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Visionary's Writing - Everything, Nothing, Red, and Green

Posted: Fri Jun 23, 2017 5:39 am
by Visionary
Link to the latest released stuff.

Index: --

Hello, everyone.
First post here, and I'm already jumping in the deep end. Heh.

Anyway: this is a story in two parts and in two overall perspectives. Read them both for the full picture.
Also, this is my first time writing a significant work of fiction in a while, so constructive criticism is highly appreciated.
It does, however, at least meet my standards for grammar and spelling and basic writing quality.


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One Little Day
When everything goes wrong.

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“Nakai, Hakamichi; could you please take Ikezawa out of the classroom? I’ll keep everyone settled, so please don’t worry about anything but her, okay?”

It seems to take an eternity for Shizune and I to reach the door and go through, with Hanako in tow.

The hallway’s unexpectedly noisy, given that it’s the middle of classes. I can hear footsteps, talking, and the sound of something clattering from further up the hallway. I doubt the noise would do Hanako any good right now, so I motion for us to move down towards the other end of the hallway.

We carefully make our way down the stairs. The three of us almost lose our balance as we guide Hanako, but we make it to the bottom. I gently let Hanako sit on the floor in front of the stairs, and take a seat on the steps.
We simply stay there for a while, waiting for her to say something. Shizune taps her shoulder a little, but she doesn’t give a response.

Eventually, though, she awakens and looks up the two very worried people trying to look out for her. We simply look at each other for a while. Hanako slowly changes from being catatonic to having a more normal, shy and withdrawn expression.
She curls in on herself a bit more, lowering her head. Her eyes move downwards and to her side. She looks almost ashamed to be here.

Listening again, the clattering sound from before returns, now a lot louder. Hanako picks up on it and seems a bit startled. We need to get moving again.

I stand up; Shizune sighs, and looks at me. I don’t need words to tell what she’s asking.

“I can take Hanako to the nurse. Is that okay by you?”

I further communicate my intentions by pointing in the direction of the nurse’s office.

She points to me and Hanako. I nod, and other, unknown voices interject suddenly.

“Careful! That paint’s heavy!”

“I think—ah, I think I’ve got this-- oh shit, WATCH OUT!”

Standing on the stairway, I turn around.
The last things I see are a number of large metal cans hurtling down the stairway towards me.

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I, of course, can’t hear the paint cans, or the screams, or the yelling. I can, however, see the paint cans teeter dangerously and then fall as the student carrying them trips on the stairs.

I manage to dart sideways and push Ikezawa out of the way. Hisao, however, isn’t so lucky: he takes a few cans full of paint to the chest. He hits the ground on his back, covered in red and green and blue and yellow.

He doesn’t move.

I can feel Ikezawa instantly tense up and see her eyes widening, but she’s not my concern anymore. I rush over to Hisao and shake his shoulders a bit. He still doesn’t make any movements, even after a couple of seconds.
I race up the stairs, taking them two at a time, and burst back into Class 3-3. The whole class turns to look at the sudden intrusion. Mutou looks alarmed, and Misha’s already translating his words.

[ Shicchan? What’s going on? ]

I sign back with sharp, decisive movements. Panic is the enemy, so I try to avoid making my movements frantic.

[ Student with paint cans tripped. Hisao got hit. He isn’t moving. ]

She relays my message without thinking, but goes pale after the details set in. Mutou is already out of his chair.

[ Lead us to him, Shicchan! ]

And with that, we’re out of the classroom again. We head down the stairs again, and come to a stop at the bottom. The two students from before are there, too, kneeling around him uselessly.
Mutou’s already down on one knee, feeling for a pulse and checking for breathing. He frowns, apparently not finding anything. He points to me, then Misha, and says something to her.

[ Shicchan! Mutou says we need to go find the nurse! Right now! ]

I nod. Right before I take off, though, I remember something and look back.
I glance off to the side; Ikezawa’s still there, of course. But she’s still not moving, aside from a faint shaking that I can notice from here.

I run up to Misha and tap her on the shoulder, signing a quick message to her before running off in the opposite direction.

[ You go get the nurse, I need to find someone else. ]

Mutou’s too focused on performing chest compressions to notice me run past him and back up the stairs.

I stop short of Class 3-3 and dash into Class 3-2. The teacher looks at me with a stern gaze, mouth open in what is probably a rebuke.
I quickly scribble something involving ‘urgent medical emergencies’ and ‘student health’ and ‘psychological well-being’ on my notepad, before tearing the sheet off and practically throwing it at her. If she wants to make an issue of it later, fine.

It’d make for a good argument.

Quickly dashing to Sato—Lilly’s—desk, I grab her by the hand and practically pull her out of it; she stumbles a bit, nearly crashing into the adjacent desks before righting herself. She, of course, seems to be more than a bit upset as I drag her out of the classroom.

Thankfully, however, she doesn’t seem to offer any resistance as I run down the hall with her behind me.
I can see Misha coming up the stairs.

[ Hey, Shicchan~! I got the nurse, he called for an ambulance! Why do you have Lilly with you~? ]

I stop as we reach the stairwell and guide Lilly’s hands to the handrail; I’m not about to try and pull her down the stairs. Nevertheless, she moves as quickly as we do, and Mutou catches sight of all three of us as we reach the bottom.
He pulls Lilly off to the side to keep her from stepping on Hisao as she reaches the landing, then guides her to Ikezawa, who seems to still be curled up.

Right, that’s done. On to the next objective.

An idea occurs to me, and I get Misha’s attention.

[ EMS is going to need to know Hisao’s condition, right? ]

We, of course, have a brief, nonspecific description of every student’s condition on file in the Student Council room. It’s for situations exactly like this: safety concerns and emergencies.

Fortunately, the distance to the Student Council room isn’t long at all, and I know what cabinet the student files are in by heart. It only takes a second of looking through the N section before I have his file.
I’m careful not to drop any papers as I pull it out, and quickly flip the folder open to the top page. Misha reads over my shoulder as I scan through for the important bits, copying them to the notepad.

Hisao Nakai. Eighteen years old. Male. Congenital heart muscle problems and arrhythmia.

One of the things our files don’t have, however, is information on medications; that is, understandably, strictly for the nurse’s eyes only. The rest of the information in the file concerns things like academic and conduct records; there’s nothing else immediately relevant for the paramedics.

I catch sight of the ambulance’s flashing lights as we go back to the scene.
Mutou’s already gone, probably back to our class room. The nurse is doing compressions. Whatever Lilly did seems to have awoken Ikezawa from her shock; she’s now clinging to Hisao’s arm and shaking slightly as Lilly holds her.
The hallways are starting to fill as the lunch break starts, and a small crowd is beginning to form.
Misha’s still following behind me and starting to look a bit out of breath.

I point to the gathering bystanders.

[ Make sure the paramedics have a clear pathway. ]

I manage to get near the doors just as the paramedics enter; I wave to get their attention and guide them to the stairwell, towards Hisao. I run alongside the man leading the EMS team. There’s another man and a woman following behind us, carrying a big red plastic chest and what seems to be a heart monitor between them.
The team leader hangs back, seemingly to assess the scene while the other two get to work setting everything up. I take the opportunity to push Hisao’s info into his hands; he looks briefly surprised, but when he looks over the paper he nods in recognition.

I move to Misha’s side and watch the scene unfold while thinking of our next steps.

The woman looks up suddenly and seems to yell something, prompting the lead to get up and forcefully pull Ikezawa off of Hisao. He roughly dumps her, on her rear, about a foot away. Lilly promptly wraps her arms around Ikezawa protectively.
Hisao suddenly tenses, and for a moment I think he’s woken up; but no, they resume compressions immediately afterwards.

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The next few minutes pass by in a blur. There’s a bag, needles, and another shock. Before long, however, they bring Hisao out on a stretcher, quickly shoving him in the back of the ambulance and collecting their things.
They drive off, the lights disappearing as quickly as they came.

Looking back, the crowd seems to have dispersed about as quickly, leaving behind the aftermath.

Lilly and Ikezawa are both huddled together in the center of the massive paint spill. Ikezawa seems even more fragile than normal, shaking violently as her eyes continue to fill with tears. Lilly’s crying as well, though I can’t tell whether it’s for Ikezawa’s sake or if she was genuinely that concerned for Hisao.
Misha’s still standing there, looking hopelessly lost as for what to do next. The nurse is nervously pacing, not raising his eyes to meet any of us as he fills out some kind of form.

He eventually returns to his office, leaving the four of us alone: Lilly, Ikezawa, Misha, and I.

We stay there for a while. Watching and waiting isn’t really my forte, but there’s nothing else I can think to do, which annoys me.
In time, however, Ikezawa stills and slumps against Lilly. I can tell they’re both exhausted from their postures: leaning, slackened, and somewhat unsteady.

I move to try and help them both up, and of course Misha comes to help as soon as she notices what I’m doing. Together, we pick them up and off the floor.
They cling to each other even now, as Misha and I form a sort of protective bubble around them. We guide them down to the nurse’s office. He looks up as we enter, but doesn’t seem to say anything.

We leave them on the bed in the nurse’s office, and I quickly make my exit. There’s nothing more I can do for them right now.

As I take my first good look outside, I notice it’s already well in the afternoon.

This day’s gone by too fast.

A Call to Yamaku

Posted: Fri Jun 23, 2017 5:58 am
by Visionary
A Call to Yamaku
When minutes matter.

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I stare at the mess below me, my face contorted in concentration.
Time is of the essence, but… one false move, one mistake, could lead to utter disaster.

I reach for a small vial off to my side, flicking its cap off with one movement.
I look at the familiar-smelling solution in my hands with trepidation. This is a matter of life and death: one drop too much-- or one drop too little—could end up killing someone.

I stare at the bottle some more, and I think out loud.

“How much vanilla to add, I wonder?”

Someone pokes their head into the kitchen behind me.

“Ichiro, you’re making meatballs. Why the hell are you adding vanilla?”

I turn around to face the speaker. I can’t really put a name to her face. ‘The new guy’ is about all I come up with.
…or, well, I guess it’d be ‘the new girl’, actually.

“Because no one’s tried it before! It’s interesting!” I respond, nonetheless.

“Well, maybe there’s a reason nobody’s tried it before! Why are you even cooking, anyway?”

“Because I was hungry, and I’m not aware that I was banned from the kitchen by the decree of Miss… um. Whoever you were.”

She looks at me with disbelief.

“Did you forget my name?”

“No, totally not! It’s, um…”

I’m saved by the sound of a bell going off.

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Acting on reflex, we both dash for the garage without a second thought; we both hop into the vehicle farthest from the door: a big, white, boxy ambulance. I clamber into the back while the other woman—Airi, I think—hops into the driver’s seat. I tune out her responses to the radio, to focus on something more important.

We’re missing someone.

“Hey, Airi! Where’s Daisuke?”

“Taking a shit, I think! And seriously, now you remember my name?”

I choose not to respond to that. Instead, I choose to watch Daisuke frantically run around the back of the ambulance and into the passenger’s seat, narrowly avoiding slamming his face against the side of the ambulance through either sheer skill or dumb luck.

“Ah, crap crap crap! I’m here, I’m here!” he says, frantically waving his arms around as if he had suddenly turned invisible or something.

Airi steps on the gas as soon as all the doors are closed, and we drive off, into a bright July day. It’d be beautiful, if the situation weren’t so pressing. As soon as we’re out of the residential areas, she hits the lights and siren.

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“So wait, Airi? Where’re we responding?” Daisuke asks.

“Some school outside the city. Yamaku Academy, I think it’s called. I wrote the address down.”

Those two words—Yamaku Academy—elicit an immediate reaction from both Daisuke and I. Daisuke goes stiff and sits up a bit straighter, leaning forward, looking infinitely more nervous now. I, on the other hand, simply groan and lean back.

“Aww, hell. A Yamaku call? What’s the call about, at least?” I sigh.

“Uh, adolescent male suddenly lost consciousness and is unresponsive. Dispatch says they’re getting CPR on him now,” Airi replies.

We sit in silence for a second, before Airi asks a question.

“So wait, what’s with Yamaku? You two seem to know the place.”

“It’s a school for the disabled. Missing limbs, the blind, the deaf, and so on,” I say redundantly.
“They’ve got 24/7 on-site medical staffing that handles most minor issues.”

Airi starts to catch on.

