The Eternal Providence

The eternal providence has appointed me to watch over the life and health of Thy creatures. – The Oath of Maimonides

Science doesn’t depend on hope.

Just once, I wished for a patron who understood that on arrival.

This next admission would make seven, and it wasn’t even midnight. I scanned the patron’s wristband to match him in the algorithm, and spouted the standard greeting for what would not yet be the last of the night before I laid eyes on my call room bed. “Welcome to PRIME, the center for Prognostic Intelligent Medicine.”

His gaze darted around the room as if expecting someone else. The golden light that streamed from the ceiling highlighted his ashen complexion. He blinked up at me. His voice raspy, like the tremor of an uncalibrated centrifuge, a warning of something wrong beneath the surface. “Where’s the doctor?”

My smile lost its politeness. “I’m Dr. Kestrel.”

His dentures slipped, and a clicking of the loose appliance accompanied each word. “Sweetheart, I don’t think I belong here. One minute I’m going in for routine results, the next they say I’ve got lung cancer, only it’s my lucky day—I’m a responder.” He squinted at my name badge. “I think I’ll leave and come back later. That okay, Hope?”

I clenched my jaw. “Dr. Kestrel.”

He winked. “I must be a lucky guy, to get a doc named Hope.”

I held my hands behind my back, squeezing one wrist tight to keep my voice neutral. “We have the best artificial intelligence medical algorithm in the world. You don’t need to worry about hope here.”

Hope promises you everything but gets you nothing. I’d learned that lesson eighteen years ago. Even a kid of eleven had grasped it. We needed something better than hope. And now we had it.

But sometimes, I almost thought the technology wasted on those who couldn’t understand it.

He mopped at the beads of sweat assembled on his lip and forehead, and continued to babble. “Hot enough out there for you, isn’t it Doc? I’m telling you, I can’t remember a Seattle summer as dry as this. And I was born here.”

He scratched at his chin, his fingertips broad and flat. Clubbed fingers, a telltale sign of chronic low oxygen. His eyes followed mine and he balled his hands at his sides. “You going to examine me or something?”

The stale odor of tobacco emanated off his clothing. Deep lines encompassed his mouth and eyes, rendering him a decade older than his actual age of—I flicked my eyes down to my smartpad—sixty-one. On the panel behind him, the PRIME motto scrolled on the digital display: We Optimize so You can Flourish.

I activated the standard admitting protocol. We did everything from our PRIME-patented smartpads—orders, charts, images, labs—all at our fingertips. Our scrubs designed so we could dock the tablets for easy access.

I flicked my eyes back up. “One, we have perfect climate control, two, it’s September twenty-third today, and three, no.”

 “No? No, what?” His expression clouded. “And what’s the date got to do with anything?”

“No, I’m not going to examine you.”

I rotated away from him and swiped my palm over the wall panel, changing the mode to transparent. “The algorithm’s already analyzed your data. There’s no need for a crude physical exam.”

I ignored his other question and appraised the activity of the unit on view through the now crystal-clear wall partition.

OASIS, the Oncologic and Surgical Intervention Success Unit.

The other residents, in their fitted, moon-white scrubs, gleamed like stars amid the sunset-orange of the nurses and the midnight-blue of the techs. A mini-universe of medicine, components orbiting and intersecting in precise harmony, steered by a force unseen.

The algorithm.

A world that didn’t depend on something as nebulous as hope.

The patron behind me, now designated #2022-571, had nothing to be worried about. As soon as the algorithm tagged a patient as a responder and eligible for curative treatment, that patient became a patron. And before a patron even stepped through the door at PRIME, the machine-learner algorithm had delivered a therapeutic assignment.

I rotated my view back to #571. We residents tended to drop the first four numbers, which designated the year of admission, and use only the last three digits to refer to them.

At least, among ourselves.

I fixed him in a hard stare. “PRIME diagnosed you at an early stage. You’re a candidate for optimal treatment. So, if I were you, I’d stay.”

“Don’t I get a choice?”

“Of course.” My smile turned brittle. “Stay here and get treated.” I waved a hand in dismissal. “Or leave and die.”

Of course, no one ever chose to leave.

