There was no sight, only sound: the steady clangor of bells amidst the red strobe of candy-striped gates; a brute, subterranean rumble vibrating his rib cage; the chitchat of heavy freight coasting over steel rails spiked into wooden planks; a lonely whistle echoing throughout the sleepy valley; the faint horn of a night train, hauntingly beautiful.
Sam stood in the middle of the train car with his eyes closed for he knew it was too dark to see. The windows were open, and he could feel the night air filtering in, whispering through his hair as it traveled down his neck and licked his bare chest with its delicious coolness.
Which was nice because he was hot.
And his chest hurt.
Sam breathed as deeply as he was able, sensing a pressure he couldn't quite place and yet knew that he had known it sometime before.
He opened his eyes slowly as she stepped out of the shadows, separating herself from the darkness, rising like a demon to claim him. He shrank away as she drew closer, swirling in a mist of shivering moonlight, shrouded in black silk. Her eyes were empty and cold like hard blue steel piercing through him. Her face was uncomfortably close to his; her breath expelled onto his naked flesh, sending icy tendrils through him, the cold growing from inside, numbing and all consuming.
And yet he was still unbearably hot.
And why did his chest hurt so much?
Sam tried to swallow as fear gripped him, constricting his throat, narrowing his airway. His heart raced, and yet he glared defiantly at her, watching a smile slowly curl her thin lips. Her blue eyes shone like the morning sky when it glistened in the sun's rays.
And for some reason, he thought about his mother. Didn't she have blue eyes? He thought she did. Maybe. At least they looked blue in that picture he saw once. He'd have to ask Dean. Dean would know.
Dean.
"Sam..." she called to him, the word like a stone thrown into a hollow pit, a single endless journey into an echoing nothing.
Sam stared at her, afraid and confused, and watched as her eyes narrowed. She looked confused, too – and worried.
"Do you remember me?"
Yes, he remembered her, but she would not be pleased to know why. Pleasure was a sort of oblivion you tended to forget. Pain was remembrance; you did not forget pain – and she had inflicted it upon him.
A while ago, she had stabbed him in the left side...or had she pulled something free?
He couldn't remember that part.
But he did remember the explosion of pain under her hand, and while the sudden pain had dissipated into a dull throb, the constant discomfort was still there.
He sighed.
The faint horn of the night train drifted to him again, and suddenly she was across the train – no...across the room.
Sam blinked.
The train was gone, and he was no longer standing. He was sitting; sitting in a bed he had been in before.
Sam opened his eyes wider, realizing he must have dozed off, and tried to regain his bearings, startled by the reality.
He wasn't listening to the horn of a train but to the shrill whine of a monitor, replaced by a steady hum as she pushed its buttons.
His bare chest wasn't cooled by the night breeze but by the swift movement of people around him; people he vaguely recognized but could not place; people that did not include the one person he was looking for, the one person he wanted.
Sam tried to speak, to call for his brother, but instead choked. He reached weakly for his face and watched as she did the same.
"Whoa, Sam. Wait. I'm going to help you, remember? But you need to relax, sweetheart."
Sweetheart. That was nice. No one ever called him that. Not that he could remember, anyway. Maybe she wasn't so bad after all...
She reached toward him again, her hands searing his flesh, trailing a blaze of fire across his face, sweeping through his hair.
Did she know how hot he was? How much his chest hurt?
Maybe he should tell her.
No.
He should tell Dean.
Dean would understand, would make it better.
Where was Dean?
"Sam..." she called to him again, hand resting on his head.
Sam thrashed on the bed, suddenly desperate to get away from her touch, from the heat that enveloped him, from the invading presence in his mouth, from the crushing pressure in his chest.
Where was Dean?
"Easy, Sam. Calm down."
"Karen..." someone called, and Sam stilled, turning his attention toward the voice.
A voice he didn't recognize; a voice that didn't belong to Dean.
A man materialized beside the woman, tall compared to her. His dark hair was flecked with gray; wire-rimmed glasses perched on the bridge of his long narrow nose. His voice was deep, reverberating in Sam's chest, increasing the already unbearable pressure.
