Silence propagates itself, and the longer talk has been suspended, the more difficult it is to find anything to say.
Such was the case as dawn spilled into the consult room that Sunday morning, pouring soft light through the window as it stretched across the floor.
Dean stared at the clock on the far wall, the minute and hour hands blurring as he focused on the second hand slowly ticking on its journey around the face, unnaturally loud in the quiet room.
It had been a little over two hours since anyone had spoken.
It had been closer to three hours since they had last seen Sam. Since he had coded; and been resuscitated; and then trached; and then whisked off for a spiral CT; and then apparently rushed to surgery – again – and would it fucking kill Dr. Collins or Karen or somebody to tell them what the fuck was going on?
Dean stood abruptly, his chair scraping across the floor like nails on a chalkboard.
No one startled at the movement.
They were hunters, after all. Nothing much surprised them, especially not the actions of each other.
But John did glance at his oldest as Dean began to pace the length of the table.
"What the fuck is taking so long?" Dean demanded to no one in particular. "He said he would be back to discuss options after the scan, and that was three fuckin' hours ago!"
"Dean."
Dean glanced at his father, continuing to pace, wondering if John really thought that tone and that stare would work on him now. At this point, he was well beyond calming down.
"Must not have been time to discuss options," Jim replied reasonably, even as his heart ached in his chest at the implication of such a scenario.
His statement did nothing to ease the tension in the room, and Jim closed his eyes briefly, saying yet another prayer, having lost track of how many he had said over the past three hours.
Bobby sighed harshly as he watched John watch Dean. He glanced at Jim, wondering if the Pastor was praying or meditating or simply resting his eyes. Jim had to be exhausted, as did Dean. Both had been at the hospital longer than he and John, and yet Bobby was already drained...emotionally, physically, and mentally. He could only imagine how the other two felt.
Bobby sighed again and was about to speak when the door suddenly opened.
Dean froze at the far end of the table, registering the doctor's presence, and then surged forward. "How's Sam?"
Dr. Collins acknowledged Dean with a glance as he closed the door behind him but did not speak.
John stood abruptly, his shoulder brushing Dean's. "How's Sam?" he repeated.
"Gentlemen..."
Dean felt his stomach clench.
Conversations that began with formalities in hospitals – and especially in hospital consult rooms – did not end well.
No one spoke. No one breathed. No one even looked at each other.
Dr. Collins shifted under their intense gaze, holding the folder to his chest as though it would protect him from their reaction.
"I must be honest with you," he said, his eyes scanning the small room as though he was trying to decide which was strong enough to bear the brunt of the news.
He settled on Dean.
Dean held his breath, braced himself as he would for a physical punch.
"Sam's had a major setback, and right now – "
"Is he still alive?"
Dean stared wide-eyed at his father, the question having never even crossed his mind; the thought that Sam had lost the fight, that his little brother was gone and not coming back being so unfathomable that it never occurred to him.
But now that John had asked...
Dean turned his gaze to the doctor. "Is he?" he asked urgently, because he had to know.
Sam had to be alive. As long as Sam was alive, Dean could handle anything else. But Sam had to be alive.
Dr. Collins sighed. "Yes. Sam is alive."
"But..." Bobby prompted, hating that there always seemed to be a "but" in their lives.
Dr. Collins swallowed. This part never got easier. "The prognosis is not good."
The prognosis is not good.
The phrase hung in the air, caught in the thick silence that continued to fill the room.
"What the fuck does that mean?" Dean demanded. "Are you giving up on him?"
"No, not at all," Dr. Collins assured calmly, accustomed to dealing with distraught family members in these tiny rooms with stark walls and hard chairs. "Sam's a tough kid."
"Damn right he is," Bobby agreed.
John narrowed his eyes. "But you're still concerned..."
Dr. Collins nodded, glancing from John to Dean, a little unnerved by the intensity of the older brother's stare.
