Dean stood in the doorway of Sam's room and knew why he had heard tears in Jim's voice when he had called the Pastor earlier to check on his brother.
"He's...um..." Jim's voice had trailed off, words failing him.
Dean's grip had tightened on the phone, fear clenching his heart and making his tone a little too rough. "Jim..."
"He needs you," Jim had said simply.
He needs you.
Jim's words echoed in Dean's mind as he quietly stepped into the room, fear filling his heart as he gazed at his little brother.
Sam was surrounded by a tangle of wires that led to monitors and IV lines attached to various bags hanging nearby. He was motionless and looked uncharacteristically small and fragile, and although there was a slight flush coloring his cheeks, the paleness lingered beneath the mauve bruises under his eyes. He didn't move as Jim smoothed the blanket over his chest.
Dean's gaze fixed on the Pastor. Jim's face was etched with concern, his eyes dark and intense, his body drawn and fatigued. The endless worry and constant care over the past several hours was draining his strength.
"Jim..." he said quietly.
Jim turned, relief flooding his features when he saw Dean standing there, a sad smile playing on his lips as he moved toward the door. "I'm so glad you're here," he whispered, his voice betraying his exhaustion and relief as he hugged John's oldest.
Dean said nothing as he stared over Jim's shoulder at the still form of his brother. The Pastor had always been more demonstrative when it came to emotions than the Winchesters, but hugging him upon his arrival? That couldn't be good...
Dean pulled back, sharing a look with Jim before approaching Sam's bed. His hand swept damp bangs aside before resting on his brother's forehead, his fingers cool against the fevered skin.
"He's been asking for you, Dean."
Dean nodded and found it difficult to speak around the knot of emotion that rested in his chest, in his throat. "I'm here now, Sammy," he whispered, leaning close to his brother, forehead against forehead, hoping Sam could hear him. He stayed that way for a moment before straightening, his eyes never leaving his brother's face. "How is he?"
He's slipping away, Jim silently answered. He's slipping away, and there's nothing we can do about it.
When no answer came, Dean looked over his shoulder at the Pastor, still standing by the door. Jim's eyes were suddenly rimmed with tears, and Dean felt his heart drop.
"Jim?"
"They're running tests," Jim managed.
Dean nodded, a sense of dread growing. "For?"
Tears slipped from Jim's eyes.
Dean felt his heart slam in his chest. "Jim..."
"They think it might be leukemia."
Dean visibly swayed, momentarily speechless in stunned disbelief. "What?"
"Leukemia," Dr. Collins repeated coming through the door in a rush, clutching Sam's chart. "But test results indicate that he doesn't have it. We ran it twice, and there were no abnormal lymphocyte blasts present in his blood."
Jim closed his eyes briefly, thankful and yet not relieved. If not that, then what? Something was clearly causing Sam's health – and perhaps his life – to ebb away from him.
"You must be the brother," Dr. Collins said coming further into the room, extending his hand. "I'm Dr. Collins, Sam's attending."
Dean continued to stare at the doctor, not interested in introductions. "Dude, what the fuck?"
"Dean – "
"No, Jim," Dean interrupted, worry and fear mixing to combustible anger as he approached the doctor, the intensity of his emotions making his expression unreadable.
Jim moved forward as well, poised to intervene if this confrontation turned physical. This was Dean, after all, and Hell had no fury like a Dean protecting his Sammy.
Jim sighed, trying again. "Dean – "
Dean ignored him. "You scare the shit out of us, talking about leukemia – and then you fly in here like some kind of fuckin' hero and tell us 'never mind'? I mean...what the fuck?"
Dr. Collins nodded. "You're right. I'm sorry."
"You're sorry? Well, whoop-de-fuckin'-do..." Dean growled, his voice echoing into the hall.
There was a moment of awkward silence filled with Dean's harsh breathing before the doctor's pager went off.
"I'll be right back," Dr. Collins said, taking the pager from his belt and stepping into the hall.
"What a fuckin' dumbass..." Dean muttered as he ran his hand over his face and sighed, trying to calm his enflamed temper. He looked at Jim and sighed again at the expression on the Pastor's face. "What?"
