Sickbay

McCoy stood next to a small desk, studying a series of monitors in the auxiliary Sickbay, trying to keep up with the flood of orders that required his approval. Thanks to Puri's untimely death, he had been given a battlefield promotion to Chief Medical Officer and was now directing the medical care of the entire ship. It wasn't as if he was new to the role of medical director. He'd run trauma centers before in the civilian world, but he was fresh out of the Academy, hadn't even gotten his regular uniform broken in yet, and he was already overseeing Starfleet's newest disaster.

It was little comfort to know that Starfleet had as much paperwork on patients as did the civilian world. Of course in Georgia, patients weren't trapped in a floating tin can, subject to a laundry list of ailments and fatalities, and certainly they didn't have to worry about the Earth running out of oxygen or gravity, or being sucked out a bulkhead breach.

He shuddered. It had been a long day and a long line of patients that had paraded before him – bloodied, burned and maimed. He'd spent hours in surgery and his staff still wasn't done with post-operative care. Sickbay was almost full to capacity. He'd sent all crewmembers who could walk and didn't need monitoring back their quarters after treatment. He'd have to assign medical staff on follow up over the next few days. He sighed inwardly. Something else to do.

For now Sickbay was quiet, except for the hum of the monitors and low conversations of the nurses as they checked on their patients who lay recovering in the beds. The crisis was over and they had saved as many lives as they could, although it hadn't been enough. He was just thinking of heading to his own quarters for some much-needed rest when a familiar, yet barely recognizable voice drew his attention.

"Bones?" The voice was hoarse and faint, the single word stretched thin.

Jim Kirk, whom he had smuggled on board the ship and begged to keep a low profile, had been anything but circumspect. From running around the ship flaunting a severe allergic reaction to sabotaging an alien drill and being promoted to acting-captain, the young man had been in the forefront of the action, pushing the crewagainst all logic or reason. He'd ultimately saved Earth from the same fate as Vulcan, saved the Enterprise and most likely the whole damn Federation.

But McCoy was still annoyed with him. His friend had been reckless and headstrong, more so than usual, provoking the Vulcan at the risk of his own life and insisting on pursuing a madman against all odds. In the end, Jim had sacrificed the warp core to keep the Enterprise from being pulled into a black hole. McCoy had found himself struggling to keep injured alive as the ship nearly shook apart from the stress. Now the ship was limping home at impulse – weakened and battered.

"How's Pike?"

He scowled at the sound of the guttural voice and turned toward where the man stood. "He's sta—"

He stopped short at the sight of Jim standing – barely on his feet – in the narrow doorway in the same black undershirt he'd put him in twenty-four hours earlier, white as bleached bone. McCoy's trained medical eye saw the perspiration covering the bruised face, the rapid, shallow breathing and the slight tremor that ran through the thin body.

"What the hell," he said. The last time he'd seen Jim had been on the transporter pad. Jim had been supporting a barely conscious Captain Pike. He'd looked exhausted, but otherwise uninjured.

"I think I—"

He barely made it to Jim as the young captain collapsed. A nurse appeared next to him as he gently lowered his friend to the floor. A dead weight, Jim's body was surprisingly light in his arms. "Get me his vitals!" he ground out.

As the nurse focused on the tricorder, he carefully pressed his fingers to Jim's carotid artery, fearing the worst. Jim's pulse was rapid and thready, his skin clammy – signs of shock.

"BP 80/45. Heart rate 110. Respirations 130 and shallow." She paused. "He's hemorrhaging."

No shit.

The color of Jim's skin, the increased respiration…he made his diagnosis before the nurse spoke.

"Anderson, get over here!" he barked to the orderly, not taking his eyes off Jim who lay unconscious and struggling to breathe. The sound of Jim's wheezing made him wince. His eyes narrowed in on the livid colors of the bruising that ran across Jim's neck. Between the blood loss and throat trauma, hypoxia was a real threat.

"Get him on oxygen. Fifteen liters per minute," McCoy ordered. He pulled back Jim's eyelid with his thumb and quickly checked his pupil response. Sluggish, which could mean concussion…or something worse. There was petechia and that meant Jim had suffered significant damage from being choked. He'd seen these signs in strangulation victims.

