed brochure on ECMO with diagrams to read and keep. "If you have any questions or concerns at any time Mr. Winchester, please don't hesitate to ask or have me paged if I'm not already on the floor."
"Thank you."
Five Days Later, ICU
John walked into the ICU from a small family sleep room they had given to him. The doctors had forced John to take breaks and rest. The small private room was often offered to a family that had a critically ill family member that would require a lengthy stay. It had a large couch with a pull out bed, and reclining chair, TV, phone, and a small bathroom. The staff had felt John needed the room and it was just outside the ICU, so he was given use until it wasn't needed anymore. He had fought them on it because he didn't like not being near his boys, but he had also looked in the mirror and realized if he didn't take a little time for himself he wasn't going to be any good to his boys.
John looked at Dean's door and saw the sign, Sterile Procedure in Progress Do Not Enter; it wasn't something he was unfamiliar with. He knew that meant the doctor was in there examining Dean and doing something with the ECMO. Dean had responded well to the ECMO, although Dr. Castle had told him just the other day that he'd like to keep Dean on the ECMO another 3 to 4 days before he tried clamping Dean off for a few hours to see how he did. John had read the brochures and asked the questions, he knew the term clamping off meant it was just a trial period to see how his son's lungs were responding. He knew if things looked positive in a few days and the clamp off had positive results that they would see about removing the tube from his son's neck.
He walked toward Sam's room. Things had become more complicated for his youngest. Two days ago Sam's oxygen levels suddenly began plunging and the doctors had found that Sam's lungs were collecting fluid which was hindering his oxygen uptake. So, they had to insert two chest tubes into Sam. John sat down next to his baby boy and looked him over. He looked horrible. He was so pale that he appeared translucent. His chest was exposed as it had been for days now. He did notice that the surgical dressing had been downsized on his abdomen. He observed the chest tubes that had each been sutured into place on each side of Sam. He looked at their output and frowned. He was hoping to see that the fluid buildup was stopping, but he could see that each tube was still putting out fluid, although it wasn't as heavy as before. He had long ago had to adjust to the tubes snaking into his son … one was his ET tube that jutted from his son's mouth that was hooked to the ventilator and the other was his nasogastric tube that disappeared into his son's nose and went into his stomach. The nurse had been providing liquid feeds to Sam via the tube, but John had asked to help and now he often fed Sam through the tube. Dean had one, as well, and he had taken to feeding his oldest, too.
"Hey Sammy," John spoke softly. "How ya doin' today kiddo, huh?" he had resorted to talking to Sam as if he were awake and he was just making small talk, but more times than not he found himself apologizing for not giving him and his big brother a better childhood. "I'm thinkin' it's time you open those puppy eyes of yours," he suggested lightly. "So what do you say?" He squeezed his son's hand. John wasn't expecting a response, but he hoped for one anyway.
"Mr. Winchester?" John looked up and saw Dr. Castle.
"Is Dean okay?"
"Yes, he's fine. The ECMO has improved his oxygen levels and it's clear we're headed in the right direction. There has been no evidence of any bleeds or neurological dysfunction. He's tolerating the treatment quite well." John offered a small smile. It was actually some good news for a change. "You can see him now if you like." John nodded.
"Thanks."
Two Days Later, ICU
John stood at Sam's door as he watched the doctor inflate the cuff pants they had put on his son and hooked to a machine. The doctor had explained that the pants would inflate and deflate rapidly for a period of thirty minutes each hour. "John," Dr. Sadikov started as he finished hooking Sam up and giving his care nurse the parameters of the machine. "This will help to stimulate the circulation in Sam's legs to prevent any clots from developing due to his lack of movement; also this will help to increase blood flow to his heart."
"Yeah," John was tired and he'd already read the material on the treatment. "How long you going to do this to my son?"
"Thirty minutes every hour they will start the machine and the pants will do their thing automatically. It's going to be a standing treatment for a few days. The pants Velcro open and closed quickly, so between treatment times we'll open them, so Sam's skin gets some air." John only nodded.
Five Days Later, ICU
Dean had been on the ECMO machine for twelve days now and John sat at his side. He still felt nauseated at the site of the tube in his son's neck. Dean had been clamped off for five hours now and Dr. Castle had looked positive.
"Things are looking great Mr. Winchester. In fact, I'd like to see about trying Dean on an idling flow for the remainder of the day and if his lungs are functioning at parameters they should be then I'd like to see about decannulating him tomorrow." John smiled.