“So if they need us around…”

“Yep! Nothing good,” I confirm.

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I jump out the back as soon as we’ve stopped. The front gate to Yamaku looks as pompous as ever, even as I slam it open. Airi and Daisuke are right behind me, all three of us running up the courtyard, carrying what seems to be half the ambulance’s ACLS supplies with us.

The call’s probably for one of the students, so the place to be is…

“Patient’s in the main school building!”, Airi calls out to me.

We’re through the doors in seconds. A dark or I think maybe even blue-haired student’s already there, waiting for us. She doesn’t say anything, instead waving to us and pointing towards the stairs.
We don’t even have to go up the stairs to find the scene; a handful of people are already congregating near the bottom. I can vaguely see a person lying on the floor past them.

The small crowd parts as the four of us approach.
The scene is a mess: there are some red and blue substances that’s been spilled everywhere, and I initially think it’s blood before noticing the paper and empty metal cans pushed off to the side. Paint, probably, then.

The patient’s a seventeen or eighteen-year old male, by my reckoning. A girl with long dark hair is clinging to his arm, wailing and obviously in major distress. A taller, blonde girl is also at the boy’s side, though she’s clinging more to the dark-haired girl than anything.
Meanwhile, there’s a man providing compressions already, who I recognize as the school’s head nurse.

Ms. Blue-Hair shoves a piece of paper into my hands before stepping aside. Daisuke takes over compressions, Airi sets up the defibrillator, and I look over the paper.

Hisao Nakai, eighteen-year old male, congenital arrhythmia and heart muscle problems.

It’s probably about this guy, then. The information’s nice to know—it means I don’t have to ask around for his name—but also damningly vague. Congenital arrhythmia and heart muscle weakness could cover so many things, they’re effectively useless for us.

“Okay, we’ve got V-Fib on the monitor! Charging to 200, get clear!” Airi calls out.

There’s a steady, rising tone from the defibrillator for a second and then a loud DOO-DEE-DOO-DEE-DOO tone. Airi glances up and down, from the patient’s head to his toes. I have to practically wrench the dark-haired girl off Nakai’s arm before we can shock; she winds up on her rear end and curls up into a ball, cradled protectively by what seems to be a curtain of long yellow hair.

“Shocking in three, two, one!”

The shock’s delivered, the guy tenses, and immediately afterwards I set about getting the airway stable. I pull out an oral airway: basically, a little plastic tube that goes in the mouth and makes sure that his tongue doesn’t end up choking him.

Shove it in the mouth, push it halfway down, twist 180 degrees, and done.

Airi and Daisuke have already switched off doing compressions, so Daisuke pulls out the bag mask and sets it on the patient—Nakai, I remind myself—on Nakai’s face.

Next step: stick him full of needles and tubes and stuff!

So, next thing to do: pull out an IV catheter, tie off his right arm with a tourniquet, and find a good vein.
The needle goes in cleanly, as does the catheter itself. I push the catheter hub further, moving it down the needle and all the way up until it hits the skin. Then the needle comes out, the tourniquet comes off, and we’re left with a tube going into Nakai’s veins.

Good thing we didn’t have to go intra-osseous. I don’t think we brought the drill with us…

I’m about to tape the IV down when Daisuke waves his hands in front of my face and yells at me.

“Everybody clear!”

That takes priority so: hands off, look up, wait for the shock…
Daisuke hits the shock button, Nakai tenses again, and the heart monitor readout goes flat again.

Right, back to what I was doing…

I tape the IV line down with enough tape to cover half his forearm, and then pull out the first medication I’m going to shoot Nakai up with: epinephrine, one milligram, IV push.

Nothing like a good dose of adrenaline to get the heart pumping again.

I practically slam down on the syringe, forcefully pushing the medication into his body. Of course, that doesn’t quite work immediately, so it’s back to compressions. I take over this time for Airi, leaving her with the meds and leaving Daisuke with the Ambu bag.

Heel of the palm on the lower third of the sternum, push two inches deep.

I keep my ears open to listen to the defibrillator’s CPR metronome, keeping in time with it. It’s utterly exhausting, and my arms start to feel like lead almost immediately, but I keep up.

Twenty-five, twenty-six, twenty-seven…

The defibrillator's electronic voice calls out in time with my thoughts.

“Three. Two. One. Ventilate.”

I stop pushing for a brief moment, letting Daisuke push air into the patient twice, before starting compressions again.
We go through five cycles of this and then we do a rhythm check, as per protocol.

Daisuke reaches for Nakai’s neck, I glance at the heart monitor.
I can see a sinus rhythm on the monitor.

“…I think I can feel a pulse here,” Daisuke announces. I mentally fist-pump.

Woohoo! ROSC, baby! Yeah!

“We have return of circulation.” I call out.

Before I can even blink Airi’s got the stretcher in place underneath Nakai, and with a single swift movement she and Daisuke bring him up; I hold the bag and the defibrillator in place, and we carry him off to the ambulance.
We end up having to make another trip for the rest of our stuff, but pretty soon we’re driving off again with Nakai in tow.

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I end up in the back with Nakai and Airi while Daisuke takes the driver’s wheel.

I end up slamming the defib—heart monitor now, really—onto a shelf and get to setting up a few more vital sign sensors: a little clip-on sensor for pulse oximetry, a blood pressure cuff, and the rest of the electrodes for a twelve-lead ECG.
I’m hovering over Nakai’s head, making sure the sensors are set up right, when his gag reflex decides to come back online.

He promptly vomits upwards, into my face.

Godfuckingdamnitshitwhyme.

Airi’s already on top of things, pulling out the oral airway and pushing Etomidate and Succinylcholine into his IV. She gets to work with the laryngoscope while I’m wiping my face off thoroughly, passing an endotracheal tube down into Nakai’s airway with relative ease. She quickly inflates and secures it afterwards.

I must still look irritated, because she breaks down as soon as she gets a good look at me.

“Pffffahahaha! Oh, god, the look on your face… At least we know he’s probably not a vegetable, right? Right?”, she says through fits of laughter.

I say nothing, instead setting up the tube with a CO2 monitor, the bag valve mask, the oxygen tank—the usual.

Once that’s all done, we check his vitals, Airi sets up two liters of fluids on the IV, and I start writing things down for Daisuke, who calls ahead to Tohoku University Hospital.

“Tohoku University, Ambulance Eight-Two calling with priority one traffic for you.”

“Go ahead Eight-Two.”

I hand him the little strip of paper that I’ve scribbled Nakai’s vitals on.

“Tohoku University, be advised we’re bringing you a priority one patient: eighteen year old male found in V-fib. Vitals are: blood pressure 73 over 58, heart rate 67 with sinus on the monitor, O2 saturation 87 percent. GCS is 8 with E-2, V-tubed, and M-5. Patient is currently intubated with 100 percent O2 and has a peripheral IV established, we’re running 2 liters of fluids. Patient has a history of unspecified congenital arrhythmia and cardiomyopathy. ETA 5 minutes if you have no further questions.”

“Tohoku University copies. Room two on arrival, see you in five.”

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We pull in to the hospital, and they take him in without further ado.

As we're walking out of the hospital and back to our ambulance, I notice that it's already past noon.
I can't help but look back into the ER. Nakai's already long gone, of course.

Poor kid. Looks like his day's just starting...

And with that thought out of my head, Airi, Daisuke and I begin the short drive back to the station.

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And that's the end. Again, thanks for reading.

Re: One Little Day and A Call to Yamaku

Posted: Fri Jun 23, 2017 2:49 pm
by Zerebos
Damn. That was a really intense read. Your portrayal of the KS characters was very good and description of all the medical knowledge makes me think you know a thing or two :wink:

Re: One Little Day and A Call to Yamaku

Posted: Fri Jun 23, 2017 4:30 pm
by Toothless
It was an interesting read. Loved the Shizune pov and how she just drag Lilly around, sound like she is used to it.

Re: One Little Day and A Call to Yamaku

Posted: Fri Jun 23, 2017 7:06 pm
by Mirage_GSM
Very well written - and with lots of medical details, too.

Over here we'd probably have gone right for the endotracheal tube if there had been someone qualified to insert it - or a larynx tube if there hadn't.

One minor nitpick: Since the nurse was at the scene he probably would have been able to give way more detailed medical information than Shizune's notes.

Re: One Little Day and A Call to Yamaku

Posted: Sat Jun 24, 2017 11:12 pm
by Visionary
Thanks for the feedback, everyone.
Zerebos wrote:Damn. That was a really intense read. Your portrayal of the KS characters was very good and description of all the medical knowledge makes me think you know a thing or two :wink:
'Intense' was definitely what I was going for; it's been a while since I've last really written anything that wasn't a nonfiction essay, and I wanted to see if I could still get emotions through.
It's also nice to know that all that research paid off-- I'm not actually a doctor / nurse / paramedic /medical professional, so I relied heavily on Google, Wikipedia, a whole bunch of Youtube videos, and so on to make sure everything was accurate.
Toothless wrote:It was an interesting read. Loved the Shizune pov and how she just drag Lilly around, sound like she is used to it.
I'm glad you liked the characterization; that was kind of the part I was most worried about.
I had a slightly more pragmatic reason for having Shizune drag Lilly around: I didn't want to kill the pacing by stopping to describe an unnecessary argument in the hallway.
Looking back on it, though, it is very much in character for both of them, so I guess the pieces fell into place in just the right way there.
Mirage_GSM wrote: Very well written - and with lots of medical details, too.

Over here we'd probably have gone right for the endotracheal tube if there had been someone qualified to insert it - or a larynx tube if there hadn't.

One minor nitpick: Since the nurse was at the scene he probably would have been able to give way more detailed medical information than Shizune's notes.
Oh god, someone who actually knows what I'm writing about.

I'm realizing now that Airi probably would have been trying to intubate Hisao while Ichiro was doing compressions-- maybe she was preparing the drugs or something when he wasn't looking?
Also yeah, Nurse probably would have been going to get Hisao's medical file or something (assuming he wasn't doing the whole bystander thing and staring, which would be out of character) after EMS'd taken over compressions from him.


As sort of a side note, the medical side of things here was the part that really interested me, with this story, and I think it's something I'd like to keep writing about for a bit longer (probably in another story).
My mom's an RN, my dad's an RT, they both work in hospitals (high-dependency / step-down unit and ICU, to be exact), so I suppose I've got a genetic predisposition to learning ACLS protocols, or something.

Also, I've got a question: if I'm going to post another story (unrelated to this one), that's another one-/two- shot like this, should I post it in its own thread, or should I keep it in this thread (as a sort of "collection" thread for all my stuff)?

Re: One Little Day and A Call to Yamaku

Posted: Sun Jun 25, 2017 7:22 am
by Mirage_GSM
It's also nice to know that all that research paid off-- I'm not actually a doctor / nurse / paramedic /medical professional, so I relied heavily on Google, Wikipedia, a whole bunch of Youtube videos, and so on to make sure everything was accurate.
That's even more impressive then. Good job!
Oh god, someone who actually knows what I'm writing about.
A bit. I'm in the Red Cross, so we learn how to use most of this stuff, but I'm not in EMS so I've yet to put anything of it in practice.
Also yeah, Nurse probably would have been going to get Hisao's medical file or something (assuming he wasn't doing the whole bystander thing and staring, which would be out of character) after EMS'd taken over compressions from him.
That's just my opinion, but in his place I would have stayed there and maybe switched of with the paramedics doing the compressions. Getting the files would have been pretty low priority. Nurse would be able to tell them all the important stuff, and they wouldn't have the time to read the files at that point anyway. Once the paramedics were gone, he would have enough time to fax the files to the destination hospital.
I'm realizing now that Airi probably would have been trying to intubate Hisao while Ichiro was doing compressions-- maybe she was preparing the drugs or something when he wasn't looking?
Hmm... Probably depends a lot on the procedures. With three people (plus nurse) on site, the work would probably divided with one person doing the compressions, one preparing the intubation/operating the ambubag and the last preparing the IV/AED with nurse alternating with the compression and preparing injections on request.
By the way, I don't have any problems believing that they'd use an oral airway. The story is set in 2008 and there weren't a lot of larynx tubes around back then, and they could easily decide that other things are more urgent than an endotracheal at this time.
Intra-Osseus is something I would not even have considered for a patient like Hisao. We're taught it's mostly used for small children whose veins are too small for holding a PVC.
Also, I've got a question: if I'm going to post another story (unrelated to this one), that's another one-/two- shot like this, should I post it in its own thread, or should I keep it in this thread (as a sort of "collection" thread for all my stuff)?
Completely your call. Some authors keep their stuff all in one thread - especially if it's all one-shots, others use a seperate thread for each. I have a collection thread for short stuff with an index as the first post and seperate threads for the longer stories. (Link in my sig, if you want to see how indexing works here.)
If it's all the same theme, I'd go with one thread.