Jim shrugged. "I don't even know where to begin."
Anger ignited in Dean's eyes once again as he approached Jim, hand alternately pointing at the Pastor and then in the direction the doctor had gone. "Jim, he should have never said anything to you about leukemia or anything else until he had the test results back." Dean shook his head, disgusted. "He should have kept his mouth shut until he knew. It pisses me off that he worried you like that for nothing."
"And you," Jim added, casting a glance in Dean's direction, knowing from experience how John's oldest handled emotions. For Dean, it was often easier to be angry than scared.
Dean said nothing, remembering the feeling of immediate, overwhelming fear that had seized his heart at the mention of that word.
Leukemia.
Fuck.
Dean shook his head again, snatching off his leather jacket and flinging it to the nearby chair. He felt his rage dissipate as he moved to stand beside Sam's bed, eyes scanning the monitors before focusing on his little brother and gently squeezing the kid's limp hand.
"It's okay, Sammy," he whispered, knowing Sam was asleep – and had been asleep the entire time – but still unable to stop himself from soothing a little brother that had always been easily upset by verbal altercations.
Jim still stood in the middle of the room, watching Dean and swallowing against the lump in his throat, then startling as the doctor reentered the room behind him.
"Sorry about that," Dr. Collins apologized, still holding Sam's chart.
Dean turned abruptly and faced the doctor, his expression instantly changing. "So, now what?"
Dr. Collins sighed as he leafed through the chart, studying the electrolyte panel. "Now we run more tests." He paused and then looked up. "I'm particularly concerned about his potassium levels; they're dangerously elevated."
"Why is that a concern?" Jim asked.
"Potassium is one of the electrolytes that can affect heart rhythm. In fact, extreme degrees of hyperkalemia – "
" – hyper...what?" Dean interrupted, lingering annoyance making his tone harsh.
"Hyperkalemia," Dr. Collins repeated and then explained. "It's a condition caused by abnormally high levels of potassium in the blood. Extreme degrees of it are considered a medical emergency due to the risk of potentially fatal arrhythmias." Dr. Collins paused, thinking. "In retrospect, his elevated potassium levels may have contributed to his initial collapse."
Jim shook his head, confused. "I thought the ruptured spleen and resulting blood loss caused Sam to collapse?"
"Correct. But hyperkalemia may have exacerbated his symptoms."
Dean took a step toward the doctor, as if being closer would increase his comprehension. "What makes you say that?"
"Well, hyperkalemia can cause fatigue, weakness, difficulty breathing, muscle and joint pain, a drop in blood pressure, decreased oxygen saturation, an irregular heartbeat..."
Jim exchanged glances with Dean. "What would cause this condition?"
Dr. Collins directed his attention back to the Pastor. "Most commonly it can be caused by ingesting large amounts of potassium, but that seems unlikely in Sam's case since he doesn't take potassium supplements...does he?"
"No," Dean answered immediately. "The only thing Sam has ingested large amounts of over the past week is – "
"...is apple juice," Jim finished.
"Huh."
Two pairs of eyes focused on the doctor.
"'Huh' what?" Dean asked, his tone sharp.
"Apple juice is moderately high in potassium – having anywhere from 125 to 225mg per serving – and if he's consumed large amounts of it..." Dr. Collins shrugged.
"Wait..." Dean shook his head. "You're saying Sam OD'ed on apple juice?"
Dr. Collins swallowed a laugh. "No. Well...I suppose it's possible but certainly not likely."
"So what is causing it?" Jim asked, hearing irritation slip into his tone.
"Hard to say. Hyperkalemia can be caused by several conditions, but in Sam's case, I think we'd be best served to consider the destruction of red blood cells due to severe injury as the cause."
"So, the rupture of his spleen caused this hyper...whatever?" Dean waved his hand as if it would help him remember how to pronounce the word.
