"The following information was generated by FairCare: Patient #ZBA 903 5-9-0," the robotic voice choked here to insert the human-recorded name, "Mr. Hill,"—pause, click—"has been reclassified and is now considered to be at red-critical risk of a ruptured aneurysm. Your morning circuit has been adjusted and remapped. It will now take you approximately 186 minutes to complete." Arthur pressed the edge of a plastic flask against his upper lip and inhaled deeply to feel the burn. Surgery for Mr. Hill, if the system approved it.
"You are late," Gregory added, then folded the car smoothly into traffic.
"I'm blaming you," Arthur said, but the car had gone back to ignoring him. He had a quick shot and tossed the flask onto the passenger seat before grabbing his phone out of Gregory's dock. He tapped impatiently through to the FairCare permissions. There were no priority settings. He felt a strange sensation: finding a squishy lump on a dog's belly. He kept looking.
Presently, they pulled into the hospital parking lot and Arthur reached for the bag he had forgotten, instead plunging his hand in a pool of whiskey on the passenger seat.
"You have arrived. You asked me to tell you the estimated time before lunch availability. I estimate you will be available for lunch at—"
Arthur slammed the door on her and wiped off his hand. His mind wandered away from the parking lot to a story of a half-remembered Comet commercial humming out warm blue light over the brown carpet of an empty living room.
He took the elevator to the 15th floor and walked down an empty ward hall toward his office. His knees winced with every step. He worked in the combined intensive pulmonary, gastroenterology, and renal inpatient unit. There was never more than one doctor on shift.
One slim folder was on his desk, not the mountain of paperwork you might expect for one of just two regular doctors, especially for a unit serving 41-50 critical patients year-round. Next to the folder was his tablet, and on top of that was a pink sticky note with a message scrawled in blue cursive. It was from Vera, the other doctor.
Smiling, Arthur peeled off the note. A quick scan of her baroque cursive told him she had left early. He didn't bother deciphering the rest and instead unlocked the tablet. She had left no other note there, no patients flagged. None were even awake yet, he observed, as he scanned the color-coded registry for less critical notifications. Arthur tucked Vera's note into the chest pocket of his coat and began his rounds, still staring down into FairCare's sky-blue glow.
Although he usually preferred to let the first patients sleep in a few minutes over whatever was dictated, he was too late this morning to deviate further from the master schedule without receiving a manual warning from human services. They were reasonable over there, generally, but they were also tracked for efficiency just like him. And with additional metrics sent back to corporate, measuring integrity and decision-making confidence levels to which doctors and nurses were not directly subject.
Exactly how human services' productivity was measured, he did not know. A retiring employee, near as possible to a friend as can be found in this kind of work, had familiarized him with human services' extensive obligations to the private sector.
That almost-friend's name was Clarence, but Clarence preferred Al, after his middle name. Arthur had visited him often over his last few months. In sharp contrast to the time-obliterating tube lights on his ward, the administrative offices were lit by claustrophobic orange domes hanging low over glossy desks, all of it lending the rooms a sense of anachronism and control. The desks and the floor were made of the same artificial wood. Al had a private office at the back of the wing. There were no windows. Curated calm dampened everything, a synthetic blanket. When Al died, Arthur found his body, the room filled with the smell of Al's shit and a hint of rotting flesh, an abrupt tear in the usual antiseptic stench permeating Arthur's whole life.
Arthur was the only person who talked with Al at work in anything other than a directly scripted data-gathering exercise. He counted himself lucky to have Vera and the rest of the unit to talk to at all, even if all those discussions were apathetic, necessary for politeness. He was exposed to those little exchanges during morning rounds more than any other time, and so, walking between rooms on this particularly shit morning, he thought of Al's decaying body slumped over a polished desk.
The first three patients of the day had been unremarkable, too, his mind observing and recording in the exact same patterns of inference, FairCare-branded animations on the screen of the tablet. Greet, check, count. Shift. Tap, slide, pause. Shift. Look, check, count. Shift. Tap, pause. With the third patient he received a second schedule warning, so he skipped the last section of the examination. He had not skipped a section in weeks, so this would not draw attention. After a few minutes dry-heaving in the bathroom, he carried on.