Re: One Little Day and A Call to Yamaku

Posted: Sun Jun 25, 2017 3:01 pm
by Oddball
A decent enough read for what it was, I guess. I'm not big into medical drama though so I might be the wrong person to judge.

Re: One Little Day and A Call to Yamaku

Posted: Mon Jun 26, 2017 3:23 am
by Hesmiyu
Oddball wrote:A decent enough read for what it was, I guess. I'm not big into medical drama though so I might be the wrong person to judge.

I have some interest, and watch some programs, such as House. M. D. Oh god, imagine House as a doctor at Yamaku.

Act 0: Deterioration

Posted: Fri Jun 30, 2017 3:10 am
by Visionary
Act 0: Deterioration

Image
(Artwork courtesy of my sister.)


This pseudo-Act covers Hisao’s time in the hospital, from his admission to his discharge (and a small bit beyond).

It’s first purpose is to probe deeply into Hisao’s condition, reconcile what we see in-game to reality, and patch the holes and inconsistencies in the canon explanation of his condition. Everything you see here with regards to Hisao’s condition is, to the best of my knowledge and research, either established medical fact, or could be easily extrapolated from the same. I also try to remain as consistent as possible with respect to canon, but I always sided with realism over consistency if they came into conflict; there is one (possibly two if you squint) major case where this happens, but even then I tried to patch it over-- you’ll know it when you see it.

This story also serves as a look into Hisao’s character, and examines why and how he became the shell of a man we see in the beginning of the main KS story. There’s really not much to add, regarding this; we all know how this begins and ends, so relax and enjoy the middle parts.

This is, by far, one of the longest monolithic stories I have ever written, at around 10k words. I feel like I passed a milestone of some kind...
As always, any feedback or criticism you could give me would be greatly appreciated.


Anyways, enough chit-chat. Thanks for reading, and… on to the story.




[ Out Cold ]

There’s a young man. He has the steady fire of life in his heart, the wonders and mysteries of science in his mind, and a light in his eyes that looks to cherished friends and a bright future.
He wants to live.

And with that anticipation, Hisao Nakai, high school student, steps into the stark white snow, and towards the naked trees of a hill in winter.

--

There’s a young man. He has the fire of compassion in his heart, the wonders and mysteries of science in his mind, and a light in his wide eyes that looks to cherished colleagues and futures preserved.
He wants to help.
And with that confidence, Dr. Nakamura, resident internist, steps into the stark white lighting of the Intensive Care Unit.



[ Admission ]

“Todai, Medic One-Eight-Five enroute. Patient is Code Three, Level One at this time; seventeen year old male, found unconscious with agonal respirations. Patient is currently unconscious, GCS is 3. Vitals for you are… blood pressure 68 over 44, heart rate 118, sinus on the monitor with intermittent non-sustained VT, O2 sat 82 percent. Patient is currently intubated with two peripheral IVs, we’re running 100 percent oxygen, chilled fluids and dopamine. Be advised, we’ve transmitted a twelve-lead, ID 1-3-3-8. ETA 5 minutes if you have no further.”

“Tokyo University copies, room one on arrival.”

--

“He doesn’t look great, I’ll grant you that. But he won’t code in the elevator, so he’s stable enough to move to ICU in my book.”

--
I slouch, ever so slightly, in my conference room seat. My head feels fogged up and slower than normal. My eyes are becoming ever harder to keep open. It’s been 24 hours since the last time I’ve even closed them for longer than 10 minutes.

I down my entire cup of coffee in one go.
The room is still filled with the sounds of talk and discussion.

Oh, right. We’re still doing rounds.

Why are they looking at me?

“Dr. Nakamura? You still with us?”

That voice… it’s, uh. The attending physician. Right.

“Sorry, sir. Just a bit tired.”

He smiles in sympathy, and I find the same sympathy in the eyes of the rest of the doctors at the table. We’ve all been there, I guess.

“We’re about to start discussing the case of Mister Nakai in Intensive,” he prompts me.

Oh, that kid. I did his history and physical, I should have his file somewhere here…

I shuffle my papers, looking for the appropriate file. It takes me a hazy minute, but I find it.
I blink my eyes and shake my head a little to keep myself awake, then I launch into the case presentation.

“Hisao Nakai is a 17-year old male presenting for sudden cardiac arrest and chest pain. He’s had no prior history of heart or chest trouble of any kind and no previous medical history.
“Patient has remained unconscious thus far, so we haven’t been able to get an ROS yet…
“Patient has no known allergies and isn’t taking any medications. Family history… first-degree relatives are noncontributory, though the family did report some extended relatives having unspecified ‘heart problems’…”

--

What’s… happening? Where… where am I?

I try to open my eyes a little bit, but a bright white light forces me to close them again. It hurts a bit less when I try to open my eyes the second time.

It feels hard to breathe. I take a short, little breath, and my lungs nearly fill with air, which startles me.
I feel cold for some reason, and start to shiver. I can’t tell if it’s the room I’m in, or if it’s just me. Every part of me seems cold, from my head to my chest to my toes.

There’s a grey circle above me. I realize that it’s a light fixture, and I’m looking at the ceiling. I try to move my head to get a better view, but realize it feels impossible. Instead, I settle for simply moving my eyes.

The first thing I notice is the plastic tubing everywhere. There’s a tube coming from my chest, right in front of my face, two coming from my arms, one coming from my mouth, and several others connecting pieces of equipment to my sides.

The clothes I’m wearing are unfamiliar; they’re a light shade of blue, and feel very coarse and uncomfortable. I can smell bleach in the air, which makes me even more uncomfortable.

The tube in my mouth feels really uncomfortable, too.

It seems to take a monumental effort to move my arms up to the tube, but I manage to grasp it with both hands. It seems to be firmly lodged in my throat, and when I try to wiggle it free, all I manage to do is disconnect part of the tube. I can hear air rushing from it as it swings free.

Some kind of alarm goes off, a shrill beeping sound filling my ears. Within moments I can hear someone opening a door. She’s dressed in blue clothing that looks fairly similar to mine, except it has a deeper blue color. It’s only when I see the emblem on her chest that I realize where I am.

I’m in the hospital.



[ Diagnosis ]

I give the cardiologist a look. What the hell kind of terms did he just throw at me?

“I’m sorry sir, cardiology isn’t my specialty. Could you repeat that?”, I tell him.

“Arrhythmogenic. Right-ventricular. Cardiomyopathy,” he repeats. “Inherited heart muscle disease. Causes the right ventricle wall to progressively become thin. And by thin, I mean piece-of-paper thin. It also causes people to go into V-tach and V-fib often, usually when they’re exercising. Seems to be associated with adrenaline,” he explains further.

I scribble that down onto a sheet of paper, suddenly thinking that I might be far too tired to process this information.

“His heart isn’t going to suddenly tear open and make him bleed out on us, is it?” I ask.

“Nah, that’s not what happens. Usually, patients are asymptomatic… until they hit adolescence, then they drop dead due to sudden cardiac arrest.”

“…really? That can actually happen? So wait, what do we do?”

He thinks for a while, and looks at an MRI we took of the patient’s heart.

“I’ve never actually seen this myself, to be honest. I read about it during my fellowship, of course, but I’ve never run across anyone who actually had it.”

He takes a deep breath, and circles something on the MRI.

“Alright, so… the big parts are the right ventricle wall becoming very thin and the potential for ventricular arrhythmias. The first part’s not that big of a deal, actually. Sure, it means his heart’s not pumping as well as it should, but it’s not outright failing. Yet, anyways.
“The second part, with the V-tach and the V-fib? That’s the lethal part. To be frank, he’s really, really freaking lucky to be alive right now. Again, the first symptom patients usually present with is SCD: they drop dead out of nowhere.

“Now, treatment normally is like every other condition that causes ventricular arrhythmias: we stick an implantable cardioverter-defibrillator in them. We get them to the cath lab, pass some leads through their veins and into the right ventricle, then we slip the ICD right under the skin, and the patient goes on to live a nice, long, and normal life.
“Normally you put the leads on the right ventricle wall, but for this disease we’d put the ICD leads onto the ventricular septum, because, you know, we don’t want to poke a hole in his right ventricle and cause cardiac tamponade.

“Unfortunately, if this MRI’s right, then his ventricular septum’s also become involved,” he says, pointing out the thinner than normal barrier separating the two ventricles.

“That makes things a lot harder,” he explains, “because now when we go to implant the ICD we run the risk of basically giving him a ventricular septal defect by accident. And it might not even work once it’s in, because the disease progression might render the part of the heart muscle we attach the leads to nonconductive.

“Even still, though, my recommendation is that we still try. No matter how you put it, an ICD is the best way to prevent sudden cardiac death in this case.”

--

After taking about ten minutes to fix myself up and figure out how I’m going to deliver this, I find myself standing in front of the patient’s door. I look at the plate, nervously.

Room 352. Hisao Nakai.

Faintly, I wonder if I should be even doing this. I’ve got like two hours before I’m done with this 30-hour shift. I could just ask someone else to deliver this, I think.
But I push those thoughts to the back of my mind. He’s my patient, so in a way, I have to do this. It’s what’s right for him, and it’s the only way I’ll learn how to do my job.

I plaster a big bright smile on my face to hide my nerves, and I open the door.

--

A doctor walks into the room, and sits down by my bedside. His face is stretched in a smile that seems too enthusiastic to be real; is he simply trying to be happy for my sake?

“Well, uh, hello there, Mr. Nakai. I’m Dr. Nakamura, and, um, I’ll be the one taking care of you while you’re here in the hospital,” he says. He sounds like he’s trying to be casual.

A silence hangs in the air for a second before I respond.

“Hi? Could you call me Hisao?” I ask him. “’Mr. Nakai’ sounds like my dad.”

He’s briefly surprised, and his eyes go wide for a second. I can see they’re a bit bloodshot.

“Eh? Okay? Sure!” he replies hastily.

“So,” he begins tentatively, “I’m guessing you have at least some idea about why you’re here.”

No. I really don’t. And I would kind of like to know.

“I really don’t. All I remember was a sharp pain in my chest… and then I woke up here.”

He looks at me for a second, seemingly thrown off by my answer.

“Oh, I didn’t… um. Well, you had a sudden cardiac arrest. Your heart suddenly stopped.”

That’s… not comforting, to say the least. I thought those only happened to old people? There’s a bigger question on my mind, though.

“What caused it?” I ask.

He sighs, now looking back on track but simultaneously a bit downcast.

“Well, that’s what I was going to discuss with you. We think you have a… condition, called arrhythmogenic right ventricular cardiomyopathy.”

The words are strange and foreign; they don’t seem to fit with the rest of the sentence.

I stay silent, and he takes that as his cue to continue.

“It’s a rare, inherited, progressive disease of the heart muscle. It… causes the outer wall of the right ventricle to become thinner and thinner, and disrupts the heart’s electrical systems,” he explains, though there are holes and pauses in his speech.
“Since the heart’s electrical pathways are disrupted, it tends to beat erratically,” he continues.
“And occasionally, the heart can begin to beat way too fast, which can be fatal. This usually happens when there’s a lot of adrenaline going around the body… so things like exercise and sports can cause these symptoms to manifest.”

I think back to the forest and the snow. There was definitely a lot of adrenaline going to my heart, then. But… will this happen every time, now? Will I suddenly die because of a little adrenaline rush?
The worry must be clear on my face, because the doctor quickly interjects.

“D-don’t worry! We can’t cure the underlying disease, but we have something to help treat it.”

He pulls out a sketch of some kind of device. It’s small and oval-shaped, with a long wire coming out of it.

“We can place what we call an implantable cardioverter-defibrillator. It looks a bit like this, and it’s essentially a miniature defibrillator that’s always on. It constantly monitors your heart rhythm, and if your heart is in a dangerous rhythm, it’ll deliver a shock to correct it. You could return to your normal life in a few weeks like nothing even happened.”