Jim cleared his throat. "Would you elaborate, please?"
"Yes, of course." Dr. Collins inhaled deeply and pulled a chest film from the folder. "We decided to do a chest x-ray first to rule out pneumothorax and other conditions that sometimes mimic symptoms of PE. But as you can see here..." he said, switching on the wall-mounted x-ray viewer and shaking the wobbly film once to stiffen it before placing it over the light. "There is no pneumothorax, and everything appears to be fine."
"That's good, right?" Jim sought to clarify.
Dr. Collins gave a noncommittal gesture – something between a shrug and a head tilt – and pulled a printout from the folder.
Dean felt dread rise in his stomach. He knew body language, and he didn't like what the doctor's was implying. "What's that?"
Dr. Collins hung the printout on the corkboard beside the x-ray viewer. "This is from the spiral CT, which shows a pulmonary embolism in Sam's right pulmonary artery."
"Which you already suspected..."
Dr. Collins glanced over his shoulder and was startled to see all three of the men standing directly behind him, staring at his finger as it marked the spot.
How did he not hear them get so close so quickly?
The doctor shifted nervously. They were beginning to freak him out. Their silent stealth and intense, unwavering focus gave them an edge he hadn't noticed before; made them seem a little unpredictable, maybe even a little dangerous.
Even the Pastor seemed hardcore.
Dr. Collins shook himself. Get it together.
"Yes," he answered John. "Sam's chest pain and dyspnea so soon after surgery were indicative of PE, as was the sinus tach shown on the ECG after resuscitation. The spiral CT just confirmed that diagnosis."
John nodded and squinted at the dark blob on the printout. "What caused it?"
"Usually we suspect blood clots originating in the deep veins of the legs from long periods of immobility and then traveling to the lungs, where they get wedged in an artery. But sometimes splenectomy patients are different. The spleen stores almost one-third of the total blood platelets of the human body, and after it's removed, the platelet count increases dramatically. This condition is known as thrombocytosis and may result in abnormal clotting of the blood, which could be life-threatening."
"So the thrombo-whatever caused the PE?" John clarified.
Dr. Collins made a noncommittal sound. "It's possible."
"So what did you do to him?" Dean asked, his tone accusatory.
Dr. Collins glanced at Dean, feeling the heat of his glare. "We took Sam down to angiography."
"Without discussing it?"
Dr. Collins shook his head at John. "There wasn't enough time."
Dean glanced at Jim. The Pastor had been right.
Jim nodded, wishing he had been wrong. "Did you place a filter?"
Dr. Collins arched an eyebrow, surprised. What did the Pastor know about filters to treat pulmonary embolisms?
"I've had parishioners over the years that have had PEs," Jim explained, failing to mention that they had all died within days of their diagnosis.
But all of his parishioners had been ill and elderly. Surely a young strong kid like Sam stood a better chance.
"I see," Dr. Collins commented. "Well, since we suspected PE, we had already started a Heparin drip. But Sam's lowered hemoglobin and hematocrit levels indicated another hemorrhage, which was not surprising given his recent history of internal bleeding."
"Shit," John hissed softly.
Dr. Collins nodded in agreement. "So we reversed the Heparin and gave him FFP to help control the hemorrhage."
"And did that work?" Jim asked hopefully.
"Yes, but we were then faced with a different problem. The body will eventually dissolve a clot on its own through a process called clot lysis, but since the clot was so massive..." He pointed again at the CT printout. "...and since Sam was showing signs of hemodynamic instability, we began low-dose thrombolytic therapy with a drug called TPA."
"And that is?" Bobby prompted.
"Tissue plasminogen activator, which is a clot-busting medication that is most commonly used for patients with myocardial infarction or CVA but can also be given to patients with other issues caused by clots, such as PE."
"Wait..." Dean shook his head. "I thought the Heparin was a clot-busting drug? Why would you stop one and then start another if Sam was bleeding from it?"
