"Look who I found in the hall," Karen said good-naturedly, coming back into Sam's room, followed by the lurker.
Dean didn't even have to look to know who had joined them. The aroma of the coffee was a good clue, but he didn't need it; he knew the sound of Jim's approach – a quiet shuffle always followed by a cleared throat when the Pastor entered a room.
Dean smiled and turned, accepting the cup he knew would already be halfway to him in Jim's outstretched hand. "Thanks," was all he said, but he knew...that Jim knew...that he knew the Pastor had made a pit stop by the hospital's chapel.
Jim returned the smile – message received – and shrugged. "Just doin' my job."
Dean arched an eyebrow, always secretly impressed when the Pastor offered a good comeback. "Me, too," he replied and glanced at Sam, who was awake but resting with his eyes closed.
Jim's smile lingered as he nodded, taking a sip from the Styrofoam cup.
Dean did the same, tracking Karen as she moved around the room, washing her hands and grabbing a fresh pair of gloves.
"How's our boy?" Jim asked, also following Karen's movements as she crossed to Sam's bed.
"He's okay right now," Dean responded. "Dealing with an infection and reacted a little...dramatically to the vent when he first woke up, but right now – we're okay."
Jim smiled softly, wondering if Dean realized he had answered in the plural. He probably didn't. With Dean, it was always "we" when it came to Sam; there was rarely an "I" or "him" because they were a package deal. What happened to one, automatically affected the other.
"How bad is the infection?" Jim asked, trying to keep the worry out of his tone.
Dean shrugged, and Jim read between the lines – pretty bad.
Jim nodded, mentally adding that issue to his prayer list. "What now? When does he come off that thing?" He gestured toward the ventilator.
"Hopefully right now," Karen answered, turning away from one of the monitors and belatedly realizing that the Pastor wasn't talking to her. She smiled her apology and glanced at her patient, trying to visually determine Sam's level of consciousness.
Jim focused on Karen as she came to stand on the opposite side of Sam's bed and noticed that Dean had moved closer to his brother. Sam seemed to sense Dean's proximity, even with his eyes closed, and instantly reached for his big brother; small hand finding refuge and comfort in a larger hand that was already open and waiting, anticipating Sam's arrival.
Jim sighed, feeling touched – as he often did when he watched the boys interact – and wondering if the brothers even realized how in sync they were.
Karen stared at Sam, determined to figure this out on her own, but then sighed and glanced at Dean. "Is he asleep?"
Dean chuckled lightly – the answer to that question was so obvious – and shook his head, squeezing Sam's hand. "Hey."
Sam opened his eyes.
"It's showtime, Sammy."
Sam blinked at him, trying to regain his bearings.
Dean smiled encouragingly and gently rubbed his brother's chest, helping to rouse and orient him. "Ready to breathe on your own, kiddo?"
Remembrance and understanding ignited in Sam's eyes and he nodded, glancing at Karen and then back to Dean.
Dean returned the nod and then looked at Karen expectantly.
Karen sighed, feeling inexplicably nervous. She had successfully weaned numerous critical patients from a ventilator, and yet she felt apprehensive. What if something went wrong? This was Sam after all...
Dean narrowed his eyes, annoyed by her prolonged silence. "Karen?"
Karen didn't respond.
Dean sighed loudly, becoming wary of her hesitation and pissed by the agitation she was causing in his perceptive little brother. He could feel Sam's muscles tense, could hear the slightly elevated tempo of the heart monitor, could sense his brother's confusion as the kid stared up at him.
"It's okay," Dean softly reassured Sam and then glared more heatedly at Karen.
Jim recognized Dean's expression. "You said you were ready to begin?" he prompted, gracefully intercepting whatever scathing comments Dean was about to hurl in her direction.
Sam glanced at Jim, seeming to just notice he was in the room, and the Pastor smiled softly even as he saw Dean's glare shift to him for the interruption.
Karen blinked and then felt her face flush with embarrassment. "Oh...um...yes," she replied, offering a silent apology with a quick smile. "But before we begin, I want you to know that I've paged respiratory to help with extubation."
"So, we have to wait until they get here?" Dean asked, his tone sharp.
