A brief note before we begin: the first part of this chapter features content that more sensitive readers may find disturbing. Discretion is advised.

Glossary:
Basic (life support): In the context of prehospital care, BLS refers to providers with an EMT-Basic certification and ambulances equipped with automated defibrillators, basic airway supplies, splints bandages, oxygen, a few drugs, and suctioning supplies. BLS ambulances in most systems do not have cardiac monitors, IV supplies, intubation kits, and more serious drugs like nitroglycerin and epinephrine. Some systems only have advanced life support (ALS) ambulances running 911 calls, and others, like my own, have both. I don't know what protocols Clallam County EMS uses, so I'm just writing with the protocols that I use. Apologies for the creative liberties.
Apneic: not breathing
Angiocath: a needle with a catheter used to start an IV.

My mind was not on work the next evening. I gave every patient the usual thoroughness and attention, but my thoughts were elsewhere. I'd written emails to a few scientists I knew who studied vampires, and was still waiting to hear back. For the short term, I'd discreetly asked Alice to bring some extra blood home next time she hunted, in case Esme was still unable to hunt.

But this was my last night working for the rest of the week, and I hadn't volunteered to take anyone else's shift. Hopefully the rest of the shift would pass quickly and quietly, and I could spend the next few days tending to my wife.

No sooner had the thought occurred to me than the telemetry phone rang. I looked around, but Katie and Malik and the other nurses were busy. I sat down with a pen and hit answer.

"This is Clallam Unit 303 coming in basic with a full arrest," came Myra's shaking voice over the line. In the background were the sounds of chest compressions and the whoosh-whoosh of ventilations with a bag-valve mask. "Five minutes out. Ready to copy?"

"Go ahead," I said, pen poised above a radio form.

"Twenty-two-year-old male, found unconscious on the living room floor by his mother. Sh-she says he was breathing when she found him but when we got there he was pulseless and apneic." There was a pause as someone shouted at her. She resumed: "Three rhythm checks, no shock advised. We, uh, have airway access with a King tube and are ventilating on a hundred per cent oh-two. Patient has no known medical history, is not taking any medications, no known allergies. Oh, um, glucose of 80. We-we'll be there in five."

"Okay, see you in five," I said, and hung up the phone. I looked up and saw that Katie, Malik, the two techs on the code team that day had gathered around me to listen to Myra's report.

"Room nine," I said, my voice calm but commanding. "Have a cardiac monitor and IV supplies ready. They're basic, so they won't have established IV access in the field. Tia, take over compressions. Malik, you're IV and drugs. Katie, airway, and Artie, scribe. Any questions?"

Everyone shook their heads. We made our preparations and stood around the waiting bed, eyes fixed on the ambulance bay door. A solemn hush fell over the ER, a silence interrupted only by the accelerated beating of human hearts.

And then the silence was over, shattered by the squeal of the ambulance bay doors. Myra rode the rails of the stretcher, doing compressions one-handed and holding on with the other. Elias walked at the head, guiding the stretcher with one hand and squeezing the bag-valve mask every six seconds. At the foot was a firefighter, his portable radio hitting the stretcher frame as he walked. Between them a young man, barely an adult, lay on a bright orange backboard, arms flopping at his sides with the force of Myra's compressions.

Elias and the firefighter steered the stretcher alongside the bed, and a storm of hands went to work unstrapping the patient. Katie took over bagging and Elias stepped back. Myra, her face a blank wall, hair plastered to her face with sweat, kept doing compressions until Elias pulled her away. We lifted the patient over to the bed on the backboard, with me careful not to bear too much of the weight, and Tia took over the compressions a half-second later, pushing fast and hard. Malik immediately uncapped an angiocath and tried for a vein on the patient's left arm. I unhooked the defibrillator pads from the automated defibrillator and plugged them into the cardiac monitor.

"Twenty-two-year-old male, found unconscious and unresponsive by his mom about five minutes before we got there. We found him pulseless and apneic with an unknown down time," Elias began. "We did two more rhythm checks en route with no shock advised, airway access with a King tube and getting good chest rise. Mom rode with us; she's in the waiting room. She says he has no medical history, no drug abuse. We worked him for about twenty minutes before the fire department got here and we could go."

"You couldn't get an ALS crew to help?" I asked.

He shook his head. "I called for one, but we only have two ALS rigs up today and they're both on the other side of the responding area, so we just grabbed a firefighter to help with compressions and got here as fast as we could."

