Soundings
The water swallowed him whole.
It had him.
Sucking, pulling,
Down.
He felt the pressure in his ears, pushing in.
Too deep. He needed to breathe, but the surface was too far above to make it in time, and getting farther away with every passing second.
His eyes were open but he couldn't see anything; too deep for light.
Something hard and implacable clamped like a seal over his nose and mouth. Nothing could get in or out.
He couldn't hold his breath forever.
Humans need air to live.
His lungs were burning. He started, too late, to struggle, even though it would only use up his air that much faster. The water – silent, numbing, cold – held him tighter. He couldn't tell which was up or down any more. Black spots and bright flashes kaleidoscoped inside his eyes. His chest felt like it was on fire and going to burst at the same time, even with the water squeezing him like winter's iron hand.
He was going to black out.
And then he was going to die.
He would give his life. It's what men did. For God. For country. For hearth and home. For wife and child.
Too late.
The blackness closed in behind his eyelids. No more sparks. No more light.
Suddenly his face was in air. His eyes open.
Breathe!
He almost couldn't remember how.
Bella.
Bells.
His girl.
He lay in the dark, panting.
The bed was too soft. Like the water sucking him down.
The hotel room was cold, sheets clammy. Streetlights leaked in through the cracks between the heavy drapes. Charlie had driven here through darkness after his trip back to Forks for the week. He had a station to run, and an investigation that was nowhere near done. He thought of Renee, in another hotel bed, with her fresh-faced husband. He thought of all the years he had slept alone.
Slowly the sound of his heart receded into the background.
The bedside clock read 3:41. They were going to trial Bella off the ventilator today. To find out if the machines were the only thing keeping her alive. To find out if any tiny kernel of their daughter was still left, underneath all the layers of brain waves that had stayed stubbornly flatline ever since she'd been brought in.
It had taken three days to work up the resolve that knowing was better than not knowing. That they'd cross whatever bridge it was going to be, when they came to it.
By then, Charlie had had to make a trip back to Forks. Maybe some part of him hoped that in his absence something would change somehow, that Bella would get better when he wasn't looking. But the only thing that happened while he was away was the social worker faxing him sheets on institutions that would take a case like Bella's if they chose to keep her alive on the machines. And some asshole having the nerve to approach Renee about organ donation. It was a good thing Phil had been there when it happened or there would have been blood, and not Renee's.
Billy'd been after him from the get-go to bring Bella home.
"We take care of our own."
And,
"All those tubes 're just makin' her throat bleed."
The dream pulled at his gut. Made him imagine things he didn't want to. That it was Bella sucked down and held by the black water. Holding her breath in the freezing cold. The surface too far above. A fist down her windpipe. No air moving in or out. Lungs burning in the silence. Down and down and down. Until the last spark winked out.
It drove him out of the sweat-sodden bed, to flip on every light in the bathroom, and retch uselessly over the bowl.
They say you dream at night about stuff you see in the day. He knew that well enough. He'd had his share of bad dreams. Less as the years gave him distance from the bright, dun land. How did Renee ever think he would move to a sunny place?
"Can we hold her hand?" Renee asked.
"It's better if you stand outside so the team has room to work if they need to."
The nurse was herding them out of the room as she spoke. There wasn't going to be any discussion on this. At least the whole wall was glass. They'd be able to see everything.
Dr. S had convinced Renee that this would be safe. Was the right thing to do. Still, she watched like a hawk as they all bustled around her daughter now. A technician was taking blood from one of the tubes coming out of Bella's arm. The doctor had said this had to be a sample from the artery, not the vein. They'd had a direct line placed into the artery in Bella's arm for the past three weeks to take samples. Said they needed it to monitor how she was doing on the respirator, and to adjust the settings. They'd taken so much blood from Bella since she'd gotten here. Renee wondered if they weren't feeding an army of vampires down in the basement somewhere.
"They're turning it off," Charlie warned. Renee wished Phil were still there. He'd had to leave before Charlie came back from Forks. His manager had been phoning him every night, saying if he didn't get his butt back to Jacksonville he could kiss his place on the team goodbye. Renee's own new job was canned. They couldn't afford for Phil to lose his as well. So Renee had had to spend the last four days alone with Bella. She and Charlie plastered up against the window now, no one touching anyone, hands on the glass like geckoes.
"Is she breathing?"
"I can't see."
"Here."
And they shuffled around, until Charlie was the point, the lookout, with the best view of Bella's face between the shoulders of the nurses and the doctor.
"Anything?"
"Not yet."
How could she not breathe? How could she stand the suffocation when no more air was being fed into and out of her lungs? All Renee could see was machinery, the tubing still coming from where Bella's face was, and the back of Dr. S's white coat.
How many minutes did they say? Before brain cells started to die? There was a clock on the wall, but Renee hadn't thought to look at it to see what time they'd started.
Dr. S was looking at her wristwatch, as the nurses' faces slowly went from sober to grim.
"Come on, Bells. Breathe. Breathe."
"You can't quit," Renee whispered. "There's no quitting, here, remember?"
