So Long, GoodBye

by Dawn N

The Winchester family is faced with a possible tragedy concerning one of their own when a hunt for an entity leaves one of them with an illness that isn't supernatural.

8. Through a Glass, Darkly

Disclaimer: refer to chapter one

NOTE TO READERS: Thanks for all of the review, comments and PM's. I wanted to try and give you all a little longer chapter. You've all been great both in patience and support since the story started and I appreciate it. This chapter is around 10 pages long and I hope it meets expectations. Happy Reading, I hope!

So Long, Good-bye

Chapter Eight: Through a Glass, Darkly

By Dawn Nyberg

"…close your eyes and you will see who you used to be left without a warning, who knew one so big could grow so small lighter than the writing on the wall … here we live with bottles and needles and truth here is your living proof that death cannot be proud…" Lyric excerpt by Janis Ian, When Angels Cry

"Sammy," Dean stepped closer. "It's okay," he soothed, but Sam jerked the sheet back up covering himself.

"Sam, son, it's …" John's voice was tentative.

"Nnn…ooo," Sam's garbled speech was angry.

Dean would later realize that he would block the next thirty minutes out of his mind … the moment of fighting with Sam and holding his arms down as the young man fought being helped as he and his father tried to get Sam up and out of the wet bedding and get him cleaned up. He would block undressing Sam in the bathroom and lifting and sitting him in the tub as his father pulled the wet bedding, sheets and blankets up replacing them with fresh ones and a bed pad on top of the sheets and would put the others in the laundry. Dean had already had a small pack of 10 bed beds shoved in the hall closet that Sam didn't know about but John was both thankful and anguished over this simple pre-planning from his first born. Dean would block his little brother's quiet sobs and whimpers as he gently cleaned his brother up and redressed him in fresh underwear and clean sweat pants and a t-shirt all the while saying soothing words to Sam to try and calm him. Then it was over …

"Need my help getting him back into the room?" John offered quietly from the cracked bathroom door. Dean had managed to pull his brother up.

"No, I got him," Dean's voice slightly strained as he opted to carry his little brother rather than put him in the wheelchair. Sam was still heavy but it was obvious to Dean he had lost some muscle mass and some weight, too. "I got ya Sammy, you're okay," he soothed once again. Sam was quiet now and wouldn't look at his brother or father not that he really could anyway. Sam over the last month or so could barely hold eye contact without his eyes wandering off despite his best efforts to keep looking at someone or something, yet another loss due to PSP.

Three Hours Later

"Guys," Bobby broke the silence around the kitchen table. Sam had fallen into an exhausted sleep back in his makeshift room in the library.

"I know, okay," Dean spat quietly. "I'll call Finley and ask him to make some arrangements."

"Dean, son we're not giving up, alright? I haven't stopped calling contacts and following possible leads but we have to keep Sammy comfortable and what happened today…"

"Look I know, okay? You think just 'cause it wasn't me on the receiving end of that experience that I don't know how much it hurt him, embarrassed him, but he shouldn't feel…"

"I know we don't think he should Dean but he's an adult and he feels he's lost what bit of control he had and dignity." John offered quietly. He couldn't believe those words were coming out of his mouth especially in relation to his baby son, but they were. "We liked the care brochure for that company, Comfort Keepers do you want…"

"I don't want," Dean answered abruptly but he sighed and remembered Sam's explicit wishes and that Dean had agreed to follow Sam's wishes and with Sam's Healthcare Power of Attorney entrusted to him by his little brother he wouldn't let him down. "I know what he wants, it's just…"

"I know son, I know," John tried to comfort. "Do you want me to call the doctor and you sit with Sammy?"

"No, I got it," Dean pushed himself stiffly up from the table and walked into the family room to make the call.