"You did well," I assured him, seeing the remorse on his face. Then, to my team, "Let's do a rhythm check."

We stopped compressions and swiveled our heads to look at the monitor. The rhythm was asystole, no electrical activity in the heart.

"I'm in," Malik announced, tossing his used angiocath in the sharps box.

"Push five of epi, then run fluids wide open," I instructed.

"Pushing epi—epi's in," he said. Artie's fingers flew over the keyboard as he recorded everything we did. A phlebotomy tech came in and quickly drew blood for an electrolyte panel and an arterial blood gas.

The EMTs hurried their stretcher out of the room to make room for us. Tia grew fatigued after a couple of minutes of compressions, so I switched out with her. Malik pushed another epinephrine, then lidocaine. Another rhythm check, still asystole. I paused so that Katie could intubate. The tube went in on the first try, and Tia confirmed the placement with her stethoscope. I resumed compressions, keeping an eye on the clock. The longest I'd ever seen anyone do chest compressions without getting tired was twenty-one minutes, so I always asked someone to rotate in for me after fifteen, even though I could easily go on indefinitely.

The lab called back with the results; all the tests were normal. This was bad; electrolyte imbalances and acid/base imbalance were fairly simple to correct. There was nothing we could do except continue our grim task.

We worked for almost half an hour in the fevered silence of a cardiac arrest, until finally, after thirteen more rhythm checks showing asystole, and no gas exchange on the CO2 detector, I told everyone to stop what they were doing. They stepped back, deflated. Solemnly, I called time of death. The cardiac monitor emitted a steady tone until someone silenced it. We stripped off our sweaty gloves, dejectedly threw them at the nearest trash can. The patient, younger than I'd been when I died, lay amid a jungle of wires and tubes with the flaccid stillness of death.

Katie stayed behind, helped me disconnect him from the IV tubing and cardiac monitor, and roll him off the backboard. The man's mother was in the waiting room, and one of us was going to have to tell her that her son was dead.

"I'll do the notification," said Katie, handing me the backboard. "You give this back to the crew if they haven't left."

She'd given me the easy job, and I was grateful. With the plastic board under one arm, I peeked my head inside the EMS room. Elias wasn't there, but Myra sat in one of the plastic chairs, shoulders shaking. When she heard me, she turned and looked up with shell-shocked eyes.

"First arrest?" I asked, leaning the backboard against the wall.

She nodded and wiped her eyes on her sleeve.

"The first one is the hardest," I told her.

She nodded again and said, "You called it, didn't you? He's dead?"

"Yes."

"It just doesn't seem fair. We were the same age, born the same month and everything. What kills a healthy young guy like that?"

"It could have been a number of things," I said. "Congenital heart defect that went undetected, or a malformed blood vessel in his brain that burst."

"Oh." She looked around the room, avoiding my gaze.

"You should tell someone about this call," I said. "Tell them what happened, and tell them how it made you feel. You'll feel better afterwards."

"Do you know this from experience?" she asked, scowling a little at the platitude.

"Yes. I'm older than I look, you know."

"It just doesn't seem fair is all," she murmured, and then became very fixated on a loose thread on her windbreaker.

"How many hours left in your shift?" I asked her.

"About forty-five minutes. We're probably going to get returned after this, provided our replacement shows up."

"Good." I wouldn't want someone in her condition running calls. "Go home, eat something, and gets some rest, okay?"

"I will. Thanks, Dr. Cullen," Myra said. "For, you know, understanding. Eli's nice and all, but this stuff's never bothered him, and he thinks I just need to get over it, whatever that means."

I gave a wry chuckle. "Get over it just means stop showing emotions that make other people uncomfortable. Myra, under no circumstances are you ever to "get over" this or anything else."

"That's funny. Also true. Well, we've been tied up here long enough. I'd better go." She stood up and awkwardly picked up the backboard with one arm. "Thanks for everything."

She walked out the door, and a minute later I heard the ambulance drive away. On the other side of the building, a piercing wail erupted from the waiting room, loud enough that a human could have heard it. It was the sound you hear when someone loses a child.

The rest of the night was quiet, as if God sought to make up for the evening's tragedy. There was a twisted ankle, some abdominal pain, and a man from the police lockup who claimed he'd been vomiting blood, despite no bloody vomit being found anywhere near him. I saw Elias with another partner; he'd stayed for a double shift. Myra, he told me, had gone home.