Maybe he should tell this man to tell Dean that his chest hurt.
"Is this his first trial of spontaneous breathing?" the man asked.
"Yes, Dr. Collins," Karen answered. "He's been breathing for about 30 minutes in CPAP mode, with excellent tolerance and no use of pressure support. But he's become increasingly agitated over the last 10 minutes."
"The same could be said for those in the hall," Dr. Collins commented leafing through a folder.
Sam wondered what that meant, wondered who was in the hall. Was Dean in the hall? If so, someone should get him. Someone should bring his brother in the room, so Sam could tell him he was hot...and that his chest hurt.
Really, really bad.
"His fever has also increased, up to 103.3."
Dr. Collins glanced at Karen. "What was it prior to that reading?"
Karen flipped to the front of the folder the doctor still held and pointed.
"A three degree jump in under 10 minutes." Dr. Collins shook his head. "Not good."
Karen shook her head in agreement. "Worsening infection?"
Dr. Collins sighed. "Most likely. How are his other vitals?"
"Blood pressure is a little low, pulse is a little weak, and heart rate is a little fast."
"All signs of anxiety."
Karen nodded. "Like I said, he's become increasingly agitated over the past 10 minutes...ever since his brother left the room."
Dr. Collins arched an eyebrow. "That probably explains it." He smiled and then sighed. "Okay, let's look at his other numbers."
"I haven't had a chance to look at them yet," Karen commented as she turned a few pages in the folder and then pointed again.
Dr. Collins scanned the information and frowned.
Karen's expression subconsciously mirrored his. "What?"
"All his numbers are a little low."
"What do you mean?"
"I mean they're a little low," Dr. Collins repeated, annoyance in his tone. "His vital capacity, tidal and minute volumes, respiratory rate, negative inspiratory force, and arterial blood gas are all a little low."
"Too low?"
"Low enough."
"I don't understand," Karen responded, shaking her head. "He's been doing really well with the SBT. He did well with PSV, and he's continued to do well on CPAP. He's fatigued, but no more than expected, and he hasn't indicated that he's experiencing trouble breathing."
"Maybe he's too stubborn to complain," Dr. Collins commented, gloving up as he looked over at his patient, startled to see Sam staring straight back him. The doctor felt unnerved by the intensity of Sam's gaze, almost like the kid was trying to tell him something. "Sam?"
Sam stared at the man with the deep voice and wondered if he could go find Dean. He was hot, and his chest hurt, and he really wanted Dean.
Dr. Collins approached the bed. "You okay, Sam?"
Sam pressed his hand to his chest in response.
"He's been doing that since we started," Karen reported.
Dr. Collins nodded. "A little chest discomfort is common when coming off the ventilator, Sam. It'll get better once we extubate and you breathe more on your own."
Sam stared up at the man with the deep voice, wondering why he didn't understand what was so obvious; wondering why he was there, but Dean wasn't.
Dr. Collins smiled as Sam continued to stare at him and quickly checked the kid's incision, noting the red lines of infection peeking out from under the gauze and shook his head. Even after all the medical advances, infection was still a doctor's primary enemy.
"While I'd like for his numbers to be a little higher, let's go ahead and suction him and prepare to extubate. We'll give him about an hour to breathe on his own with an oxygen mask to assist, and then I'll be back."
Karen nodded. "What about that?" she asked, pointing at Sam's incision.
"Let's maintain current dosage of antibiotics and then revaluate in an hour." Dr. Collins discarded his gloves and washed his hands. "Have you paged respiratory?"
"Yes," Karen replied, staring at Sam and feeling her earlier anxiety return.
Was he trying to tell them something? Maybe she should get Dean...
She sighed and shook her head at herself.
No.
If she called Dean in now, she'd never get him back out. Besides, she was being ridiculous. Sam was fine; he was just uncomfortable and tired from the SBT.
"Karen?" Dr. Collins prompted.
Karen blinked. "Yes?"
"I asked if you've page respiratory."
"Oh...um...yes," Karen replied, willing herself to relax. "I asked Ashley to come up..."
"And your wish is my command," said a voice from the door.