"Yes, I think it certainly contributed to it. But the condition can also be indicative of improper kidney function – specifically the inability of the kidneys to excrete potassium, which is hallmark to acute renal failure – or impairment of the mechanisms that move potassium from the circulation into the cells...or a combination of these factors."
"Wait. Renal failure?" Dean asked, hoping he had heard wrong.
Dr. Collins nodded. "Yes, unfortunately."
Dean returned the nod. Fuck.
"So, now what?"
Dr. Collins glanced at Jim and began writing in the chart. "I'm ordering another electrolyte panel to measure the potassium levels again. Sometimes the initial elevation can be due to hemolysis in the first sample."
Jim shook his head. "Hemolysis?"
The doctor looked up briefly. "It's the breaking open of red blood cells and the subsequent release of hemoglobin into the surrounding fluid which can cause an inaccurate measurement of potassium..." His voice trailed off at the look of bewilderment on Dean's face. He smiled. "Research it."
"Yeah," Dean said, glancing at his little brother. Sam would love that.
"Anyway," Dr. Collins continued, beginning to write in the chart again. "I'm also ordering blood tests for renal function as well as a renal ultrasound."
"So now our primary concern is Sam's kidneys?" Jim asked, his brows drawing together.
"Well, we need to determine their level of functioning in order to properly diagnose and treat, especially since hyperkalemia is highly suggestive of renal failure. And of course, in the midst of all this, we can't forget about his ruptured spleen and the resulting hypovolemic shock." Dr. Collins checked the monitors before continuing. "Sam's blood pressure and O2 sats...both are still dangerously low. His heart rate has dropped as well."
"But that's good, right?" Jim sought to clarify. "It was too fast before."
"It was," Dr. Collins agreed. "But now it's dangerously low. I'll order an EKG. "
"They did one at the house earlier," Jim informed, not wanting Sam to endure any more tests and procedures than necessary.
"Yes, I know. But Sam's status has changed." The doctor crossed to the bed and began to palpate Sam's abdomen.
"Don't hurt him," Dean warned, knowing it was unnecessary but unable to stop himself.
Dr. Collins smiled softly. "I won't."
Dean crossed to the other side of the bed, his hand resting on Sam's arm as he watched the doctor closely. "What are you checking?"
"His spleen, which, unfortunately, is working against itself."
"Meaning?" Dean asked, arching his eyebrow.
Dr. Collins sighed, rearranging the blanket and stepping away from the bed. "When the spleen enlarges, it traps and stores an excessive amount of blood cells and platelets, thereby reducing the number of blood cells and platelets in the bloodstream. This process creates a vicious cycle: the more cells and platelets the spleen traps, the larger it grows; the larger it grows, the more cells and platelets it traps. Eventually, the greatly enlarged spleen also traps normal red blood cells, destroying them along with the abnormal ones."
"Okay." Dean glanced at Jim. "So..."
"So," Dr. Collins repeated, "given this situation, it's highly likely that Sam's red blood cell count was dangerously low prior to his fall because of his enlarged spleen and has only been exacerbated by the rupture of his spleen and subsequent hemorrhage."
"But you said earlier that if Sam was kept still, his spleen should clot and heal itself, right?" Jim asked.
"Theoretically, yes," Dr. Collins agreed. "I've had several patients over the past few years that responded well to that plan of treatment, but then sometimes..."
"Sometimes?" Dean and Jim asked together.
"Sometimes excessive numbers of blood cells and platelets can clog the spleen, interfering with its functioning – and its healing of itself – and there have been cases when an enlarged spleen actually outgrows its own blood supply."
"Jesus," Dean whispered, his grip tightening around Sam's arm.
"That scenario would, of course, be especially devastating to Sam's system since his blood supply is already alarmingly low due to the hemorrhage," Dr. Collins continued. "And while an enlarged spleen is not a disease in itself, it is the result of an underlying disorder."
Dean sighed. "Like this hyper... "
" – kalemia," Jim finished, glancing at Dean.
