AN: I think 4 months might be the shortest period between posts I've ever managed...
AN2: Still not an MD, so all errors are mine and wikipedia's!
Life is occupied in both perpetuating itself and in surpassing itself. If all it does is maintain itself, then living is only not dying.
- Simone de Beauvoir
He awoke to the sound of shoes scuffling on linoleum, and the puff of oxygen against his mouth and nose. Opening his eyes, he blinked heavily as the mint green wall came into focus. For a long time, all he did was breathe; staring at the wall. He lifted one heavy hand and rested it atop his thigh, where his awakening fingertips found the gauze and dressing over the upper half of his quad.
Dressing? He struggled to make sense of the discovery; he remembered pain as he let his questing fingers run rampant over the limb until he encountered gauze over the old drain site. Huh. Another puff of oxygen hit his nostrils, and he realized he was on O2. He let his head fall to the left as he sought out the bedside monitors. O2 was at 97 percent with the mask. Damned opiates; depressed respiration. On the other hand, they also dulled pain. His hand and neck ached distantly, and he absently rubbed the site before realizing he sported a new CVC in his internal jugular and an arterial line in his wrist. Great. Just great. Blood pressure normal—now. One new bag of premium AB was hanging on the stand above him. Letting his head loll to the right, he found Wilson asleep in an armchair beside his bed. Everyone was in their familiar places. He sighed then, let his eyes close and his head fall back on the pillow as the glass door quietly slid open, and a nurse entered soundlessly.
"Good morning, Dr. House. I'm Andrea." She greeted quietly. He opened one eye to peer at her as she settled his chart on the bedside table and began making notes.
"Any pain?" she asked briskly, and House decided he liked her. No nonsense. No handwringing. No hand holding. He shook his head, and she took in the monitors, then turned his hand over and pressed her fingers to his wrist anyway.
"You're alive." She pronounced quietly. "100 bpm; a little faster than I'd like. Are you sure you're not in pain?"
He shook his head again, and she returned her gaze to the monitor in search of answers.
"You are running a slight temp. 101.4. Possible infection brewing. I'll go ahead and talk to Dr. Morris, he's about due for rounds. You have a preference for NSAIDs?" she asked.
House swallowed; shook his head. "No NSAIDs. Check hepatic function first." He hesitated, and then decided he might as well enlighten the nurse so she didn't dose him the next time he fell asleep. Which was more likely to be sooner than later. "Transfusion reaction." he whispered.
"Are you thinking a tainted bag?" she asked, and he let his gaze flicker up to the bag and then back at her.
"No. Too many transfusions." He said hoarsely. "Three last six months."
"I see." Andrea told him as she scribbled it in the chart. "I'll mention it to Dr. Morris. Dr. Simpson will be stopping by as well. Anything you'd like in the meantime?"
"Water?" he asked, and she gave him a small smile before handing him a cup of ice chips. He gave her a sour look, and she laughed quietly before finishing her notes and heading for the door.
"I'll send someone in to draw some blood for labs, and see that Dr. Morris stops in to talk with you first when he hits the floor." She promised. He nodded gratefully as she slid the door closed. The gentle thump as it made contact with the frame was somehow enough to rouse Wilson; who snorted himself awake sharply.
"House?" he asked sleepily, and ran one hand through his greasy, matted hair. House settled for nodding; feeling tired once more as he let his head fall back into the pillows. "You feel okay?" Wilson asked around a yawn, and he shrugged.
"Yeah. Tired." He admitted, letting his right hand rest lightly atop his oft injured leg. He still couldn't remember what he'd done to it this time, but he surmised from Wilson's disheveled appearance that he had been there for it.
"Thanks." He said softly, and Wilson shrugged this time.
The cold from the cup of ice chips was numbing his hand, so he slowly lifted the cup to his mouth and nibbled a few pieces out. He felt a wave of exhaustion roll over him, and he let his hand fall back to the bed as his eyes closed involuntarily. He felt Wilson lift the cup from his lax fingers, and struggled to open his eyes once more.
"Got you a new couch." Wilson offered quietly. "Your old one was ruining my back."
In truth, House's old couch had been blood sodden enough that he'd deemed it beyond recovery.