That’s calming, though other concerns come up. What about batteries? What do I do if I damage it? I don’t voice these, though, because it looks like the doctor has more to say.

“The procedure does have its risks, though. Especially in patients with your condition, there’s a chance we could end up puncturing the walls of the heart, or the walls separating the chambers inside the heart, and there’s a chance the device may not work once it’s implanted. Still, it remains the best and most effective option for patients in your case.”

The idea of having a hole in my heart is terrifying.

Still, this disease is clearly no laughing matter, and if I have the chance to have a normal life… I’d take the risk.



[ Treatment ]

The two days between the diagnosis and my procedure pass in the blink of an eye. The doctor describes the procedure, alternatives, and risks a bit more for me. My parents, Iwanako, and what seems to be most of my class all visit at some point, even if only briefly. A flood of cards seems to arrive at my room: a nonstop parade of ‘get-well’s and ‘hope-you-feel-better’s rapidly accumulates on a table near the side of the room.

I try to keep a cheerful face on through it all—at least people actually seem to care about me-- but even so I can’t help but feel a bit apprehensive in the face of this upcoming operation.
I’m sure my fears will come out to nothing; this is, after all, a fairly routine and noninvasive procedure. It’s not open-heart surgery or something like that, as my doctor explained.

It’s also better than a lifetime of medications.

Soon enough, I’m lying on my back in what seems to be an operating room. It doesn’t seem to be quite as big, or as crowded as I’d expected an OR to be, though.

A woman in scrubs looks down at me from my side. When she speaks, she seems relaxed and maybe even a bit friendly. She holds her arm out and gestures to the room.

“Welcome to the cath lab. You know what we’re about to do, right?” she inquires.

So, I’m not in an OR. I nod.

“We’re going to keep you awake for this procedure. We’ll make sure you don’t feel any pain, of course, and we’re going to administer something to keep you calm. But we’re not going to fully knock you out.
“I’ll have to ask that you try not to move at all while we’re doing this, okay?”

That sounds agreeable. I’d much rather not be unconscious again, and I didn’t plan on jumping around while they messed around with the insides of my heart. I nod.

“Great! Let’s get started.”

They inject something into my chest, underneath my collarbone, that makes part of it go numb, and then they make a small cut and start inserting a tube into it.

The novelty of having another thin plastic tube going into my chest wears off after a bit, and I zone out, thinking about how life is going, outside of the hospital. My thoughts drift to Iwanako.

When she first showed up at my door, I was elated. We’d have a chance to patch things up.

In the end, however, we ended up saying nothing to each other except for the usual, routine things: ‘how are you feeling’s and ‘I’m fine, how about you’s. She didn’t seem to want to bring the subject up, so I went along with it and stayed silent.

She did say she’d come to visit me after my procedure though, which offers a bit of hope.

Tomorrow, I tell myself. I’ll be able to patch things up with her tomorrow.

I’m thinking about ways I could bring the subject up, when a sharp pain in my chest interrupts my train of thought. I tense up, involuntarily, and the doctor notices.

“Huh?”

She notices something on the monitor, and goes pale, her eyes widening in shock.

“Oh shit, I think the stylet just tore his septum wide open.”

It suddenly becomes a lot harder for me to breathe, and I can feel my heart start to pound away like a jackhammer.
What’s happening? What’s going on?!

I start to squirm a bit in panic, but this seems to make things worse.

“Sir? Sir, I’m going to need you to stay still—fuck, now there’s a hole in his right ventricle—sir, stay with me here…!”

I can feel panic making its way through my system as the edges of my vision go dark.

“Shit, I think he’s crashing, page cardiothoracic surgery,” is the last thing I hear before everything goes completely dark.

--

After a good eight hours of sleep, I’m feeling back on my feet again.

I step back into the ICU with a pep in my step, which fades when the nurse hands me not one, but two operative reports. I scan over both of them; they’re about Hisao’s ICD implantation.

…advancement of the second ICD lead was attempted, but was interrupted … due to a sudden rupturing of the ventricular septum…

Shit, shit, shit. We were afraid of that, weren’t we?

…patient began to involuntarily move due to chest pain, causing additional damage to the septum and perforation of the right ventricular free wall before additional sedation could be administered…

…acute pericardial tamponade ensued, and patient was referred to cardiothoracic surgery for emergent ventricular wall and septal defect repair.

That’s… bad. Actually, that’s about as bad as it could have gotten.

Fortunately, the second, emergency surgery seems to have gone a lot smoother. According to the report, he’s stable now, though I imagine he’s lost a lot of blood.
One last part near the bottom of the second operative report, however, draws my attention.

Patient is now showing 2:1 Mobitz II atrioventricular block, presumably secondary to injury to the ventricular septum and Bundle of His. Implantation of a permanent pacemaker is recommended.

Are you kidding me? Now I—Hisao, I remind myself—now Hisao has to deal with this on top of his existing condition? The first thing it strikes me as is unfair.

Then the guilt hits. I mean, even if I’m only a first-year resident, I’m still taking care of Hisao. I could have said something, maybe. Maybe if I’d been more awake, more inclined to think, then, I could have done something.

I go to page for a consult with Cardiology. Time to figure out where we’re going with this.



[ Consultation ]

“Well, damn, Nakamura. Looks like you’ve got a really bad case, here.”

I look up from Hisao’s patient file. No shit, it’s bad; I didn’t need him to tell me that.
I bite back telling him that thought, however, and try to move forward.

“…okay. If it’s as bad as you say, where do we go from here?”

He thinks for a minute, leaning back for a chair and looking up at the ceiling.

“Well, we saw how ICD implantation went: poorly.”

No need to say that again.

“But I think that might’ve been a one time thing. Another try may be warranted in his case.”

Wait, what? But didn’t we just agree that it went badly the first time? Why try it again and risk a second set of complications?

I’m about to ask him why, but he changes the subject first.

“I went ahead and took the liberty of printing out a couple of reports on the disease, if you want to look over them,” he says, pushing a somewhat thick stack of papers my way.

I look at the article at the top of the stack, and read its title aloud.

Arrhythmogenic Right Ventricular Cardiomyopathy Type 5 Is a Fully Penetrant, Lethal Arrhythmic Disorder Caused by a Missense Mutation in the TMEM43 Gene. That’s…,” I say, a bit lost for words.

“One hell of a title, isn’t it? But I mean, it gets the point across. And yeah, I also ordered a couple of gene tests run while you were out. Hope you didn’t mind,” he fills in for me.

I really don’t mind, but I’m also very confused.

“Thanks, but… why? Don’t you have your own patients?” I ask.

“Admin actually told me to help you with this guy due to his ‘rare condition’ and ‘unique circumstances’, so I’ve been meaning to catch up to you ever since you came in this morning. And frankly, I’m not complaining, or anything: this is the most interesting case I’ve seen in a while.”

Something about the way he mentions Hisao irks me.

“I mean, scientifically speaking, I think we’re treading new ground here. ARVC is rare enough, and I couldn’t find anything like this in any of the literature I’ve looked at. We could write a paper on this, or something,” he says, somewhat excitedly.

I move the stack of papers to the side so I can look at my patient files again.

“So… treatment options?” I prompt.

“Oh, right. Yeah, an ICD is… in the air. You do realize we’re going to have to implant a pacemaker too, right? And we could run into the same problems as with the ICD.
“Anyways, our second-line options are drugs. The two main ones we’re going to use here are sotalol and amiodarone; the first is a beta-blocker, the second is the antiarrhythmic we all know and love. Together, they help prevent some of the dangerous ventricular tachycardias from happening.”

This is the first time I’ve ever heard of sotalol, but I’ve heard of amiodarone; it’s used in ACLS protocols for ventricular tachycardia and fibrillation, among other things.

“Oh, and don’t worry. I’ll write this down for you. Anyway, there are going to be a few more drugs we’ll have to prescribe.
“Next drug up is an ACE inhibitor to hopefully slow progression of the disease and reduce the effects of heart failure. I’m thinking ramipril for that. Now, we’re not going to start him on anticoagulants yet; not until his heart fails more. We’re also going to need drugs to manage his post-op pain, so that’s going to be opioids for the next few weeks, maybe something weaker for long-term use if the pain turns out to be chronic.”

Alright. Sotalol, amiodarone, ramipril, and pain meds.

“Is that it?” I ask.

“For now, yeah. We’ll have to see what side effects start happening, of course, before that’s definite,” he answers.

“So, anything else besides drugs?”

“One more big thing for therapy: he’ll have to change parts of his lifestyle around. You know how I said that adrenaline tends to cause cardiac arrest with this disease?”

Yeah, that part sticks out in my head. Mainly because Hisao seemed to nearly panic when I mentioned that to him for the first time.

“Well, as it turns out, it doesn’t just cause ventricular arrhythmias to occur. As it turns out, adrenaline—or really exercise I think—seems to aggravate the disease as a whole. Makes it progress faster, manifest sooner, and so on,” he says with a wave of his hand.

“So I’m guessing no more sports for Hisao?”

“Well, most of the literature I’ve read actually goes a bit further and says no strenuous physical activity at all. There was actually a whole study done on this; I think it’s in the stack, there,” he mentions, pointing to the stack of reports he passed to me.
“Kinda counterintuitive, isn’t it? You’d think exercise would make his heart stronger, but nope, exercise makes it weaker,” he quips, chuckling slightly.

“On a more serious note,” he continues, “… well, there’s a reason why most of the people who suddenly die with this condition are athletes.”

That dour note in the conversation leaves us both in silence for a couple of seconds. I’m almost afraid to bring this next subject up, but our discussion has been steadily veering towards this for a while, now.
It’s also something I know I’ll have to convey to Hisao sooner, rather than later.

“Speaking of… death,” I begin tentatively, “what’s his prognosis?”

He sighs, leaning back in his chair. There’s an unreadable expression on his face. He glances at a few graphs in front of him.

“…honestly? Not good. That’s why I’m pushing for the ICD and also a pacemaker now,” he says. He leans forward, eyes focused on me.

“Ultimately, there are three different things coming together to kill him: sudden cardiac arrest and potential complete heart block in the short-to-medium term, and progressive heart failure in the long run.
“Those first two, the SCA and the AV block, are pretty similar in terms of treatments and timeframes: if we can get both of those two devices implanted, Nakai should be able to live out a long, though maybe not full lifespan.

“If that can’t happen, however? Like, if it turns out we can only get one of those devices in, or if a lead fails or something? Then we’re looking at a 10-year prognosis of 50% for him, or less.”

He pushes a piece of paper across to me.

“See the top graph, there? Graph A? He’d be in the control group, for that study.”

I look; he seems to have drawn a line around where the 50% cumulative survival mark would be… and it meets the graph at around the nine-and-a-half year mark. Going by the graph, he’s more likely than not to be dead before he reaches 30…

“If he makes it into his 50s and 60s by some miracle, then he’ll have heart failure to contend with. At that point, the wall thinning will have spread to both ventricles,” he finishes, leaving me in stunned silence.

What? Seriously?

Even though I’m not the one with that dismal prognosis, I can’t help but feel shocked. I didn’t think it’d be that bad.

I mean, I guess it’s a better prognosis than if he’d had, say, a STEMI. But still, for someone so young…

“…so I guess our only option is to have him go in for implantation again. Or is a transplant an option?” I ask.

He simply gives me a look.

“Do you know how hard it is to find organs for transplantation in this country? He’ll probably be dead long before he has any chance of getting off the waiting list.”

Oh, right. Damn.

We sit in silence for a while. I eventually bring up the question on both our minds.

“…how are we going to tell Hisao?”



[ Disposition ]

It’s been a week since I woke up from my surgery, and my third week in the hospital overall.

According to the doctors, I’d been in emergency surgery to close holes in my heart that formed while they were trying to implant the device in my heart.
Now everything hurts like hell. Especially my chest. They’re giving me medications to reduce it, but I can’t help but wonder how long I’ll have to keep taking them. Weeks? Months? Years? The rest of my life?

On that note, my thoughts drift to my heart. How long will I have to live with this, too? Am I going to be stuck taking pills for the rest of my life and hoping my heart doesn’t kill me out of the blue? How much of… well, my life will I have to miss out on because of this?