Dr. Collins shook his head. "No, we don't typically see an enlarged spleen with hyperkalemia – but then every patient is unique in what symptoms he or she presents. In my 20 years of practicing medicine, I've learned to 'never say never.'" He shrugged. "One of the most well-known and common causes of an enlarged spleen is, of course, mononucleosis, but I'm sure that was ruled out prior to Sam's tonsillectomy, so I think – "
"No, it wasn't," Dean corrected, suddenly uneasy. "The doctor at the clinic didn't do any tests. I even asked the prick if he needed to, but he assured me Sam had strep and needed surgery immediately."
Dr. Collins narrowed his eyes. "He diagnosed strep without doing a strep test?"
Dean nodded, wishing he had punched that doctor in the face.
"Unbelievable. What a dickhead..." Dr. Collins snorted and then immediately caught himself. "I mean – "
"No," Dean interrupted. "You got it right the first time. He was definitely a dickhead."
"Gentlemen..."
"Sorry, Jim." Dean glanced at the Pastor, then back at the doctor. "Sam did have the white patches in his throat, though, just like he usually does when it's strep."
"Yes, but sometimes patients with mono can present with a white film on their tonsils that resembles the patches...or on rare occasions, strep can occur along with mono. That's why it's crucial to test, especially before recommending surgery. And we usually allow the patient to get well before performing the procedure." Dr. Collins shook his head, clearly disgusted.
Jim sighed. "So, now you're thinking mono?"
"No, I'm not thinking it; I'm diagnosing it. We'll run a monospot test to be sure, but Sam's white blood cell counts were elevated enough to indicate mono. But since I assumed mono had been ruled out prior to his surgery a few days ago, I just thought the increased levels pointed to Sam's post-op infection. But mono explains all of his original symptoms – fever, fatigue, weakness, sore throat accompanied by swollen lymph nodes and tonsils...and an enlarged spleen."
"An enlarged spleen that none of us knew about," Jim commented.
"Exactly," Dr. Collins agreed.
"Well, even though I'm pissed this wasn't caught sooner – and beyond pissed that Sam had surgery he didn't need – this is good news, right? Mono is easy to treat."
Dr. Collins shook his head at Dean. "If Sam had been diagnosed correctly four days ago, then yes...treatment would've been relatively easy – just rest, plenty of fluids, and avoidance of physical activities to protect his spleen. Unfortunately, the situation is much more serious now. Sam's spleen has ruptured, and I'm concerned we're bordering on life-threatening blood loss at this point, especially considering his other organs – like his kidneys – are showing signs of possible failure."
"What about a blood transfusion?" Jim asked, not caring how desperate he sounded.
"Not an option right now. He's not stable enough."
"Then do the surgery," Jim countered.
"Also not an option at this point for the same reason."
"Then what are our options?" Dean snapped.
"We continue to monitor him over the next few hours. We monitor his vitals as well as urine output, and we see if the meds I've prescribed raise his blood pressure and cardiac output. That's all we can do right now."
There was a moment of silence as Jim and Dean stared at each other, overwhelmed with information and anxiety.
"Well..." Dr. Collins glanced at the clock. "It's getting late, and I have a few more patients to see. We'll begin running those tests in the morning." He turned toward the door. "Good night."
"Good night," Jim returned as he sank into the nearest chair, listening to the doctor's footsteps fade down the hall.
"Ah, Sammy..." Dean sighed, carefully adjusting the nasal cannula's tubing over his brother's ear as he brushed back Sam's hair. "What are we gonna do now, kiddo..."
Jim's gaze shifted from the door to Dean. "We should pray."
"For what reason?" Dean asked sharply. "To hear ourselves talk?"
"Sam believes in prayer," Jim reminded. "He would agree with me on this."
"Sam also believes in unicorns."
"Dean, this is serious."
"Do you think I don't know that?" Dean asked, glaring at the Pastor. "Sam was misdiagnosed on my watch."
"You didn't know."
"He had surgery he didn't even need because of my decision."
"A decision you based on a doctor's recommendation, Dean." Jim paused, knowing John's oldest too well. "This is not your fault."
"Maybe," Dean conceded quietly. "But I knew something was off with him, and I still left him."
"You didn't want to..."