"No, Heparin is an anticoagulation drug, meaning it prevents clots from forming. TPA dissolves clots that have already formed."
"Does it work?"
Dr. Collins nodded at John. "Yes, it does an excellent job of dissolving clots – which is what Sam needs – but it also significantly raises the risk of bleeding – which is..."
"...what Sam doesn't need," Dean finished.
Dr. Collins sighed. "Exactly. Starting thrombolytic therapy is usually contraindicated in patients that have just undergone surgery for the same reasons we reversed the Heparin – the increased risk of bleeding – but at that point, Sam's life was in danger, and we had no choice. I assure you we're administering the lowest dose possible and are monitoring him closely."
"Is Karen the one monitoring him?" Dean asked, his tone acidic.
Dr. Collins nodded, wary of Dean's attitude. "Yes, she's with him now."
"I want a different nurse," Dean stated bluntly.
Dr. Collins shook his head, confused. "Why? Karen's an excellent nurse."
"Excellent nurse, my ass! She's the reason Sam coded," Dean accused. "If she had been paying closer attention to my brother, instead of doing God knows what, Sam would've gotten help sooner." He shook his head, clearly disgusted and pissed. "I want a different nurse."
"Well...um..." Dr. Collins faltered, not sure how to respond. "Again, Karen is an excellent nurse, and I can't imagine her neglecting a patient. Symptoms of PE are often nondescript and hard to diagnose until there's an emergency situation. It's just the nature of the condition. And with Sam having just come off the vent, it wasn't unusual for him to present with chest pain or shortness of breath. So..."
"Karen should stay."
Dean cut his eyes at Jim, prepared to argue, but pausing when he saw the Pastor's determined yet compassionate expression.
Jim held Dean's gaze. "She's a good nurse, and she cares about Sam. But she's also human, and we all make mistakes."
"But Jim – "
Jim shook his head, continuing to stare at Dean. "Only she and God know the true nature of her mistake, Dean. And if she was negligent – for whatever reason – she knows it, and the guilt she feels will be punishment enough."
Jim paused, not for effect but for Dean's comprehension, for John's oldest to realize the truth of his words.
Dean narrowed his eyes, desperate to hold on to his anger about this – pissed and wanting someone to pay for what had happened. "So, what...forgive and forget and all that crap?"
"No," Jim answered patiently. "We don't forget experiences that frighten us. But we can forgive and move on."
Dean sighed harshly, hating how Jim always spoke so softly; always handled him so patiently; always knew how to calm and soothe him – even when he didn't want to be calmed and soothed.
Dean glanced at John, wondering why John was just staring at him indifferently and thinking his father should take lessons from the Pastor.
Dr. Collins cleared his throat. "So...about Karen..."
Dean sighed again, because as usual, Jim was right. Karen had been good to them, and he knew she would never have intentionally put his brother at risk.
Jim smiled softly, knowing he had won. "She stays."
Dr. Collins nodded but looked to Dean for final confirmation.
"Fine." Dean gave a hint of a smile at Jim and nodded as well. "She stays."
Dr. Collins glanced at John, knowing the decision had already been made but thinking he should at least make a show of asking Sam's father for his input about his son's care.
John shrugged. He was mildly pissed earlier, but he didn't really know the woman. Jim and Dean had been around her longer than he had. She seemed nice enough and capable enough, and as long as she wasn't a demon or some other supernatural threat, he didn't really have an opinion about her.
"Is that okay with you?" Dr. Collins prompted.
John shrugged again. "Sure."
Dean snorted. His father's active involvement in the decisions about Sam's care was...pathetically detached. As usual.
Bobby shook his head and rubbed his hand down his face. Nothing was simple with this crowd. No wonder he was practically bald and had gray hairs in his beard. He only had so much tolerance for unnecessary dramatic bullshit, and the bastards were draining him dry.
