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Elf Academy 3: The Enemy Within  by Fiondil

29: Elves in Distress

“Can you believe them?” Elrohir whispered to Elladan and Serindë as they stood over Glorfindel’s bed. Serindë was smoothing the blankets while Elladan was checking the monitors. Elrohir stood at the foot of the bed. “Only when you’ve been taught our healing techniques will you be master healers indeed. What rubbish! I still think we should tell them we already have our medical degree and there’s no need to fake one the way they will have to fake theirs.”

Serindë looked over at her fiancé, giving him a surprised look. “What do you mean you already have a medical degree? I thought you never bothered with being doctors.”

“We never bothered to practice medicine, Sarah,” Elrohir replied. “There’s a difference. Dan and I went to Columbia and then interned at John Hopkins back in the fifties. After the Second World War, Loren insisted that we get our medical degree. He said it was foolish for us not to have legitimacy in that field even if we chose not to practice. That’s why we were working at an electronics printing company before we came here. Even so, we still kept up with the latest medical techniques and procedures, attended medical conferences and kept all our credentials current. Loren and Darren both insisted on that and it’s not that we didn’t practice, we just didn’t practice on a regular basis. We’re really just going through the motions here. This is pretty much a refresher course for us. Our primary purpose is to be able to pass the boards and then we plan to return to school for specialized training as surgeons. When we were at Columbia we stuck to general practice medicine, but when this war comes, they’ll need surgeons, not family doctors.”

“I’ve known you for two years now, and I don’t know you at all,” Serindë said with a shake of her head.

“Which is just as well,” Elladan said, joining the conversation. “Couples should spend a lifetime learning about each other. That way they can never take each other for granted.”

Elrohir and Serindë exchanged smiles. “You’re very wise,” Elrohir said.

“Which is why I’m the oldest,” Elladan quipped and both Elrohir and Serindë chuckled in amusement.

“Well, I know that what Ernie said rubbed you two the wrong way,” Serindë said, “but I wouldn’t let it upset you too much.”

The Twins gave her considering looks and Elrohir frowned. “You’re changing your tune. Hours ago you were calling them all snobs and dropping them from the wedding invitations list. Does that mean you’re going to move back to Edhellond?”

“No. I still think they’re snobs, and no, I will not drop them from the wedding invitations list, but he did have a point about him teaching you those techniques you’re going on about, or if not him, then maybe Randall or Manuela. They don’t seem as snobbish as the others.”

“She has a point, Bro,” Elladan said. “We could do with some training in that sector, not so we can go around calling ourselves master healers, but because those techniques will be useful in the future. You know what Glorfindel and Ada always said: no warrior dismisses any weapon at hand however lowly. The same is true here.”

“I know, but it’s just the idea of having to beg for lessons,” Elrohir said. “No one offered to teach us and that just seems wrong to me.”

“Well they’re offering now,” Elladan pointed out.

“Only because we’ve griped,” his twin retorted. “They should have offered to teach us from the get-go, don’t you see? But instead, they looked at us and said to themselves, ‘Half-breeds. Probably couldn’t be taught anyway’, and simply dismissed the idea out of mind.”

“Except that they know that Ada, who is even more a half-breed than we are, was taught, so I think your reasoning is somewhat faulty,” Elladan said in a reasonable tone. “At the same time, I agree that they should have offered to teach us from the beginning, as a matter of courtesy, if nothing else.”

“And to think that Ron could raise the shield with the others and we never knew that about him. What else don’t we know?” Elrohir sighed.

“That can probably be said of any of us,” Elladan replied. “We all have hidden talents and we don’t necessarily advertise them to all and sundry, not even to our closest friends and family.”

“So you think we should ask to be taught these techniques?” Elrohir asked.

“I think it would be foolish not to even if it means swallowing our pride to do so,” his twin replied.

“I agree with Dan,” Serindë said. “You should take advantage of the offer however backhanded it was. If nothing else, you can show them that you’re just as good as they, better, in fact.”

“She’s right,” Elladan said.

“We don’t have to prove anything to anyone, least of all to that lot,” Elrohir countered with a scowl.

“No, but maybe we need to prove it to ourselves,” Elladan rejoined and Elrohir’s expression became more thoughtful.