The fourth patient was a recent arrival. Newer patients took a measure of real effort. As Arthur entered the room, the skin above his right eye twitched. He pulled a fresh set of gloves out of his coat. There was no reason to touch a patient. Drew the stool over to the side of her bed.
She was 62, and her heart was failing. He looked up. Her hair was pure white and delicate. She once had a round, friendly face edged in loose skin. Despite the extra flesh, her strong brow and cheekbones stayed visible, like the way her slightly bent knees were visible underneath her thin white blanket. She had been admitted a couple days ago. Arthur was frustrated he hadn't noticed her earlier; he tried to mark the sickest on their first day. She didn't do more than glance at him.
"I forgot your name," Arthur said, glancing off apologetically.
"Debbie," she said.
"Dr. Clark."
"I know. Nice to know you." She held out her hand, palm to the side, and they shook hands in the quick, pleasant way people who speak in line shake hands before they forget each other again.
"Since you're a new patient, I'll have to check a few things. Rita already has your height and weight, and it's similar information." This was a lie.
She didn't respond. From that point, their speech was purely practical. She lifted her wrist when asked so he could attach the pain measurement wristband, and she confirmed it was not too tight. He tested the connection between the wristband and his device, directed her to move her limbs, her head. He sent the stimulus to her wrist and waited for a threshold—this always took far longer than the time allotted to the task by the master schedule. After her pain threshold had been parameterized, a particularly long testing phase in her case, he used an extra minute of time to palpate the tumor. He nodded to say goodbye, but she was looking out the window at the road or the buildings across the street.
Thankfully, the next 20 or 30 patients did not require any hand assessments, and his conscience did not compel him, either, which meant just one pair of latex gloves, no hand sanitizer, and zero patience. He was back on schedule before lunchtime.
Rita, one of his day-nurses, arrived at her duty station outside his office at the same time he turned the corner. Arthur paused outside his door and watched her dock a tablet and log the computer out.
"Do you have time for burgers today?" Arthur asked.
"I brought a salad. It should be perfectly soggy by now." They laughed without looking at each other. "Salads are disgusting!" She yelled after him as he fled down the hallway.
Arthur walked alone to the cafeteria. After lunch, he finished his rounds and spent the next three hours reviewing and approving several hundred patient files, including some of fourth floor's overflow. By 6:00 PM, the usual numbness had sunk in fully. He had a drink from the flask he kept in his desk for these moments and tested for sweat stains on his jacket. Finding them, he leaned back and held his arms up, hoping to dry them out somewhat while he waited for Vera to arrive. She swept into the office only 12 minutes late, three minutes less than usual.
"Anybody stand out today?" She always asked that question.
He always said, "Nobody who isn't colorful," gesturing vaguely at the tablet, and she always smiled. It could be his presence that caused it, but at this point he suspected it was the inertia of routine.
Something seemed to have disrupted his own. Instead of continuing in the usual way, he paused and thought of his patient Debbie, her fabric skin, the friendly smile, a crooked incisor, and the way she touched her temple when she turned toward the window. It was only a moment's interruption. When he looked over to respond to Vera and put her mind at rest, he saw she was already leaving the room. He had missed his favorite part of their script: the part where she told him something about her husband or her daughter and wished him good night.
That night Arthur lay awake in bed for longer than usual, and although he toyed with a connection between this disruption in his own silent script and the routine bout of insomnia, he could deduce nothing more than the feeling that Debbie was keeping him awake. There were claws in his stomach and his mind. They were scratching away at his stomach lining.
If only sleep were located somewhere in the body. Not as a receptor, but the sleep itself, a stone. Somewhere deep down, where the thing with claws was struggling and tearing, was another ache, like a collapsed vein, and every night he probed for the pain with a dull needle. He had tried to get some help. They gave him drugs. But he had looked for other help, too. From the help-line application that quickly relinquished him and his clear liability risk, to a real-life therapist before quietly deactivating his account.
The live therapist spent most of her time staring at a tablet, rephrasing the screen. It was a familiar interaction, the roles the same on both sides, Arthur noticed, doctor or patient. Arthur knew she was only gathering data on him and passing it through an algorithm. Maybe there was some "real work" that would have begun, but he had left before the end of their session.
