A/N: Thank you all for reading and reviewing. We have reached the end of our journey (as promised) and answers are forthcoming...
A/N II For Merisha
Multum In Parvo
Dum Vita Est Spes Est
A huge fish tank dominated one entire wall of the waiting room at Sean Riggan's office, and Sam had a funny feeling the big one was considering him as a potential snack. As Sam paced towards the tank the fish—a large Oscar—would charge at the glass his fins up in an aggressive pose, and as he turned to stalk in the opposite direction the fish would follow along the tank as far as he could.
"You are going to be fish food if you aren't careful," Dean said, his voice amused, but Sam caught the waver of nervousness no one else would hear. His brother was worried.
"Yeah," Sam replied, tossing him a grin and paced past the fish, stopping long enough to make it charge. He heard Dean chuckle. A glance at the clock showed that it was still ten minutes until the scheduled appointment time. They had arrived early to fill out paperwork. Dean was sitting in the chair closest to the reception desk, tapping his fingers on his leg. From the rhythm, Sam guess it was a heavy metal song of some kind and Dean was tapping out the guitar part. His brother wasn't always prone to air guitar, but he kept time with the guitar as often as the drums. It occasionally drove Sam nuts—especially like now, when there was no music that Sam could hear.
The Day Before
Sam bought tickets for the movie and handed Dean the glasses for the 3-D. His brother smiled at him, the smile a little crooked because of the tube taped to his nose. A fleeting frown crossed his face and Dean poked at a button on the monitor for the device. "Burp," he said before Sam could ask.
They walked into the theater and Sam eyed the concession area. He doubted Dean could get popcorn past the tube. "Do you want anything Dean? The ticket has a coupon for candy on it."
"Do they have Red Vines?" Dean grinned at him.
Sam smiled remembering the first time they'd had Red Vines at a movie theater. "If you bite the ends off, Sammy, they make a straw for the Coke," Dean told him. Since then he couldn't eat them without thinking of a movie theater. He got a box of the candy and two Cokes and they headed into the theater. The seats were large and Sam grinned when his brother discovered that the seats reclined. His good humor disappeared when he heard the beep of a button on the monitor.
"It's just the one for laying down, Sam." Dean nudged him. "Kick ass theater. Shhh. Previews are starting."
"I didn't say anything."
"Well you were, I heard you thinking." Dean nudged him again. "Thanks," he said quietly, then leaned back, putting on his 3-D glasses.
Sam watched his brother out of the corner of his eye until the feature started. There had been a tension in Dean's shoulders when they'd pulled up at the cinema, but by the third preview—for some large budget alien invasion film—Dean was relaxed, poking Sam, commenting on the previews and the action. Whatever had been lurking there, was gone, in fact Sam wondered if he'd imagine it until he glanced over and caught Dean looking at him with a small smile on his face.
"What?" Sam asked.
"I just haven't seen a movie in a long time," Dean said casually.
"This one is supposed to be good." Sam got it then, the tension, the simple statement. He nudged his brother and settled in to watch the film.
Two and a half hours later they stumbled out of the theater, blinking in the evening sun. Dean had a happy smile on his face. Sam had enjoyed the movie as well, although he had been aware of every time his brother had reached for the buttons on the monitor. He'd kept track of how many times Dean had used it, and wondered what each was for, but he hadn't asked. They got quietly into the Impala and Sam headed back towards the hotel.
"Are you hungry?"
"Not really," Dean said with a sigh. "Maybe we should get something to take back to the room?"
"Pizza?" Sam suggested and was surprised by the look of horror on his brother's face. He mentally kicked himself, getting cheese past the tube would be miserable. "Milkshake?"
Dean smiled. "I think I saw a Dairy Queen by the hotel."
"DQ? Not somewhere else?"
"No, theirs are lower fat..." Dean stopped himself, turned red and looked out the window.
Sam filed that fact away. He intended to continue research on Operation De-Stealth Dean after his brother went to sleep, even though Dean had promised to tell him everything. It was something to do. He was having a hard time finding things to do, one of the after effects of the other Sam's time on earth seemed to be a lingering insomnia—and on those nights when he did sleep, he was plagued by nightmares that he knew were not the imaginings of his subconscious, but memories of hell. In desperation, about once a week, Sam would take a sleeping pill just so he could shut it all off for one night.