Sam watched as another woman entered the room and approached his bed. She had short blond hair pulled back in a high ponytail and wore a white long-sleeved shirt under green scrubs.
Had she seen Dean? Maybe she could go find his brother and bring him in the room; so Sam could tell him about his chest pain; so Dean could make it better.
"Thanks for coming, Ash," Karen said, accepting the folder from Dr. Collins.
"Yeah, yeah," Ashley responded, smiling as she waved her hand dismissively before grabbing a pair of gloves from the box on the wall. "I almost got attacked in the hall, though. I think his family is getting restless."
Dr. Collins exchanged knowing glances with Karen. "I'll go do crowd control while you two extubate," he said as he turned toward the door.
"Good luck," Karen teased good-naturedly, setting the folder on the bedside table.
"Thanks," Dr. Collins replied dryly, stepping into the hall.
Ashley approached the bed and stood beside Karen. "Are we ready?"
Karen nodded. "Yep. Dr. Collins just gave orders to extubate."
Ashley returned the nod, eyes scanning their patient. "He's a cutie."
Sam glared at her, wondering if she would still think he was cute when his chest exploded from the building pressure within.
He closed his eyes, fighting the urge to cry.
Where was Dean?
Karen smiled at Ashley. "He's definitely a cutie," she agreed. "And sweet, too. Aren't you, Sam?"
Sam opened his eyes and pressed his hand to his chest once again, hoping they would finally get a clue.
They didn't.
Karen gently moved Sam's hand back to the mattress and reached for the suctioning catheter on the wall. "Alright, sweetheart, let's suction you, okay?"
Sam shook his head slightly.
No.
Not okay.
Dean wasn't there, and nothing was okay.
He shifted restlessly on the bed, feeling crowded by their close proximity and reaching hands.
"Relax, Sam," Karen soothed, suctioning the endotracheal tube and then Sam's mouth as Ashley loosened the fasteners around the tube. "Almost over."
"Boy, he's scrawny, but he's feisty," Ashley commented, surprised by the strength with which Sam pushed her hand away.
Karen laughed. "I think it runs in the family. His brother – "
" – is freakin' hot," Ashley finished and nodded for emphasis. "Seriously."
Karen laughed again. "Yes, I know. I've noticed. And you should see him with Sam..."
"Let me guess...protective older brother who's a badass to everyone he meets and yet he's incredibly sweet and gentle with his little brother."
"Exactly," Karen affirmed, placing the suctioning tube back in its slot.
"Wow," Ashley replied, passing two towels to Karen. "I think he just got hotter."
Karen grinned, draping one towel over Sam's chest and the other across his lap, noticing the kid staring at her again and wondering what he thought about them discussing his older brother.
Sam listened to the women beside his bed, wondering if they knew how pissed Dean would be if he knew they were ignoring his nonverbal pleas for help.
"Okay, sweetie, this isn't going to be comfortable, but Ashley is going to pull the tube now."
Without further warning, Ashley did just that, pulling out the endotracheal tube in a steady, quick motion, causing Sam to gag and cough. She placed the tube on the towel in Sam's lap as Karen held the other towel to his mouth, collecting the secretions as he continued to cough and gasp.
"It's okay, Sam," Karen assured, rubbing his back with her other hand as she wiped his mouth and chin. "Slow, easy breaths. You're doing good..."
Sam squeezed his eyes shut, wondering if she knew she was a liar, if she knew how far away from "good" he was at the moment.
"D..."
"Shhh," Karen soothed. "Not yet. Don't speak yet, Sam. Just breathe."
"Blood," Ashley noted quietly, glancing at the tube and then at the towel Karen held.
Karen nodded. "He's five days post-op from a tonsillectomy."
Instant realization lit in Ashley's eyes, and she returned the nod. "Damn. Poor kid."
"Yeah," Karen agreed, knowing that the usual sore throat and raspy voice resulting from intubation would increase at least tenfold for Sam. She took out a penlight from her pocket. "Okay, sweetheart, open your mouth for me."
Sam felt the coolness of her hand as it lightly pulled on his chin and opened his eyes.