One Hour Later

Dean sat by Sam's bedside. "Hey kiddo," he offered lightly at his brother who was looking out the window as best he could. "I talked to Dr. Finley, okay? Sammy, it's not time to take you anywhere … remember you agreed to try healthcare aides and nurses?" Sam turned his head toward his brother. His eyes met his brother's for one glorious moment and drifted off again not keeping solid contact. He nodded.

"Rrr …remember," he forced out.

"Sammy, they're gonna call in a little bit the doc said and make arrangements to start coming. He said they'll probably be asking what you prefer … you know … a guy or girl takin' care of ya when they're here," Dean took a breath and concentrated on not letting his voice waiver, he had to be strong for Sam. "The doc said this company makes an effort to be consistent with a couple caregivers to any one patient, so some days you may have one and then others the next, but always the same two unless something unexpected happens, that'll be good, right?" he offered trying to sound upbeat. Sam just nodded but Dean saw his brother's hands clenching and unclenching the cotton blanket that covered his legs. He put his hand up and grasped his brother's right calf and gently squeezed. "Easy, Sammy," he soothed. "You're not alone kiddo you never will be," he said in gentle firmness. He wished Sam could still talk like he did but it was so difficult for him now that what little words he did force himself to utter were like little miracles to Dean and he clung to them even when they were garbled and slurred.

"Ddd…don't care ggg…girl or ggg…guy," Sam forced out. "Hhh..heavy," Sam started and looked frustrated when he knew what he wanted to say would take a while to get out.

"Heavy?" Dean looked a little confused and then he smiled softly as he understood. "You're not a heavy weight Sammy and anyway the doc gives them all of your info, so they won't send someone who can't handle things and we're here to help, too. Look, I get that you want help with some stuff from somebody other than Dad, me or Bobby, but I still gotta be able to do something. I can help moving you and stuff," there was a hint of pleading and hopefulness to Dean's voice that Sam picked up on easily. His body was failing him but he still knew his big brother better than anyone else in the world, even their dad.

"Okay," Sam slurred out and Dean offered a gentle smile in return and patted his brother's leg. The phone could be heard ringing in the family room and shortly after there were footsteps down the hallway on the wood floor.

"It's the healthcare place," John said from the doorway. "I'll keep Sam company while you talk to them, okay?"

"Be back soon Sammy," Dean smiled and left the room.

One Week Later, May 1, 2006

"I wish I had better news I do," Dr. Finley offered. The doctor knew that tomorrow was Sam's twenty-third birthday and what he had just conveyed to Sam's family was difficult.

"You're sure?" John winced at the shakiness of his voice.

"Yes, unfortunately," the doctor began. "It's clear that Sam has fully moved into stage three of the disease process and has begun exhibiting some random symptoms associated with stage four, as well."

"He hurts," Dean's voice was quiet. "The nurse suggested Tylenol and heat rubs but it doesn't really help, not like it did. I don't want him in pain."

"I know it's difficult but PSP patients frequently experience non-specific pain in the late stages."

"I know," Dean's voice was flat. "I've read more journal articles and other crap about this damn thing than probably you," he spat. "I want you to give him something for the pain. There has to be something that can help." The doctor didn't take offense to Dean's anger because he knew when it came to his younger sibling Dean was a pit bull.

"I'm sure you probably have read more than me," he offered. "It appears based on your observations and mine that his limbs seem the most painful to him, yes?"

"Yeah, please I just don't want him in pain."

"I'll prescribe something for him that your R.N. caregiver can administer to him when he has a pain episode and we'll see how that goes. I may consider prescribing him a pain patch, as well. I know you want him comfortable, me too, but with non-specific pain sometimes finding the right med can be trial and error, so let's see how this one goes."

"Thank you," John offered genuinely. Bobby offered a nod of approval.

"I also wanted to address his recent exam and tests and I feel it's time that we consider a feeding tube."

"He can still eat," Dean said quickly.