His hands plucked at the sheets and he cast an uneasy glance around the room. “You’re not like any doctor I’ve ever met.”

The door opened before he finished speaking, and Abbie Fuentes, charge nurse, breezed in. Her brisk movements belied her age which I guessed nearing sixty. Her dark straight hair pulled back in her usual low braid. Her features warm but overlaid with a no-nonsense air which made all the patrons—and residents, if I was honest—quick to follow her instructions. “That’s right, Mr. Greenwood. Dr. Kestrel’s our High Resident. Don’t let her scary looks fool you.”

He glanced from her to me and rubbed at his chin again.

“She is kind of scary—” He held up his hands and his voice sped up. “But nice-looking. I mean…hell, to us old guys, the docs here all look like kids.”

His cheeks reddened and he cast sidelong glances at the transparent wall view. The comment managed to come off rather sweet. It almost made me forgive him his ignorance.

Abbie reviewed his biometrics. “Careful, her head’s big enough already. Doctors, you know.”

She waggled her eyebrows at me, but I didn’t miss the edge that sharpened her voice. It didn’t matter what the nurses thought of me. I didn’t need them. I was here for one reason. To be the best of the best. Part of the solution. The fix.

An alert on my screen distracted me — a missed call from Peter. I frowned. The second one this week.

A text followed. Hey, Hopeless. Call me.

The old nickname made me blink. A prickle passed over my scalp, and a short sigh escaped my lips. I had a wearisome night of admissions ahead of me. Duty came first, I’d have to call him back later. My chest tightened. He’d understand. He always did.

I closed my eyes and took a slow breath.

When I opened them, I saw the patron still had a look of terror in his. I supposed I should say something to settle him down, but I didn’t have the words. Words never worked anyway. My mind flashed back to Peter. Why was he calling now? I let out a bigger sigh. His timing always was impeccable.

I swiped my hand over the control panel and changed the wall surface back to opaque. The view of the unit disappeared and multiple flatscreen monitors materialized in its place. The room lighting dimmed.

“Here.” I gave a grudging point to the screens. “We’ll be monitoring all your biometric data—so you’re always safe. And this—” I used my finger and thumb on the touchscreen to magnify the images of the tumor in his left lung. “— is why you’re here.”

He peered down at his body. Shook his head. Fidgeted with the remote and studied the various monitors in silence. He then returned to scrutinizing me. “Your parents must be proud of you.”

I kept my eyes fixed on the wallscreen. My fingers twisted the pendant on my neck. I could sense rather than see Abbie sneaking glances at me from the other side of the room.

I swung my gaze back to him in time to catch the uncertain look that crossed his face. He stammered his next words. “I mean, they must be proud of your success, at such a young age.”

I lifted my hand to the wall panel and the monitors disappeared at my careful touch. The room lights brightened. I strode toward him. My words crisp and practiced. “My mom is dead.”

My dad not worth mentioning.

“I’m sorry—”

“There’s no need to be. It was a long time ago.”

I didn’t need his sympathy. Why should I? He was the only sick one in this room. I crossed my arms. “Patron Five—”

Abbie cleared her throat.

I stole a glance at my smartpad. “Mr. Greenwood, I’m twenty-nine years old. I’ve been in residency training for five years. I can assure you, I’m quite good at what I do.”

Five long years. Now one last year as High Resident. So close to achieving all for which I had worked. I yearned to be on the other side of it already. The post-residency position at PRIME. No one would ever again have to suffer like she had. Our success at PRIME Seattle would soon pave the way for widespread implementation. Her death wouldn’t remain meaningless.

Another chime of the smartpad distracted me. The lab interface, my DNA sequencing array had finished. I edged to the door.

“Dr. Kestrel, can you take a look at this?”

Something in Abbie’s voice caused my brow to tighten. I crossed back to see what she was referring to, only to halt in my tracks at the noise that came from the patron’s duffel bag. His squirming duffel bag.

I pivoted to face him, my lips pressed in a flat line. I thrust a finger toward the bag. “What is that?”

His face fell, and he snatched up the bag. Pulled out a small creature, hairless except for a shock of fur jutting up from its scrawny head, held up with a bright pink bow. It wiggled in his lap. He beamed me a shy but proud smile. “This is Twinkles.”