Karen smiled encouragingly, and Sam did as he was asked, feeling her tilt his head back as she looked in his mouth.
"Huh..." Karen said, confused at what she saw.
Ashley glanced at her. "What?"
Karen shrugged, pulling back and allowing Sam to close his mouth. "There's increased inflammation and edema, but the scabs back there are relatively intact, and there's no trace of blood." She paused. "So if his throat isn't bleeding..."
Ashley shook her head as Karen's voice faded, once again looking at the blood on the tube and the towels and not liking the implication.
Sam glanced between the women. Did they get it now?
Karen shared a look with Ashley. "You're the respiratory therapist. What do you think?"
Ashley shrugged. "Hard to say. We don't want to overreact, so maybe just monitor for the next hour and see if the issue resolves itself?"
Sam stared at the woman with the blond ponytail. Was she serious?
Karen felt uneasy with the wait-and-see option but nodded. "Okay," she agreed and nodded again, trying to convince herself that was a good idea. She sighed and smiled down at her patient. "Okay, sweetie, I need you to say something."
Sam had several "somethings" he wanted to say to them but decided none of that mattered. Only one thing ever mattered to him. He inhaled nosily and then exhaled a shuddering breath. "D'n..."
Karen smiled, feeling her heart swell. "Now, how did I know you were going to say that?"
"These two are too much," Ashley commented, feeling unusually sappy.
"Trust me, I know," Karen said, noticing Sam's left arm protectively curl around his stomach as his right hand clutched at his chest. "Sam? What's wrong?"
Sam swallowed, then winced and coughed, causing him to wince again. "H'rts."
"Probably from the coughing," Ashley suggested.
"And the fact that that his incision is infected..." Karen added. "I'll ask Dr. Collins about increasing your pain meds, okay?"
Sam didn't respond immediately, his eyes searching the room. He didn't need more drugs. He needed his big brother. "Where – "
"Shhh," Karen hushed, already knowing. "We'll get him. You just rest and be quiet for now. Your voice is a wreck."
"Thirsty."
"I know," Karen responded as Ashley removed the soiled towels. "The oxygen you're receiving is humidified, so that will help ease your sore throat for now. We'll wait about half an hour or so, and then I'll bring in some ice chips, okay?"
Sam sighed, not really caring. She could keep her ice chips as long she brought in Dean.
"Sam," Ashley called and waited for him to focus on her. "I'm going to put this on you," she said, placing an oxygen mask on his face.
Sam nodded, exhausted and grateful for the extra help to breathe.
"You need to wear it for at least a few hours, okay?"
Sam stared at the woman with the blond ponytail, wondering idly why she and the other woman asked him "okay" after everything they said to him. He seriously doubted they were asking his permission, so did that mean he looked stupid, like he would need further explanation to understand? If anyone was stupid, it was them for not understanding what he had tried to tell them multiple times – his chest freaking hurt.
Karen exchanged a worried glance with Ashley as Sam stared blankly at them.
"Sam – "
"'Kay," Sam replied irritably, hoping they would shut up, go away, and get Dean.
Ashley laughed, collecting the endotracheal tube and turning toward the door. "As I said before, scrawny but feisty..." she reaffirmed.
"So it seems," Karen agreed, amused and a little surprised by this side of her patient. "Hey..." she called. "Send Dean in."
"Mmm, my pleasure," Ashley responded in a sultry tone, earning another laugh from Karen.
"Behave," Karen admonished, reaching across Sam and shaking her head as Ashley exited the room.
"Sam's asking for Dean," Ashley reported to the three men standing outside the doorway as she tossed the towels into the soiled linen bin in the hall. "Which one of you is Dean?" she questioned, hoping her feigned ignorance wasn't too transparent.
"I am," Dean responded instantly, invading her personal space as he pushed by her. "Sammy..."
Sam smiled weakly when he saw Dean, immediately reaching toward his brother.
Dean felt his protective streak flare and grasped Sam's hand, noticing his brother's flushed cheeks that attested to the kid's rising fever. "You're burning up, kiddo," he commented, other hand sweeping under damp bangs then down the side of Sam's face.