"His choking is becoming worse Dean even with the use of the thickening agent. It's becoming too dangerous to allow him to keep eating. Also, it's clear he is no longer wanting food as much and he has lost weight …"

"I know," Dean conceded. "I make sure what he eats when he eats is healthy … I even add those concentrated vitamin and mineral drops to his milk shakes, I…"

"Dean you and your family have done an excellent job with Sam, but we are at that fork in the road. I know from Sam's directive he indicated that he would allow hydration by IV or the NG tube. He also agreed to allow a NG tube to be placed but he was very definitive on the fact he did not want a surgically placed feeding tube in his abdomen. Although, it was discussed at length with him that a surgical tube is the preferred method for long-term placement but he was very clear on his denial of surgical placement. You have his power of attorney, so I need your approval."

"The NG tube," Dean began with a hesitant voice and John placed a calming hand on his son's shoulder. "It's the one that goes down his nose into his stomach, right?"

"Yes, and can be easily removed if needed."

"You're sure he needs it now," Dean didn't want to accept that it had come to feeding tubes and IV's. Sam was still his little brother and he might not be able to communicate that much anymore but he still smiled and Dean knew he was in there but his body was just betraying him.

"Yes, it is my professional opinion that it is needed and I conferred with Dr. Litvan and she agreed that based on the progression and increased swallowing problems even with the thickening agent that it would be in Sam's best interest to have the tube placed. I'm not saying that the occasional nutrition by mouth is out of the question but he'll beginning receiving most of his sustenance by the tube. His caregiver will provide additional oral care for him since he won't really be consuming much pf anything by mouth now. Of course, he could refuse the tube at some point which some patients will do, but we'll cross that bridge if we come to it. "

"Does he know about you wanting to put the tube in?"

"Yes, I spoke with him after his exams. I know he understands me but as you're well aware his communications abilities have severely declined since our last visit." Dean nodded.

"Fine, give me the paper; I'll sign for the tube." Dean signed and pushed the paper back toward the doctor.

"I'd like to do it today," Dr. Finley began. "I know tomorrow is his birthday, so if you want to make him a thickened ice cream malt or something it should be okay just monitor him. Sometimes there is a bout of depression for PSP patients once a tube is placed. It's once less control they feel they have," the doctor paused a moment and looked at Sam's family. "The trips are getting harder for him to come here even with the Comfort Care nurse helping, so rather than change his care over to a visiting physician program I'd like to remain Sam's doctor and just come to see him at your uncle's."

"You can do that?" Dean asked suddenly. It was pretty stressful for all involved when Sam had his appointments especially for Sam.

"For most of the check-ups yes, but when there are more extensive exams I'd rather him come to the Outpatient clinic. I can send someone out for blood work or other simple lab testing and have the results prior to my visit. There are of course some lab work he may need that will require a trip in but I will make every effort to reduce those visits, if possible, but they be necessary as long as he remains at home and not an outside facility."

"We understand," John broke in. "We're thankful you're willing to remain Sam's doctor I'm not sure he'd take to the change with a new physician very well."

"Yes, I agree and I'm happy to do it. Now, about the placement of the tube … I'd like to be today. Sam's personal nurse is with him in the exam room, but would you …" he looked at Dean.

"Yeah, I want to be there for him. Will it hurt?"

"It won't be comfortable but pain shouldn't be a real factor. I can spray a small amount of numbing agent to the back of his throat to help a little, okay?"

"Thanks." Dean looked over at his father and then Bobby.

"We'll be here son, go be with Sammy."

Ten Minutes Later, Treatment Room 2A

"Okay, Sam here we go? It'll be done soon," Dr. Finley encouraged. Sam squeezed Dean's hand in fear.

"It'll be okay Sammy, I'm here," he soothed. Sam's eyes went wide as the NG tube entered his nose and followed the doctor's instruction's for swallowing; he gagged at the intrusion he felt going up his nasal passage and down his throat into his stomach despite the spray. "Easy, Sammy," Dean felt his stomach clench and the bile rise at what his little brother was going through. The doctor handed the nurse a cup.