He got a second surprise when he pulled up to the drive-thru window and Dean asked for a small shake with no whipped cream. He handed the drinks to his brother and drove back to their room, running through all the facts again. Now that the immediate worry about Dean's heart was gone, everything else was coming back. The anti-nausea drugs for chemo, his brother's changed eating habits, and that bastard Willard had obviously been trying to treat him for something that was already there, not a heart condition, because Dean had discussed the drugs with his doctors. Sam was sure he had heard them wrong, he knew erythromycin was an antibiotic and that had to be wrong.
Dean settled in to watche TV, chuckling happily when he discovered Top Gear on the hotel's on demand cable. Listening to his brother's occasionally orgasmic sighs over the cars on television, Sam opened the laptop and did his best to research a hunt, but when he was sure his brother wasn't looking, he would search various topics in hopes of narrowing down his list of suspects as far as Dean's health went.
It wasn't encouraging. In fact it's depressing.
Sam sighed and shifted. Dean was asleep, looking uncomfortable. Sam slipped across the room and into the bathroom. Dean's shaving kit was sitting on the sink along with another bag, opening it, Sam discovered the mother lode of prescription bottles. He pulled out a couple, then stopped. Dean said he would tell him, in fact he had offered more than once and it had been Sam that had halted the conversation. He could wait. After splashing water on his face he walked back into the main room and flopped on the bed.
"What?" Sam looked over, his brother was watching him.
"I can't sleep. Last time we played you were down fifty million and I think twelve years of slavery."
"No, I won back ten years with that royal flush I got in Nogales. Remember?"
"Oh right." Dean sat up and punched a button. "I had two pair."
"Two, sitting up and chest pain. Go get the cards and get ready to lose."
"Dean?" a woman asked, opening the door to the back.
Dean stood and Sam fell in behind him. The woman frowned at him, Sam smiled at her. She turned bright red and led the way down the hall. Dean elbowed him in the ribs. She gestured them into a room. Sam sat in a small armchair and Dean perched on the exam table. She took Dean's blood pressure and pulse, then left with a smile.
The door opened almost immediately and Sean walked in. The doctor shook their hands, then sat down. "Well, how'd you do with the test?"
"It's not the worst thing that's happened to me," Dean said.
"That good?" The doctor laughed. "I've been there, so I understand." He pulled a computer screen in front of him. "So..."
"So?" Sam said, Dean speaking at the same time. His brother glanced over, Sam smiled reassuringly, even though he could tell Dean was at near full on panic stage.
"You don't have GERD, in fact you have less acid reflux than most people, although you are a little more sensitive to it when it does happen." Sean smiled. "So that's good."
"I'm thinking it's bad," Dean said.
"What?" Sam asked, looking from Sean to Dean. His brother was white. He got up and leaned against the table.
"No it's not...Is that your normal blood pressure?"
"What?" Dean frowned at the doctor.
"Ninety over sixty?"
"Yeah, that's about right."
"Hmm, okay, well that changes things a bit but still..." He pushed the screen away and focused on Dean. "You have an esophageal motility disorder. They are more common in older people, you have an idiopathic presentation."
"I'm lucky with those," Dean said bitterly.
"I see that," Sean said, glancing at the computer. "With your esophagus we are dealing with two that are related. One—the constant pressure you feel day to day, it's what makes it hard to swallow. I bet you have pills pop back up whole sometimes."
"I do," Dean confirmed.
"The other—what caused the pain that put you in the hospital—that's happened before hasn't it?"
"Six times in the last three months."
"Six?" Sam looked at his brother. "Dean..."
"It's okay, you weren't around Sam."
Sean followed their conversation with an odd look, then cleared his throat. "So six times?"
"Maybe more, that's just when it got bad enough..."
"Ah, I understand," the doctor said with an understanding nod. "It's called Nutcracker Esophagus."
"That sounds painful," Sam said.
"And fun," Dean added.
"Oh, lots of fun. We called it that because the pressure in the esophagus exceeds the amount of a mechanical nutcracker. It's why the nitro they were giving you helped. That's where we come to the good news, bad news."
"What do you mean?" Sam asked, edging closer to his brother.
"Treating this is mostly about comfort measures. Usually we put you on high blood pressure medication. It has the side effect of relaxing the spasms in your esophagus. The problem is your blood pressure is low, so we are running the risk of it going to low. So, here's what we're going to do. I'm going to prescribe a shorter acting medication. Take it as soon as you start to feel the chest pains getting bad, you know the difference, I'm sure. But monitor your BP closely."