"Never liked it." House murmured, and Wilson felt a smile threaten.
"Go to sleep." Wilson told him. "When you wake up we need to talk about getting you Life Alert or something." House didn't reply, and Wilson thought maybe he'd already fallen asleep when he flipped his middle finger up defiantly. He'd gotten it.
When House woke next, Wilson was nowhere to be found. He breathed slowly, enjoying the hazy, comfortable feeling brought by heavy opiates and let his hand ghost onto his right leg again. Yep. Still wrapped in gauze. Arterial line in his wrist. O2 mask over his mouth and nose. And—yep. Catheter. Damn.
Purple rubber-gloved fingers appeared in his periphery and he startled—or would have, if he hadn't been so damned drugged. As it was, all he could manage to do was turn his head slowly and stare suspiciously at a green-scrubbed lab tech who waited patiently beside the bed.
"What the hell?" he mumbled thickly.
"Sorry, Dr. House. I need to draw some blood."
"Warn a guy, first." He grumbled crossly, even as the lab tech set down her plastic tote and began to dig through it as she set up for the draw. He turned his head away, giving her access to the CVC port. She was efficient, he begrudgingly admitted. She swabbed the cap, drew the requisite 3-5 ml and discarded that before snapping the vial into place and taking the specimen. She even remembered to flush with saline without being reminded; he'd ended the career of one tech just after the infarction when she'd failed to do so. He'd been leery of lab techs ever since.
"Do you need anything, Dr. House?" she asked kindly, and he shook his head. She left without another word, and he was left to his thoughts; scattered though they were. What had he been thinking about? Ah, the pressing question of How He Had Come To Be Here. He searched his memory again, but could only recall a handful of recent events. He'd been on the couch, he'd watched some TV. His leg had hurt, but hell, it always did these days. The scattered memories he could conjure were of no help in figuring out what had happened to him. So when his thoughts drifted again, he let himself go.
The sound of someone calling his name brought him back to awareness, and he found Simpson standing next to the bed with an unreadable expression.
"Shall we see how you're doing today?" Simpson was wielding a pair of bandage scissors, and after he threw the blanket back he moved the shears swiftly through the cottony gauze without apparent effort. "Andrea said you had some concerns about a transfusion reaction?"
He did? He blinked tiredly, and lifted a hand to rub his eyes. God, morphine was wonderful, but he felt like he'd been trampled by an elephant. His confused expression must have spooked Simpson, because he set aside the scissors and took up the tympanic thermometer and stuck it in his ear almost before he could think.
"103, House. You look a little out of it."
Oh. So that was why he felt so fuzzy.
"Yeah." House admitted, because he knew he was. Simpson sighed, and resumed cutting away the gauze. Cold, rubber-gloved fingers prodded incisions new and old and House turned his face away. He never liked to look at his leg these days; he tried to ignore it as much as possible.
"Molly took some blood earlier; your hepatic values are elevated but still in range for your new baseline. No sign of a transfusion reaction. You do, however, have a nice infection brewing. Here." Simpson poked his leg and House craned his head to see the faint red erythema of an infection from the newly-sutured line.
"Labs?" House asked finally, and Simpson smiled.
"Ill have Andrea bring them by. I was thinking of going with vancomysin, but I'll let you decide. You're the ID guy. We're also going to have a discussion this afternoon about your pain management."
"Why?" House asked, idly watching as Simpson pressed a saline-soaked square into the infected area and rinsed with more saline before packing it in. The wet-to-dry dressing again, then. House had become intimately familiar with most types of wound care since his own were either slow to heal or had developed nearly every type of infection he'd ever read about. Luckily, he hadn't developed MRSA. Yet.
"…you aren't being honest with your team." Simpson was still speaking, and he desperately tried to catch up again. "Wilson said you've had episodes of bradycardia and breakthrough pain since returning to work. Are you in any pain now?"
House considered this revelation. Wilson was lucky he was too stoned to care, really, about the egregious breach of privacy. "No. I'm fine."
"House." Simpson paused in re-wrapping his leg to look him square in the eye. "If the Embeda's not working, we can get you on something else."
House shrugged, and Simpson sighed. "So, not working then?"
"No." House mumbled.