"Here Sam, drink this thickened liquid and swallow this should help with the gagging, okay?" Sam nodded and did as he was told. "There," Dr. Finley said confidently. "It's done Sam. It's over, no more, okay?" He patted Sam's leg. The doctor finished checking placement and one final exam and talked to the family about the tube and talked to the nurse and Dean and sent his patient home.

Two Days Later, Bobby's House

"You've got it down Dean and your father and uncle did great with the tube feeding, too," Valerie, Sam's home care nurse encouraged. She had shown all three men how to use the NG tube and introduce nutrition into it for Sam.

Sam plucked at the tape holding the small port end of the tube to his cheek. "Here sweetie, I'll get the cotton tape and that should stop the itching from this tape.

"Thhh…Thank you," Sam slurred out. Dean smiled at his brother. His sibling was quiet the last couple days and he feared depression had set in as the doctor had warned but Sam seemed to be rallying a little but Dean suspected it was more for him and their Dad, Bobby, too. He was thankful that Sam was still able to enjoy his birthday ice cream malt by mouth the other day without problem but had had a small choking incident when he tried to eat something else later without using the tube but Valerie had been able to suction him and had encouraged the use the NG tube.

"There, how's that?" Valerie asked in her usual cheerful voice as she smoothed the new cotton tape onto Sam's face. She had been very helpful to not only Sam but everyone in the house. She had had two other PSP patients in her career as a nurse, one as recent as a year ago and she was a welcome resource for Dean when he had questions on how to help Sam as much as he could.

"Thanks, Valerie," Dean answered easily and Sam offered a small smile toward the middle-aged one, of what Dean figured was around forty-five.

Two Weeks Later, Mid-May

Valerie was down the hall getting some clean wash cloths for Sam's room while Dean administered Sam's afternoon feeding. John and Bobby had gone to town for a grocery trip and John was meeting with a fellow hunter to discuss a possible lead for Sam. They didn't do any hunting or supernatural business around Valerie and kept those books and items out of her view.

"Okay, Sammy, looks like we've got some Ensure and the special diet cocktail the doc prescribed for ya to put some meat back on those bones." Dean smiled at his brother. Sam would smile back but his communication had become worse over the last week and now would only speak every so often. Dean hated a silent Sam but the alternative was unthinkable. Dean wanted to hope for good news when his Dad returned from his meeting in town but hope was a rare commodity these days and he wouldn't waste one minute with his little brother. "Okay, one last bit and…" Sam jackknifed up and began vomiting the mixture, he inhaled and gagged wetly. He began grabbing at his throat in desperation. "Sammy! Help! Valerie!" It had always been a potential risk that the tube could promote vomiting but there hadn't been any problems since its placement a little over two weeks ago.

Sam was already losing consciousness when Valerie ran into the room. "Dean!" her voice was urgent as she went to Sam. "Call 911, tell them Sam has aspirated vomit and isn't conscious," she hurriedly placed a stethoscope to her patient's chest. "He's not moving any air. Tell them he's not breathing but a nurse is present, go!" Valerie quickly grabbed a suction tube to help clear some of the vomit and went about helping Sam to get some much needed oxygen.

Twenty-Four Hours Later, ICU

Dean ran a hand over his tired eyes. "The aspiration event is much more severe this time Dean, and he has a bad case of aspiration pneumonia," Dr. Finley spoke with a solemn voice.

"But, you're treating him, he'll be okay, he just needs some help right now." Dean's voice was ragged.

"Dr. Finley, my son, can get through this can't he?" John stood stoically next to his eldest son with Bobby close by. His lead from the previous day hadn't panned out and he was still no closer to saving his son.

"Sam has developed a significant fever and we are addressing it aggressively, but his body is weakened and…"

"No, you keep treating him and he'll get better, he will," Dean prompted as he looked through the glass window at his brother.