"Really?" It felt foreign to him that his life had become a slew of medical terms he had learned. Decannulate, Idling Flow, arterial blood gas test, clamped off, nasogastric tube the list was endless but he knew each one of them now, and he knew that decannulate meant the doctor would remove the tube from Dean's neck and his son would be off of ECMO.
"Yes, really," Dr. Castle assured. "He's doing fantastic. I'm thrilled with the ECMO result we achieved with Dean." The doctor excused himself and John sat by his firstborn. It was hard to believe that sixteen days had past since the transplant surgery.
Seven Days Later, ICU
John watched Sam and worried at his red cheeks and pasty complexion. They knew Sam had contracted an infection, but the extent of the infection or what kind hadn't been determined yet and he waited to hear the blood test results. Sam's condition had been on a steady decline and he wasn't missing the concerned looks from his son's care staff including Dr. Sadikov. He looked at Sam's surgical site. It had closed and the sutures were dissolving. The bulky bandage had been removed. John looked at the lengthy scar wanted so desperately to make everything better for both of his boys. Sam's chest tubes had come out a few days ago and he was thankful for that small bit of good news. Although, the healing sutures on his son's sides were a reminder of the previous chest tubes. Dean was off ECMO and had begun triggering the vent just two days after coming off ECMO. They were weaning him off the ventilator slowly. He was improving and the swelling from the steroids had gone down a great deal. John could recognize his son's handsome features now. Dean had begun making purposeful movements four days ago and the staff felt confident he'd wake from his coma soon.
"John," Dr. Sadikov walked in with Sam's chart and papers.
"How is he? How's Sam?" John wasn't comforted by the doctor's expression.
"The infection is in his blood, John."
"You mean septicemia?" The doctor looked taken aback by John for a moment. "I've been reading pamphlets," he added. "You're talking blood poisoning, right?"
"Yes, and no," the doctor added. "Usually, septicemia is bacterial based problem, but it appears that Sam has developed a staph infection and it's systemic."
"But, you can put him on antibiotics now … you know what it is you're dealing with, so you can take care of it," John looked at the man with hopeful eyes.
"John, we'll start Sam on a strong course of antibiotics, but the comprehensive blood tests have given me some worrisome results."
"Like what?"
"There is evidence that the staph is attacking some of Sam's organs, there are signs that his heart and kidneys are getting hit and his liver enzymes taken on the remaining lobe are showing slight compromise due to the infection. He's been through so much and his body simply isn't equipped to fight this infection."
"What are you saying?" John looked at his son with anguished eyes. The doctor took a breath.
"John, it may be time to step back and…"
"And, what?" John hissed under his breath as he saw the DNR papers attached to Sam's chart. "What? Sign those papers? Stop treatment and let him die?" His rage was barely contained.
"It would be letting him go John. Neurology believes that despite the EEG results showing that brain activity remains albeit it fits with the activity consistent with a deep coma, they believe that Sam is in an irreversible coma."
"I don't give a damn what they say … my boy is fighting with all he's worth, and you're going to damn well help him fight." The doctor nodded. "And, this hospital can take those DNR papers and shove them up their ass." The doctor blinked in surprise, but he understood the desperate feelings John must be having.
"We'll proceed with the IV antibiotics. We'll be aggressive in his care," he assured. John offered a curt nod.
Later that Evening, ICU
Sam was having an exam by a doctor that specialized in hospital acquired staph infections of patients and he'd been asked to leave, so he sat with Dean. "Hey, Sport, you're lookin' good," he offered. "You'll be beating the ladies off with a stick pretty soon." John held Dean's hand and nearly jumped out of his seat when his son's fingers curled around his own. "Dean? Son, can you hear me?" John stood up and leaned over his son touching his forehead and then he watched Dean's eyes move beneath his eyelids. "That's it Dean," John encouraged. "Come on son, open your eyes … you can do it." John's heart was pounding in his chest. He continued his gentle urgings. Dean's brow creased and it was then that John knew his son was on the edge of consciousness. "That's it kiddo, come on…"
It was as if a weight had been lifted as he watched Dean's eyes flutter rapidly and finally open. Dean's tired eyes blinked sluggishly as sleep pulled at him once again wanting to take him back under into sleep. "No, Dean, open your eyes, focus on me kiddo." Dean's eyes opened slowly and miraculously settled on his father's face. John could see Dean focusing and when he saw the recognition in his son's eyes he smiled. "Welcome back son," his voice was warm and thick with emotion. As Dean came fully into consciousness he became acutely aware of the tube down his throat and he reacted with violent gagging. John called for help and was ushered out while Dean was tended to by the staff. He stood outside with his gaze alternating between each of his son's room. Sam's door was still closed and now he felt desperate to be with one of his children. Dean's door opened a few minutes later.