They'd been barely moved into the dingy little bungalow in White Swan. Bella at almost five, sitting on the floor, determined to tie her shoes by herself, small fingers struggling with the puzzle of the loops, childish voice lisping, "There's no quitting, here, Mommy."
"That was our motto. Remember?"
Through the glass, Renee heard the nurse call "Three minutes."
"Have we got the ABG yet?"
Gibberish. It was all gibberish.
"Four minutes."
More chattering, reading off numbers. Sats, and CO2, those were the things Renee knew to listen for. Sats above 90, CO2 below 60 meant hope.
"Five minutes."
Renee saw the nurses shaking their heads. Couldn't they just give her one breath? To get things going?
The second hand on the wall clock swept slowly down the numbers.
"Dr. Sabswari – "
"Keep going."
Both Charlie's hands were clenched in white-knuckle fists against the window.
"Six – " Suddenly a light flashed and a beeper beeped and everyone in the room got very quiet and still. Only for a moment. Then they started bustling around Bella. No one looked happy.
"What happened?"
"She took a breath. She's breathing." Charlie's voice choked. He slumped for a moment, then moved aside so Renee could see. It was hard because of all the activity around the bedside, but she caught glimpses of her daughter's chest moving.
Renee tried to go in, but Charlie held her back.
"Let them do their work."
Renee didn't understand. What more was there to do? Bella was breathing. That's all that mattered.
Ten minutes later, Dr. S came out of the room, face flushed, tucking wisps of hair back behind her scarf.
"We've resumed ventilation. But her respiratory reflex is intact. She was breathing on her own for a solid four minutes."
Renee didn't understand. If Bella could breathe, why did they put her back on the machine?
"Come," said Dr. S, "Let's go where we can sit to talk."
The family room again. With all the games and toys on the floor. For brothers and sisters of very sick children.
It was two in the afternoon, and there was another family in the room when they got there. Dr. S drew Renee and Charlie to a corner alcove. It felt like some kind of conspiracy they were hatching.
Why the ventilator still, what's next, did she show any other signs – Renee and Charlie's questions came fast and hard, even if it was in near-whispers. The doctor had to hold up her hands to explain.
"The reflexes governing Bella's breathing appear to be intact. Normally, when a patient has neurological scores as low as Bella's it's not recommended to take them off of ventilation. Such patients don't usually sustain a normal breathing rhythm in an apnea test. Bella did."
"So what does that mean?"
"It means that she may be able to be maintained without a ventilator."
"So maybe she's not as bad off as we thought?"
Renee knew it. They just needed to give Bella a chance. But the doctor was shaking her head.
"What I'm going to say now is very difficult."
"Just give it to us straight, doc."
"Bella's breathing reflex is intact, it's true. But that's all she has. We recorded her EEG throughout the test and checked her reflexes after it. Nothing has changed. She remains in the deepest coma I've ever seen short of complete brain death."
The doctor paused to let that sink in.
"If there were some abnormality with Bella's labs, if her lungs or heart or liver or kidneys weren't working properly, if there were some fluid or clot putting pressure on her brain, we could perhaps be more hopeful with the result of this test. When there is an organic problem, sometimes once that is resolved the brain can recover at least some of its function. But this is not the case with Bella."
Which made no sense at all to Renee. It should be that if all of Bella's body was working fine then they just had to wait for her to wake up. The doctor was still talking.
"With no injury or organic dysfunction holding back her brain, we can only conclude that whatever has damaged it is permanent. That she persists in such a deep coma when all of her body systems would permit her to wake means that something has devastated her brain in a way that can't be reversed."
"So you're saying that this apnea test hasn't really done anything."
"It's placed you in a very difficult position."
The doctor continued carefully. "Since all of Bella's vital organs seem to be healthy and functioning normally, it may be that she can persist, physically, in this twilight state for a very long time. Perhaps years. You, her family, will need to revisit again and again whether this is what you want for her, or what she would want for herself."
Renee was no way ready to think about that. It was too soon. Bella had only been in this coma for three weeks. Three weeks that had gone by in a blink.
"So how does taking her off the machine fit in with this?"
"It would reduce the stress on her lungs. It would make her existence more peaceful."
"Do it."
"She needs to be able to sustain spontaneous breathing for an extended period. We have a test for that. And she would need permanent airway protection."
"What's that?"
"If you decide to go forward with this, I recommend performing a tracheostomy first. The breathing tube that she has now is not recommended for long term mechanical ventilation. The inflatable cuff that is holding it in place would eventually erode the lining of Bella's trachea. As for independent breathing, the current tube is even less ideal. The artificial airway of the tube is smaller than Bella's natural airway and so she has to inhale and exhale harder to pull and push the air through it. Replacing it with the tracheostomy creates a much shorter and wider airway that will give Bella a better chance at breathing on her own. I recommend placing a PEG tube at the same time she's under anaesthesia for the trache. Once she's recovered and stable from the surgery, we can attempt a spontaneous breathing trial. If she can sustain normal breathing cycles for the duration of the test – I'd want to see her maintain for an hour at least – then I think it would be reasonable to attempt to just allow her to breathe on her own. If she exhibits distress, you of course always have the option to re-ventilate her."