"Good." Simpson finished layering the gauze and taped it together. "I'll give Coleman a call; see when he can come in and give us some options."
The feel of cold fingers pressed against his wrist woke him again; his eyes fluttering open to the sight of a new nurse in a Spongebob scrub top taking his pulse. He grunted then, feeling annoyed by her presence but overall, too warm and comfortable and sleepy to protest.
"Sorry, Dr. House." The nurse said kindly. "I like to do it the old fashioned way."
A retort came to mind, but he let it go. He remained still; drowsily watching as the nurse checked all of his lines and the output from his foley. She lifted the blanket and he did protest then; when the cold air rushed in and sent gooseflesh crawling up and down his leg.
"Hey." He murmured anxiously; feeling her fingers probe his leg beyond the gauze. Her sharp eyes examined his lower leg and poked his foot. She inspected his toes for their color, and inflated the blood pressure cuff around his ankle. He squirmed uncomfortably at the build up of pressure before she let the cuff deflate and counted it down.
"95/62." She patted his leg and tenderly worked a slipper onto his foot without disturbing the leg itself. She pulled the blanket back up and tucked it in around him.
"Do you need anything?" she asked as she scribbled her findings in his chart. He shrugged, his thoughts skipping back and forth like a poorly played game of pong. Morris had been in earlier; he'd said something about—
"Labs?" he asked sleepily.
She nodded, opening the chart and slipping the pen back into her pocket. She flipped through a few pages before handing them over to him.
"These are from 7:45 this morning, Dr. House."
He squinted at the sheets, squinting to try and bring the values into focus. AST was 135, ALT 352; Alkaline phosphatase was 147. All normal—or close to his new normal since the infarction. The CBC ranges showed his white count had skyrocketed up to 12. Perfect.
He blinked, and the numbers on the page swam up at him. The nurse was staring at him patiently, and he realized he had no idea what she'd said.
"What?" he asked crossly; suddenly grateful for the fever warming his skin and masking the embarrassment that flushed his cheeks.
"Did you agree with 's recommendation for vancomysin?"
Did he? He squinted again at the page, trying to organize his scattered thoughts. Something had caught his attention when he'd scanned the page, but he couldn't remember what.
"No." he decided at length. "Linezolid, not vancomysin. Possible hepatic impairment with elevated lab values. Start linezolid 750 mg b.i.d."
The nurse hastily began making notes in his chart, and he tipped the paper in her direction. God, it was hard to think. Sighing heavily as she took it from him, he brought a shaky hand up to rub at his eyes.
"I'll bring a loading dose in a moment. Do you want it IV or P.O?"
"IV." He mumbled thickly. No way he was swallowing one of those horse-pills. He let his eyes drift closed as the nurse walked away; her shoes squeaking softly on the floor. In his mind, he traced her path to the drug cabinet behind the nurses' station and back again. And even as he felt the CVC tubing move and felt the rush of warmth through his jugular he drifted, content in his cocoon. He listened while the nurse tidied up; straightened his blankets before gliding toward the door. With the antibiotic onboard, he felt a little better. Somehow.
"Hey—uh, nurse." He forced his eyes open to find the nurse waiting patiently near the door. Uncharacteristically, he regretted not knowing her name. "Did Simpson talk to Coleman?"
The pretty nurse stepped back into his room and hefted his chart off the table. She flipped through the tabs; then paused as she skimmed the notes.
"It looks like—yes, he did put a call in. He requested Dr. Coleman stop by to see you when he can."
"Okay." He mumbled sleepily; letting his eyes close at last. The nurse slipped away quietly; the sliding door scarcely made a sound as she pulled it shut. He didn't want to—couldn't, really—think about whatever recommendation Coleman might make. The Embeda had been hailed as a wonder-drug in trials for back pain; but he knew most of his own pain had been chronic and neuropathic, as opposed to chronic disc herniations or myalgias. As much as he didn't want to admit it, the Embeda hadn't worked; was never going to work.
Truthfully, he couldn't think of another opioid that wouldn't leave him fuzzy and drained. Or a non-narcotic that would keep the pain at bay. He squeezed his eyes shut resolutely; pushing away the incipient fear that threatened to overwhelm him. Coleman would think of something. He would.