"But I did," Dean snapped.
"Dean, you – " Jim stopped as a weak cough interrupted him, followed by restless movement on the bed.
Dean's eyes widened as he exchanged glances with Jim, and then gently rubbed Sam's chest, being careful of the wires. "Sammy...you waking up for me, kiddo?"
Sam stilled, obviously listening, and Dean had to smile when he saw his little brother's face scrunch. A waking-up-Sammy expression didn't get more classic than that.
"C'mon, Sam," Dean encouraged. "Halfway there. Open those eyes."
Sam latched onto his brother's voice and gradually rose to consciousness, fighting his way through thick layers of hazy fog caused by the medications. His eyes slowly fluttered open and after a few moments, focused on Dean, standing next to the bed.
"Hey," he said quietly as weariness pressed him to the mattress.
Dean smiled affectionately at the sound of Sam's weak, hoarse voice, tousling his brother's hair and then resting his hand on top of the kid's head. "Hey yourself, Sammy," he replied softly.
"You're here," Sam commented, breathless.
Dean nodded. "Yep. Heard you were looking for me."
Sam smiled weakly. "'Bout time."
Dean's smile widened, heartened by his brother's response. "Go ahead. Smile and laugh it up while you can, Sammy, 'cause I'm gonna kick your ass later."
Sam laughed softly and then coughed again. "For what?"
"For scaring the shit out of me."
"Bring it," Sam whispered, dimples making a brief appearance as he smiled, for he knew that teasing was one of Dean's ways of showing affection.
Jim felt a smile tug at the corners of his own mouth, his heart warmed and his resolve strengthened by the banter of John's boys. If anyone could get Sam through this, it would be Dean. Sam drew his strength from his big brother; he always had.
"Are the two of you going to carry on like this all night?"
Dean shrugged and then winked at Sam. "Maybe."
Jim shook his head as he shifted in the chair and leaned back against the wall. "So much for my beauty rest..."
"Why don't you go home and get some rest?"
Jim shook his head immediately. "Absolutely not."
"Jim, seriously. Just for a few – "
"No, Dean. I'm staying and that's – "
"Pastor Jim," Sam said softly, his eyes closing briefly. "It's okay...just go."
"Oh," Jim said, drawing it out and nodding slowly. "I see how it is...why you wanted Dean here – so the two of you could gang up on me."
"We work better as a team," Dean said, winking again at his brother.
Jim remained silent for a moment, realizing the significance of Dean's words. "Yes, you do," he agreed, rising and crossing to Sam's bed.
"So, it's settled?" Dean asked, staring at the Pastor from the opposite side of Sam.
"What's settled?"
"You're leaving."
Jim arched an eyebrow. "Are you kicking me out?"
"Yes," both brothers answered together.
Jim smiled, loving these boys and appreciating this light moment.
"Fine," he relented after a few minutes, knowing the brothers needed this time together. "But only for a couple hours." He gently tousled Sam's hair. "You rest up and get better."
"Mm-hmm," Sam mumbled, sleep pulling at him again.
"And you behave," Jim said, turning and pointing at Dean.
"No promises," Dean admitted and then laughed at Jim's expression. "I'm gonna walk Jim to the elevators, Sam. I'll be right back, okay?"
"'Kay," Sam responded, more asleep than awake.
Dean glanced at Jim and then followed the Pastor into the hall. "I still haven't heard from dad," he reported as they walked toward the elevators. "Did you get in touch with Bobby?"
Jim nodded. "He came by a few hours ago to check on Sam and then headed out."
"Good. And if Dad's okay when Bobby finds him and I find out he was just ignoring my calls for whatever reason, I swear I'm gonna – "
"Kick his ass," Jim finished and then chuckled at Dean's disbelief in his choice of words. "Bobby and I already discussed that plan."
"It's a good one," Dean agreed. "Nice language, by-the-way."
"What can I say?" Jim shrugged. "I hang around a rough crowd."
Dean laughed in response, watching as Jim pushed the button with the downward arrow.