"Well?" John's face was hopeful. "How's my son?"
"I extubated Dean from the breathing tube and he's actually oxygenating quite well and I have him on regular room air." Dr. Sadikov responded.
"No oxygen?"
"No oxygen," the doctor confirmed. He lowered his voice, "I think it's best he doesn't know about his brother for a while. His recovery could be drastically compromised. He's still critical John, but he is out of the coma and getting stronger."
"Is he awake?"
"In and out," the doctor answered. "He'll have questions once he becomes more coherent. Be honest, but leave out the fact the transplant came from his brother until I feel he's strong enough to hear, okay?" John nodded. The doctor and John talked for a few more minutes and then John was aloud in to see his son. He sat quietly down in the chair beside his bed. He put a hand on his son's arm and smiled. Dean stirred and opened his eyes. John made eye contact with him and smiled.
"Hey son," he replied softly. Dean began move his mouth, "No, Dean, don't try to talk now, okay. I'm here. Get some rest." Dean offered a small smile … it was a dim comparison to his usual 1,000 watt Dean Winchester smile, but it filled John with joy nonetheless. John took Dean's hand in his own and squeezed gently. "Rest, Dean, you're okay," he assured. Dean wrapped his fingers weakly around his father's as his eyes drifted closed and he succumbed to sleep.
Twenty-Minutes Later, ICU
"Mr. Winchester?" Dr. Cruz, the Staph infection specialist spoke softly at the doorway to Dean's room. "I hate to disturb you, but I'd like to talk to you outside." John nodded and closed Dean's door behind him as he left.
"My son, how is Sam?"
"The IV antibiotics need a chance to work and in the interim we are using various different drugs to help support his body. Sam's infection is systemic as you already know and staph doesn't discriminate on where it wants to attack, so we are being vigilant." John could hear the rhythmic inflate and deflate of the cuff pants on his son.
"You're using the pants again?"
"Yes, Sam's cardiac output has decreased and I consulted with a cardiologist on staff that recommended we reinstitute the pants in an effort to increase blood flow back toward the heart in conjunction with a couple IV meds to help his heart."
"What's wrong with my son's heart?"
"Well, as you were told there is evidence that the infection has attacked his heart among other organs and we are trying to prevent any heart tissue death."
"You said," John rubbed a hand over his eyes. He felt dizzy and fought to focus on the doctor who kept fuzzing in and out. He hadn't really been sleeping or eating that much the last few days since Sam's condition worsened and he wanted to be near both his boys and not in that little room the hospital had provided him. "His heart output is decreased … what does that mean?" The doctor eyed John and could see there was a problem.
"Mr. Winchester," he reached a hand out. "Maybe, you should sit down before you fall down. When was the last time you slept or ate?"
"I'm fine," he groused. "I asked about my son's heart output." The doctor relented, but kept a watchful eye on his patient's father.
"Sam's heart isn't pushing out blood as efficiently as it should. His heart muscle is tiring from the strain of trying to profuse his body and circulate blood. The pants should help force blood back toward his heart and hopefully improve its output and help with some of the heart strain he's under due to the infection."
"Can he go on ECMO? The kind for his heart and lungs? It helped my other son when he just needed help with his lungs. Maybe it will give him time to get stronger," John offered as the room seemed to tilt on its axis and he shook his head slightly trying to clear the thick fog settling.
"If it weren't for the staph infection ECMO could have been an option, but I'm sorry because of the staph infection in his blood he isn't a viable candidate."
"4B is having a run of PVC's," a telemetry nurse called out from her station of ICU monitors as a code team started to roll a crash cart toward the room, Sam's room. Dr. Sadikov was already on the move and spared a glance at Dr. Cruz and John.
"My boy…" John took an unstable step toward Sam's room. "Sammy…" even in his current overly exhausted physical state and foggy brain he knew PVC's meant Sam was having a kind of heart arrhythmia, but his heart was still beating. He wished he hadn't learned all the different medical terms he had, but with two children both fighting for life he had to know them.
"Code Blue, 4B, Code Blue," the telemetry nurse called out which sent a few other people into action and they ran for Sam's room. John knew in that moment his young son's heart was no longer beating. He felt his heart race, its pounding pulsing in his ears, and just as quickly his world grayed around the edges and was quickly swallowed by darkness. He vaguely recalled hearing someone nearby speaking urgently at him and then all encompassing darkness consumed him.
To Be Continued
I haven't started chapter 4 yet, but I will soon. I will try to post again next weekend or sooner if time permits.
I hope you enjoyed chapter 3. Thanks for reading, I appreciate it!