"I can do that," Sam said immediately. "We have a cuff, I know how to do it."
"What happens when the meds don't work anymore?" Dean asked.
Dean held up his hand "I don't want to know, not yet. I'm guessing it's not good, and I don't want to know."
"It's successful in about..."
"No, I don't want to know, I have learned enough lately to know that it's downhill no matter what. So, thanks, but no thanks, we'll worry about that one later."
"Okay." Sean smiled. "I'll write you a prescription for the meds, do you need a refill on anything else?"
"Okay. I've sent everything to Brian as well. Call one of us if you end up in a hospital, so we can find someone nearby to help. And from personal experience, I can tell you a blender really helps on days when it's all bad... A blender is your best friend."
"Thanks." Dean took the paper the doctor handed him.
"Keep in touch." Sean handed him a business card with a handwritten number on the back. "I'm a patient too, and I know sometimes it helps to talk. Don't hesitate to call."
"I won't. Um..." Dean hesitated, glancing at Sam. "Do you have a patient packet?"
Sean looked at Dean, then at Sam. "Oh, yeah, of course." He opened a drawer and pulled out a folder and handed it to Dean. "Here's some info on esophageal motility disorders too. There are a few suggested diets, but what you are already on will cover that mostly."
Dean nodded and walked out of the room, Sam trailed behind him feeling like he had missed a lot of something. He suspected it had to do with the conversation he and Dean were going to have. The fact that Dean seemed to take the whole problem with his esophagus in stride was freaking Sam out. It seemed huge to Sam. He swallowed, suddenly very aware of that process.
They were silent as they went out of the office and down the elevator, and the silence just seemed to grow. Sam swallowed again. He couldn't stop himself, his throat ached, his head was spinning with what the doctor told him and he couldn't stop swallowing. Dean was quiet when they got into the car, reading the handout the doctor had given him about the esophageal motility disorders.
"Let's stop at the park," Dean said as they drove by the entrance to the forested area.
Sam pulled in and drove along the road until he found a quiet area with an empty picnic table. He parked the car and they got out. Dean had the folder in his hands. Sam swallowed again. I have to stop doing that. He trailed after Dean, his brother walked past the table and further along the path, deeper into the sun-scented woods, finally stopping at a large log. He sat down and set the folder carefully beside him. Sam looked around for a moment before joining his brother on the log. It was beautiful, for all that they were in the middle of a city, it felt like they were a thousand miles from anywhere.
"Like camping without the wendigos." Dean laughed.
"We really should try camping without them sometime." Sam smiled.
"Yeah, or orcs, or scary things that drag you off, or..."
"Maybe camping is something we should avoid."
"Yeah." Dean smirked, then frowned. "We need to talk."
Sam shifted so he was facing his brother, without thinking about it he swallowed again. Dean noticed and smiled. "Do you have cancer?" Sam blurted out before Dean could even get started.
"Cancer?" Dean frowned. "Oh, you found the Zofran."
"Yeah." Sam felt tears starting to burn in his eyes.
"No, it's not cancer, Sammy."
"I have the Zofran? Did you find the Phenergan too?" Dean shook his head. "That doesn't matter. I have that one too. It's weird, the oral Zofran works better, but the IV Phenergan seems to help more—of course that one makes me..."
"Want to watch curling?" Sam offered with a smile.
"Yeah." Dean sighed. "There are other drugs in my bags too, Sam. Quite a little pharmacy these days." He looked up at the trees. "It's an idiopathic presentation as well."
"It's called gastroparesis."
Sam frowned, his knowledge of Latin breaking that down quickly and supplying "stomach paralysis." He looked at his brother. "Dean?"
"It means just what you think it means."
"My stomach doesn't work right anymore, Sammy, and I'm lucky enough to be one of the rare people who just got it. Most of the people who do get it—and it's pretty rare—are diabetics."
"What causes it?"
"It's a problem with the nerves. I started really having problems when..." Dean trailed off, his eyes bright. "Anyway, Lisa convinced me to go to a doctor and he referred me to Brian. I was extremely lucky, Brian guessed the issue right off. A lot of people can go years before a proper diagnosis. And the test is simple. I ate a radioactive egg salad sandwich and laid on a table."
"According to Stan Lee you now have superpowers."
"I know, I ate radioactive stuff, but I'm not sure what the power of egg salad is." Dean smiled. "Anyway, what should have emptied out of my stomach in half an hour was still there three hours later."
"Oh god, Dean..."