I wrinkled my nose. “It looks like a lab experiment gone wrong.”

He clutched the creature closer.

“She’s a Chinese Crested.” His voice trembled. “Please. She won’t be any trouble. I don’t have anyone to take care of her.”

As if to accentuate his words, the Seattle skies chose that moment to unleash a downpour, proving me right—the September equinox would mark the end to the dry spell. The equinox, when night and day had equal reign over the hemisphere before one again dominated the other, would herald the shift back to the rain, restoring the balance. Fat drops hammered the window. The animal shivered and whimpered.

I shot a sidelong glance at Abbie. She busied herself at the monitor. Didn’t look up. Muttered under her breath. “I don’t see anything. It’s all clear over here now.”

I rubbed my brow. The dog licked the patron’s face and his expression lit up with joy. I twisted my mouth. What did it matter to me if the patron kept his freakish pet with him? Peter would love this. I resolved never to tell him.

I resumed my path to the door, and cast a scowl at Abbie. I’d better not hear about this later from the nurses. She smoothed the smile playing at her lips to a blank expression.

 I positioned one hand over the door sensor and hesitated. The patron shouldn’t be so terrified, really. The algorithm eliminated the guesswork from medicine. I tossed the words back over my shoulder. “You’re going to be fine.”

He clasped the dog to his chest. “You promise me, Doc?”

“I promise, your treatment is routine and will go perfectly. Patrons never die at PRIME.”

Science has no need of hope. Thank the universe for that.

 

* * *

 

I’d forgotten all about the dog until three weeks later.

The shrill tones of an alarm broke the silence in the dead of night. I swung my feet to the floor of my call room. I hadn’t been sleeping anyway.

My brain identified the singular alarm.

Code Blue. The real thing. Not one of the monthly drills we still ran for regulatory purposes.

As High Resident, I would know. I planned those. And there was no drill scheduled tonight.

My smartpad localized the source of the alarm to OASIS. To the room of #571.

I raced out of the narrow room. The sweeping curves of the passageway blurred in my peripheral vision. The cooler air of the corridor rushed my face. My lungs pulled deep breaths. Cardiac muscle fibers contracted to pump the oxygen to my skeletal muscles. Those muscles drove my legs to sprint.

The three minutes to reach the unit stretched into eternity, and then I was there.

First to arrive. My pulse a steady beat in my ears. A testimony to PRIME’s exercise regimen, not even elevated. But my senses skyrocketed.

I crossed into the room and my pupils constricted at the intense light, triggered to ignite to maximum by the alarm. The glare a blinding contrast to the night-muted illumination of the hallway.

The penetrating white gleam revealed a macabre scene. Patron #571, supine and unconscious in the centrally located bed, blood erupting from his mouth and nose.

I donned protective garb in quick motions—gloves, gown, mask—all the while the mantra played in my head. Patrons never die at PRIME.

A horrible clinical certainty filled me, with the same inevitability as the day I had witnessed the death of my mom. This man was about to die. And being at PRIME wasn’t going to make a difference.

Another resident arrived on my heels, and time snapped back to normal. He shouldered past me to the head of the bed, grabbing the Augmented Reality goggles.

A wave of acid rose in my throat and I lunged to stop him. Of course, it would have to be Dr. Leach.

My clinical instincts kicked in. “Get the patron off his back.”

My orders brisk, as if this only one of our monthly drills after all.

My fingers groped at the pendant at my neck. My thoughts careened like molecules trapped in a beaker heated over high flame. How could this be happening to a PRIME patron, especially one under my care? Me, the High Resident.

The lanky red-headed resident who’d pushed past me, Leach, looked down his pointy nose. “That’s not the protocol and you know it.”

The blood pooling in the patron’s airway gurgled like water trapped in a clogged hose with no outlet. I didn’t need the A.R. goggles to visualize the anatomy. The branching of the airways down to the source of the bleeding. The tumor in his left lung.

We would have only one chance to get oxygen to his tissues.