"No, they just need to be present when the actual tube is removed, but while we wait, we'll go ahead and start Sam's SBT with PSV while I monitor his vitals, his RSBI, and – " Her voice faded at the darkening scowl of annoyance on Dean's face. "And I should probably explain what all of that means."
"Probably," Dean agreed bluntly.
Jim cut his eyes at him and sighed. Most of the time, Dean's sarcastic gruffness just made him all the more endearing. But other times – like now – that particular trait made him offensive. "Dean – "
"It's okay," Karen interrupted. "Sometimes I get too wrapped up in my job and forget that others don't really understand what I do."
Dean and Jim exchanged glances. She was preaching to the choir on that one.
"Anyway," she continued. "SBT means spontaneous breathing trial in which Sam will attempt to breathe independently, even though he'll still be connected to the ventilator. PSV – pressure support ventilation – is one of the techniques we use to wean patients from the vent. The ventilator will deliver a set amount of positive pressure into the lungs each time Sam initiates a breath, but he will be able to control the length and depth of each respiration and will be able to breathe at his own rate."
Dean nodded, absorbing the information and feeling Sam's intense gaze, wide eyes filled with alarm and doubt. He squeezed his little brother's hand – relax...you can do this – and then glanced back at Karen.
"And the RSBI?"
"Oh yeah," Karen commented, having forgotten about that...but not surprised that Dean hadn't. "That's the rapid shallow breathing index, which I will monitor along with his vitals. It will help us determine if Sam can tolerate extubation." She paused, not wanting to be Miss-Glass-Half-Empty, but needing to share information on all possible outcomes. "Of course..." she sighed. "Not all spontaneous breathing trials are successful. Sometimes the patient is unable to tolerate the SBT and must be returned to full ventilator support."
Sam's eyes widened, the heart rate monitor attesting to his increased anxiety.
Dean shook his head slightly and squeezed his brother's hand again – that's not gonna happen...you can do this – and then glared at Karen.
"Sorry," she apologized. "I'm sure Sam will be fine, but I have to share all the information."
"Of course you do," Jim agreed, glancing at Dean – tone it down – and then smiling at Karen.
Karen returned the smile, thankful to have the Pastor as a buffer. "Any other questions?"
"How long will this take?"
Karen glanced at Dean as she pressed one of the buttons on Sam's bed, raising her patient to sit more upright. "It depends on the patient. Our goal is for Sam to tolerate PSV for at least 15 to 20 minutes and then we'll switch over to CPAP – constant positive airway pressure – for about 30 minutes. CPAP is a final trial of spontaneous breathing prior to removing the endotracheal tube. In this mode, Sam will still breathe on his own but will have the benefit of the ventilator alarms if he has difficulty. If all of that goes well, we'll probably extubate. It'll just depend on Sam and his lungs."
Dean nodded, confident that Sam's years of endurance training were about to pay off. He winked at his little brother and then frowned at Karen.
"What's that?" he asked as she prepared a syringe.
"A sedative," Karen responded, extracting the dosage from the vial, thumping the side of the syringe once, and then slowly administering it to Sam through his IV. "Not enough to knock him out but enough to help him relax a little more."
Dean sighed, torn between being thankful – at least Sam would calm down – and annoyed – he was more than capable of soothing his little brother without the assistance of drugs, thank-you-very-much.
Karen smiled, sensing Dean's internal struggle. "It's part of the protocol when weaning a patient from the vent," she said, hoping he understood that her sedating Sam was due to hospital policy and not because she doubted his big brother abilities.
Dean gave a hint of a smile.
"And this is a bronchodilator," she continued as she administered another syringe. "It should help ease any wheezing that Sam might experience." She dropped both syringes into the red sharps container on the wall and grabbed a long tube. "Okay, sweetie, before we get started, I'm going to suction you."
Sam made a strangled sound of alarm and shifted on the bed, hand tightening on Dean's.
Dean returned the pressure. "It's okay, Sammy. Relax. No big deal." He glanced at Karen, hoping she realized this was going to be a team effort...and he was self-appointed Captain. "Right, Karen?"
Karen nodded, immediately understanding the game plan. "Nope, no big deal at all," she reassured. "I'm just going to inset this suctioning catheter into the endotracheal tube..." She pointed to the tube protruding from Sam's mouth. "And then I'll suction excess secretions into this suctioning canister..." She pointed to a different container on the wall. "And that'll be it. Then we'll start the SBT."