When he finally slept, he dreamed. Arthur stood in one of the doorways leading to the hospital courtyard. The sky was coated in thick clouds reflecting the bright lights of the city. They glowed bright white like endless banks of fluorescent lightbulbs. From where he stood in the doorway, he looked from the clouds to the dull white walls and the little garden in the center of the courtyard. It was just a few beds of light purple flowers, and he was never good with flower names, but when the wind brushed their slightly sweet scent past his face, he could feel their petals and knew them. He wondered how the flowers would feel if he were close enough to lean down and drag his face through them. The wind was moving the smell of flowers in a strange way, and it coated everything.
Suddenly, a crowd of people stepped from the shadows and clustered together along the edges, emerging from doorways around the edges of the garden. They stood there, asymmetrical silhouettes against the white walls of the hospital courtyard, and the smell of the flowers coated them, too. Occasionally, someone would shift their weight or move their head. Arthur waited at the door for a long time. None of them noticed him there. They were all looking down, faces lit up blue with the light from tiny glowing screens. Arthur wanted to walk over, to touch one of them. What massive project was underway in the little garden? What required 20 devices with dark shapes attached and the only sound a tapping, as on a fish-tank?
He found he could not move, so he looked down at his feet. But they were not there. If Arthur had tried to explain to somebody where they were, it would have been impossible. His feet had become part of the tile. Then he looked at his arm, but there was no arm there, just the door. There was no reflection in the glass—no floating eyeglasses or disembodied toupee, no empty jacket. Only emptiness, blank space.
He awoke hot underneath a sheet soaked in sweat, and his morning routine tumbled along like water through poorly planned irrigation. Stopping, doubling back, choking on itself, and then breaking free to the goal, the wheat field, the sink, the toaster. Never really pausing, never flowing uphill. The whole commute went along like that.
If the hospital had been empty when he arrived, he probably wouldn't have noticed. It's possible he would have gone on not noticing for the rest of the day and into the next, except Vera was missing, and she had not left the customary note. He walked across the courtyard, quickly past its little clusters of purple flowers, and on to the administration wing.
She was at the reception kiosk when he walked in.
"What happened?" Arthur asked.
"You don't even say hello anymore," Vera said, joking.
"Sorry," Arthur said and returned her wry smile. But Vera did not say anything else or smile back, she just stared into the blue-white flow of the front desk kiosk. Arthur walked back down to his unit and into their office.
The tablet sent pulses of yellow light out from the desk and cast them across the ceiling. Periodically, it would emit a low series of calming chimes, which was the second-tier alert. This was why somebody had to be in the office; that was the policy. It was what he should have spoken to Vera about, asked about where the hell she had been, why she was up there and not here—but she hadn't even looked at him.
Arthur realized he had been thinking about Vera, wasting time, for 30 seconds. Although, it wasn't his job to be first on the scene. The Crisis Response Team would send somebody up to his office when they had determined what kind of intervention was necessary. He sometimes took it upon himself to show up early; he had caught several mistakes that way. The room displayed on the tablet was 354. Once he slipped inside, breathless, he remembered the significance of the number.
It was Debbie's room. His face must have been flushed from running down the hallway, because she tilted her head in a quiet question as he entered. He ignored the look, straightened up his jacket, and after a cursory scan of Debbie's body position, he paged his section's CRT. Where the fuck were they?
Debbie opened her mouth, closed it. Arthur's instinct was to anticipate and reassure. Help was on the way, should already be there. But it was against hospital policy to discuss the monitoring and alert systems with patients. It was considered dangerous because, they said, it would create unnecessary panic and raise anxiety levels across the board—a key metric that was consistently low among inpatient units with the best rates—simple math. The truth is unsanitary. He repressed the urge and stared blankly at the wall, imagining her heart beeping steady on a nonexistent patient monitor.
His tablet chimed quietly, a quiet sound meaning Debbie's heart had stopped. The CRT was still not there. He didn't hear anybody in the hallway. But he could hardly bring himself to look at her. One second passed. Two. Ten.
A careful balance of old instinct and practical analysis took over. The dream-state that had blanketed him since last night shredded against the present moment's friction, the friction of automation, and he was able to begin CPR.
Debbie inhaled. The sound was rough and violent, the opposite of a sigh. Arthur was relieved, although he couldn't breathe at all. She would live.
The CRT idiots burst in and across the room to the side of her bed. One of them, a stubbly guy with dirty blonde hair pulled back in a ponytail, looked to Arthur.