"Now that we've got that settled..." Bobby commented dryly, making sure everyone in the room knew what he thought about the time spent on that particular sidebar. "How 'bout you finish telling us about Sam..."
"Yes, of course." Dr. Collins nodded eagerly, thankful for the help in getting back on track. "After the spiral CT, we took Sam to angiography to place a Greenfield filter."
"What's that?" Dean asked, not liking that none of this had been previously discussed.
"It looks kinda like this," Dr. Collins responded, bending his wrist downward as he cupped his hand and spread out his fingers. "The filter has six legs that are joined at the top, creating a cone shape. It's a common alternative treatment when anticoagulation is contraindicated and will help prevent any more potentially fatal blood clots from forming and lodging in Sam's lungs."
Dean felt his heart rate increase, not liking the phrase "potentially fatal" being used in the same sentence as his brother's name.
"So, it kinda spreads everything out and gives plenty of room for whatever to get through?" Bobby clarified, glancing from the doctor's hand to the film still illuminated on the wall.
"Well...kind of," Dr. Collins partially agreed. "When a clot enters the filter, it's directed toward the center and is trapped in the cone." He demonstrated with his hands, his left moving toward his right and then being trapped. "But the filter is designed to allow adequate blood flow around the captured clot." He removed his left hand from his right's grasp and spread out his left fingers, moving them in a sweeping motion to simulate how blood would flow. "Over time, the natural process I mentioned before – clot lysis – will dissolve the trapped clot, thus preventing it from reaching Sam's lungs and creating another PE in the future."
There was silence as the men absorbed the information.
"So is this why Sam was rushed to surgery?" John asked. "For this filter?"
Dr. Collins nodded. "Yes, it's a surgical procedure."
"Did you hurt him?" Dean demanded, still uneasy about this. He had always been suspicious of surgical procedures, but his recent experience with Sam's unnecessary tonsillectomy had made him even more so.
Dr. Collins smiled softly – Sam's comfort always seemed to be one of Dean's primary concerns – and shook his head. "No. Sam was completely under during the procedure. And while I don't normally like patients to be put under anesthesia twice in such a short time period, it couldn't be helped in this case."
John nodded, understanding but not liking it.
"So, this surgical procedure..." Bobby began, arms crossed over his chest. "What did it involve?"
"Well..." Dr. Collins began, impressed that these men always wanted the details on their youngest, whereas most families just stared at him, too overwhelmed to ask questions. "The filter was placed in the inferior vena cava – or IVC – which is a large blood vessel found in your abdomen that continues up to your heart, inside your chest. During the procedure, a catheter was inserted into the blood vessels in Sam's groin. Sometimes we go in through the neck, but because of the trach, we decided against that." He paused. "A fluoroscope was used to guide the catheter into Sam's IVC, then the filter was inserted through the catheter and into the IVC where it attached to the walls of the vein. The catheter was then pulled out, and the filter was left in."
"Is it permanent?" John asked, wondering about long-term implications.
Dean glared at his father, knowing what John really wanted to know – if this filter would affect Sam's ability to hunt.
"Yes, the filter is typically permanent," Dr. Collins responded. "But it should not cause him discomfort or adversely affect Sam's life."
"He should be able to resume normal activities?" John persisted.
Dean's glare intensified. If John Winchester thought Dean was going to allow him to push Sam right back into hunting again after all of this, his dad was a bigger dumbass than Dean thought.
"No."
The word was spoken with such force and authority, that at first, Dr. Collins thought John had incorrectly answered his own question. But then he realized – as did everyone else in the room – that Dean was the one who had delivered the answer.
John arched an eyebrow. "What?"
"No," Dean repeated, staring meaningfully at his father. "Sam won't resume normal activities."
John's expression hardened. He knew exactly what Dean was saying.
"Actually..." Dr. Collins hesitantly corrected. "The filter should not pose any hindrances to Sam. He should be able to resume – "
"No," Dean said again, not even looking at the doctor. This was no longer a medical discussion.