They stood in companionable silence as they waited for the elevator to arrive, both feeling the momentary levity fade as it was replaced with the ever-present gravity of the situation.
Dean swallowed hard against the sudden lump in his throat, the pressure in his chest. "I can't lose him."
The light above the elevator lit up as the doors slid open, spilling people into the hall.
Jim remained silent, knowing Dean didn't expect him to reply. He squeezed Dean's shoulder – I know, hang in there, we'll figure this out – and stepped into the elevator.
Dean held Jim's gaze until the elevator doors closed and then sighed shakily, heading back down the hall. Moments later, he returned to his brother's room to find a young, attractive nurse – brown, curly hair...blue eyes...toned body hugged in all the right places by lavender scrubs – gently moving Sam's arms and legs.
"You're doing good, sweetie. Almost done..." she was saying as Dean entered.
"Whoa, Sammy. Didn't know you had a girl in here," Dean teased as he approached the bed. "Next time, put a towel on the door or something. Give a guy a little heads up, huh?"
Sam attempted to smile, but the pain caused by the nurse's movements of his limbs elicited a soft moan instead. His right hand crept from beneath the blankets, and he fumbled weakly for his brother.
Dean immediately stroked the length of Sam's arm and clasped his hand, unnerved by the bruises that marred his brother's flesh. "It's okay, Sam." He frowned, his attention focusing on the woman on the opposite side of the bed. "Do you have to do that?"
"Yes," she answered. "We have to keep his blood circulating. Tomorrow physical therapy will have him on their caseload, but for tonight it's just me." She paused and smiled. "I'm Karen, by-the-way."
Dean nodded but did not return the smile or his name. He couldn't care less about pleasantries and introductions right now, hot nurse or not; he could tell by the look on Sam's face that his little brother was in extreme pain and that was his sole focus.
Dean grimaced, pained himself by Sam's discomfort. "Are you almost finished?"
"Well..." Karen's voice trailed off as she lifted her eyes to check the monitors. Her gaze scanned the screens and her brow furrowed. "Actually, I think that's enough for now. I don't like some of those readings."
Dean's attention snapped to the screens, alarmed at her tone. "What's wrong with them?"
"They're still extremely low," Karen said, meeting Dean's gaze.
"Like they've been the entire time?"
"Yes, but that's not a typical response since activity of any kind usually raises most of those numbers." Karen leaned closer to her patient. "Sam? I'm going to leave you alone so you can rest now, okay sweetheart?"
Sam coughed but said nothing.
Karen directed her attention to Dean once again. "The cough is a new development and definitely something we'll need to monitor throughout the night, along with those," she said, indicating the monitors.
"Of course," Dean responded, memorizing the current numbers so he would have a baseline.
"And we'll need to monitor that as well," she added, pointing to the catheter drainage bag.
Dean nodded.
"Call me if he needs anything," Karen instructed as she quietly left the room.
Dean nodded again, not taking his eyes off his brother. Sam looked paler now – if that was even possible – and his breathing was shallow, as though he couldn't get enough air even with the extra supply of oxygen coming through the nasal cannula.
"Sammy?"
Sam's eyes cracked open in response to Dean's voice.
"You still hangin' in there?"
Sam remained silent and closed his eyes again, coughing a little louder than before.
"Sam." Dean frowned, squeezing his brother's hand. "Talk to me, kiddo."
"Dean..."
"Yeah, Sammy?"
"Don't...feel good."
And I don't want to talk, Dean read between the lines.
"I know," Dean soothed, placing his other hand on Sam's forehead, trying to determine if his brother's fever was up or down. Touch was such a subjective way to tell. "What can I do to make it better?"
Sam didn't verbally respond, but his grip tightened ever-so-slightly on Dean's hand, relaying the message loud and clear: Just stay.
Dean smiled tenderly, pulling a chair closer to the bedside and sitting down as he continued to hold his little brother's hand, squeezing back. You got it.
TBC
The good news: Dean's back...yay! The bad news: this will probably be my only posting this week. Blame Thanksgiving. No worries, though. We should be back on schedule next Monday.