Anderson arrived with a stretcher. They had to move fast. McCoy had no idea how long Jim had been bleeding or how extensive his injuries, but when a patient collapsed, especially a patient like Jim, it was a bad sign.

Suddenly he was surrounded by medical personnel, all taking a hand in moving Jim. He gripped Jim's shoulders, taking a position at Jim's head. "On three. One. Two. Three."

They moved as one, lifting the man to the stretcher. Jim's body was boneless and alarmingly unresponsive. The nurse crossed his arms over his middle and held them in place with one hand as the stretcher moved.

"How much O-Negative whole blood do we have?" McCoy asked as they approached an empty diagnostic bed.

"I think we're out."

"Don't think," McCoy growled. "I want to know."

"Yes, doctor."

They quickly transferred Jim to the biobed. Immediately the monitors sprang to life and a series of warnings sounded. McCoy scanned the monitor display. Everything he saw indicated hypovolemic shock and class III hemorrhaging. There was bleeding from the spleen and kidney, a fracture of the larynx and hyoid bone, and significant edema of the suproglottic tissue. Minor compared to the internal bleeding, but it was compromising Jim's airway. Lack of oxygen in the blood was the biggest concern.

An oxygen mask was placed over Jim's nose and mouth while two other nurses swiftly cut away the soiled clothing. In seconds he lay naked on the bed, exposing a multitude of bruises across his chest and abdomen.

Christ, McCoy thought, quickly taking in the condition of the body before him. Deep purple and red hematomas covered most of Jim's abdomen and left hip, as well as his neck and throat. They were stark and vivid against the unnatural pallor of his flesh.

"Peripheral perfusion is poor," Chapel said, checking the blood flow in Jim's extremities.

He instructed a nurse to start a urinary catheter and cover Jim's battered body with a warm blanket. The biobed temperature setting was increased to combat hypothermia and shock.

McCoy barely had time to register his friend's condition; his mind was already racing as another alarm sounded. "Give me an arterial line and hang two liters of lactated Ringers."

Christ. There was so much damage. The O2 sat warning had gone from red to yellow, but was still too low. Blood volumes were dangerously low, sending his heart into arrhythmia which was displayed across the monitor. He placed his hands on Jim's abdomen, feeling the rigidness beneath his fingers. The abdominal cavity was filling with blood.

"I want an ABG, Chem 7 and a unit of plasma." He drew the blanket back to prepare to insert the central line. The nurse next to him disinfected the area and handed him the catheter.

"Systolic pressure is falling," Chapel said. She was quickly preparing the plasma.

Jim was losing too much blood, too fast.

McCoy drew on his years of medical training: empathy, not sympathy, don't over identify with your patient, focus on the task at hand. His hands were steady as he carefully threaded the catheter into the subclavian vein. "Push 25 mgs of Prostatin." He had to try to slow Jim's heart rate down.

"Urine output is 20 mL."

Too low. Damn. They had to restore Jim's fluids and get oxygen into his system before his organs began to suffer damage, but none of that would matter if Jim went into cardiac arrest. He was in tachycardia and unstable.

"Where's Tomas?" he asked of the whereabouts of the other surgeon. He needed another set of surgical hands.

"Off duty, Doctor."

"Not anymore. Wake him up and get him in here." He'd just finished inserting the catheter for the central line when another warning alarm sounded. His eyes snapped up to the monitor. "15ccs of Phenabaro, stat!"

Goddamn it, Jim was failing.

It took an hour to stabilize Jim before they could get him into surgery, an hour of pushing meds and plasma, inserting drainage tubes and trying to keep oxygen and blood flowing to the major organs.

McCoy put a hand to the back of his neck in a vain attempt to ease the ache that had settled in over the last few hours. He had spent three hours in surgery last night repairing Jim's lacerated liver and spleen. Jim had lost a great deal of blood from internal bleeding and was already physically exhausted prior to surgery. The surgery had not gone well.

Three units of whole blood… and Jim's heart still stopped during surgery. He had bled so profusely they couldn't keep his volumes at acceptable levels, even though he was pushing it in as quickly as he could. Jim went into arrest half way through surgery. Tomas had tried to deal with the internal bleeding and McCoy had focused on restarting his friend's heart. Jim had been in tachycardia so long, it had damaged his heart. Even a young, strong heart like Jim's had its limits. The newest surgical techniques and medicines had given Jim a marginal chance. By the time they controlled the bleeding and repaired the damage, Jim's heart rate had stabilized somewhat and McCoy had been able to move on to the injured throat, which sustained more damaged than he'd first thought and required surgical repair.

