Devonshire Squires Chapter Thirty
Time.
It could be both a friend and an enemy.
Four minutes into the ambulance run, as they turned onto Commercial Road, Sherlock stopped seizing. John looked at his watch and announced, "twelve and a half minutes." The paramedic in the seat alongside the trolley noted it on the paperwork. Too long.
The small woman was the driver, and as the ambulance swayed and bucked on its heavy-duty shock absorbers, John fought a wave of nausea, and focused on the blood pressure cuff. "sixty seven over forty three". Too low.
"Pulse is one sixty four." Too high. But Sherlock's finger tips and lips were not blue. True he was sweating profusely but that might be fever, not hypovolemia.
The medic handed him the digital ear thermometer. He inserted it carefully, waited for the beep and then read the digital display out loud: "forty point three." She noted it down. Way too high.
The second bandage was now showing signs of red bleeding through, but not at a rate that would suggest arterial. Not too bad. But he wouldn't rule out a nick in the external jugular vein, not yet anyway.
The finger pulse oximeter was showing sats of 83 percent, probably caused by the rapid shallow breathing. "Tachypenaea," which was duly noted. Not good.
Septic shock? Or blood loss? He was blind with just the symptoms, and needed better equipment now.
"How long now?"
The big blonde peered through the small window, and turned back to him. "Depends on traffic. But, even at this time of night, we'll be cutting it fine."
oOo
Time flies.
According to the clock on the wall of the resuscitation room at The Royal London Hospital, they'd been here for twenty eight minutes. John was standing at the back, watching the trauma team do their jobs, trying to stay calm.
The x-rays displayed on the digital screen showed a dislocated twelfth rib, located over the right kidney. Blood samples had been taken and a whole barrage of tests ordered, from tox screens and electolytes to BUN, serum creatinine and GFR tests for renal failure. A CT scan might help figure out whether the shallow breathing had led to a chest infection or vice versa, and to rule out another possible cause from a damaged diaphragm muscle- but that had to wait its turn in line. Or it might be an infection in a bruised kidney that was causing the temperature spike. The patient was severely dehydrated, but what fluids they were pushing weren't showing up in the renal output yet; the bag on the side of the bed connected to the Foley catheter was showing only a trace of cloudy pink liquid; the tell-tale sign of kidney damage. He tracked the team's movements, ticking off each procedure, each result, against his own preferred timetable. He kept quiet, knowing that his presence in the room was a mere courtesy, and that he could be expelled if he interfered. Being here was better than being out there; he'd suffer in silence for the chance to observe.
They were on the case, but it was going to take too long to sort out all the symptoms from the underlying causes. The battlefield trauma surgeon inside his head was screaming for attention. With blood pressure still tanking, it was only a matter of time.
John distracted himself from the tick-tock of his internal stopwatch by thinking about the moment that they'd cut off the blood-stained hoodie, sweat soaked tee shirt and then removed the trousers. The rainbow of bruising around Sherlock's waist and back had been shocking. That and the dislocated rib must have meant he was in constant pain every time he drew a breath. And yet he did nothing; didn't reach out to me. A whole week of increasing debilitation, and he'd never once sought John's help. All the time in the world to avoid ending up here, but he hadn't taken it.
Sherlock's delirious exchange with Mycroft had told him more about what was going on in that head than any conversation they'd had since he'd returned, and quite possibly more than they'd ever talked about, even before he went AWOL.
That's what John had settled on calling it when talking with Mary. Not a "fall", more of a willful jump. But that wasn't the half of it. The disappearing act for two years? Not a "hiatus", because clearly Sherlock had been rather busy during the whole time away. Before tonight, he'd thought that AWOL was the right term- he'd not given his permission to go, so the consulting detective had been absent without his leave to do so. In his own misery and then anger about that fact, he'd not really thought about what Sherlock had endured while away. Sherlock had not said a word about China, or about Serbia for that matter. John made a mental note to talk to Mycroft about both. He needed to know more. But not now. Now's not the right time.
"Another unit, please." The consultant's request was calm, but drew John away from his thoughts like a shout. IV blood and fluids were being pumped into Sherlock to try to control the haemorrhagic shock, but the rate of blood loss was not reducing, which meant that surgery would be needed. Sherlock had been intubated as soon as he arrived; the blood ox levels were too low to avoid it. If he was right, the exterior jugular over the sternocleiodmastoid muscle had been nicked, it would need suturing, if not a graft.
He waited for the next order from the trauma team. Come on; it's about bloody time you admitted it.