"Is she stable?" the ponytail asked, as if Arthur had called them in himself.
"It's been nearly 15 minutes!" Arthur shouted.
The ponytail winced but largely ignored him, and after they stood silently around her prodding their tablets for a few minutes, one of them patted Debbie awkwardly on the head and they left. Arthur watched her chest rising and falling.
Arthur's tablet made more noise. He was late for his next patient. He did not leave.
Finally, Debbie opened her eyes and looked over at him. They smiled at each other for an instant before he ran to his next patient.
Afterwards in the hallway, he listened to the quiet hum of white noise filling the place. He looked at the immaculate floors. They were white and empty and, for the moment, they disgusted him. Eventually, he lost himself in work. He felt clean again.
Resurfacing briefly in his office, his gaze hovered over the desk and tablet. Part of his job description was to "review patient care plans and assess for accuracy; forward suggestions to Comparative Analysis." Since he couldn't easily recognize most patients in his massive caseload, he rarely made these suggestions and always reviewed the care plans with vodka.
Each time he tapped the green approval button, the tablet blinged and whisked away the screen dramatically, first shrinking it back from the screen before sliding the next one into its place. Arthur found himself watching the animation closely. It felt like taking a bite out of something crisp.
He recognized Debbie's name in the registers. He took another drink and leaned back into his chair. The plan had been updated per her incident. For half an hour, Arthur stared into the tablet and considered the plan. Then he shook his head. It felt like a lump was growing in his stomach, larger every minute, a burning sensation rising up into his diaphragm and spreading across his chest. More than any conscious thought, it was this that drove him out of the office and towards the administrative wing.
The touchscreen at the administrative reception kiosk presented three broad red buttons: Schedule, Information, Complaint. When he pressed the complaint button, the screen went dark and the kiosk asked him to have a seat in a warm female voice. She was much less strict than his car.
As he sat down in one of the glossy white chairs along the wall, it occurred to him he had left his tablet in the office. His thighs twitched with indecision, and he grimaced at the blank, whitewashed walls of the room.
The door opened, and an older man with a futile combover poked his head out. They stared at each other, both expecting the other to speak first. Arthur wiped his hands on his slacks awkwardly.
"You must be Arthur," said the man at the edge of the door. He ducked back down the hall without saying anything else. Arthur stood at the entrance until he heard another door swing open down the hall. The empty hallway was lined with identical doors without signs, symbols, or numbers. On the right side toward the end of the row, one was ajar. His footsteps were muffled on the carpet and in the soft orange light of the hallway. For a moment, he felt like he was looking in on the world through a window.
The combover was bent over his desk when Arthur opened his door, and he did not look up.
"I have a complaint," Arthur said.
The man looked up at him over his glasses, glanced wistfully at his work, then looked up again and spoke in a voice simultaneously monotone and aggressive.
"I am aware. Why don't you sit down?" He gestured toward the single fake leather chair in front of the desk and pressed his lips into a smile. Arthur sat down and shifted his weight. The chair was not as cozy as it looked.
"I have a patient on the third floor that I'm—"
"You have a patient-related complaint?" The man looked back down at the screen built into his desk and began prodding it with surprising vigor.
"Yes. The issue is with the patient's—"
"What is your unit?"
"PGR inpatient."
"Supervisor name?"
"Off-site."
"Thank you. License ID number, badge number, and tablet PIN, please."
Arthur answered these questions and more.
"Thank you," said the combover. "And what is the complaint, please?" After completing the barrage of clerical questions, his interest faded. He spread his fingers over his desk-screen to record the information and waited, staring into it.
"One of my patients—"
"Patient ID number?"
"#179433AE." Arthur considered dictating a string of random numbers, but the man would probably not react at all. Just dutifully record the complaint and thank him for speaking his mind, according to his script for patient complaint processing. Or whatever.
"Deborah Entegard, age 57, 12 percent longevity assessment score, 83 percent aggregated resource usage, patient care plan updated as of 14/07/33. Is that the correct information?"
"To the best of my knowledge."
"Then what's your complaint?" The combover's voice sharpened slightly. "For anything more complicated than inaccurate reporting, you have to complete Forms 41, 50 and 51 to submit simultaneously with your complaint ticket. I don't see any such forms."
I'm going to reach over this desk and stab you to death with your comb, Arthur thought.