Jim now laid in one of the CCU beds, a fourth unit of whole blood slowly dripping into his veins. Despite this, he was nearly as white as the blanket that covered him.

With a sigh, McCoy sank into the chair at a desk in the central location of the Critical Care Unit in Sickbay. He'd finally pulled himself away from Jim's bed to attend to his other duties. Dr. Puri's office was located in the main Sickbay area in the section that had been closed off due to damage. The desk was normally used as a circulation station for the nurses as it allowed the occupant a clear view of the patients in the CCU. McCoy had taken over it so he could keep a close eye on Jim and still fulfill his other duties.

As acting CMO, he now had the responsibility to direct the medical staff and oversee the care of the wounded, as well as finalize the medical examiner's reports which had been waiting for his signature – a task that was becoming more daunting with each signature. Most of the fatalities were green cadets. McCoy wondered if the dead count would have been lower if the crew had been more seasoned. But the truth was, they were no older than Jim. Maybe they had that sense of immortality that always seemed to come with youth and that had lead them to their deaths.

A monitor alarm sounded.

McCoy's head snapped up as he zeroed in on Jim's bed. He rose quickly and closed the distance even as a nurse rushed toward the bed. It was an oxygen saturation alarm. McCoy quickly assessed the problem. The seal on the oxygen mask had broken. He quickly reset the mask, leaning close to his friend while keeping his right hand securely over the mask; his left hand reached to the overhead monitor and silenced the alarm.

He looked closely at Jim, whose eyes were partially open, a liquid blue that was dulled by the medications. A very small frown marred the pale features. It was difficult to know how lucid Jim was. Patients coming out of extended surgery were always confused, their thoughts muddled by prolonged anesthesia and medications. With the blood loss and traumatic injuries, Jim would be struggling to understand where he was and what had happened.

"You're in Sickbay, Jim. You were bleeding internally. I took you into surgery. You're all right now."

Jim dragged his hand across his middle and McCoy quickly captured it, noting how overly warm the skin was. He removed his own hand from the mask, but kept a light grasp on Jim's hand, hoping the contact would ground his friend. He glanced up at the monitor and frowned.

Jim's temperature had increased a full degree since he'd last checked an hour ago. He looked down again at Jim who stared unseeing at him. The blue eyes were confused and filled with pain.

"Everything's all right, Jim. You can rest now."

Jim mouthed something, his frown deepening.

"You can't talk. Your throat's had surgery."

His eyes closed.

"Just rest," McCoy repeated and turned to the nurse. "Get a blood sample and run a culture."

"Yes, Doctor."

He stood by the bed and studied the pale face. Tension tightened the skin around the sunken eyes. Despite the analgesic, Jim was still feeling pain. Not surprising, considering they'd cut him open from navel to sternum. The contusions on the torso were substantial. Even the bruising on the left frontal and zygomatic bones hadn't improved, though he'd treated the fracture seventeen hours earlier, after Jim had disabled the Romulan drill. Medical protocol would have him pushing Vastox, the newest complex peptide and COX blocker effective in reducing contusions and inflammations. But he'd never tried the drug on Jim and the side-effects were risky, often compromising the cardiovascular system in humans.

McCoy looked up at the monitor again. Jim's heart rate had been stable since surgery, but not as strong as he would have liked. Stopping the internal bleeding was only one problem. The massive blood-loss had done considerable damage and Jim's already exhausted body was struggling to recover.

He looked down again at his friend. He had to admit that he didn't understand Jim's drive, that single-minded pursuit to win at all costs. He'd seen glimpses of his determination at the Academy, but nothing like what he'd witnessed in the past twenty-four hours.

"I don't believe in no-win scenarios," Jim had told Spock.

But was that true? McCoy couldn't believe that all this was a desire to win. Jim wanted to stop Nero more than anything. Was it because Nero had killed Jim's father and sealed Jim's fate? An alternate reality. How different would Jim's life had been if Nero hadn't interfered?