****

Finrod and Eärnur stopped at the nurses’ station so Eärnur could update Glorfindel’s file, informing those on duty that the Twins were watching over the Elf-lord, then they left. For a while as they stood waiting for an elevator, they were both silent. Finrod gave Eärnur a tight smile.

“I think they are determined to take everything we say as condescension on our part.”

Eärnur blew out a disgusted breath. “It’s Elrond all over again times two.”

“The apple does not fall far from the tree, my friend. We both know this,” Finrod commented. “Is there a reason why none of you healers have bothered to teach them healing techniques that they may not know or know only imperfectly? I confess I never thought to enquire. I think I simply assumed all of you were sharing your knowledge with them even as they were sharing their knowledge with you.”

“Mortal techniques are not as reliable as our own,” Eärnur said. “We are going through all this because we recognize that we have to do things legally by their standards, not ours.”

“But you do not like having to do so,” Finrod rejoined as the elevator door opened and they stepped in.

Eärnur pressed the lobby button and the door closed. “I admit it’s interesting to see how far they’ve come and they have been very ingenious in creating things like ultrasound and those MRIs, but our ways are so much more elegant and less intrusive. Vardamir is fascinated by it all, more so than the rest of us. Laurendil and Manwen are willing to play the game and find it amusing.”

“Yet, none of you bothered to find out what the Twins already knew about elven healing techniques and then offer to teach them what they did not know.”

Eärnur shrugged. “What can I say? Perhaps we were remiss in not doing so. To tell you the truth, I don’t think I really thought about it. The Twins are competent enough in scanning and diagnosis, and with the Mortal medical technology at hand, they can do well enough. Blood inducement, raising shields, those are more advanced techniques that I don’t think we thought would be necessary with Mortals and that is whom we will be ministering to for the most part.”

“Well, now that you are aware of how they feel, are you willing to teach them these techniques? I can certainly teach them about raising shields, or perhaps I’ll ask Vorondur to do it. His offering to teach them what he knows will not be seen as condescension. I will speak with him and with Vardamir about it.”

The elevator came to a stop and the door opened revealing the main lobby. They stepped out, nodding to those waiting to get on and headed for the front entrance.

“One question I do have is this: is your reluctance to teach the Twins due to your belief that their mixed heritage is a detriment?”

Eärnur stopped, forcing Finrod to do the same. “Of course not!” the Teler protested, but when he saw the skeptical look on Finrod’s face he revised his answer. “Maybe, in the back of my mind, I did. I remember what a time we had with Elrond.”

“And that was due more to the fact that he was resistant to the idea of being tutored by journeymen healers who were ages younger than because he did not have the ability to master those techniques. I do not think you will have that problem here, but you will have a problem because right now they are resistant to anything any of us from Valinor have to say to them. I would give them a few days to calm down before broaching the subject. Try for humility. Allow them to feel that they are in the right and you are in the wrong, even if you do not think so.”

Eärnur gave him a sour look. “If that is what you counsel, my lord,” he said stiffly.

Finrod rolled his eyes. “And I thought the Twins were being impossible. Yes, that is what I counsel. You are, of course, free to ignore my advice as you have done in the past, though you might recall that every time you did, you landed yourself in even deeper trouble than before. Now, let us go. I need to be at work soon.”

“Go ahead,” Eärnur said. “As it is, I’m officially on duty in another hour myself. I’ll just go find some breakfast in the meantime and I’ll continue to check in on Glorfindel. Who was supposed to take the watch after you?”

“Vardamir said he would. I was only planning to stay until I needed to be at the bookstore. I still have a couple of hours before the store must open but I think I will go there now and do some work. We got another shipment of books yesterday that needs to be sorted out.”

“Then I will see you later,” Eärnur said.

“Call me or have someone call me if there is any change in Glorfindel’s condition.”

“There shouldn’t be. Vardamir won’t bring him out of healing sleep before tomorrow.”

“Nevertheless….”

Eärnur nodded. “Nevertheless.”

With that Finrod left, and Eärnur watched in amusement as the Mortals who were in the lobby automatically gave way to him without even realizing that they were doing so. Once Finrod passed through the revolving doors and into the night, he went in search of breakfast, reviewing his conversation with the Elf-prince. If he hurried, he’d have enough time afterwards to check in on Glorfindel again before reporting for his shift in Pediatrics.