Sam nodded and leaned into his brother's touch, too-warm cheek cupped by a cool hand. He closed his eyes and sighed, feeling marginally better.
Dean always made things better.
Sam opened his eyes and blinked at his brother.
Dean smiled affectionately and lowered his hand, two long fingers gently pressing around the incision. He sighed harshly. "I still don't like the way this looks, Sammy."
"Dr. Collins took a look at it and said we would maintain current course of treatment with antibiotics, and he would check back in an hour," Karen reported, standing against the wall, giving the brothers their privacy while she wrote in Sam's chart.
Dean narrowed his eyes, having liked Dr. Collins for the most part but now reverting to his original impression of the man – he was a dumbass. Anyone with eyes and half a brain would know this infection was beyond the usual course of treatment.
Dean opened his mouth to speak but stopped when he felt Sam squeeze his hand. He looked at his little brother, not liking the expression on Sam's face. "You okay?"
Sam shook his head and pressed his hand to his chest.
Dean frowned. "It still hurts?"
Sam nodded.
Dean glared over his shoulder at Karen. "I thought you said that would get better."
Sam didn't wait for her to respond. He grabbed Dean's other hand and pressed it to his chest, covering his brother's hand with his own, holding it there.
Dean's frown deepened as he felt Sam's rapid, erratic heartbeat against his palm; the shallow rise of his brother's small chest barely moving his hand.
This was not good.
Dean swallowed, trying to calm his own racing heart, as he sat on the edge of Sam's bed, hand sliding from his brother's chest and coming to rest on the back of the kid's neck.
"Scale of one to ten..."
Sam weakly held up both hands, ten fingers stretched wide before closing and resuming their positions – one hand grasped in Dean's hand, the other resting in the center of his chest.
"Shit," Dean hissed. "For how long?"
Sam opened his mouth to respond, but gasped instead as pain flashed across his face; his hand tightening around Dean's; his other hand pressing harder against his chest as his eyes squeezed shut.
"Whoa. Hey..." Dean said just as the alarms started to blare. "Sammy..."
Karen approached the bed, her attention darting to the monitor. "O2 sats dropped to 82."
"But he's wearing a mask..."
"I know," Karen answered, exchanging worried glances with Dean before setting the folder on the bedside table and directing her attention to her patient. "Sam, do you have chest pain?"
Sam nodded excessively – now she finally got it – before his head lolled to the side, his grip loosening on Dean's hand as the monitors continued their gradually increasing din.
Dean squeezed his brother's neck, his hand. "Sam!"
"Shit," Karen hissed.
"What?" Dean asked frantically.
"It all makes sense now..."
"What does?" Dean demanded.
"Damnit! I should've known..."
"What?" Dean yelled, seconds away from shaking the answer out of her.
"Possible acute PE," Karen responded.
Dean's eyes widened, heart pounding at the fear and panic in her voice, at the increasing unresponsiveness of his brother. "What the hell is acute PE?"
"Pulmonary embolism." She looked over her shoulder toward the door. "Ashley!"
In the hall, Ashley heard her name called from within Sam's room.
"How's Sam?" one of the men asked as she turned toward the room's door.
Ashley glanced at him, wondering first what happened to his face...and second if he was Sam's dad. She could see the resemblance – if she tilted her head and squinted – but she could definitely see the favor in Dean.
Ashley dropped the endotracheal tube into the disposable bag the nursing assistant gave her and tied it off, handing it back to the assistant.
"Didn't Dr. Collins update you?" she attempted to evade, hearing Karen call her name again.
"He started to but got a page and had to leave," the Pastor informed.
Ashley nodded, wondering if Sam's family was religious.
"Ashley!" Karen called for the third time.
"So, how 'bout you tell us..." the third man said, his tone gruff, his appearance grungy. "How's Sam?"
"I'm sure he's fine," Ashley assured, but the words had barely escaped her lips before a deafening series of beeps erupted from Sam's room, followed by a blinking light over his door.
They stood in stunned silence before launching into a flurry of activity, Ashley pushing through the door and then attempting to block entry even as all three men surged forward.
TBC…on Wednesday