I dismissed the sinking in my gut. A part of me comprehended the futile situation. But another told myself that I could save him anyway. I couldn’t let myself stand by and do nothing.

Not this time.

I would never forgive myself if I didn’t try.

The plan that formed in my mind I’d seen implemented only once before, but I was certain I could carry it out. Even if it wasn’t in the algorithm.

The algorithm.  It kept doctors on track, it kept me on track. It ensured I was the right kind of doctor and it culminated my life’s work. I would never question the algorithm.

But this was my patron. My responsibility.

I gripped my necklace tighter, and made my decision.

I placed my other hand on Leach’s arm to get his attention. “Turn him left side down. We need to do a selective intubation of the right mainstem bronchus.”

Leach ignored me in his usual imbecile manner and kept the patron flat on his back.

The unconscious man’s body spasmed, choking on his blood.

The stench of bodily fluids mixed with the pervasive citrus scent of the hospital sanitizer. I stifled a gag,

The pounding feet of the code response team reverberated through my skull. The additional staff swarmed the room. A rainbow color of scrubs, the responders had come from all different units.

I drove away my extraneous thoughts.

Focus. This is PRIME. You’re the best. You’re not powerless. This is not that day.

Code Blue … Room 6 … OASIS … Oncologic and Surgical Intervention Success Unit…” The soft, soothing voice of the central system clashed with the pounding in my brow.

I gritted my teeth and stepped to the foot of the bed.

The rest of the team moved into their positions, my code drills paying off. Leach paid no attention.

Code Blue … Room 6 … OASIS … Oncologic and Surgical …

I used the anger to find a welcome sharpness in my mind, like cold surgical steel. I leaned over to yank the A.R goggles off Leach’s eyes, and used the strap to pull him closer to my level. My words terse and even. “I said, turn this patron on his left side. We’re doing a selective intubation. Of the Right. Mainstem. Bronchus.”

Leach wrenched out of my grasp and barked his orders to the team. “Follow the algorithm. Keep him on his back.”

The nurses traded uneasy glances but continued their actions. One monitored the automatic chest compressor. One attached the leads to the defibrillator that had descended from the ceiling. Another relayed the medication protocols from the computer algorithm. Behind them, the PRIME motto continued to scroll digitally. We Optimize so You can Flourish.

I suppressed an incongruous urge to laugh. This patron was not flourishing. Not at all.

Leach continued to line up the intubation in the standard way, crouching over the head of the bed. It wasn’t going to work. He was a by-the-book thinker, but this was not a by-the-book scenario. There wasn’t time for lengthy explanations. Or small-minded power struggles.

I didn’t need to explain. I was the High Resident.

I bent down to whisper in his ear. “If you can’t do it, get out.”

His hand slipped. A fountain of blood coated the equipment in a slimy film. He threw the intubation kit down on the hospital bed. An ugly sneer twisted his face. The A.R. goggles followed, flung with such force that they bounced toward the door.

I didn’t flinch, and let my lips twist upward in a silent dare.

His gaze broke away first.

He snapped off bloody gloves and cast them down next to the discarded instrument. He made a show of storming out, pausing by the monitor long enough to growl his opposition. “Let the record reflect Dr. Kestrel is taking over intubation.”

He spun toward the door and a sickening crunch came from under his foot.

He didn’t stop.

For a split second, no one moved. All eyes frozen on me.

I allowed myself a microsecond of silent victory and strode to the head of the bed. “What’s everyone waiting for? A formal invitation? Get this man on his left side – now.”

“But Dr. Kestrel, the A.R. goggles…” The nurse closest to me gave a helpless gesture toward the floor. “We’ll need to calibrate another pair.”

“No time. I’ll do it without.”

I could do this without the A.R. overlay. I would do this myself.

I seized the backup laryngeal blade off the code cart. I bent over the bed, my elbows on either side of the patron’s head. My hands as steady as Newton’s gravitational constant.

I inserted the blade to sweep the tongue out of the field of view. “Suction. I need to see the cords. Let’s go people. Hurry it up.”

The respiratory tech materialized at my side.

With the blood suctioned away, I had the vocal cords in perfect sight. I kept them fixed in view and extended my hand out to the side with the palm up. “E.T. tube.”