****

The first sign of trouble was noted by Serindë. Elladan was out of the room in search of more coffee for them and Elrohir was sitting in one of the two chairs for visitors brooding. Serindë was standing by the bed, brushing a hand through Glorfindel’s hair, quietly speaking to him. What she said was not important; it was her soft tone, full of caring and love for the injured Elf-lord. Elrohir had assured her that even in healing sleep, he would be able to hear her and speaking to him would comfort him.

“Roy, something’s wrong,” Serindë said, turning to him.

Elrohir was out of the chair and by her side in a second, automatically checking the monitors.

“What?” he asked.

“Look.” She pushed back Glorfindel’s hair and Elrohir grimaced as he saw the purplish–brown patch along the Elf-lord’s left temple, running down toward his ear.

“Let me examine him,” he said softly and Serindë moved away to give him room and Glorfindel privacy. He pulled down the bedcovers and pushed up the gown to examine the area of the surgical wound, noting similar patches of discoloration. The door opened and Elladan came in bearing a tray with coffee for them all.

“What’s up?” he asked, putting the tray down on the table between the two chairs.

“I’m not sure,” Elrohir answered. “It looks like post-transfusion purpura. What do you think?”

He stepped aside to give his brother more room to examine Glorfindel. Elladan did a brief visual examination then closed his eyes and held his hands out, scanning. Without opening his eyes, he said, “Find a stethoscope.”

Elrohir ran out of the room and was back with a stethoscope in a matter of seconds, pushing it into his ears. He leaned over as he placed the other end on Glorfindel’s chest. “I hear crackling,” he said as he straightened.

“ARDS?” Elladan asked.

“Possibly,” Elrohir replied with a shrug. “Look, BP has dropped a bit.” He pointed to the monitor where blood pressure was being recorded.

“But he’s not hypotensive, not yet. Hmm….possible dyspnea and hypoxemia, definite purpura,” Elladan muttered. “Let me take a listen.” He held out his hand for the stethoscope and Elrohir gave it to him and then took Glorfindel’s wrist and felt his pulse.

“Pulse is thready,” he said.

Elladan nodded as he listened to Glorfindel’s chest, grimacing. “He’s definitely in respiratory distress. You can hear the wheezing.”

Even as he was speaking, Glorfindel’s mouth opened, though he remained unconscious, and it was obvious that he was trying to draw in a breath.

“Do you think it’s ARDS then?” Elrohir asked, automatically increasing the flow of oxygen into the nose tube.

“Might be but I’m not sure. The breathing difficulty is pretty sudden. You don’t see that with ARDS. Might be TRALI. The time-frame is correct.”

“You think the use of Mortal plasma could be the cause?” Elrohir asked.

“It’s possible. Even with Mortals lung injuries can occur after transfusions if the transfused plasma contains antibodies that cross-react with the platelets in the recipient. I know they filtered the plasma as much as possible but it’s not a hundred percent foolproof. Damn! BP just dropped again. Look!”

Even as he pointed to the monitor, Glorfindel began struggling, gasping for breath. His eyes flew open but it was obvious that he saw nothing around him and they closed almost at once. His skin became bluish and his breathing became more and more ragged.

“Is he going to be okay?” Serindë asked anxiously where she was standing in a corner out of the way, but the Twins ignored her as they continued discussing Glorfindel’s condition and possible treatment.

“We need to get him on the ventilator,” Elrohir exclaimed as he helped Glorfindel to sit up to help him to breathe better. “This oxygen tube isn’t enough.

“We should try a corticosteroid,” Elladan suggested. “That should help with inflammation.”

“He needs a vasopressor, too. Epinephrine. We need to get that blood pressure back up.”

Elladan nodded. “I’ll get them. You get him on the ventilator. Sarah, come with me. You shouldn’t be here.”

“No, let her stay,” Elrohir said. “I need someone to hold Loren while I get him on the ventilator and the nurses won’t have the strength.”

Elladan nodded as he headed for the door, but it opened before he got there and Vardamir and Eärnur came in. Elladan didn’t bother to stay but ran out of the room.

“What’s going on?” Eärnur demanded, even as he and Vardamir rushed to the bed.

“TRALI,” Elrohir answered curtly as he began pulling out the nose tube to insert the throat tube.