Without further explanation or warning, Karen did just that, smiling softly at her patient. Sam's eyes were closed, one hand grasping Dean's, the other bunching the sheets.
"You're doing good," she praised over the slurping whoosh of the suctioning. "Almost done."
Dean's thumb soothingly rubbed his little brother's as he glanced over his shoulder at Jim, comforted by the Pastor's presence, thankful to have reliable backup, should the situation call for it. Never could tell with Sam.
Jim smiled encouragingly, holding the expression until Dean turned away. He glanced at his watch and inwardly sighed. While he had been downstairs getting coffee – and yes, praying – John had called to say he and Bobby were about 30 minutes away from the hospital.
That had been at least 10 minutes ago.
The Pastor sighed again, crossing to the door and closing it.
Dean's attention flickered to him.
"Just want to give Sam a little privacy..." Jim explained, not mentioning that he also wanted to give them a barrier to John's imminent arrival.
Dean nodded, turning back to Sam as Karen placed the suctioning tube back in its slot on the wall.
"Sam..." Karen waited for her patient to look at her. "I'm about to begin the pressure support ventilation, okay?"
Sam blinked at her and then glanced at Dean, as if seeking reassurance that it was indeed okay.
Dean smiled, knowing his cue. "Sounds good."
Sam stared at Dean for a few more seconds and then nodded at Karen.
Karen smiled, noting Sam's relaxed expression and wondering if it was the effect of drugs...or of big brother. "Okay, now...you may experience some discomfort when you start breathing without the assistance of the ventilator, as you would if you were exercising any other muscle that you hadn't used in a while. But I will continually monitor your vitals and the amount of air you're breathing, and if you start feeling too anxious or start having trouble breathing, we'll stop, okay?"
Sam and Dean nodded together.
"Also," Karen added, glancing at Dean and Jim. "If his blood pressure, respiratory rate, pulse, or EKG indicates excessive fatigue, we'll stop."
"And if we have to stop, how soon can we try again?" Jim asked from his position by the door.
"Tomorrow," Karen replied, accustomed to seeing disappointment at that response but still feeling an extra stab of guilt. "But I'm sure Sam will do fine," she countered, with confidence she didn't feel, as she adjusted the settings on the ventilator.
"Damn right he will," Dean agreed heartily, squeezing Sam's hand.
Sam tightened his grip as well and closed his eyes as he felt a building pressure in his chest. He weakly raised his other hand and pressed against his sternum.
"It's okay, Sammy," Dean soothed, gently removing Sam's hand and resting it back on the mattress. "It'll pass. But let's not add extra pressure with the weight of your hand, huh? It'll get better, just breathe through it."
"Dean's right, Sam," Karen encouraged.
"Just like always..." Dean commented and winked at Karen.
Karen laughed, feeling some of her own tension ease.
Dean glanced back at Sam, seeing his brother's expression beginning to relax. "Better already?"
Sam nodded, feeling Dean brush his bangs from his eyes as he opened them.
Dean smiled. "You're doing good, kiddo. Halfway there..."
Karen began to shake her head – they weren't halfway there, they were just getting started – but stopped when Dean scowled at her.
Oh.
Right.
She got it now. "Halfway there" was more motivating than "hang in there, you've still got a long way to go".
Karen smiled. Guess that's why Dean was Captain of this team.
Dean nodded, seeming to read her thoughts, and looked amused as he settled into his routine of keeping watch over Sam and the monitors.
When 20 minutes had passed with no problems, Karen allowed herself to start to feel excitement. Maybe Sam had finally caught a break, maybe he would soon be extubated, and she would finally hear his voice. He had communicated with her numerous times but always nonverbally, and she was embarrassed to admit how much she wanted to hear him speak.
"Okay, sweetie," she said, smiling down at her patient. "I'm switching over to CPAP now. We'll wait another 30 minutes or so, and if you continue to do well, we'll talk about extubation."
"Awesome," Dean responded, ruffling Sam's hair – and then freezing when he heard it.
In the hall.
Down by the elevators.
Muffled by the distance and the closed door but still deep and demanding.
The voice he would know anywhere.
Dean narrowed his eyes, feeling his heart rate increase. He glanced at Jim and saw the realization on the Pastor's face as well.