He got what he was waiting for a moment later, when the consultant said, "Get on the phone; the vascular surgeon was due down here ten minutes ago, and we can't wait much longer. I need an acute surgical admission now."
At last. But, this was the NHS; how long would Sherlock have to wait? John's internal stopwatch started ticking louder.
oOo
Time can crawl.
Surgery was performance under pressure; a delicate act of timing. Knowing just how much time under your knife the patient could tolerate, and for how long the means could be withstood in order to achieve the desired ends. Surgery was a brutal business and always cost in the short term, but it was a price worth paying to get long term survival. That's what had attracted John to it in the first place, of all the medical specialisations. One knew by the time the patient was wheeled out of the operating room whether the operation was a success. Of course, things could go wrong later, complications could set in. But, during the operation there was feedback about your progress at every moment. Monitors and the support team kept the surgeon fed with a steady stream of information, beyond what he could see with his own eyes and feel with his own hands. Even the silence inside an operating theatre was reassuring; no news meant good news.
In a waiting room, there was nothing except a clock on the wall that told you how long you should have been in there rather than out here, how long you'd not heard anything at all about what was going on. Mary understood that, and she stayed with him, calm, quiet- her presence a comfort in this most uncomfortable time. She didn't try to utter any platitudes about how Sherlock would be all right. Outside of an operating theatre, no news was just that- no news. It could be that things were going terribly wrong in there, but they would be none the wiser out here, until it was too late, and they'd run out of time.
He'd always thought it would be easier for non-medical professionals. At least they wouldn't be plagued by thoughts of what exactly could be going wrong in there. But, watching the time taking its toll on Mycroft Holmes, John wasn't so sure. The man had stood for a while, sometimes using his phone, uttering monosyllabic comments in response to a conversation that was impossible to follow from this end. In between telephone calls, he paced. Then he sat, but fidgeted. Finally, he'd loosened his tie.
Mind you, Mycroft probably didn't have to wait for many things. When you sat at the top of a national and international intelligence system, what you didn't know probably didn't exist. Or, at least it could be found out if you shouted loud enough. It was different here. He wasn't shouting because there was no point, and he knew it. John didn't interrupt whatever thoughts Mycroft was thinking about the limits of his power.
John kept silent, knowing that nothing he could do would move those clock hands forward any faster.
oOo
Time passes.
John stopped watching the clock, because it was driving him mad. He timed things differently. How many times Mary had been to the coffee machine, and then a short time later her visits to the loo- four so far. Or how many times Mycroft went through his routine of pacing, phoning, sitting, fidgeting- John gave up after ten. The tie had been removed and the collar unbuttoned.
John knew he'd been awake all night because it always distorted his sense of time. He'd learned back in his days of being on-call at night to divide time between light and dark, because that was all that really mattered. Only when it was light enough to be able to see outside would he dare to look at the clock to see how much time was left before the end of the night shift. Only then would he allow himself to think that he'd survived another night without a patient dying.
It was still dark outside when someone came to tell Mycroft that Sherlock was in post-op. But no one was available to talk to him yet, until the patient's "other issues" had been dealt with. It wasn't a straight-forward surgical procedure, and he might have to go back into theatre for something else.
Dawn had already started to soften the edges of the blackness at some point, just before they were told he'd been moved to ICU. Sometime before the black became grey, Mycroft was summoned to talk to a consultant. When he returned, his face was unreadable.
Mary was the first one to break. "For God's sake, tell us what's going on."
A flicker of something- perhaps annoyance- crossed his face. "I'm not a medical specialist. You would know more about what it means."
John crossed his arms and glared. "Then tell me exactly what they said, and I'll tell you what it means."
Mycroft then reeled off what sounded like a perfect repetition of what had been said to him:
"He's critical, but stable. The injury to the exterior jugular vein has been repaired, but there may be nerve damage, and the sternocleidomastoid muscle was sliced, too, although not severed. An infection, probably started in the dislocation of the costotransverse joint, which combined with renal contusions, set off complications. He's at A.K.I.N. stage two, whatever that is. The chest infection is secondary- no compromise to the diaphragm caused it, but tachypnoea is still present when they tried to extubate him, so he's back on a ventilator. The last temperature reading was 39.5. The tox screen came back positive for opiates and cocaine. He's receiving bloods, fluids, IV antibiotics and lorazepam…The rest was just platitudes and different ways of saying that they don't know what his prognosis really is."
He glared at John, who had stood up. "Translate, please."