He had to.
Wilson stood at the nurses' station outside the Cardiac ICU with House's massive chart laid out on the desk before him. He'd disappeared to let House sleep off the remnants of his anesthesia, and to check in on a few patients of his own. House had still been asleep when he'd returned, and he'd decided to take a peek at his chart rather than waking him. He'd surfaced a couple of times according to the nurses—once when they'd done a vitals check, and again when Morris had stopped in. His labs had been run just after 7:45 that morning and his white count was already on the rise. Damn. How did he pick up an infection so fast?
He turned slowly to find Dr. Morris standing behind him with a faint smile. He gestured toward the lounge's padded armchairs and Wilson folded the chart up and reslotted it before reluctantly crossing to a chair and sinking down into it.
"How is he?"
"He came out of the anesthesia well, as you know—he surfaced thinking he had a transfusion reaction brewing."
"Typical." Wilson snorted; it was very much House's MO to surface with a diagnosis on the brain.
"No sign of one, but he does have a nice infection. Erythema along the suture line. Simpson's already been by to see to it." Morris rose to pour himself a cup of coffee and gestured to Wilson, who shook his head. He'd had enough of waiting room coffee for the time being.
Wilson sighed unhappily. "He won't like that he was wrong." House wouldn't be happy with the set-back, either.
Morris shrugged, and cradled his styrofoam coffee cup with both hands. "He's running a mid-grade fever of 103; he knows his judgement is impaired for the time being. He's very forgiving when he's half-baked."
"What's he on?"
"Simpson suggested vancomysin, he requested linezolid. 750 mg b.i.d."
"I thought you said his judgement was impaired?" Wilson asked challengingly; though he was unsurprised when Morris simply shrugged.
"Even half-baked, he's a better ID guy than the rest of us. I see no reason not to let him choose his own antibiotic."
Wilson nodded then, unsure what else he could say. Morris studied him kindly as he got to his feet. "Simpson talked to him about his pain management; he admitted the Embeda isn't working. We put a call into Coleman, he'll swing by today.
"He admitted it?" Wilson asked wryly. Morris snorted.
"Okay, not so much an admission as a surrender."
Wilson ran a hand through his hair and sighed again. "What do you think Coleman will say?" he asked quietly. Morris shifted uncomfortably, and then sighed himself.
"You know as well as I do that he can't perform procedures on opiates, and non-narcotics aren't going to manage the neuropathic pain. So he'll either try an opiate and change the way he runs his practice, or he'll try and suck it up with a non-narcotic."
"He won't be able to function on a non-narcotic." Wilson said quietly.
"No, he won't." Morris agreed.
He surfaced much easier this time; now that the linezolid had been on board for a few hours and had started to work on his infection. He felt less fuzzy and more aware of his surroundings. He shifted cautiously from his left side onto his back and opened his eyes to find Coleman's portly frame beside his bed in his lab coat, coke-bottle glasses and dorky bowtie.
"Mitch and Erik tell me you're not faring well on the Embeda." Coleman said without preamble as he lowered the bedrail and perched on the edge of the mattress; still cradling House's massive chart with one arm.
"No." he admitted reluctantly, toying with the edge of the blanket. Coleman stared at him for a few moments before he snagged the rolling table with his foot and pulled it close. He laid the chart down reverently and flipped it open.
"Yeah." House admitted quietly.
House paused; trying not to think about it. He hadn't wanted to assign it a number. A pain rating gave it power over him, and he didn't want to think about the pain. The way it had been during the initial infarction and just after the debridement. No, no numbers. The pain couldn't win.
"Greg, if you don't give me a rating, I can't help you. I can't offer solutions." Coleman leaned his bulky frame in close until he was as close to House as he could get. "I know you don't want to be in pain. We can manage it, and get you on a solid regimen to minimize your discomfort. But if you decide you're going to be pigheaded about it—then you're going to hurt. It's as simple as that. So talk to me."
"Seven." he admitted softly, and looked away. He couldn't meet Coleman's sympathetic gaze; or even see him in his periphery.
"That a baseline or breakthrough?"