I try to watch some television to get my mind off things. It’s really the only thing I can do anymore; I’m not really allowed to walk around, anywhere, since I need to be constantly hooked up to the ICU monitoring equipment.

I eventually land on a channel showing something that isn’t sports, news, or soap operas. It’s an anime… a slice-of-life one, by the looks of it.

After only a few minutes, I can’t help but feel bored. This is just normal life. Why would anyone watch this?
Escapism? They want to imagine themselves in a normal life... in place of their normal lives? Or because their life isn’t normal?

And that’s when a realization hits me.

That’s exactly what I’m doing.

The next few minutes are a blur. I think I panicked and frantically mashed the power button as hard as I could, but I really don’t remember much. My mind was spinning far too fast to pay attention to that.

Am I really ‘abnormal’ now? Am I a disabled person?
Is that who I am, now?

I close my eyes and force myself to calm down, before a nurse comes rushing in to see what’s wrong.

I really don’t feel like watching TV much, after that.

--

A week and a couple of medical scans later, my doctors want me to go in for another try at the device implantation. Apparently, due to ‘complications’ from the previous attempt, I now need two devices implanted; one to fix my original condition and another to cover for the damage caused by the surgery.

Apparently, I’m going to be completely anesthetized this time around; they don’t want to risk a repeat of what happened last time. They want to make absolutely sure I don’t move during the operation, in other words.

They repeat the same assurances from before: you’ll be able to head back to your old life, you’ll be able to enjoy a healthy lifespan, these two devices won’t be an inconvenience at all, we probably won’t poke a hole in your heart.
I’ve started to tune them out, however. So far, nothing they’ve said has actually happened or come true, and I’m slowly realizing that none of that will probably ever come true.

I go along with what they’re saying, though, to keep them happy. It seems a lot easier than protesting. Nod as they explain things. Say yes if prompted, or no if it’s a bad thing like sudden death.

I wonder when I started thinking of sudden death as merely a ‘bad thing’. I make it sound like an inconvenient rainstorm.

Your forecast for today is cloudy, with a chance of sudden death. Be sure to keep an umbrella handy!

A voice brings me out of my thoughts. Someone’s asking me something.

“Sir, I’m going to put you under, now. Could you count backwards from 100, for me?”

Sure, that sounds easy enough.

One hundred. Ninety-nine. Ninety-eight. …ninety-seven.

Ninety… six…

--

The next thing I know, a full day has passed.

My chest doesn’t hurt any more than normal, which I think is a good sign. There is also a new lump right underneath my collarbone, which I also take as a good sign. It’s hard and about the size of a wristwatch.
My shirt can hide it pretty well, but I’d hate to see how people react when I take my shirt off. My first thought is gym class and the locker room, but if I remember my doctors correctly, that’s something I won’t be doing anymore once I get out of here.

Well, to be fair, my surgical scars would probably be more noticeable than the incongruous lump by my neck. I’m really starting to look like Frankenstein’s monster, now.
Unbuttoning my clothes and inspecting my chest, I can see there’s one huge one running down the center of my chest, looking like stereotypical stitching; a smaller one right above the lump; and several down by my sides.

It’s only when I look up that I realize that Iwanako’s been watching this whole time. She turns bright red and practically runs out the door when our eyes meet.

I hastily button my shirt up again, and she nervously reenters the room after a few minutes.

“If—if you’re, um… busy…” she starts, “I-I could come back later.”

I should probably be embarrassed, but I can’t find it in myself to care about her insinuation. I’m more worried about my chest, to be honest, though in a different way than usual.

It feels like I’ve exposed a part of myself, a deep and personal portion of myself. It makes me slightly uncomfortable.

We don’t say anything to each other for a few minutes. Occasionally, Iwanako’s eyes will drift over to my chest, up to my heart, then dart away, and she’ll look guilty. And then it’ll happen all over again.
I try to get us out of this awkward silence and stimulate some kind of conversation.

“So, what’s going on with… um, class?” I ask, realizing that I sound like my mom.

“…boring,” Iwanako replies after a few seconds.

I want to bring up that snowy day.
…but I have no idea how. It seems almost impossible; I’d have to get the atmosphere right and segue into the topic and all that stuff, and that just seems too monumental to undertake right now. And besides, even if we did start talking about that… where would that go? What would we actually do, have a date in my hospital room?

I could get a candlelit table, then probably burn to death as I realize that the room air is ninety percent oxygen or something. Or I could try and eat dinner with her—and spill half of it onto my bed and clothes, wouldn’t that be just great?

Or I could sit in this silence, which seems to be just as painful. But it lingers, and eventually, she picks her things up and leaves, as silently as she came. We said maybe all of three sentences in total to each other.



[ Prognosis ]

It’s been about four and a half weeks since Hisao’s been admitted to us. In that time, he’s become stable enough to be moved out of the ICU, and to the cardiac high-dependency unit. The change seems to have done him some good; he’s stopped staring out the window for hours on end, and started reading various books to pass the time.

I open the door to his room slightly to make sure he’s awake. He’s currently engrossed in a book, but he looks up as soon as he hears the door open.
I try to give a friendly wave, then the four of us file into the room: me, the cardiologist, and then Hisao’s mother and father.

The parents take up positions by Hisao’s side, and the cardiologist and I move towards the front of the room, facing them. I glance at the cardiologist for a sign. He nods, and I proceed.

“Hello, Hisao. How are you feeling?”

“Fine?” he replies, warily glancing from side to side at his parents.

I nod at that, and give a weak smile.

“So… today I’d like to discuss your treatment plans from here… and your prognosis.”

His parents seem startled by this, but Hisao looks terrified. Undoubtedly, he’s thinking of medical dramas, stories of cancer patients, and the ‘you have one year left to live’ death knell.
And… well, I can’t say he’s wrong.

“So, I’m fairly sure you already know about the two procedures Hisao’s undergone for implanted defibrillator and pacemaker insertion,” I continue.

His mother raises her hand.

“Er—we’d knew he’d undergone a second procedure, but… we’re not sure how that went. Someone tried to explain it to us, but…”

I glance at the cardiologist, who shrugs. I’m a bit thrown off by this; did no one actually explain the outcome to any of them? How did we miss that?
Oh well. This is as good a time to go over that, as any…

“Oh, um… so… the procedure was met with mixed success. We were able to implant a pacemaker for your heart, but we couldn’t find a place to put the defibrillator leads without either risking either further damage to your heart or negative interactions between your pacemaker and the defibrillator. In the end, we chose to only insert the pacemaker,” I explain. The three of them nod in understanding.

“I’ll leave explaining your treatment options to Dr. Akimoto, here. He’s an attending cardiologist, here.”

I motion for the cardiologist to take over from here.

“So, with ICD therapy conclusively ruled out, our primary treatment route is going to be medication. For the most part, these will be aimed at suppressing life-threatening arrhythmias and slowing down the thinning of the heart walls. Over the coming weeks, we’ll be working with you to determine a medication regimen that will hopefully reduce the chances of cardiac arrest and heart failure.

“Now, before you came here, did you do any sort of competitive sports or regular exercise?”

His father interjects this time.

“I know he played some soccer, but I’m not sure it was competitive.”

Hisao shakes his head, silently. Non-competitive, then.

“Okay, then. I’m afraid you won’t be able to do that any longer. Putting stress on your heart—for example, through aerobic activities such as running, soccer, and basketball—seems to aggravate this disease, making it progress faster and making sudden cardiac arrest more likely.”

The parents look a bit scared, understandably, but Hisao simply nods glumly; was he expecting this? The cardiologist waves his hands around slightly and gestures for them to hold up.

“Now, that’s not to say you can’t do anything physical, period. Lighter activities should be okay; your heart won’t fail just because you went for a short jog or swam around for a bit. If it’s not too hard on your heart and it’s not endurance-based, you should be fine doing it in short periods,” he explains, causing Hisao to perk up slightly. Why do I get the feeling he’s only going to care about this part?

The cardiologist nudges my arm a bit, and I take over again.

“As far as treatment goes, that’s all we can do. There isn’t really a cure for this disease, seeing as it’s genetic in nature. Actually,” I add, remembering something, “both of you may want to get screened for this disease as well. Even if neither of you are showing symptoms, at least one of you must have the disease. I further recommend that any extended relatives on the affected side of the family get tested as well.”

The mother looks shocked, and the father’s hand briefly begins to move towards his heart, dropping before either Hisao or his mother notice. I think I can guess what side of the family it runs in, now…

I choose not to bring it up, however. This is better done in a private talk.
Instead, I bring up the other subject no one wants to talk about.

“So, about your son’s prognosis.”

His mother seems to shrink, drawing her hands close to her chest in scared anticipation. His father puts a supportive hand on Hisao’s arm. Hisao looks downcast, but stares ahead at me, regardless.

“Your son, unfortunately, is affected with one of the most severe and, yes, lethal variants of this disease. The primary cause of death from this disease is sudden cardiac arrest, which can occur fairly randomly. The second major cause of death with this disease is progressive heart failure, which will begin to manifest when he’s 50 to 60 years old.”

There’s the primer. Now for the news…

“However, with cases like yours, where ICDs are not offered or cannot be given… half die within ten years.”

They’re all shocked by this. There’s silence, and staring.
I try to inject some hope.

“Now, that’s not to say he’s hopeless. His prognosis is certainly far better than some other cardiac diseases, and it’s not like his condition’s going to steadily worsen until he’s bedridden and dies. If he’s smart, doesn’t stress his heart too much, and keeps emergency treatment close at hand, he may well live a full life.”

But I wouldn’t count on it, is what I leave unsaid.



[ Progression ]

The days blend into each other, from there.

The bright florescent lights above me are always on. The city is always just outside the window.

The rhythmic beeping of the ECG is always in my ears. The strong smell of antiseptic is always in my nose.

There’s always a book in my hands. I think reading is about all I can do, at this point.

--

I learn a lot more about my condition. Or conditions, I think—keeping track seems pointless, at the rate I seem to be gaining them.

In the end, I give up on trying to untangle the medical word salad, and pick out the one word that seems to be coming up the most often in relation to my heart.

Arrhythmia.

A strange word. A foreign, alien one. One I don’t want to be in the same room with.

From what I gather, it’s a rare condition. It makes the heart beat erratically, and occasionally it makes the heart beat way too fast; this is often fatal.

It’s congenital, of course. They said it was no surprise, that I was able to go on for so long without anything happening; but they also said it was a miracle that I survived, and that most people with my condition die suddenly without ever being diagnosed.
I guess it was supposed to make me more appreciative of what life I have left, but it doesn’t really do anything to cheer me up.

In any event, there’s a lot of things I have to avoid, now.

I have to avoid hits to the chest, for example. Apparently, this may set off an ‘episode’ inside my heart; I think it has something to do with either the pacemaker or the medications.

I have to avoid strenuous activity, too. This makes more sense; stressing the heart would naturally seem to make it more likely to fail suddenly.

I also have to avoid alcohol (which sounds easy enough), caffeine (which sounds harder), and adrenaline (which sounds impossible). Supposedly, these substances make me more likely to have heart ‘episodes’.

I’ll have to avoid these for the rest of my life because, of course, there isn’t a cure.
There’s only treatment, to prevent the symptoms.

Which is why I’m staying here.

--

Sometimes Iwanako visits. Sometimes she doesn’t. When she does, we simply sit in silence.

What is there to say? What would we do, make plans for a future that I know won’t happen? Resurrect a relationship that had no chance of survival in the first place? Say words to each other that we already found impossible to force out, what seems like an eternity ago?

I conclude that there’s nothing I can do, here. Eventually, she disappears.

--

Sometimes my parents visit. More often, they don’t. When they do, we sit in silence.

We’re all at a loss. I’m not sure how I’d even get started with trying to comfort my mom, who by all signs seems likely to outlive me. I’m not sure how I’d try to comfort my dad, who seems to have aged 20 years and who now has a strange-looking lump in his chest, underneath the collarbone.

I force myself to be honest, and realize there’s nothing I can do, here. Eventually, they disappear too.

--

My old friends already disappeared a while ago, so I’m left with just myself.

I should probably resent them for leaving, or feel guilty for pushing them away… but I can’t find it in myself to really care about what they do.

I mean, they have things to do and lives to live out, right? And while they go on, I’ll just be… here, I guess. There’s nowhere else I’m going, right?

There’s really nothing else I can do, here.