John wondered how much it had cost Mycroft to admit that he didn't know everything and had to ask for help in understanding the significance of all that medical jargon. The doctor thought for a moment, and then put it into words. "Okay, in the right order, this is what happened. Last Friday, Sherlock was in a fight when Stuart Bradshaw, otherwise known as the Cunningham Crusher, who kicked him in the back. It dislocated the twelfth rib, and damaged the cartilage between the bone and the vertebra. That's the trouble with the twelfth rib- it floats- not connected to the sternum, just to the backbone."
John found his right hand and forearm mimicking a spine, while his left shoved an imaginary bone further into Sherlock's body. "So, the blow freed the rib from the joint and shoved it into his kidney, bruising it; they won't know for sure how much damage has been done, but I saw blood in the renal bag in the trauma room. That said, if the bleeding was too severe then they would have operated after they finished the vascular suture. But an AKIN score of two says the kidney isn't working properly, and that will have all kinds of side effects affecting his recovery."
John drew a breath. "The pain from the rib and kidney would have been excruciating every time he took a deep breath. So he didn't. Shallow breathing for a week almost always sets off congestion in the lungs. The infection took hold; he's got pneumonia. He's probably been cutting down on the fluids, because it would hurt like hell to pee, and he'd see the blood in the urine. Knowing Sherlock, out of sight means out of mind, so he'd cut down on drinking water so he wouldn't have to think about it. Actually, that probably helped the kidney, but was bad news for the infection- made it worse. There is a real danger of septicaemia, which could kill him."
John looked up at Mycroft. "Sherlock would justify the morphine as self-medication. The cocaine would be used as a little 'pick-me-up' when five days of morphine took its toll on his deductive capacity. He'd ignore the fever, which by the time he got to the gym must have been hitting 40 degrees. The infection and the cocaine together would be a powerful push on body temperature, which probably made him seriously delusional- enough to pick a new fight with Alec Cunningham, who wanted to kill both of us."
The doctor crossed his arms and gave Mycroft an answering glare. "By the time you got there, Sherlock was hallucinating, high as a kite, in agonising pain and…not in his right mind."
Mycroft listened to the litany, before adding just a single word to the end of the list, "…suicidal."
Trying to fill the silence that now fell, Mary intervened. "We were lucky then that John was able to deflect Sherlock's attempt to cut his carotid artery. The seizure stopped him from fighting back. That's what the IV lorazepam is for, by the way- to stop any more seizures. The downside is that all that thrashing about would have damaged the kidney more if the rib was pushing into it."
She had moved between the two men, and looked from John to Mycroft, and then back again. "Now we wait. Time will tell."
oOo
Time could be cruel.
The next forty eight hours passed in a series of peaks and troughs. John stayed; Mary went off briefly to make sure the practice could cope with both of them being away, and then made regular relief runs to give John time to rest, wash and poke at some food as if he intended to eat it. Mycroft disappeared, but Ashley Lewis reappeared, and was on the phone entirely too often, still smarting no doubt from the reprimand in the gym. Every piece of medical news, no matter how tiny, was called through.
They hit the first trough when Sherlock's throat started to swell, making the intubation difficult. The choice was to do a tracheostomy or to extubate him and hope he would breath enough on his own after the first wave of antibiotics started to knock down the infection. That low was rapidly followed by a high, when he was taken off the ventilator and managed to get just over a barely satisfactory oxygen saturation level. Extubated, over the next four hours his sats improved as the fever retreated a bit.
Then the urologist consultant announced he wasn't happy with renal function; it wasn't improving. Tests showed pyelonephritis had set in, and the antibiotics weren't making as much progress in that department as they were with the pneumonia. An ultrasound scan was followed by a contrast CT scan, and the urologist conducted regular dip tests which showed that kidney function was not as much a problem as persistent bleeding was. So they scheduled a renal angiographic embolization procedure to block the bleeding artery, and hope that it would allow the kidney to recover. The alternative was to lose the kidney altogether. Sherlock was whipped back into theatre for the procedure. For the six hours after that, they held their collective breaths…
…and time moved on. He was moved out of the ICU to the High Dependency Unit. The regular tests started to show an improvement and the urologist announced at the end of the second night it had worked. Sherlock's blood pressure began to improve, and his temperature came down even more. He was moved again at five pm to a private room, conjured up from somewhere in a hospital whose general surgery wards were chock-full of patients. Just how Mycroft had managed that in an NHS hospital, John didn't dare ask. But, he was grateful.
Then, at the end of the forty eight hours of roller-coaster ride, Sherlock regained consciousness.
Author's Note: I've done my best with the medical information above, but I am missing my medical beta, the incomparable Kate221b. This is dedicated to her, in appreciation for all the help she has given me in FF and in RL.