House swallowed; remembering now the pain that had driven him to the couch. He remembered the sharp prick of the needle and the first sweet rush of release following the last dose he'd taken. He remembered the rising pain when he'd awakened; the burning fear in the pit of his stomach when he'd realized he was out of morphine. But then it was too late. Too late to do anything—
"Fuck," he whispered hoarsely, feeling tears in his eyes. "I can't—fuck."
"Too high to count?" Coleman asked mildly, and House nodded in shame.
"Visceral or deep somatic?" Coleman was writing as he asked his rapid-fire questions.
"Both." he sighed then, still unable to look at Coleman. He cleared his throat and forced himself to trace the pain's path through what remained of his quadriceps. "Deep somatic characterized in the lateral vastus intermedius, medial vastus lateralis, medial vastus medialis. Some sartorius involvement within the femoral triangle; visceral all—all over." He finished feebly.
"Good, Greg." Coleman said quietly. He paused in his writing, and pressed the call button. Puzzled, House turned to eye Coleman speculatively. "I thought I would see if Mitch would be willing to go over the site with me."
"You've seen it." House murmured anxiously.
"I need to see it again." Coleman slid from the edge of the mattress and lay the chart aside before filling his hands with hand sanitizer and rubbing them together briskly. He reached up into the cabinets and dug out two gloves; snapping them on as the ICU door slid open and Simpson himself stepped inside with a nurse.
"Coleman. Did you need something?"
"Ahh, Mitch. I wondered if you would be so kind as to assist. I'd like to see Greg's leg once more." Coleman moved around the bed and gestured for the nurse to lower the other rail.
"You've seen it." House said again, and even Simpson looked skeptical.
"I concur. Little has changed since we discharged him last."
"Greg has suffered breakthrough pain and recently had an occlusion in the femoral artery that necessitated the placement of a stent. It's difficult to say at this point what the spasm may have done to the surrounding muscle fascia before the penrose was pulled. I'd like to see it firsthand." Coleman looked up patiently, his eyes were almost bug-like beneath his enormous glasses.
"All right." Simpson nodded slowly, and stepped over to the hand sanitizer dispenser. After lathering both hands, he dug out his own gloves. He motioned for House to throw back the blanket, and gestured to the nurse for the sterile, still-packaged scissors she held in her hand. Coleman stepped forward then, and with a subtle tilt of his head, Simpson stepped back and let him take the lead. Blunted bandage scissors slid easily through layers of gauze as Coleman snipped expertly up the length of the leg. He peeled the cottony surface away from House's leg tenderly, taking care to release each of the sticky fibers from his still-raw flesh. House looked away.
"Still some drainage." Coleman murmured, and House could see Simpson nod.
"We had to expect it, with the loss of the drain."
"How much discharge are we talking?" Coleman asked, even as he knelt down beside the bed to peer at House's leg at eye-level.
"Minimal." House supplied at last; still staring intently at the wall. "It was past time for the drain to come out anyway."
"The infection seems to have cleared up nicely, at least in the fascia. Still using the wet-to-dry?" Coleman sat up once more, and stood beside the bed, where he took House's foot and knee in his hands.
"Yes." Simpson said smoothly. "We're going to continue doing so until the drain site clears up. It's the only on-going infection for the time being; we'll try to be aggressive with it from the start."
Coleman tapped the top of House's foot, until his gaze found Coleman's beetled eyes. "I need to do some range-of-motion." He said apologetically. House nodded, and braced himself. Coleman lifted his leg carefully and evenly, but even so, House could feel each nerve ending send a warning spark directly to his brain. He breathed, carefully, as Coleman manipulated his foot with the knee bent. Up, down, left, right. Given that his knee was not engaged, he felt only a slight tug in his calf that fortunately didn't spark any further pain in his leg.