"I'm here now, aren't I? I'm urgently disputing a patient care plan," Arthur actually said.
The man sighed like he had just received news a close friend was moving to Mars.
"This is not usually done. I'll enter a miscellaneous comment on the report. It's the best I can do without the proper paperwork... I see you've already left several."
"Fine. I think we should attempt her heart surgery. The odds aren't great, but it's better than what essentially amounts to hospice care while we wait for it to fail."
The man looked at him.
"Do you have an actuarial science degree?" He asked finally.
Arthur didn't know what to say.
"What makes you think that your instincts trump clear-cut, utilitarian analysis? And you know better, I suspect. You know what you're suggesting is a waste of resources. It would likely cost another patient their life. You know how this works. This isn't the dark ages. You don't have to be a scientist to understand." Arthur was pleased to hear the man's voice begin to develop a frustrated inflection. Any tone at all felt kinder than a complete lack of one.
"Are you going to record the complaint or not?" Arthur asked.
The man poked the screen with his whole body. One hair broke free from the top of his head. Arthur watched it bounce up and down with each jab.
"It's been recorded. Anything else I can help you with?" His voice had returned to its original toneless venom.
Arthur left without saying anything. He didn't go back to the office, didn't leave a note for Vera. It occurred to him she might have done the same thing. It was a passing thought, though, and his mind was spinning with ID numbers, blind rage, sadness, blended brains, little streaks of oil paint, smell of an overworked motor driving the blades of a decrepit blender around and around, around, around, until he collapsed onto his bed.
The line between sleep and waking was blurry, and his world was grayscale, except for a reddish tinge provided by his ancient alarm clock.
People with uncertain outlines walked back and forth past his bed, pacing, sometimes hunching toward the floor like they were about to vomit. One of them stopped and turned toward him, reached out. Its hand was swollen and pink—he looked up at its wavering arm to its face. There was no skin around its mouth. It moaned, a long, hoarse noise more digital than organic, and the muscle in its jaws pulsated as if twitching phantom lips. Its tongue writhed grotesquely before it pulled back, still silent, and rejoined the figures moving back and forth, back and forth through the gray darkness of his room.
It had become daytime. The figures receded. Arthur couldn't remember when he had woken up. He found himself sitting on the side of his bed, soaking with sweat. The thought briefly crossed his mind that if he stretched his neck far enough back, it would be possible for the vertebrae in his cervical spine to grind, crack, and pop themselves forward to lodge in his windpipe.
He let his routine draw him down from his conscious mind again. When he arrived at work, he almost grabbed his tablet and started his rounds. Instead, he left the tablet on the desk and crossed the hall to the supply closet. The CRT was supposed to check the magnetic lock every time they used it. They never did. It had been broken for nearly as long as Arthur worked there. Vera plundered it for amphetamines, opiates, and occasionally sanitizing wipes.
At the closet, he grabbed a black nylon bag and filled it with two vials, two IV bags, a jar of painkillers, and a set of surgical tools in a case. Nobody else would be on the unit for three hours. More than enough time to attempt the surgery. Presuming Debbie was willing.
She was sitting on the edge of her bed when Arthur walked in. The sun was out, and Arthur realized it had stopped raining since his commute. She was leaning back on straight arms, her hair gauzy in the light streaming past her from the window.
"Arthur," Debbie said. Arthur realized he had never told her his name. She must have found it on the patient portal. Arthur smiled and sat down on his stool next to the bed.
"What's in the bag?" Debbie asked.
Arthur wanted to say something. Debbie shifted her weight forward in the seat and looked him in the eye. One of her eyebrows shifted. A long time ago, he would have thought she was pretentious for that. But he hadn't seen the movement in so long— or maybe he had changed so much since he had last seen it, that he had realized it was a look of love.
"I think I know what it's for," she said.
"I need to operate."
"You have my permission."
"I have to tell you I'm not supposed to do this."
"What do you mean?" Something changed in the way she was sitting. Her thin shoulders pulled in and her blue eyes flickered.
"I mean that you're legally required to be on hospice care."
There was a surprisingly comfortable silence.
"I think I'd rather not know what you're going to do. I know it's my heart... Better knock me out before I change my mind."
They both laughed. Arthur took the IV assembly out and hung the bag from the stand at the edge of her bed, locked the door, inserted the IVs, and watched Debbie go under.