"Dean, he isn't currently triggering the vent at all and his lung volume is poor despite the best efforts from the Respiratory Department. They are addressing his secretions and trying to suction his lungs more deeply, but…"

"No, he can come back from this," Dean assured. He was quiet for a moment. "Doc?"

"Yes?"

"Valerie said, I didn't do anything wrong with the feeding, but could I…"

"No, Dean, this was always a potential complication from the NG tube that's one of the reasons surgical tubes are preferred for long-term feedings but Sam was quite sure of what he wanted. This isn't your fault." The physician assured.

Two Days Later, ICU

Sam's fever was still present and they had begun more IV antibiotic treatments. The Respiratory staff came and went suctioning, checking and adjusting settings on the vent and taking arterial blood gas reading from the PICC line that the doctor had placed the other night. Dean's mind remembered the patient brochure the doctor had provided him before he signed the consent, although it was designed to be read by the patient, it was his decision to make for his brother who wasn't conscious.

The info as always seemed overwhelming to him as he had read it:

What is a PICC Line and Why Do I Need It?

A PICC line is, by definition and per its acronym, a peripherally inserted central catheter. It is long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access. It is similar to other central lines as it terminates into a large vessel near the heart. However, unlike other central lines, its point of entry is from the periphery of the body and the extremities. And typically the upper arm is the area of choice.

A PICC line provides the best of both worlds concerning venous access. Similar to a standard IV, it is inserted in the arm, and usually in the upper arm under the benefits of ultrasound visualization. Also, PICCs differ from peripheral IV access but similar to central lines in that a PICCs termination point is centrally located in the body allowing for treatment that could not be obtained from standard periphery IV access. In addition, PICC insertions are less invasive, have decreased complication risk associated with them, and remain for a much longer duration than other central or periphery access devices.

Using ultrasound technology to visualize a deep, large vessel in the upper arm, the PICC catheter is inserted by a specially trained and certified PICC nurse specialist. Post insertion at the bedside, a chest x-ray is obtained to confirm ideal placement. The entire procedure is done in the patient's room decreasing discomfort, transportation, and loss of nursing care.

A PICC line may requested for a variety of treatment options which include some of the following:

-Prolonged IV antibiotic treatment;

-IV access obtainable by less invasive and longer lasting methods;

-Multiple accesses obtainable with one access line;

-TPN Nutrition;

-Chemotherapy

-IV access related to physiological factors; and

-Home or sub-acute discharge for extended treatment.

PICCs are frequently used to obtain central venous access for patients in acute care, home care and skilled nursing care. Since complication risks are less with PICC lines, it is preferred over other forms of central venous catheters. A PICC is not appropriate for all patients. Proper selection to determine the appropriateness of this device is required.

The PICC may have single or multiple lumens. This depends on how many intravenous therapies are needed. A PICC line can be used for antibiotics, pain medicine, chemotherapy, nutrition, or for the drawing of blood samples. PICCs can be inserted by radiologists, physician assistants or certified registered nurses. They are inserted using ultrasound technology at the bedside or ultrasound wit fluoroscopy. Chest radiographs are also used to confirm placement of the PICC tip if it was not inserted using fluoroscopy.

Dean and his father sat at Sam's bedside both feeling lost from the doctor's last visit a short while ago. Sam's condition hadn't improved and in some ways had worsened. They were now adding an IV drug to help with Sam's low blood pressure and Dr. Finely had said with solemnity that Sam's condition was very critical and if he didn't start responding to the treatment soon that his Advanced Directive may have to be considered being implemented. Dean shook his head, that wasn't happening, it was too soon. Sam was still alive, his heart still beating and in Dean's book that meant somewhere in there his brother was fighting and he'd make damn sure he got all the help he needed to win this battle. Sam was coming home and there wasn't another possibility. Dean wasn't letting him go…

To Be Continued