"That was the first step, Brian got me on the anti-nausea meds and we discussed treatment options."
"What is it with erythromycin? That's an antibiotic."
"It is, but it can help gastric motility. I decided being on an antibiotic forever didn't sound like fun. There are other drugs too, some okay, some not. All have side effects of course." Dean swallowed. "It doesn't get better. In fact, it's been getting worse. I know you've noticed the way I eat."
"You were being stealthy."
"Not stealthy enough, what gave me away?"
"Plain low fat yogurt."
"Yeah, that would, wouldn't it?"
"Since the only time I remember you voluntarily eating yogurt was frozen with Reese's Peanut Butter Cups mixed in and hot fudge on top, yeah, pretty much."
"Most days I can tolerate the yogurt, as long as I stick to low fat. I've started getting that Greek kind, it's a little higher protein, and getting enough protein is an issue sometimes." Dean swallowed. "Before you ask, yes, I have been throwing most of the food away. I have a protein drink made with water for breakfast and lunch, then something solid for dinner. Not much."
"Yeah, I was getting that."
"How bad, Dean?" Sam asked, now that his brother was talking, he knew it was all going to come out, he just wanted the bandaid ripped off as fast as possible.
"Right now, I've been doing okay. Stop looking at me like that, except for the chest pain, it hasn't been all that bad. I've been eating as well as I can lately. I even managed to sneak in a few bites of burger that didn't bounce. It does get bad, though. Even with the meds, I lose one meal a week, maybe two."
"Lose? You mean vomit?"
"Yeah. I've been hospitalized twice with a really bad flare. That's how I know about feeding tubes." Dean blinked. "And eventually I might know a lot more. My intestines are paralyzing, Sammy, and now with this esophagus on top of it—I've known that I was probably heading for a permanent feeding tube sometime, but..." He blinked again, a tear shimmering on his lashes. "If that doesn't work, there are other options, IV that kind of thing."
"Dean..." Sam was trying to get his head around all the information.
"It's funny, I can face down the apocalypse, the end of the damn world and say okay, let's get the party started. And this—this..." He stopped and looked up, meeting Sam's eyes. "I'm scared to death, Sam. It's out of control and it's my own body. I can't eat anymore, and I didn't even know how much that meant—being able to just eat whatever I wanted to, when I wanted to. Some days all I can do is keep water down, and that's a struggle. Other days I can eat, but it just sits there. I..." Tears were tracking over Dean's face. "And now this? My esophagus, Sammy. What happens when it just doesn't work anymore? What happens when... When..." And Dean broke, a soft sob escaping his lips.
Sam pulled his brother into a tight hug, letting his own tears fall, wondering if Dean had even let himself think about what it all meant before now. If he had grieved, or looked beyond the day-to-day reality of his life. Sam held on until Dean stopped shaking and wiped his nose on Sam's shirt—a Winchester tradition that worked both ways.
"I don't know what to do," Dean said simply.
Sam picked up the folder and opened it. Inside was "The Patient's and Patient's Family Guide to Living with Gastroparesis." He tucked the information about the esophageal disorders into the folder as well. Dean was right, this was hard, in a lot of ways harder than the monsters they fought, it was every day, and maybe meant a slow decline worse than anything Hell could dream up. Still, it didn't matter, they had gotten through everything else, they would get through this. He looked up at his brother. "I've got your back, Dean, no matter what we're facing. We'll face this together too."
A soft light appeared in Dean's eyes as a small smile touched his lips. "Thank you, Sammy." They were quiet for a long time, their shoulders touching, staring into the forest, each lost in thought.
"You want to go get a milkshake, Dean?" Sam said, breaking the silence.
"Yeah, sounds good." He looked over at Sam. "Thanks."
A/N III: So, for those of you who have asked, or are curious, yes, this is coming from personal experience. For all my angels who make this bearable, thank you. I don't walk alone, for fellow patients, I am with you. Gastroparesis, related disorders, and esophageal motility disorders are uncommon. Many patients can suffer for years before they get the tests that lead to diagnosis. Awareness is the first step to finding a cure rather than just offering comfort measures and stop gap solutions for a condition that effects every aspect of every day of a patients life. Most people don't even think about the food they eat, for GP patients it's not just about the food they eat, but the food they can't and in the end the slow decline that eventually affects quality of life. Spreading Awareness One Person at a Time is the rallying cry. To learn more go to www (dot) gpawarenessfund (dot)com