"I'll take care of it," Jim assured, turning to leave.
"No, I will," Dean corrected, holding the Pastor's gaze.
Jim nodded, continuing to stand by the door.
Dean consciously rearranged his expression, not wanting to upset Sam, who, between the sedative and the distraction of being weaned off the ventilator, was oblivious to their father's arrival.
And that was good. Sam had enough to worry about right now without adding John Winchester to the list.
"You're still doing really well, Sam," Karen praised, actually meaning it and feeling more of her own anxiety begin to fade. She smiled up at Dean and then frowned. "What?" she mouthed, sensing something was wrong and not wanting to alert Sam, whose eyes were once again closed as he concentrated on breathing.
Dean shook his head and then lowered his face closer to his brother. "Sammy..."
Sam opened his eyes.
Dean smiled affectionately as he felt some of his own tension dissolve. He was always amazed at how something as simple as Sam looking at him – with all that trust and love – could calm him down and help him focus. "You're kickin' ass, kiddo. Totally making this vent your bitch."
Sam made a sound – a weak laugh choked out around a tube – and the corners of his mouth twitched in a smile.
Dean's smile widened and then faltered.
Sam tilted his head. What?
"Nothing."
Sam narrowed his eyes.
Dean chuckled. "Nothing you need to worry about right now," he amended.
Sam held his gaze for a few seconds and then blinked, seeming to relax.
"But I need to step out in the hall for a minute, okay?"
Sam wrinkled his nose, expressing his displeasure at that idea.
"I know," Dean agreed. "But I'll be right back. And Jim will stay in here with you while I'm gone." He glanced over his shoulder, not surprised by the startled expression on the Pastor's face. "Won't you?"
The two words were phrased as a question but were meant as a statement.
Jim sighed, hearing the unspoken message and took comfort in the knowledge that at least Bobby would be in the hall to referee if things got physical. "Yes, of course," he replied, coming to stand beside Dean.
Karen shifted uncomfortably, making a conscious effort to keep her focus on her patient and the ventilator, and not the conversation within a conversation that was taking place across from her.
"Be right back," Dean assured, squeezing Sam's hand and the releasing it into Jim's grasp.
Jim's palm pressed against Sam's as his fingers seized the cuff of Dean's shirt, causing the older brother to pause. "Two things..." he said softly, watching Sam's eyes close once again.
Dean arched an eyebrow.
"You're still in a hospital..." – so keep it down – "...and he's still your father..." – so watch your mouth.
Dean swallowed a sigh, annoyed by the reminders – only one of which he would try to keep. But he had too much respect for Jim to show his irritation at being treated like a child, so he nodded and felt the Pastor release his sleeve just as John appeared at the door's window.
Dean felt his heart slam in his chest, adrenaline spurring him to hurry because no way in hell was John Winchester coming in this room right now.
In the next instant, he was in the hall, door closed behind him, and face-to-face with his father. His eyes scanned John's injuries, taking in his dad's bruised jaw, black eye, and split lip.
Dean smirked and glanced at Bobby. "Thanks."
"My pleasure," Bobby replied, standing to the left of John.
John ignored them both, continuing to stare at his oldest. "How's Sam?"
Dean didn't respond.
John arched an eyebrow, realizing nothing had changed in the few hours since their phone conversation. He sighed harshly and moved to sidestep around Dean, only to find himself blocked...by Dean.
"You're not going in there," Dean stated bluntly.
"The hell I'm not," John said, his tone sharp. "I want to see Sam."
"Fine, you can see him," Dean agreed. "From out here."
John narrowed his eyes but looked through the window anyway, feeling his heart drop as a lump of emotion rose to his throat. Sam certainly didn't look well. Not at all. Unnaturally pale, uncharacteristically small, unnervingly fragile. His youngest son's eyes were closed as he rested on the bed, nestled in a bank of pillows, surrounded by a tangle of monitor leads and IV lines. John could barely see Sam's face from the tube that protruded from the kid's mouth, and he was suddenly overcome by the urge to hug his son.
John swallowed against the surge of emotion as his attention shifted to Jim, feeling pissed – if the Pastor had watched Sam more closely, they wouldn't be in this mess – and jealous – he should be the one holding Sam's hand, not Jim.