Renee knew perfectly well what a PEG and a trache were. Charlie wasn't the only one who'd been reading up. They were going to cut her baby full of holes for their tubes – one in her throat for air, and one in her belly for food.
Memory surrounded her: night times after bath, plunking small, towel-wrapped Bella down on the big bed, blowing raspberries on her tummy as she put her pajamas on. Bella had loved that, all the way up until they had moved to Salt Lake. Breathing was supposed to mean that Bella was going to get better. They were going the wrong way.
"And if all this goes well, then what?"
"She needs to be placed in a long-term care facility."
"That's it?"
"Yes. There's nothing more that we can do for her here. I'm sorry."
"What if she still needs the ventilator?"
"There are facilities that provide that. Our social worker will help you choose one that will serve Bella best."
The doctor stopped talking. The afternoon light coming in through the window lay across the floor puzzle in a dim, fuzzy square. Overcast. With a faint smell of old coffee. The other family was long gone.
"You didn't think she'd breathe, did you, Doc?"
"The only way to find out was to attempt the test."
But what good had it done?
"I recommend that you and Renee get legal conservatorship. Patients as compromised as Bella is experience repeated setbacks that would end life unless aggressively treated. With conservatorship, no matter Bella's age, you will be able to make quality of life decisions on her behalf."
"A fancy way of saying we should cover our butts now in case we decide to pull the plug later."
The doctor shook her head. "It's not that simple. If you decide to go ahead with the tracheostomy, I think there is a fair chance that Bella will be able to breathe by herself, off the ventilator. Add to this that her lungs, heart, liver, kidneys, digestive system are all functioning normally: there really is no such thing as pulling the plug for Bella. You would have to actively withhold care – fluids and nutrition – to end her life."
Starve her to death. That's what was being said. Lying in that bed, with tubes coming out her throat and stomach, wasting away, because someone decided that everything that made her Bella was already gone. It would take days. Renee broke down. Charlie put his arms around her and held her.
"No way in hell we'd ever do that."
"Of course not." The doctor's voice was disembodied and distant. All Renee could feel was herself curled forward on her knees on the couch. And Charlie beside her. How had they come to this?
"And I would never suggest such a thing. However, in her current condition, Bella will remain at very high risk for complications. I would urge you both to allow removal of her catheter, so as to reduce the risk of urinary tract infections; but with the tracheostomy and complete immobility in the bed, she will always be at high risk for developing pneumonia, and possibly other infections as well. In her condition, these would be life-threatening. Each time that she does so, you will need to decide whether or not to give antibiotics, to invasively suction her airway, to perhaps resume ventilation – all of the aggressive interventions that would keep her alive. Or will you provide comfort measures only, and allow her to slip away."
"We're kinda getting' a little ahead of ourselves, aren't we, Doc?"
"I'm sorry. It's a lot to take in, and all of it is hard. I'm truly very sorry. But it's my duty, both to Bella and to you, her parents, to make sure that you have all the resources and information you will need to make informed decisions about what care you wish for your daughter going forward from here."
So they were going to operate on her. Then see if she could breathe off the machine. Then send her to an institution for the rest of her life.
"Ok, then." Charlie stood, and Renee followed, wiping her face, and going through the motions of shaking the doctor's hand and thanking her for all she'd done.
They walked out of the hospital, into cool, open air once more, and Charlie suggested they get some early dinner at Jak's Grill nearby. It was going to be awkward; since she and Phil were just about broke from this trip, and she knew Charlie would insist on paying for her meal, even though she was married to someone else now.
They took the cruiser. It pretty much ensured a parking space. The ride to the restaurant was dead silent.
Everything had changed. Renee's whole life. Bella's whole life. And no one had been able to explain to her how or why this had happened. She should have never let Bella come to Forks. None of this would have happened if Bella had gone to Jacksonville with her and Phil. But crying over that wouldn't change anything. It never did.
A/N: ABG=Arterial Blood Gas. It is the blood test that measures CO2 level for the apnea test. CO2 level of 60 or above means that the respiratory center is not sensing CO2 or is not effectively signaling the body to try to breathe. Normal CO2 level is between 35 and 45 mmHg, so 60 is a critical high. The body not correcting it means that the respiratory center of the brain is dead.
Sats=oxygen saturation of the blood. Measured by a light-sensor clip put on a finger. For people with normal lung and circulatory function one expects the saturation to be above 90 (=90%. 100% is the highest it can go.) People with pulmonary diseases or heart failure may have a baseline in the high 80's. Below 80% is not sustainable for the body.
Once again thanks to Delirium01 for holding my hand through all the medical ins and outs of this chapter. To WoodLily for keeping me sane through my interminable revisions.
Thanks also to all of you readers for your ingenuity in responding to my last chapter even when ff.n wouldn't allow second reviews. To those who signed in as guest or anonymous, please know that I read and enjoyed your every word, even though I could not answer.
Teaser for next chapter will go up on my profile page in the next few days.