The endotracheal tube was in my hand before I finished giving the order. I inserted it past the cords and rotated it ninety degrees to the right. The tech attached the ventilation bag and forced oxygen through the tube down into the right lung.

In a single motion, I released the blade and whipped my stethoscope off my neck. I placed the diaphragm over the right chest and nodded to the team in triumph. “Breath sounds.”

But before I could finish the mental pat on the back, a new alarm blared.

The nurse stationed at the patron’s head had panic in his eyes, his fingers over the carotid artery. “I’ve lost the pulse.”

The melodic mechanical voice filled the room. “Pulseless ventricular tachycardia. Shock advised.”

I signaled the team with a sharp nod.

The patron’s body arched upward in response to the jolt of electricity. My mind flashed to another body, another code, so many years ago. I shut that out.

The nurse at the carotid shook his head. “Still nothing.”

The dispassionate mechanical voice advised another shock. The patron’s body jerked again.

Sweat dripped down my back. Come on … come on….

The nurse bobbed his head, relief in his eyes. “Pulse detected.”

The impersonal mechanical voice confirmed. “Sinus tachycardia.”

The in-room x-ray glided down from the ceiling and within seconds the digital images popped up on my smartpad. I pumped my fist to see the E.T. tube in the desired position in the right mainstem bronchus.

Only then did I let myself look at the patron’s face.

The clamor of the code team faded around me. His ravaged appearance came into horrible focus. Mr. Greenwood, I reminded myself. I had forgotten or perhaps never learned his first name.

My words came back to me in appalling clarity. I promise, your treatment is routine and will go perfectly. Patrons never die at PRIME.

I blinked rapidly. Had that really been only a few weeks ago?

I let myself see now the endotracheal tube emerging from his mouth. Face and chest smeared with blood. Eyes closed. Jaw hanging open.

I was the general who, having seized victory, looks back only to find the troops are all decimated. I clenched my fists to stop them from trembling.

I whirled on the closest nurse. Abbie. “How did this happen?”

She crossed her arms. Her face downcast. “Sometimes, it’s beyond our control.”

She lifted a hand toward me, then dropped it.

“You did everything you could. It’s not your fault. It’s no one’s fault.” Her eyes scanned his body. “Sometimes, we have to let them go.”

I scowled. Heat flared in my chest. She was wrong. Something had gone wrong. How had the cancer progressed past the PRIME-directed therapy? Patrons didn’t code. Especially not those under my care. That’s the whole point of PRIME, Prognostic Intelligent Medicine. It wasn’t our job to let them go.

A sharp yip emerged from the bathroom. The freakin’ dog.

I pressed my lips into a narrow line.

Abbie opened the door and crouched to scoop up the animal. Without meeting my eyes, she drifted out on the heels of the rest of the code team, leaving me alone with the patron.

My gaze shifted to the blackness of the night outside the window. The hiss of the ventilator filled the room. The hammering of the Seattle rain had stopped. A ghost of myself stared back at me from the window. The reflection didn’t match my disheveled insides. I ran my hands through my cropped dark hair. The thick hair I’d shorn years ago, sick of the comments about it reminding everyone of hers.

I squared my shoulders and wheeled away. I didn’t want to see myself right now.

I opened my smartpad and made myself look at his name.

Brad.

Brad Greenwood.

Despite my temporizing measures, Brad would never again take care of Twinkles.

I shook my head at myself. I’d known the dog’s name, but not his? What was wrong with me?

But I’d long ago stopped bothering to learn the patron’s names. The algorithm assigned their treatments. As residents, we learned their numbers, and that’s all we needed to know. The endless rotation of patrons coming in, patrons going out. The algorithm designated the patrons as responders. And we carried out the treatments, for cure.

But instead of leaving here as another cured patron, Brad Greenwood would be leaving as a patient, to transfer to HEARTH, where the incurable patients went.

HEARTH, the HospicE And Restful Transitions House. Where patrons never went.

Patrons never die at PRIME.

Which meant Abbie was wrong. Somehow, this had to be my fault.

And I wasn’t going to let it go.

Next Chapter: The Enemies of Truth and Philanthropy