John sighed as he looked to the opposite side of the bed, pleased to see the woman being gentle with his son, but still wondering how she would react to holy water or a muttered "Christo". Had anyone tested her?
"Who's the woman?"
"Karen, Sam's nurse."
John nodded, remembering talking to her on the phone earlier. "Does she check out?"
Dean didn't respond, momentarily startled...then embarrassed...then pissed with himself that the thought hadn't even occurred to him. All this time Karen had been close to his brother, had even been left alone with Sam, and Dean didn't even know for sure that she was safe. He had just assumed...and that was unacceptable, both by his dad's training and by his own standards when it came to looking after Sam.
Shit.
John nodded again, not even looking at his son, Dean's silence being answer enough. "You didn't think about it," he stated and then sighed. "Fine. We'll do it later."
"Yes, sir," Dean replied before he could stop himself and then shook his head, disgusted by old habits and by how his anger had started to wane. How did his dad always know which buttons to push to manipulate him?
John gave a hint of a smile, pleased that although Dean was as pissed as he had ever seen him, his son was still obedient by default. That was a start.
There was silence as John watched Karen adjust something on a machine and then reach over to Sam's face. "What's she doing?"
"Sam's being weaned from the ventilator right now," Dean reported, observing his father for a reaction.
John's eyes widened slightly at the announcement, the only sign of emotion to cross his face, as he reached for the doorknob...only to have Dean step in front of it.
John cut his eyes at his oldest, glaring. "Dean..."
"You're not going in there," Dean repeated, trying to regain the upper hand.
"I don't have time for this shit, Dean," John snapped. "While you're stomping your feet like a two-year old, Sam's in there, and he needs me."
"You're right," Dean agreed evenly, feeling his anger slowly start to build again. "He's needed you this whole time, and you weren't here. You don't get to show up now and act like father of the year."
John continued to glare his annoyance. "I got here as soon as I could."
Dean snorted. "Give me a fuckin' break."
"Watch your mouth."
"Kiss my ass."
"Dean..."
Dean knew that growled tone, knew his dad was getting pissed and was more likely to kick his ass than kiss it, but he didn't flinch. "You should've come back when I called to tell you about Sam getting his tonsils out."
John sighed. "It was routine surgery."
"That didn't turn out to be so routine – "
" – only because your brother fell and made things worse."
Dean could feel his blood pressure rise. "Are you blaming Sam for this?"
"No, I'm not blaming him. I'm just saying he should've been more careful," John responded matter-of-factly. "And you should've asked more questions and demanded more tests before you let your brother be misdiagnosed and have surgery he didn't even need."
Dean felt his heart slam in his chest. "So you're blaming me?"
"No, not entirely," John replied bluntly. "If I blame anyone for this current situation, I blame Jim. He should've kept a closer watch on Sam. Your brother was Jim's responsibility."
Dean stared at his father, speechless.
John shook his head. "What?"
"You are un-fucking-believable."
"Dean – "
"Sam is not Jim's responsibility, Dad."
"He was during that time period," John corrected.
"Only because you called me away from him, which was total bullshit, since you left as soon as I got there."
"I needed you."
"Sam needed me more, and I knew that – and you knew that – but like the selfish, manipulative sonuvabitch you are, you made me choose because you didn't care what Sam needed. As usual, you only cared about what you needed."
"That's not true," John said quietly, shaking his head for emphasis.
"Bullshit," Dean hissed.
"Dean – "
"You know..." Dean began conversationally, staring at his father as though he was struck with a revelation. "I don't think you even realize you're full of shit. I think you've been lying to yourself and to the rest of us for so long that you just open your mouth and out comes bullshit."
"Enough, Dean," John snapped, his voice louder, his eyes flashing with anger, his hand curling into a fist by his side.
Dean paused, fully expecting his father to strike him – and prepared to reciprocate.
John sighed, trying to rein in his temper, wondering if Dean knew he could press his buttons just as well as he could press Dean's. "Listen – "
"To more bullshit?" Dean interrupted. "No thanks."
"Damnit, Dean! Shut the fuck up and listen to me!"
Dean's eyes widened at his father's outburst, and then he smiled apologetically at a nurse as she passed them in the hall.
She scowled her disapproval but said nothing and entered the room two doors down from Sam's.
There was silence.
And then more silence.