"Yes, he will," John stated, as though the decision was already made, as though, per usual, he wasn't asking Dean's input, he was just delivering the order.
"No, he won't," Dean countered, his tone just as authoritative as his father's.
"It's the family business," John declared.
"It's bullshit," Dean corrected.
Jim sighed.
Bobby did the same.
And Dr. Collins realized father and son were talking about something over his head.
"This is not up for discussion, Dean," John replied coolly. "I'm his father, and – "
"Give me a fuckin' break!" Dean yelled. "You finally drag your ass here, offer a few words of support, a slap on the back, and you think that fixes everything? You think that makes you a father?"
"Dean..."
"No, Jim," Dean interrupted, glancing at the Pastor and shaking his head, refusing to be calmed this time. "You and Bobby are more of a father to us than he has ever been." He looked back at John. "You suck as a father."
Jim briefly closed his eyes as Bobby glanced at Dr. Collins, giving the physician a sarcastic, humorless smile.
Welcome to our life.
Dr. Collins blinked, unsure of how to react.
Dean stared at his father. He knew he had cut John deep – though his dad's expression didn't show it – and God help him, but it felt good to cause John the same amount of pain his dad had caused him over the past few days.
John glared, sensing Dean's satisfaction at finally saying what had been brewing for a while.
And Dean glared back, just getting started. "Your priorities have been so fucked up for so long that I don't think you're in any position to make decisions about Sam."
John's expression darkened, explosive anger barely contained. "And you are?"
"Damn right, I am!" Dean responded, eyes flashing vivid green, intense with emotion. "Unlike you, I always put Sam first."
"Is that why your brother is fighting for his life right now, Dean?" John asked, his tone a mixture of taunting sarcasm. "Because you put him first and made the best decisions for him?"
Jim's eyes widened as Bobby's expression hardened, but both had the same internal reaction – Oh, shit – and both readied for action.
John knew it was a low blow, a verbal sucker punch to his own son; but wounded pride and hurt feelings loosened the tongue and didn't play fair.
Dean felt momentarily stunned – as if his father had physically struck him – and then he was all movement, enraged and out for blood. "You sonuvabitch!" he yelled, lunging toward his father.
Jim quickly intercepted Dean as Bobby moved to block John's approach, the movements of everyone forcing Dr. Collins into a corner of the small room, pressed up against the door and holding his breath.
The physician had seen family arguments over the years – stress and exhaustion had a way of intensifying emotions and pushing buttons – but this beat all. He was apparently right before; these men were unpredictable and a little dangerous.
And that especially sucked for him because he hadn't told them the worst of the news about Sam.
After a few more seconds of swearing and throwing punches, of yelling and shoving, of chairs scraping across the floor, father and son were separated to opposite sides of the room – Dean with the Pastor, and John with the other one.
Dr. Collins observed the men in the silence that followed, watching as the Pastor slowly released Dean, one hand lingering on the boy's chest, making sure he was truly okay. Dean nodded once and then took a step back, distancing himself from the Pastor but continuing to glare at his father across the room.
John remained expressionless as the other one – his name started with "B" – roughly pushed him against the wall and held him there, undoubtedly in nonverbal warning to back off and calm down. John shook from B-guy's grasp, shoving him back as more nonverbal words were exchanged. B-guy didn't seem fazed, holding John's stare until John looked away first, glancing over at his son. B-guy did the same, first looking at Dean and then doing a nonverbal check-in with the Pastor.
It was confusing and dizzying and fascinating all at once.
"I wanna see Sam," Dean suddenly announced, eager to be with his brother, to check on Sam himself. "Now."
Dr. Collins sighed, wondering how in the hell he was going to tell them the rest of Sam's current diagnosis. "Well..."
"What?" Dean and John asked sharply in unison and then glared at each other from across the table.