"Okay, Greg. I'll be quick. Just remember to breathe." Coleman warned, and House closed his eyes. Coleman slowly extended his leg and House felt the pain ramp up immediately. The tattered remnants of his quadriceps sent a flurry of signals as synapses in his brain, forever severed from the nerves of his leg, sought to make a connection. He sucked in a breath, then another; feeling his heart rate quicken and sweat begin to form along his temples and down his back. Coleman tenderly lifted his leg and watched the corresponding muscles shift and move; once hidden beneath his skin, now visible on the surface. Whatever it was that Coleman hoped to see, House would never know; lost as he was in his world of pain. He was dimly aware of the moment when Coleman set his leg down; when the flurry of signals from leg to brain began to slow. He breathed shallowly while Coleman and Simpson attempted to draw him out of his silent world, but he felt an invisible wall holding him just beneath the surface. In the end, he felt the tubing of his CVC move and then the wall slowly dissipated beneath a rush of warmth in his veins that chased away the icy cold that held him under.
"You with us, Greg?" Coleman asked, and House blinked at him wearily before nodding, slowly.
"…BP's coming back up." Simpson said, and House could hear the beeping of the cardiac monitor begin to slow. "Pulse is back down around 100."
"Your leg looks as I expected." Coleman told him as he stripped his gloves off. "I would like to do an xray—"
"And I told you, it's unnecessary—"Simpson interrupted.
"—to see if the stent is properly placed in the femoral." Coleman finished.
"—and unwarranted, given that his foot pulses are intact and grossly normal." Simpson concluded.
"So—" Coleman smiled doggedly. "—we've come to the conclusion that we will do nothing so long as your pulses are present. And now we come to the part of our consult that I anticipate you have been waiting for."
"I imagine you've come to the conclusion that you have two choices: opiates or non-narcotics. Do you have anything in mind?"
House hesitated; he'd prefer neither, but truthfully—that wasn't an option. And he didn't—couldn't—live with the all-encompassing pain he knew he'd feel if he went with a non-narcotic.
"Opiates." He whispered hoarsely.
Opiates meant everything would change. His practice would have to change. He wouldn't be able to perform his own procedures—labs, radiology, biopsies, lumbar punctures—
"—you have one in mind?"
House startled then; he hadn't even realized that Coleman was still speaking. He'd thought about it, of course. Even made a mental list. Did it make a difference, he asked himself again. "No." he said softly.
Coleman sat down beside House on the mattress again, his squat, heavy body shifting the mattress enough to tip his head toward the pain management specialist. House looked up at him with bleary eyes.
"Greg, I'd like to start you on Vicodin. I think the efficiency of the hydrocodone absorption from the cytochrome 3A4 will benefit you, as will the paracetamol for the cyclo-oxygenase inhibition of prostaglandin production. Do you concur?"
House nodded slowly; Vicodin had been at the top of the probable list of synergistic medications he'd compiled for himself. Secretly. As Coleman had said; the combination of the pharmacodynamics made it very effective for the visceral and deep somatic pain he suffered in the mutilated fascia of his leg.
"Very well." Coleman slid to his feet heavily, and gestured to Morris, who had come to stand inside the ICU doorway. "Erik, as Greg is still your patient; I leave him in your care. I would suggest a dose of at least 45mg. Do you agree, Greg?"
"Yes." he croaked. "Tonight?"
"I think we'll leave that up to Erik. Will you keep him in the ICU longer, or is Greg stable enough to go to the floor?"
Simpson had one of the nurses retrieve a wheeled cart filled with the saline solution and the rest of the supplies he would need to re-dress House's leg. He said nothing for a long moment as he soaked the 4x4 squares and then began poking them into the still-open gap between fascia and half-formed, knobby scar tissue.
"I think we should keep him in the ICU for one more night. If everything looks good in the morning, we'll transition him to the floor. What do you think, Morris?"
"I agree. If his cardiac status remains stable another 12 hours, we'll transition him onto the floor."
"Very well." Coleman offered his hand and when House took it, he clasped their joined hands. "I'll expect to be updated on how the Vicodin is working for you." He said sincerely, and House nodded.
"We'll keep a close eye on him." Simpson promised as he finished layering the gauze feather-light over his mangled leg. All three men headed for the glass door; one after the other. House stared after them for a long while; tracking them to the nurses station before they were lost to his sight. He breathed slowly, grateful that the consult was over; that Coleman had independently come to the same conclusion that House himself had. His practice would change; his leg would hurt—but neither would be as bad as he imagined they might be. The morphine bolus that Simpson had pushed after the leg exam had eroded his fear and now he was boneless in the mattress. It was over.
The pain hadn't won.