--

I’m not sure when the realization comes—hours, days, and weeks all feel the same, now—but eventually, it hits me.

I’m already dead, aren’t I?

Not in a literal sense, obviously. But metaphorically; a ‘death of the soul’, as the literature I’m reading might put it. Ultimately, however, it’s a fairly simple concept to grasp.

Hisao Nakai has, for the most part, passed on. He died, that day, on that snow-covered hill.
His friends and family received the news, they grieved and mourned their losses, they buried him in a sterile, solemn tomb… and their lives continued after that. His parents, and a girl who may have been his lover, came to visit, of course. But eventually, they moved on.

And, left behind, I remain. Like a ghost, or a remnant. Unable to move forward with the whole, unable to pass on fully.

--

The nurses and doctors all start to blend together, like the time; blue scrubs without faces and white coats all alike come and go from my room with regularity.

I suppose if I cared enough to focus and actually look at who they were, I’d be able to distinguish between them and even recall their names. But I usually don’t need to do that.

The routine interactions happen silently: a nurse walks in, perhaps holding some kind of equipment. Sometimes they wave, but eventually they go about their task silently. Sometimes I have to sit or stand up, but I usually know when that has to happen, so I do so almost automatically. Sometimes I have to nod or shake my head to answer questions, but I do that silently too, of course.

Occasionally, I’ll need to give a more detailed response, and when I do the coarseness and unfamiliarity of my disused voice always surprises me.

Sometimes I can see their feelings in their eyes, and catch looks of pity, sadness, resignation, and guilt fairly often. But no matter what they feel, they do their jobs like clockwork.

--

I’m assigned new patients, of course. Work continues. I see the young and the old, the chronically ill and the acutely infirm. I see trauma patients, cancer patients, STEMIs, CVAs and more.

But Hisao remains constant. He is stable.

His condition beyond that, however, is not much better.

Clinically, I can see why it happened. He withdrew into himself, abandoned his support network, and in turn his support network abandoned him. He has nowhere to go, no one to turn to.

And yet, he lives. Even if it is only because we won’t let him die.
Not yet.

Over the course of weeks, we work out his medication regimen; it’s a delicate biomedical balancing act, a series of pills that act and react and effect, and eventually cancel out to, hopefully, leave behind a Hisao that’s slightly less likely to die, and nothing more. No added nausea, no added hypotension, no added hyperkalemia.

It doesn’t all cancel out, though.

His QT interval is now somewhat longer than normal, and he can add acquired long QT syndrome to his laundry list of conditions; there’s no avoiding that when combining amiodarone and sotalol, however.

Sometimes his pain medications don’t work at their normal efficacy, and he’s left with a lingering, distracting pain in his chest.

And yet, if it weren’t for the medical gown and the monitoring equipment… he would look perfectly normal, on the outside.
It’s a bit strange, how someone with insides as messed up as his could look so normal. But I suppose that’s simply how it turned out.

I try to do what else I can to make him comfortable and improve his potential outcome, though it’s not much.

I order an electrophysiology study and a catheter ablation procedure to try to reduce the severity of the disease, if only for a short while. It doesn’t seem to work, of course: new arrhythmogenic foci seem to crop up within weeks of the procedure, rendering that effort null and void.

I order an exercise stress test, and the results come back dismal. He seems to accept the results quickly, however; probably, because they merely reinforced our initial recommendation of exercise restriction.

I try to find a crack in this disease, something we can exploit to treat it maybe just a bit more effectively, something to use to try and claw out just one or two more years of expected lifetime.

Eventually, I come up empty, and my energies are shifted elsewhere. There are others, I realize, who could better use my help.

There’s nothing more I can do, here. For the most part, I move on.



[ Discharge ]

But, every day I am here, I must make rounds, and I see him, if only for fifteen short minutes. We sit in near-silence, I go over what’s changed in his medications and ask if he’s feeling anything new. Nothing has, so he shakes his head and I leave.

During my short lunch break, however, I overhear parts of a conversation between two of my colleagues from Neurology. I hear something about a school—I catch the name Yamaku Academy—and I’m intrigued, so I walk over and ask about it.

It’s a school for the disabled, offering a top-notch education and a ‘crack medical team’; apparently, one of our own internal medicine residents transferred there to work as a head nurse after finishing his residency, two years ago. I end up writing down some basic contact info for it.

--

Hisao’s out-of-hospital continuing care plans pose some difficulties. I think it’s in his best interest if we get him out the door as soon as possible, of course. But how?

His medications need to be monitored, adverse effects need to be watched for, his lifestyle change must be enforced, and someone needs to be there if worst comes to worst.
Otherwise, all of this would have been pointless.

A public high school probably isn’t the best place for him to recover, in light of this. Monitoring is nonexistent, complications could arise from the pacemaker, and if another cardiac episode occurs at school, the chances of him surviving are slim.

I pull a piece of paper from my pocket. There’s a name, a web address, and a phone number on it.

--

I make some inquiries and do some research on Yamaku; as it turns out, they’re fully equipped to do intensive outpatient monitoring. This isn’t the first kid with major internal disease they’ve seen, and it certainly won’t be the last.

After a short discussion on the phone, they send over a few transfer forms for Hisao.

--

I wrap up my explanation and introduction to Yamaku fairly succinctly.

“… and that’s why I recommend we transfer your son to Yamaku Academy for the remainder of the school year.”

Hisao’s parents seem fairly impressed by the school, and their curiosity seems to overtake their worry about their son, for a moment.

The father speaks up though, after a minute’s silence.

“Wouldn’t this be hard on him, though? What about his friends at school, and that girl who used to visit him a lot?”

I glance to the conference room door, as if I could look down the hallway, to room 352 and its isolated inhabitant. I sigh, and collect my thoughts.

“… You know your son better than I do, and you’re right to be worried. But, as his assigned physician and as the person who has been overseeing his care for the last three months… well, to be frank, I’m not sure he has those friends anymore, and I’m worried about how he’d resume life at his previous school.”

They’re confused, understandably. How long has it since they’ve been around, again?

“No one comes around to see his room anymore. Even the high-dependency unit nurses seem to have picked up on this.
“And, although I’m not a psychiatrist or any kind of mental health professional… the way he’s reacting to this does not seem healthy. Nor does it seem conducive to patching things up with his former friends.”

They don’t look confused, anymore; instead, they seem guilty. Haunted, perhaps. They must have noticed something was off, but maybe they didn’t know he was this isolated?

Given how Hisao reacted when his friends were coming around to visit, I suspect that he’d merely attempt to avoid the subject—or possibly even them altogether—for the rest of the year. Or possibly take his bottled-up resent out on them. Or simply mope for the entire year and remain a loner. Or be ostracized by the rest of his class as a ‘cripple’.

All told, his prospects at his previous school do not look good.

Hisao’s parents mull over their choices for a few silent minutes. They briefly glance at each other, after which the mother speaks up.

“Thank you, Dr. Nakamura. I think we’ll have to go and take a look at this Yamaku Academy for ourselves, though, before we make a decision.”

I nod, we all stand, and I shake their hands.

“Understandable. In any event, when you’ve reached your decision, you can simply contact me and schedule another meeting; we can settle any needed paperwork and follow-up then. It’s been nice meeting you.”

--

In the end, Hisao’s parents decide to transfer their son to Yamaku, as per my recommendation.

The paperwork takes a few days to get sorted out, but finally, Hisao’s transfer is finalized.

I hope I got the orders and recommendations section correct in his Yamaku medical file; I marked off ‘Sports’ and ‘Phys. Ed. Classes’ under restrictions, but since I didn’t want to completely limit his options, I left ‘Other Physical Activities’ unrestricted.
I sincerely hope that’s not interpreted to mean that he can start an exercise regimen, or something.

The rest of the forms were easier to fill out, and there’s only a few other notes I had to add:

“PT must avoid physical shock to chest area to avoid pacemaker lead complications.”

“Acquired LQTS and electrical instability of heart muscles may make PT highly susceptible to commotio cordis—again, physical shock to the chest must be avoided to prevent induction of ventricular tachycardia or ventricular fibrillation.”

“Medications may have unforeseen side effects in out-of-hospital environment; please report these to hospital physicians at once.”

“Regular checkups should be conducted to assess heart function and electrical characteristics; please record at least an ECG. If possible, an echocardiogram with ventricular ejection fraction measurement should also be recorded. Please report any changes to us as soon as possible.”



[ Bundle of Hisao ]

With all the paperwork complete and all the preparations made, there’s not much more to do, except observe Hisao’s condition and wait as his scheduled discharge draws ever nearer.

It comes, right as he crosses the four-month hospitalization mark.

--

He’s set to be discharged in the morning; it, of course, just coincidentally seems to be scheduled at the tail end of a 30-hour shift. I’m much more used to it, after four months, but even still I’m sure there’s some tiredness showing on my face.

His parents show up a few minutes before the scheduled time. They’re somewhat dressed up, as if we were going to hold a celebration in Hisao’s room. The thought’s laughable.
The walk to Hisao’s room is short and silent, as always. When we get there, I tuck my patient files underneath my arm and take a breath. I put a weak smile on my face, mostly to mask my fatigue, and step into the room.

His parents fan out, and take their usual positions by Hisao’s side.

I prepare to give him the news, but quickly realize that I need to pull something out of his file, first. I end up spending a bit of time rifling through and sorting the files in my hands. I move the required paper—Hisao’s prescription—up to the top of the stack, set it aside, and sit down on the bed to give Hisao the news.

I look him in the eyes for a moment, and wonder how to start.

--

“Hello, Hisao. How are you today?”

I don’t answer him but I smile a little, back at him.

“I believe that you can go home; your heart is stable now, and with some precautions, you should be fine…”

--

In the end, there’s a young man. The steady fire of life is all but extinguished in his damaged heart, fear and dashed hopes fill his mind, and his eyes look out onto an uncertain future.

And still, he wants to live, once again.

And with that uncertainty, he steps into the sunlight, towards the gates of a school in spring.

[ End of Act 0 ]

Deterioration - Epilogue and Notes

Posted: Fri Jun 30, 2017 3:11 am
by Visionary
[ Epilogue: Survival ]

It’s been twelve years since my first heart attack.

I’m back in my home city with my wife, visiting my parents. It’s a long weekend, for both me and my students at Yamaku.

It’s a cold February morning, and everywhere I look, stark white snow covers everything: the streets, the cars, the shop awnings and fixtures, the naked trees planted here and there.

A gust of chill wind catches us, and by my wife’s request, we go into a nearby café.

The inside of the building is nice and warm, and my wife immediately and deftly seeks out a free table, leaving me to line up and order for the both of us. The line’s fairly long, and I grimace as I realize I’m going to be here for a while.

My eyes are drawn to the man in front of me. He’s wearing a familiar set of scrubs; Tokyo University Hospital ones, if I’m remembering correctly. That brings back unpleasant memories.
Actually, upon closer inspection, I notice that there’s more that’s familiar about the man than his scrubs. He seems to notice me staring at the back of his head, however, and turns around.

“Ah, I’m sorry, do you need some… thing…” Dr. Nakamura asks, the words fading away in disbelief.

We both stare at each other.

...

For the longest time, he was the face of the unpleasant memories from my hospitalization. He’d represented everything I’d come to resent about hospitals: the sterile, fake interactions, the hopelessness and the stagnation, everything.

But as the years went on, my thoughts on him, and hospitals in general, have mellowed. He’s just a man doing a job; he doesn’t deserve all that extra weight and connotation attached to him.

I try to restart the conversation, but he beats me to it.

“So, how’s… uh, how’s life going for you, Hisao?” he asks, and I follow along in a heartbeat.

“Pretty good, actually. I got a teaching job at Yamaku Academy.”

He blinks in surprise, as if he wasn’t expecting me to actually say something.

“Oh… congratulations on that. How are you holding up, health-wise?”

“I’ve had a couple of problems, here and there, but I’ve been mostly fine so far,” I reply, before turning the questions back on him. “How about you, though? How’s life going for you?”

He smiles, and I can tell it’s genuine by its warmth.

“Pretty good. I finished my fellowship a few years back, and I’m teaching at Tokyo University Hospital now, as an attending.”

The thought comes to us both at the same time, and we both blurt it out to each other.

“What subject are you teaching in?”

We’re shocked into silence for a second, but I recover and answer first.