After what just happened, neither wanted to be in sync with the other right now and seemed pissed that they couldn't turn off that characteristic.
"Where's Sam?" Dean demanded, taking a step toward the doctor.
Dr. Collins sighed again. There was no easy way to broach this subject. "He's in isolation."
"Isolation?" Dean repeated.
"Why?" John asked, feeling dread rise in his stomach.
"For his protection." Dr. Collins paused. He hated this. "Because a pulmonary embolism isn't the only thing Sam is dealing with right now. In fact, it's the least of our worries."
Dean glanced at John, not surprised to see his father staring straight back, not surprised that their anger had vanished – at least for now – as they once again united for Sam.
"That's unsettlingly cryptic," Jim commented, his tone polite but his expression not. Patience had left the building the instant he had to referee a Winchester free-for-all. "Elaborate, please."
Dr. Collins nodded, feeling his heart rate increase. "Sam has overwhelming postsplenectomy infection – OPSI – also known as postsplenectomy sepsis syndrome."
Dean looked at his father again. What the hell was that?
"That as bad as it sounds?" Bobby asked.
"Unfortunately, yes," Dr. Collins answered. "Because Sam no longer has his spleen, he's at an increased risk of infection, especially during the first two years after surgery. As a rule, children are at a greater risk for developing sepsis than adults. In fact, some children are kept on antibiotic therapy until they are 16 years old to help prevent infection, and all asplenic patients are advised to get a pneumococcal vaccine before surgery. But due to the emergency nature of Sam's situation and his critical condition at the time, he was not vaccinated prior to the procedure. And then the incision got infected and..."
"...and now we're royally fucked," Dean finished blunty, staring at the doctor.
"Well..." Dr. Collins hesitated. Those weren't the words he was going to use, but... "Yes."
"Sonuvabitch!" Dean hissed. "I told you not to use that damn drain tube!"
"I know you don't agree, but it was needed at the time," Dr. Collins countered. "That it became occluded was unfortunate but – "
"What if I kicked your ass?" Dean asked conversationally. "Would that be unfortunate, too?"
"Dean..." John warned, as Jim shook his head, and Bobby chuckled softly.
Dr. Collins swallowed. "I know you're upset..."
"No, I'm fuckin' pissed!" Dean corrected. "First, Sam almost dies because you waited too long to remove his spleen; then he codes and almost dies again because one of your nurses wasn't paying attention to him; and now he's got some kind of massive, life-threatening infection because you didn't take the right precautions?"
Dr. Collins was speechless. It was hard to argue with the truth. He sighed as he looked around the room, taking in the dark – almost threatening – expressions of the men, each pair standing on opposite sides of the table but united in their contempt for him and in their love and protectiveness of Sam.
"I'm sorry," he offered lamely. "I'm – "
"Save it," John growled, taking a step toward the doctor. "What now?"
Dr. Collins glanced at Dean, noticing he had stepped closer as well. "Because aplensic patients have a decreased ability to clear bacteria from the blood and also have lowered levels of immunoglobulin M – a protein in blood plasma that helps to fight viruses – they are susceptible to a host of pathogenic microorganisms. But encapsulated organisims, such as Streptococcus pneumoniae are the most common pathogen implicated in OPSI, and blood cultures have confirmed its presence in Sam's case."
"Strep?" Dean repeated. "I thought Sam didn't have strep."
"He doesn't," Dr. Collins agreed. "Well, not the kind of strep you're thinking of. There are numerous strains of strep, and this particular strain is known to cause various kinds of pneumococcal infections, including sepsis."
"How do you treat it?" John asked, not caring about any other details right now. Nothing else mattered except how they were going to make his youngest well.
Dr. Collins sighed. "To treat the infection, Sam is receiving high doses of broad-spectrum antibiotics through his IV as well as immunoglobulin. To treat everything else – "
"Everything else?" John and Dean interrupted together.
Bobby shook his head. "What else is there?"