“What? Are you sure?” Eärnur asked.

“Look for yourself. He’s having trouble breathing and he’s hypotensive and there’s definite post-transfusion purpura.”

“He may just be suffering from delayed hemolytic reaction,” Vardamir said. “Look. His temp just spiked.”

“Check his urine,” Elrohir said as he inserted the ventilator.  “I don’t think it’s dark and that’s one of the symptoms of a hemolytic reaction. Sarah, hold his head steady. I need to override the gag reflex.”

“I still don’t think it’s acute lung injury,” Eärnur said. “Fever isn’t one of the symptoms for that and now he’s definitely got chills.” And they could all see that Glorfindel now had the shakes, his skin glistening with sweat.

Elladan stepped inside just then, carrying a couple of hypodermics and some vials. “I’ve got a corticosteroid and a vasopressor.”

“Here, give those to me,” Vardamir said. “I’m not convinced he needs the corticosteroid. You two can go and take Serindë with you. Eärnur and I will take over.”

“Excuse me?” Elladan said in affront. “Who died and left you in charge of the universe?”

“That’s telling him, Dan,” Elrohir said as he stepped back and adjusted the pressure on the ventilator.

“As the one who actually did the surgery, I have precedence over you,” Vardamir said. “I’m taking over and you’re in the way. Now go.”

“I’ll order a diuretic,” Eärnur said.

“Diuretic! You don’t administer a diuretic if the patient is suffering from acute lung injury,” Elrohir exclaimed.

“And that’s assuming your diagnosis is correct,” Vardamir said. “Did you scan him?”

“Of course I scanned him!” Elladan nearly shouted in anger. “Do you take me for a fool?”

“I take you for someone who does not respect the chain of authority,” Vardamir said. “At the first sign of trouble, you should have contacted one of the healers instead of trying to do this on your own. You’re clearly not capable of making a sound diagnosis. Now, leave and let us do our work.”

“Contact one of the healers?” Elrohir retorted. “I’ll have you know—”

“I have no time for this,” Vardamir practically snarled as he administered the vasopressor through the IV. “Auta! Sí!”

And such was the force of his command that in spite of themselves Elladan, Elrohir and Serindë found themselves stumbling out of the room before they realized what was happening. The three stared at one another in shock.

“They’re going to kill him,” Elrohir whispered in anguish. “If they give him a diuretic, they’ll kill him.”

Before either Elladan or Serindë could respond they saw Kyle Stoner running toward them. “What’s going on?” he demanded.

“It’s Loren, Kyle,”  Elladan explained. “We’re pretty sure he’s suffering from TRALI and we were in the process of putting him on the ventilator and administering a corticosteroid and vasopressor.”

“Which ones?” Kyle enquired and Elladan told him before continuing to explain about Vardamir and Eärnur.

“They’re planning to administer a diuretic. Mir threw us out, said we were incapable of making a correct diagnosis. He said since he was the surgeon in charge then he would make the decisions.”

Kyle’s expression hardened. “Oh, he did, did he? Okay. You three stay here. Don’t go away. I’ll handle this.” With that he stalked into the room and they heard him shouting, “Whatever you two think you’re doing, stop right now!” Then the door closed and they heard no more.

“Is Loren going to be all right, Roy? Dan?” Serindë whispered.

Elrohir gathered her into his arms and kissed the top of her head. “I don’t know, vanimelda. I don’t know.”

****

Kyle Stoner took a quick look at the monitors as he reached the bed, effortlessly analyzing what they told him and coming to several conclusions at once. “Did you administer the diuretic?” he asked the two Elves as he gave Glorfindel a visual scan and then took his stethoscope out to listen to his heart and lungs.

“Yes,” Eärnur said and proceeded to describe which kind and how much.

“And you are convinced that Loren isn’t suffering from acute lung injury?”

“He’s got a high fever and we had to remove the ventilator because he suddenly started becoming sick,” Vardamir explained. “It’s clear that he’s suffering from delayed hemolytic reaction, which makes sense, considering that we pumped a lot of Mortal blood into him and it wasn’t completely compatible.”

“Then how do you explain the hypotension?” Kyle demanded. “How do you explain these purplish patches? Is his urine dark?” Even as he asked the question he was bending down to examine the urine collection bag. “No? And that’s one of the classic signs of DHR. Have you listened to his lungs?”