“Well, for me… science. Physics, to be specific; I’ve always had a head for the subject, I think, and… I guess I took inspiration from someone in my life.”

He chuckles a bit.

“Funny how that works, huh?”

He’s silent for a bit, but continues.

“…I actually went into Cardiology. I’m a bit like you, I suppose. I always was good at science and biology and… to be honest, I took inspiration from you,” he finishes, shocking me. He continues on before I can say anything.
“You know, you were the first patient ever assigned to me. It was my… second day there, I think. First shift, technically… but we worked long shifts. Anyway, I was about to fall over at any second due to exhaustion, and then they brought you into the ICU, and my administrator basically went, ‘yep, he’s yours, good luck’ and that was it.”

He sighs, and I can sense a tinge of melancholy in it.

“And then the next four months happened… you know how that went,” he says, leaving those memories untouched for the both of us.
“And by the end of it, I realized what I wanted to specialize in. I think… I wanted to do better by you, in a way. I wanted to make up, somehow, for screwing your case up as badly as we did. For damaging your heart even more.”

I’m left speechless. During my entire stay there, through that entire four months… he really cared. And even after I left, he still felt guilty enough to try and make amends by proxy. That’s…

“Thanks,” is all I manage to say.

We’re silent for a long while as we shuffle slowly to the ordering counter.

“Um, do you mind if I ask a favor of you?” he starts suddenly.

“Not really, go ahead?”

He seems to be thinking over something, with his hand on his chin in concentration.

“Well, you see… there’s been a recent admission to the ICU. Young girl, about sixteen years old, in second year high school,” he explains.
“She seems to have inherited a particularly severe form of congenital long QT syndrome, leaving her susceptible to episodes of torsades de pointes and cardiac arrest. And, unfortunately, her immune system seems to react aggressively to the presence of implantable cardioverter-defibrillators, removing those as an option.
“We’re looking to send her to Yamaku for post-discharge continuing care, but I’m afraid that won’t be for a long while,” he further clarifies.

This description is starting to sound very familiar.

“All of her visitors have stopped coming, at this point. She just sits there and watches TV, all day… do you think you could try and reach out to her?”

I smile, in spite of the story.

“Of course. When do you want me to come up?”

“I’m thinking every two weeks or so, if that works with your schedule. I know it’s a bit frequent and the trip is long and you have a job, but…”

I cut him off.

“I can work with that. Actually, I think I can go a bit more often; it’s only an hour or two going either way, right?”

How could I say no?

[ End of Story ]




Notes for the curious:

There’s four main physical conditions I’m having Hisao juggle, here. They’re all quite serious, if treatable, in their own right, but together they’re a potent and lethal combination. I included my sources for everything about each condition (mostly so no one yells at me for giving Hisao ALL THE HEART CONDITIONS while thinking it’s unrealistic).

--

Arrhythmogenic Right Ventricular Cardiomyopathy, type 5, with additional ventricular septum involvement: this is an inherited condition affecting the connections between the muscle fibers in the heart. In affected people, these connections become weaker than normal, and over time this leads to gradual replacement of the muscles in the heart with fat or scar tissue, due to the regular physical stress and strain placed on the heart.

This sets the stage for reentrant circuits to form, particularly within the ventricles (the largest and most strained muscles in the heart), leading to very frequent occurrences of ventricular tachyarrhythmias (V-tach, V-fib, etc.) and sudden cardiac death.

In addition, because heart muscle cells aren’t replaced, the gradual replacement described earlier also leads to a progressive weakening of heart function; ultimately, this leads to outright failure of the right ventricle to pump effectively, followed by similar failure of the left ventricle and thus, complete heart failure.

Strenuous physical activities or endurance-based (aerobic) exercises have been linked to faster progression of the disease in symptomatic patients, and increased chance of symptom expression in previously asymptomatic patients. This seems to be caused by the greater stresses these exercises place on the heart: as the heart beats faster, the blood flowing through it stretches and strains the heart muscle fibers even more, causing cell degeneration and replacement to happen faster. Thus, all of the symptoms happen faster, or earlier.

There are at least a dozen different variants of ARVC, each associated with a different genetic mutation. ARVC type 5 (or simply ARVC5) is linked to a point mutation in a gene labeled TMEM43 (TransMEMbrane protein 43). It seems to be particularly lethal compared to the other variants, and unfortunately, it seems to be both autosomal-dominant, and 100% penetrant: if you have even one copy of the gene, you will have the disease at some point.

This means that any child Hisao fathers has a 50% chance of inheriting the condition. This also means that one of Hisao’s parents must also have the disease-- it’s made quite obvious who has it, in-story. As an aside, this could make for interesting plot threads to continue...

The ventricular septum is usually spared by this disease, though I opted to target it too, mostly to pave the way for further complications and difficulty in treatment.

Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3667685/ - "Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC/D): A Systematic Literature Review"
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4278158/- "Arrhythmogenic right ventricular cardiomyopathy: From genetics to diagnostic and therapeutic challenges"
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2427209/ - "Arrhythmogenic Right Ventricular Cardiomyopathy Type 5 Is a Fully Penetrant, Lethal Arrhythmic Disorder Caused by a Missense Mutation in the TMEM43 Gene"
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809992/ - "Exercise Increases Age-Related Penetrance and Arrhythmic Risk in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy Associated Desmosomal Mutation Carriers"
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3133766/ - "The Impact of Implantable Cardioverter-Defibrillator Therapy on Survival in Autosomal-Dominant Arrhythmogenic Right Ventricular Cardiomyopathy (ARVD5)"
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4521905/ - "Treatment of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia: An International Task Force Consensus Statement"

--

Mobitz II Second-Degree Atrioventricular Block, secondary to failed ICD implantation and ventricular septum injury. The bundle of His, which transmits electrical signals from the atria (upper chambers of the heart) to the ventricles (lower chambers) has become damaged, and now it intermittently ‘drops’ electrical impulses as they travel across it; as a result, the ventricles (which are the primary drivers of cardiac output) occasionally no longer contract, leading to “missed beats” by the heart.

Though this condition is often symptomatic, it usually isn’t lethal. However, it can rapidly progress to a third-degree, or complete, AV block, which can lead to hemodynamic instability, cardiac arrest, and sudden cardiac death. Thus, it’s usually treated with an implanted, permanent pacemaker.

In the end, this doesn’t really affect Hisao that much; it does, however, force him and his doctors to make a choice: defibrillator or pacemaker? It’s a sadistic choice, in the end: he needs both to have any hope at enjoying a full lifespan. It’s also a secondary reason for Hisao to avoid physical shock to the chest (to avoid the pacemaker leads from suddenly popping out of the thinned heart muscles).

Sources:

https://lifeinthefastlane.com/ecg-library/basics/mobitz-2/
http://emedicine.medscape.com/article/161919-treatment

--

Acquired Long QT Syndrome, secondary to treatment with sotalol and amiodarone. This is the commonly-accepted (if somewhat flawed) fan explanation for Hisao’s arrhythmia from canon, and can manifest both due to genetics and due to medications; sotalol and amiodarone are both well known for having QT interval prolongation as a side effect.

This condition serves as the primary reason for Hisao to avoid physical chest shocks; for those curious, this is because the prolongation of the QT interval, combined with an already electrically-unstable heart, could potentially make him more vulnerable to commotio cordis (Latin for “agitation of the heart”), where a physical shock to the heart during the upslope of the T-wave can induce ventricular fibrillation.

Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767957/ - “Drug induced QT prolongation and torsades de pointes”

--

Chronic pain, secondary to an emergency thoracotomy. Thoracotomies are surgical incisions into the chest, and in Hisao’s case I suspect he had an anterolateral sternotomy, a median sternotomy, or possibly both; the former cut is made into the side of the chest (usually the left) and is usually done during a traumatic cardiac arrest (to relieve Hisao’s cardiac tamponade and to quickly repair the hole in his ventricle). The latter cut is simply a large incision made straight down middle of the chest and into the sternum, from the collarbone downwards to the end of the sternum; it’s the incision of choice for most open-heart surgeries (for example, the one needed to repair the ventricular septal defect from the failed ICD implantation).

Unfortunately for Hisao, thoracotomies are one of the most painful surgeries to undergo; the residual pain from a sternotomy is extreme enough to often prevent patients from breathing effectively in the post-operative period. Furthermore, the pain sometimes becomes chronic, lasting for months to years, if not for the person’s entire lifetime.

Thus, I imagine one or more of Hisao’s many medications includes medications to deal with the post-operative pain.

Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2453516/ - “Post-thoracotomy Pain Management Problems”

--

Note that this list only includes physical stuff that Hisao has; I’m sure you could make a case for him having some kind of depression during his hospital stay, but I haven’t done enough research into that to make the call.

Re: Visionary's Writing - Act 0: Deterioration (Latest 6/30)

Posted: Fri Jun 30, 2017 10:40 am
by Mirage_GSM
Okay, most of that is WAY beyond my paygrade, but most of it at least sounds legit :-)

As for things that stuck out to me:
- One thing the VN never claimed Hisao's condition to be was "progressive". In fact it's explicitly stated that it isn't.
- Performing heart surgery while the patient is awake is something I've never heard of before.
“Oh shit, I think the stylet just tore his septum wide open.”
And I think stuff like THIS is why it isn't done. :lol:
- Hisao doesn't have a permanent pacemaker.
I could get a candlelit table, then probably burn to death as I realize that the room air is ninety percent oxygen or something.
I suppose that's just Hisao not knowing what he's talking about...
“Er—we’d knew he’d undergone a second procedure, but… we’re not sure how that went. Someone tried to explain it to us, but…”
About a week(?) after the procedure and nobody told his parents???
“both of you may want to get screened for this disease as well. Even if neither of you are showing symptoms, at least one of you must have the disease.
If what he said earlier is correct, the disease would have shown itself long ago in either of them considering their age, so it's pretty certain neither of them has it; one of them just carries the recessive gene.
my dad, ... who now has a strange-looking lump in his chest, underneath the collarbone.
Unlikely for reasons stated above.
I hope I got the orders and recommendations section correct in his Yamaku medical file; I marked off ‘Sports’ and ‘Phys. Ed. Classes’ under restrictions, but since I didn’t want to completely limit his options, I left ‘Other Physical Activities’ unrestricted. I sincerely hope that’s not interpreted to mean that he can start an exercise regimen, or something.
Well, obviously Nurse is pushing Hisao to excercise in the VN, and I hope you did not intend to imply that he did that because of an ambiguously placed X on some form without reading the rest of his file - because it would be completely out of character for him.
This is the commonly-accepted (if somewhat flawed) fan explanation for Hisao’s arrhythmia from canon,
Leaving aside that "fan explanation" and "canon" are mutually exclusive, this is actually the confirmed type of arrythmia Hisao has, according to the developers.

So, all in all I think you made Hisao quite a bit MORE ill than he actually is in the VN. Might have been better not to overdo it so much.

Nice touch on the Epilogue - that is actually a story that would be interesting to read as well.

Re: Visionary's Writing - Act 0: Deterioration (Latest 6/30)

Posted: Fri Jun 30, 2017 12:42 pm
by Visionary
Mirage_GSM wrote: As for things that stuck out to me:
- One thing the VN never claimed Hisao's condition to be was "progressive". In fact it's explicitly stated that it isn't.
- Performing heart surgery while the patient is awake is something I've never heard of before.
First off: thanks for the detailed critique! Your concerns touch on a lot of things I was concerned about myself, with regards to this story.

- Yeah, the first concern is something I was afraid of; but with heart conditions lifespan seems extremely binary-- everything is either completely fine and the condition would never come up, or the condition is lethal within years.
- Cardiac catheterization procedures (such as ICD implantation) really aren't surgery, per se, and since they're minimally invasive they don't have to knock you out completely-- they may administer medications to numb the catheter insertion area and calm the patient slightly, but general anesthesia is kind of overkill for these procedures.