"Well, for one thing, Sam is now trached, and we're still dealing with the vent. A common clinical observation is that patients wean more rapidly from mechanical ventilation following tracheotomy, but we have to get Sam to that point. Due to the amount of trauma and stress his body has had to endure in a relatively short time span – it's been less than 24 hours since his admittance – we are keeping him heavily sedated and will most likely continue to do so for at least the next few hours."
"And then Sam will wake up?" Dean asked, desperate to interact with his brother.
Dr. Collins shrugged. "Not necessarily. We'll evaluate everything at that time and then we'll determine whether or not to decrease his sedation."
"And once you decrease his sedation, then Sam will wake up?" Dean clarified, because he needed to know. He needed to be there the exact moment Sam opened his eyes; he needed to be the first person his little brother saw.
Dr. Collins smiled softly, having some idea of Dean's thought process and touched by his devotion to his brother. "Yes, after we decrease his sedation, Sam should begin to come around."
"And then you'll remove the vent and the trach?" Dean persisted, knowing Sam would panic, would be instantly upset the second he realized – he remembered – what had happened.
"Hard to say," Dr. Collins answered honestly. "We certainly want Sam off the vent and breathing on his own again as soon as possible, but that will be determined by numerous factors – the amount of edema still present in his throat and airway, his O2 sats, tidal volume, minute volume, blood gas levels..."
Dean sighed but nodded. As much as he wanted his brother awake and breathing on his own, he didn't want to rush the kid. He could wait as long as Sam needed because there was no way any of them could handle another setback.
"You have other concerns, besides the trach?" John asked.
"Yes," Dr. Collins confirmed. "Sam's blood pressure is still extremely low, so we're giving him vasopressors to try to correct the hypotension. I'm also concerned about his urine output. It's also extremely low, and while we're administering vasodilators, we may have to consider hemodialysis in the near future."
"Dialysis?" Jim repeated, wondering when Sam would catch a break.
"It's a possibility," Dr. Collins confirmed. "Sam's liver panels have shown that his liver is recovering, and he's no longer in acute liver failure – which of course is excellent news, very encouraging. And I'm hoping with more time and perhaps a little extra help, he will bounce back from the acute renal failure as well. The OPSI does, however, complicate things and makes his body have to work twice as hard to overcome everything else."
There was silence.
"Will he survive?"
All eyes turned to John.
"Yes," Dean answered instantly, his tone sharp, his expression hard. How dare John ask that; of course Sam would survive. Whether or not their dad realized it, his little brother was a fighter.
Dr. Collins sighed. "To be honest, death can occur within 24 to 48 hours of OPSI onset, and mortality remains high despite aggressive antibiotic therapy and intensive medical care."
"Doesn't matter," Dean insisted, shaking his head. "Sam's gonna kick this OPSI –and whatever else – in the ass. He's gonna make it."
John closed his eyes briefly. He wasn't one to give up – anyone that knew him would testify to him being a stubbron sonuvabitch – but this didn't sound good. Sam was so sick, so medically fragile.
He glanced at Dean, holding his son's gaze.
Then again, as much as it hurt to admit it, no one – not even himself as Sam's father – knew his youngest like Dean. If Dean said Sam was going to fight, was going to pull through and make it...then he believed him.
"Damn right, he will," John agreed, nodding for emphasis as he continued to hold Dean's gaze, fascinated that no matter how many times their anger and pride tore them apart, Sam always brought them back to center, back together.
Dr. Collins smiled softly. He admired these men's confidence in Sam, their obvious love and devotion for the scrawny kid in Room 7b who, by all intents and purposes, should be gone...no longer with them...expired...passed away...dead. And yet, he hung on. With tenacity that should have long since diminished, with strength that should have waned, with determination that should have faded...Sam clung to what was his. And Dr. Collins admired that, too; respected it, even.