Both Elves shook their heads. “We scanned him…” Vardamir started to say but Kyle interrupted him with an impatient huff.

“How many times have I told you, do not ignore Mortal medical procedures? I’m not totally convinced that your scanning tells you everything and no doctor” — and he stressed the word so they knew he was speaking to them as if they were Mortals — “ever fails to listen.” Again he stressed the word. “Now, get him on the ventilator. We’ll administer an antiemetic so as to relieve the vomiting and…”

At that very moment, Glorfindel went into spasms and his breathing became more erratic. Monitor signals went off. “Hold him down!” Kyle shouted to Eärnur, then rattled off a series of instructions to Vardamir, sending him scurrying for an antispasmodic.

“He’s slipping his leash!” Eärnur shouted.

“What the hell does that mean?” Kyle demanded.

But before the Teler could explain, Glorfindel’s body arched again, almost bending in half at the waist and then he collapsed onto the bed and the monitors went flat-lined. “Code blue!” Kyle nearly screamed and he pressed an alarm button by the side of the bed. In seconds, the room was crowded with people as they struggled to save Glorfindel. It took them three tries to get the heart restarted. When the crisis was over and the ICU team dismissed, Kyle gave Vardamir and Eärnur a stern look, his voice cold and clinical.

“You administered a diuretic when you should have gone ahead with the corticosteroid. All the symptoms were there for a classic transfusion-related acute lung injury. If you had taken the time to actually listen to Loren’s lungs you would have known this.”

“But the fever and chills….”

“I admit they aren’t associated with TRALI, but the hypotension and the purple patches suddenly appearing, indicating subcutaneous bleeding? Those are classic symptoms. If you were really undecided as to a course of treatment, you should have contacted me.”

“You?” Vardamir asked, his eyes widening.

“Yes, me, Doctor! I’m the chief surgeon after Dr. Harris. You may be hotshot healers back home, but you are not doctors, not yet. Your arrogance, your refusal to even consider that you might be making the wrong diagnosis, nearly killed Loren. And I don’t appreciate you treating two of our doctors as you treated Dan and Roy.”

“They are not trained as we are,” Eärnur said. “We are planning on offering to teach them elven healing techniques they never learned.”

“That’s all well and good,” Kyle retorted, “but just remember this: unlike you two, Dan and Roy actually have legitimate Mortal medical degrees from a Mortal university. They’ve already done their residency and in one of the most prestigious hospitals in the world. You can sneer all you want because they don’t know your fancy-dancy techniques, but don’t ever dismiss them. You do not have that authority. Not here. Not in this hospital. Do I make myself clear?”

There was a long pause before, first Vardamir, and then Eärnur nodded.

Kyle let out a breath. “Good. Now, I want you to go out and apologize to Dan and Roy. I told them not to leave. They should be outside waiting. And once you’ve done that, you’re both dismissed for the day. I’ll have Randall or Manuela come in and keep an eye on Loren. Let’s go see the Twins.”

But when they left the room, there was no sign of either the Twins or Serindë and those on duty could not tell them where they had gone.

****

Words are Quenya:

Auta!: Go away, depart.

Sí: Now.

Vanimelda: Beautiful and beloved.

Note on medical terms:

1. Antiemetic: an agent that counteracts nausea and relieves vomiting

2. Antispasmodic: an agent that relieves or checks spasms or cramps

3. ARDS: Adult Respiratory Distress Syndrome

4. Corticosteroids: a class of synthesized steroid hormones used to treat inflammatory or allergic conditions or diseases

5. Delayed Hemolytic Reaction: occurs when the donor blood-type doesn’t match or work with the recipient’s blood type. Symptoms include chills, fever, nausea, pain in the chest or back or dark urine.

6. Dyspnea: difficulty in breathing

7. Hypotension: abnormally low blood pressure

8. Hypoxemia: inadequate oxygenation in the blood

9. Post-transfusion purpura: purplish-brown spots or patches on the skin due to subcutaneous bleeding

10. TRALI: Transfusion-Related Acute Lung Injury, usually occurs within six hours of the transfusion

11. Vasopressor: a hormone, such as epinephrine, that raises the blood pressure by constricting the arteries





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