He'd watched Jim on the bridge as Spock had ordered the Enterprise to rendezvous with the fleet and abandon Pike to the Romulans. Jim had been enraged and unwilling to listen, arguing to the point of mutiny and earning him expulsion from the ship.

"How the hell did you get back here anyway?" McCoy asked quietly of the unconscious man.

Leave it to Jim Kirk, the only cadet to have beaten the Kobayashi Maru, to pull off the impossible. McCoy wasn't surprised that when he found himself marooned on Delta Vega, he'd refused to accept his fate. What was it McCoy had said to Spock? That kid doesn't know how to quit. But that didn't explain how he'd gotten back on the ship.

"Doctor."

Speak of the devil. He turned to the sound of the voice and saw Spock standing straight-backed and still just outside the private area where Jim lay. "Captain."

Whether he wanted it or not, Spock was captain now, overseeing the Enterprise. The fleet had all but been disseminated by the Romulan ship and Enterprise had only just survived, holding together by a weakened hull and damaged engines. McCoy didn't even want to think about how close they'd come to certain death…or how close they still might be.

"You have an update on Captain Pike's condition?" Spock asked.

He took a step away from the bed and released Jim's hand. "He's stable, but critical. I've done all I can for him here. Starfleet Medical is better equipped for the specialized surgery he'll need."

Spock nodded once, his gaze drifting to the unconscious figure. "And the commander?"

He raised his eyes at the sudden demotion. He couldn't help it, but he saw the stern Vulcan with a lethal expression, his hand tightening around Jim's throat. "He's critical and unstable. How long before we get to Earth?"

"At our current speed, one week."

"One week!" They didn't have enough medical supplies to last a week, not to mention what the delay in treatment would do to Pike's recovery rate.

"I have notified Starfleet of our situation. They are sending a ship to transfer the wounded to Earth."

McCoy scowled. "You might've opened with that. When are they due to arrive?"

"In approximately eight hours."

He nodded. That didn't give him much time to prepare, but then again, it was a long time for patients like Jim and Pike who needed more care than the ship could provide. He looked at the unit of whole blood hanging above Jim. They had to ask for volunteers to get the four unitsJim needed. If he needed more….

The monitor beeped a warning.

McCoy glanced up, seeing Jim's heart rate fluctuate with an irregular rhythm. "Damn it," he said softly.

A nurse appeared on the opposite side of the bed.

"It's all right," he told her, dismissing her with a nod. The medication was supposed to be stabilizing Jim's heartbeat. He didn't like what he saw, but he didn't want to react to a singular event. It could be fatigue or stress that caused the irregular rhythm. Nothing catastrophic.

"Is there anything you need?" Spock asked.

He had almost forgotten the Vulcan was still there, and turned to him in time to see a pensive expression on the otherwise disciplined features. What, he wondered, did Spock think of all of this? Spock had nearly killed Jim, and this after charging him with cheating and trying to get him expelled from the Academy. Hell, he may have succeeded in doing just that. Jim was technically still on suspension, at least as far as Starfleet was concerned. Besides a handful of people, no one knew Jim was here.

"I have a list," McCoy said, "but I doubt you could fill it."

And like that, the mask was in place – passive and indifferent. Spock nodded once and left.

McCoy shook his head. The Vulcan was an enigma – stoic and reserved one moment, enraged and lethal the next. He'd seen his planet destroyed, his mother killed. Anyone else would have been curled in a fetal position under a desk nursing a bottle of malt liquor.

A soft moan drew his attention. He laid a reassuring hand on Jim's shoulder and watched as the tiny frown slowly eased and the man sank back into a heavy sleep. Jim always looked so young to him, but pale and struggling to breathe, the arrogant young man appeared vulnerable, something he was not used to seeing.

For the first time since stepping foot on the Enterprise, he wondered what fate awaited Jim on Earth? Would the Academy Board rule in Spock's favor and expel Jim? Or would Jim's recent stint in command and the inarguable fact that he'd just saved Earth – by breaking all the rules – mean reinstatement?

Pressing the call button, he summoned a nurse to sit with Jim. He had a lot to do before the transport ship arrived and he wanted to make certain the new ship was prepared for the critically wounded.