He meant what he had said before – Sam was a tough kid. And if any patient was going to beat the odds, was going to prove him and his over 20 years of medical experience wrong, it was going to be Sam.
But he had to follow protocol.
Dr. Collins sighed. "Sam is certainly fighting – no doubt about that – but unfortunately, it's too soon to tell how this will turn out. At this time, the prognosis is still guarded."
Dean glared as John just stared at him, and Dr. Collins wasn't sure which was most unnerving.
Jim cleared his throat. "Well, doctor, you're certainly entitled to your opinion – even if it's wrong – but when Sam gets better, will he have any long-term side effects from any of this?"
Dr. Collins glanced at the Pastor, amazed at how the man could conduct himself so politely and yet still cut to the bone.
"Will he?" Bobby prompted gruffly, annoyed that this doctor just stared at them sometimes.
Dr. Collins blinked and then shifted where he stood. "Every patient is different, but yes. Typically, patients who survive OPSI often have prolonged and complicated recovery periods with serious long-term effects."
"Like what?" John and Dean demanded in unison.
Dr. Collins shrugged. "Well, like I said, every patient is different, but most long-term effects result from whatever complication they dealt with during the OPSI. So, in Sam's case, he might experience long-term effects on his breathing or possibly even long-term effects of renal failure, if that issue doesn't correct itself soon."
John glanced at Dean and then back to the doctor. "When will we know?"
"Not any time soon," Dr. Collins answered. "We're still days away from that conversation. Right now our primary concern is keeping Sam stable..." – and alive – "...so, we'll be closely monitoring his vitals as well as the dosage of TPA, antibiotics, and immunoglobulin. We'll also be monitoring the incision as well as the trach and vent." He looked around the room, making eye contact with each man. "I assure you that we're doing everything we can for Sam."
There was silence as Jim glanced at Bobby, and then they both looked at John and Dean, who were looking at each other.
John nodded at his son – nonverbal reassurance he knew Dean needed, knew Dean would appreciate despite their earlier altercation.
Dean returned the nod, marveling at the mercurial nature of his relationship with his father. One minute he hated the bastard, despised him for his arrogance and stubbornness, for his selfishness and pre-occupation with the hunt.
And the next minute...
Dean sighed.
He didn't know how he felt the next minute – how he felt now – but he did know one thing.
"I want to see Sam," Dean announced.
"So do I," John agreed and saw Jim and Bobby nod as well.
Dr. Collins didn't respond.
Dean narrowed his eyes. "What?"
"Sam is in isolation, which means only one visitor is allowed at a time, and you must wear disposable protective gear each time you enter his room – gown, gloves, mask, and booties over your shoes. We must take strict precautions to keep everything sterile and not introduce new bacteria or viruses, which would, of course, worsen his current infection."
"Whatever's best for Sam," Dean responded, not liking having to suit up like that, but always willing to do anything to help ensure his brother's safety.
Besides, when Sam finally woke up, the kid wouldn't need to see his entire face to know it was Dean; Sam would just know. And they could communicate with just eye contact. They did it all the time.
Dean smiled softly, physically aching in his chest with his desperation to see Sam, to be with his brother and hold the kid's hand until he woke.
Dr. Collins removed the CT printout from the corkboard and the chest film from the x-ray viewer, placing both back in the folder he still held. "So..." he began, sighing as he glanced between John and Dean. "Who's first?"
As if he needed to ask.
Dean snorted and didn't even glance at his father as he stepped forward, giving the doctor – and the other three – the answer.
Dr. Collins nodded, glancing over his shoulder as he followed Dean out the door and into the hall.
TBC
Christmas, 14 inches of snow and ice in one day, power outages, "unavailable" Internet connections, and traveling all conspired to delay the posting of this chapter. But hopefully it was worth the wait.
Thanks for your continued interest in and support of this story; the amount of reviews and the degree of enthusiasm is truly humbling. Thank you! See you in the New Year...