It would be better to have a second set of hands. And an anesthesiologist. And access to a heart-lung bypass machine, even though Debbie was, thankfully, an excellent candidate for off-pump surgery. He just wouldn't have anything to fall back on. Arthur set his tablet to the patient monitor and set it up next to the bed. If her vitals dropped too far, the CRT would get their alert. They would probably have to try and complete the surgery, though.
He checked Debbie's vitals again. Then he pulled a small, circular saw blade out of his bag. This was the worst part. Usually, there was a machine with three slim arms that slid through the ribcage. They were all in designated operating theaters though, and he would not be able to get her under one of those before somebody stopped him. Even if he did, the machine couldn't accept Debbie's biometrics and he'd need to spoof them.
Arthur turned on the saw. The sound wasn't soothing, exactly, but it did bring him back. It reminded him of his first years at the hospital, before they had introduced the robot and the tablet for rounds, then the administrative monitoring system, algorithmic patient care, the harm reduction services department.
Debbie didn't move much when he pressed the saw against her sternum. He realized he had forgotten to check the timer, or pinch her, or any of the other things even a student would remember to do. He would revisit the ethics of this later, he decided, and applied firm pressure to the saw as he split Debbie's sternum into two pieces. Working carefully with clamps, he slowly prized her ribcage open to reveal her heart and lungs.
The heart beat regularly, throbbing and jiggling a little each time so it shimmered in the fluorescent lights of the room. Its movement seemed to Arthur an involuntary muscle twitch, little spasms of life, an abrupt and repetitive movement that if observed in other muscles might signal a serious neurological condition.
Thoughts like this bubbled up from the bottom of his mind. He observed them, let them pop, then returned to his hands and the task. He installed a system of tubes to drain the blood from the heart and another system to stabilize the heart. He was relieved; he had not forgotten everything. He felt a warm wave of guilt on the back of his neck as he began to enjoy himself.
Under normal circumstances, a portion of saphenous vein from Debbie's legs would have been ideal for the bypass. No time for that. He pulled out one of the vials. Inside, the vein appeared to be thawed. Gently, Arthur lifted the vein out of its glass and hung it on one side of the incision. He set the vial on the tray, discarded the saltwater, changed his gloves. The heart was tolerating its position well, slightly rotated.
Using a u-shaped piece of metal and a single stitch, Arthur occluded a portion of vein the near the left ventricle. He picked up a scalpel and nicked open the vein. It bled manageably. It didn't take much longer to attach the new vein to the opening. Then it was a simple matter of repeating the process at the other end. He cleaned up around the new vein and removed the clamps and let her sternum pull itself shut. Then he wired up the bone, stitched the skin closed carefully and sanitized the wound, changed her monitor status to high alert in the system, and turned out the lights as he left the room.
It had been hours. His tablet was crammed with notifications summoning him to a meeting with hospital administration. There was that tearing in his stomach most of the time. It grew larger. He tried to analyze himself, to find the source and picture his own heart, his diaphragm, the contents of his stomach. But it defied diagnosis.
Arthur never went to the meeting. Days passed. When he visited Debbie, he checked the incision on her chest and paid careful attention to her vital signs. When he wasn't in her room, she was forgotten. His life was only spasms of activity. Wake up, make coffee, make lunch, start the car, watch the road. Tick the box, check the pulse. Hold the door open. He got away with it.
One night, about three months after, his tablet lit up as he came back from lunch. It began to chime incessantly and he checked. A CRT had already responded. He looked at the name. Of course it was hers. It almost didn't seem to matter. He counted ten chimes until it stopped. After a few minutes, her status changed. She had died. He left the hospital.
Outside, the first winter snow was falling, light and sharp. The wind burned as the snow whipped across his face like a thousand tiny needles.
He stopped to look at a footprint beside the half-shoveled path. Vera's footprint. He was embarrassed by how happy he was to see it there, a sign of life. He glanced around to check if anybody could see him, and then went down on all fours over the mark in the snow. His face was inches from the ground. He held himself there, staring at the footprint, until the sunlight on the snow started to melt the shape to ice. There was nothing for it. He pulled out his tablet and checked the bus schedule, purchased a one-way ticket to another city, and dropped the device in the snow.
He began to walk. Sometimes it's all you can do.