Really, what should have happened with that first procedure is: catheter with lead wires goes in, the physician in the cath lab places the leads into his right ventricle, Hisao thinks over things for a few hours, then they slip the rest of the ICD under his skin, and then sew up the small holes they made...
And I think stuff like THIS is why it isn't done. :lol:
...But of course, nothing is ever that simple.
- Hisao doesn't have a permanent pacemaker.
I always figured that pacemakers were just one of those things that you quickly learned to not notice in your everyday life (like glasses), so maybe it never comes up in the main story?
...well, except for Lilly's good end; don't they stick a pacemaker in him, then? Whoops.
I suppose that's just Hisao not knowing what he's talking about...
Hisao doesn't seem to know much about medicine in general (case in point: "yep, it's 'arrhythmia', dunno what kind, it's all a soup of words to me").
As a side note, I'm fairly certain I thought this way for some time in real life: it wasn't in a hospital, and the exact details elude me, but a friend of mine had a sister who was on a ventilator (I think?) after an accident, and the entrance to her room had one of those 'no smoking -- oxygen equipment in room' signs; for a while I thought that anyone who tried smoking in the room would instantaneously set the whole room ablaze (because even as a kid I knew fire + oxygen = more fire).
That was years and years ago, though.
About a week(?) after the procedure and nobody told his parents???
Yeah, you got me there-- I had to find some way to reveal what happened with that procedure, but In retrospect that might not have been the best way to do it.
Personally, I imagined it as: someone (maybe the cardiologist) tried to explain it to his parents, but they didn't understand it for whatever reason, and now they're asking for a repeat of the same information.
If what he said earlier is correct, the disease would have shown itself long ago in either of them considering their age, so it's pretty certain neither of them has it; one of them just carries the recessive gene.
my dad, ... who now has a strange-looking lump in his chest, underneath the collarbone.
Unlikely for reasons stated above.
The exact condition that Hisao's inherited from his parents has a very long asymptomatic course.
The median age at which symptoms tend to manifest is actually around 30 years old, IIRC; but it has been known to manifest sooner, during adolescence (usually in athletes).
Also, ARVC is an autosomal dominant trait.
I hope I got the orders and recommendations section correct in his Yamaku medical file; I marked off ‘Sports’ and ‘Phys. Ed. Classes’ under restrictions, but since I didn’t want to completely limit his options, I left ‘Other Physical Activities’ unrestricted. I sincerely hope that’s not interpreted to mean that he can start an exercise regimen, or something.
Well, obviously Nurse is pushing Hisao to excercise in the VN, and I hope you did not intend to imply that he did that because of an ambiguously placed X on some form without reading the rest of his file - because it would be completely out of character for him.
Aaaaand this is one big discrepancy I couldn't really find a way to resolve too well. Personally, though, I'd see it as less OOC for the Nurse and more a communications screwup on Dr. Nakamura's part; maybe he sort of expected the nurse to magically know about this rare disease that was way out of either of their specialties, and expected him to know the full intricacies about the disease?

To be fair, however, I didn't realize just how important exercise restriction was until I really started digging deep into the research so I could write the latter segments. And by then, I'd already written around half of the story, so I decided to just try and handwave it away and continue with the rest of the story.
Leaving aside that "fan explanation" and "canon" are mutually exclusive, this is actually the confirmed type of arrythmia Hisao has, according to the developers.
The course of treatment Hisao ends up on in KS doesn't seem to fit with LQTS. If he'd actually had just that as his condition, his doctors would have just stuck an ICD in him, put him on a regimen of maybe 2-3 medications, and let him go back to his normal life: in other words, what Dr. Nakamura was telling Hisao prior to his first procedure.

It's stuff like this, however, that made me write this story in the first place: I wasn't satisfied with LQTS as the explanation and wanted to find my own explanations.
So, all in all I think you made Hisao quite a bit MORE ill than he actually is in the VN. Might have been better not to overdo it so much.
Yeah, trying to find the right mix of conditions to replicate what we see in story was difficult, and this was the other major discrepancy I noted. Strictly speaking, though, there aren't many 'outward signs' of his disease-- except for the whole 'frequent cardiac arrest' thing, and the looming threat of heart failure in 20 years or so.
And if I'm remembering details correctly from the Shizune route good end, I believe that Hisao thinks that he doesn't have long to live anyways-- which would totally fit with the expected progression of this disease.
Nice touch on the Epilogue - that is actually a story that would be interesting to read as well.
Thanks! I wanted to go with a nice, introspective, and dare I say happy end to Deterioration.

If I tried expanding on the epilogue, though, it'd probably end up reading like a genderswapped version of either this story or KS as a whole, with less introspection and brooding from the main character.
EDIT: ...on second thought, maybe not, actually-- I might just go ahead with this...

Re: Visionary's Writing - Act 0: Deterioration (Latest 6/30)

Posted: Sat Jul 01, 2017 9:42 am
by Mirage_GSM
...well, except for Lilly's good end; don't they stick a pacemaker in him, then? Whoops.
Exactly what I was referring to.
maybe he sort of expected the nurse to magically know about this rare disease that was way out of either of their specialties, and expected him to know the full intricacies about the disease?
Nurse probably didn't but in this case it would still be HIS screwup for not reading the rest of the file or calling back to the doctors for more details. In fact in your story Nakamura personally called Yamaku and discussed HIsao's case with them before even suggesting it to his parents. One would assume that he talked to the head nurse on that occasion.
And if I'm remembering details correctly from the Shizune route good end, I believe that Hisao thinks that he doesn't have long to live anyways-- which would totally fit with the expected progression of this disease.
I tend to put that down to pessimism on his part - or the very real risk of dying prematurely due to an accident. (Not quite certain what the exact circumstances of that quote were)
If I tried expanding on the epilogue, though, it'd probably end up reading like a genderswapped version of either this story or KS as a whole, with less introspection and brooding from the main character.
If you do, I suggest not going quite as heavy on the medical jargon. The interesting bit in that story would be more the personal interaction between Hisao and the girl.
The course of treatment Hisao ends up on in KS doesn't seem to fit with LQTS.If he'd actually had just that as his condition, his doctors would have just stuck an ICD in him, put him on a regimen of maybe 2-3 medications and let him go back to his normal life...
You'd have to ask Silentcook for details on this, but I can think of two possible explanations for this:
a) The story is set ten years ago, and the procedure might not have been as common back then. In fact it seems the first implanted ICD was used in a dog in 2003...
b) Artistic license. Letting him go back to his normal life would have made for a pretty boring story :-)

Everything, Nothing, Red, and Green

Posted: Thu Jul 06, 2017 3:18 am
by Visionary
I wrote a little thing about Rin.

--

[ Everything, Nothing, Red, and Green ]

--

Listen:
Rin Tezuka has become unstuck in thought.

--

There’s a mural. It’s white, and red, and the color of the sea, and the color of thought, and the color of that feeling you get when you wake up and have no idea where you are and you’re confused. It has the texture of uncaringness, the form and shape of exhaustion, and the taste of a long night.

In short, it’s black. Or grey. Or maybe purple.

--

There’s also a boy. His hair’s like grass, he’s got a sheep on in summer, and his face is like an empty horizon. He’s sitting there, staring at walls. His eyes glaze over, like the inside isn’t talking to the outside, and like the outside’s holding down the fort while the inside sorts its shit together. Sorting shit seems like a boring pastime, to Rin. Shit is all brown and lumpy. Or is it brown and smooth, like worms?

Or are those tapeworms? Shit with tapeworms?

But sometimes if things go bad there’s also red. And blood. And maybe intestine? Sometimes it’s also black and lumpy and coal-like.
Also, there’s diarrhea.

So, there’s six categories: Shit that is brown and lumpy, shit that is brown and smooth, shit that is tapewormy, shit that is red and bloody, shit that is black and lumpy, shit that is watery like diarrhea, and shit that is blobby.

Make that seven categories.

She paints a sausage-like shape. It’s black and red and brown and pale.

--

She hops onto another train. This one tastes like the color purple again. Or was it grey?

It seems to be heading towards the world’s end. She wonders what that would look like. It seems like it would be the color red, or orange. Like the sun.
No, wait, the sun is white. So it was all of them, or really none of them. It was everything, nothing, and orange. And red.

A tuft of hair drops down onto her face. It is red, but it isn’t everything, or nothing. Her hair exists, and she supposes it would keep existing for a while longer. Until it fell off, stopped existing, and was replaced with something that existed again.

--

There’s a spot of white. There’s actually a lot of spots of white, but this one is important. It doesn’t fit. Well, it fits with the now, but it doesn’t fit with the station.
There’s a lot of other trains in the station now. It’s annoying because you have to clean them and secure them and get all the people off and then all hope is lost because there’s no time for that.

Trains are annoying. They’re there, though, and because of that Rin must do what conductors do. Whatever it is they do, in any case. Rin knows that she does not know music or train-conducting art or train-driving art. She merely does visual art.

That still leaves the matter of color, though. She asks for directions to the station. Fortunately, there’s a boy with a sheep and an empty horizon on hand to help.

“Is green a good color to add?”

--

The taste of a long night is unpleasant. It’s also hard to get out of your mouth. But Rin perseveres and preserves. She jams metaphorically, and spreads literally.

Now, she’s a tree. Or a gargoyle. Or a lamp.
She prefers the latter. They’re light and heat and warmth and nice. The wall is nice, too. Or at the very least, it’s comfortable to lean against. Or comfortable to be exhausted against. It gets the long-night-taste out, is what she means.

A boy walks up to her. He’s green and has an empty horizon and is actually surprisingly good at conducting.

“How’s it going?” he asks.

The train isn’t really going anywhere. It simply is. And then sometimes it isn’t, and then it’s replaced with another train. And then it is again.

That must not be what he’s asking about, though. Rin Tezuka isn’t going anywhere, either.

Her legs feel like lemon juice. Or orange juice. Or car battery juice. It’s not a pleasant feeling, in any case. They’re not going anywhere. And neither is Rin Tezuka.

--

Rin Tezuka is moving now, and it’s snowing sideways.

There’s a hill, and flowers, and a nice afternoon sky. It’s blue and purple and white and dark and light and everything at once. Or not-everything at once. The horizon stretches on forever, but it doesn’t seem to stretch onto Hisao’s face. Even though he’s staring at it.

It’s still snowing. It’s still also sideways. It’s like clattering and chill and warmth and kindling. It’s also like beginnings and endings and everything in between. It’s like anticipation of a new lover’s arrival. The.
On that thought, she looks at Hisao. She would just read the instructions, but Rin seems to have misplaced them. Or the instructions misplaced her.

The train leaves its station, and Rin opens her mouth to let it through.

“Hisao.”

“What is it?”

“Do you love me?”

He looks like an electric shock, or a telephone pole.

“I don’t know. Maybe I do.”

Rin wonders what that means, and her thoughts wander off and become speech, becoming steam and smoke and clouds and her voice in the wind.

“What does that mean?”

“…I don’t know,” Hisao replies.

--

Well, actually, the train seems to have entered the station again. Or the barge. Or the rocket. Or everything maybe? The train-rocket-barge. She closes her eyes, lets it be refurbished and cleaned and sorted.

Of course, she (still?) loves him.

She opens her eyes, and for once, merely says the words. And they really are words, and they’re clear, this time.

“I love you.”

There was an odd taste in her stomach. Like a rope, or a piece of string. Tied, wrapped, twisted and knotted. It’s the taste of sleepless nights and rainy days and pure exhaustion. The taste of cold, of confusion, and of distance, dreams, disconnects, all mished and mashed and mushed.

There’s still an odd taste in her stomach. But it’s also in her head, and it feels like… like it’s gone but at the same time it isn’t. It also tastes sweet, and salty, like tears and tea and sugar and pure time. It tastes like the horizon, or like a clock. Like disconnected dreams of distance turned into clouds of steam and smoke.

“I… don’t think there is a word for this,” Rin says, the words still clear to her and to Hisao.

There are questions still burning a hole in her mind’s pocket, however, so she takes them out, and asks for change.

--

There’s a lot of other questions involved. There’s also a lot of change involved.

But at the same time, Rin doesn’t really think it matters. They can just watch the clouds, while they figure it out.

She stands on a rock, tries to reach the sky, and looks to the horizon. It’s not empty, anymore.

“I have decided something,” she says, to the once-empty horizon, and to Hisao, who once carried it.

“It’s all right to be me after all.”

She opens her arms out wide, tries to catch the sideways snow, embraces the vast and form-filled horizon. It’s filled with time and light and warmth and ideas and trains and words and people. Or, more importantly, a person.

Rin Tezuka turns, and looks at said person.

“Hisao?”

“What is it?”

“What’s the word for when it feels inside your heart that everything in the world is all right?”