John sighed again. "I know you're upset and pissed – and that's the only reason I'm going to forget we had this conversation – but regardless of what you think right now, I do care about you and your brother."
Dean snorted. "Wow, Dad. Thanks. That makes everything better."
"I mean it, Dean," John said earnestly. "You boys are everything to me."
Dean remained silent for a moment. "Then why do you always choose the hunt over us?"
The truth of those words was like a physical blow, and John felt winded, standing there in front of his oldest, speechless.
Dean nodded slowly. "That's what I thought."
Silence once again settled between them.
Dean was vaguely aware of Bobby still standing in the background, and he glanced in his direction, appreciative of the hunter's quiet support.
Bobby nodded once and then glanced at John.
Dean's focus shifted back to John as well, seething anger slowly dissipating to a hallow sadness as he realized he would never view his father the same way again. The hero was gone, and all that was left was a vengeful, selfish man who routinely chose the hunt, chose complete strangers over his own children, his own family.
And to Dean, that was unforgivable.
Family always came first. Period.
Dean sighed, overwhelmed and startled by the urge to cry, and turned away, preparing to reenter Sam's room just as Jim opened the door.
Dean blinked at the Pastor's sudden appearance and felt his heart drop as he realized he had been in the hall longer than he intended. "Is Sam okay?" he asked urgently.
"He's fine," Jim assured, wondering if the same could be said for those in the hall. Judging by the tension and dark expressions, he would bet not.
"If he's fine, then why are you out here?"
Jim smiled. "Nice to see you too, John."
John scowled. "Answer the question, Jim."
But Dean wasn't waiting for a response. He ducked around the Pastor and entered Sam's room, glaring over his shoulder at John – stay out – as he closed the door.
Karen turned, startled. "Dean?"
"Christo."
Karen frowned but didn't flinch or change eye color. "What?"
Dean shook his head. "Nothing."
Karen smiled nervously. That was...weird.
"Is he okay?" Dean demanded, approaching the bed and then glancing down at Sam, seeing his brother's eyes were open. "Are you okay?"
Sam nodded drowsily and closed his eyes again.
Dean didn't feel soothed. Sam was relatively alert before he left earlier and now his brother could barely keep his eyes open. "Why is he so out of it?"
"He's just tired, but I promise he's fine," Karen responded. "He's still experiencing a little pressure in his chest, but everything looks good overall. We just have to wait for Dr. Collins to make the final decision to extubate and then someone from respiratory will come to assist."
"How long will that take?"
Karen shrugged. "Hard to say. Dr. Collins should be here soon, though." She paused, dreading the next part. "In the meantime, you're going to have to wait out in the hall."
"What? Why?" Dean snapped.
Karen sighed. "It's hospital policy that patients' family members are not present during extubation. That's why I sent your uncle out just now."
Dean stared at her.
"These rooms are small and get pretty crowded pretty quick," Karen further explained. "Plus, extubation can be a little messy sometimes, so it's also for the patient's privacy."
Dean snorted. Messy? Five days ago, Sam had thrown up on him. It didn't get much messier than that. And privacy? There was no privacy between him and Sam; they shared everything.
Karen stared at him and sighed again. "You're not gonna go quietly, are you?"
Dean gave a hint of a smile.
Karen batted her eyes excessively. "Please?"
Dean laughed and shook his head. "Nice try...but no. Bad things happen when I leave Sam."
"You can still see him through the window," Karen countered. "And if there's a problem, I promise I'll call you back in." She paused. "Please, Dean. You know I wouldn't ask you if there was a way around it."
Dean seemed to consider her words as he carded his fingers through Sam's hair, remembering all the ways Karen had bent the rules before. He sighed loudly, hating this. "Fine," he begrudgingly acquiesced. "But I'll be watching at that window, and if the extubation doesn't happen in the next 10 minutes, I'm coming back in...to stay. Period."
"Yes, of course. Absolutely." Karen nodded, hoping Dr. Collins and the respiratory therapist moved their asses. "Thank you," she added, knowing how hard this was for Dean.
Dean didn't respond, giving one last stroke to Sam's hair before leaving the room.
TBC on Monday
As I was editing this chapter, it also grew to almost 30 pages, resulting in yet another cut. Sam's extubation and the reveal of the complication will be in the next chapter, but at least John arrived this time, right?