"I thought she was one of the good ones, but I guess some people can't handle the pressure," he said, as I signed his report.

"Give her time," I advised. "She'll learn to deal with it. I did."

When my replacement finally arrived, I drove home through the early morning light at what for a human would be a truly unsafe speed. Even with the events of the evening, I hadn't forgotten Esme's condition. At the red light before the gas station, I checked my email on my phone. Anna Camp, a vampire physiologist in Sydney, had sent me a couple of pages of her notes, plus a link to a paper she thought might be relevant, and Beatrice Sutcliffe from Oxford had given me as much as she knew. I didn't have time to peruse in depth before the light turned green and I shot off into the night.

Alice had left an entire gallon of moose blood in the fridge, more than I'd asked for. I sniffed it, and my mouth watered with venom. It was blander than predator blood, but it was rich in iron and proteins, which was the important part.

Esme hadn't had anything to drink in almost two weeks, and while vampires could survive long periods without food, we started to weaken after three weeks to a month. After that came cognitive symptoms, difficulty concentrating and the occasional hallucination. Almost a year of starvation was needed to send a vampire into a desiccated, semi-comatose state, where we could exist indefinitely. I knew because I'd lived it, the early stages at least. The later stages, the coma, I'd watched the Volturi inflict on a rogue vampire. It had not been a pretty sight. I shuddered at the thought of Esme experiencing even a little of it. Her human life had been harsh and short, so I always tried my best to keep her second life as comfortable as possible.

I poured some of the blood into a cup, careful not to spill any, and zipped up the staircase to the room Esme and I shared.

She was lying on the couch where I'd left her, chest rising and falling sporadically, sunken spots under her eyes bruise-purple against a waxen face. She barely stirred when I came into the room.

"Esme," I said. "Esme? How do you feel?"

"All right," she murmured. "Weak. The pain's gone, though."

"Well, I suppose that's something. Can you sit up? Alice brought blood from her last hunt."

She needed my help, but she was able to raise herself into a sitting position. I held out the cup of blood. She sniffed at it, then turned her head away, disinterested. I sat down next to her, biting my lip in worry. Vampires never refused blood. Even at the depths of his depression, Jasper had never stopped hunting. Our defining trait was our need for blood, and starvation only made the thirst burn stronger.

"Darling, you're becoming ill," I protested. "You need to drink something. Just a few sips, please?"

"I don't want any blood, Carlisle," she said, resting her head against my chest. "I'm just tired. I wish I could sleep. You know, that's something we never got to do, sleep next to each other. It figures—sleep is such a vulnerable state, and by the time I finally meet someone I can be vulnerable with, I've lost the ability to sleep."

"We can do other things together," I murmured, wrapping my free arm around her shoulders. "We can climb to the top of the tallest mountain and I'll hold you in my arms while the snow falls all around us."

She smiled into my sweater. "I'd like that. Or we could fill our lungs with water and sink to the bottom of a coral reef, and I'd hold your hand while we went to find a moray eel."

I shuddered; I hate eels and she knew it. "Maybe we could just lie in the sand and watch the sunlight on the water above," I suggested. "But first, you need to be strong enough." I lifted her chin and held the cup to her lips. She tried to pull away, but I tilted the glass up and managed to get a sip or two into her. She swallowed, looking disgusted.

"I said I wasn't thirsty," she protested. "Carlisle!"

"You need nutrients," I said. "You need iron, and you need proteins and platelets, and you're dehydrated. I'd feed you straight plasma if I could."

"I'm fine like this," she protested. "Besides, it tastes like rotten metal. Alice must have left it in the fridge too long."

I took a quick sip myself. It tasted like moose blood, colder than I was used to, but still palatable. Good, even. I sighed and put it down on the coffee table.

My laptop was on the table where I'd left it charging. I shifted us so that Esme was laid out across my lap, and I could reach over her and check the notes that Anna and Beatrice had sent me. I hoped her illness would turn out to be something simple, a bad reaction to a new type of wood varnish she'd been using, or something like that.

Anna's notes were rudimentary, the basics of how vampire physiology worked. I'd known most of it, but not all. The venom used to incapacitate a victim is also our means of reproduction. It rewrites the human DNA on a cellular level, causing a cascade effect of changes, not all of which were fully understood. The end result is a being made of a material that more resembled industrial ceramics than flesh and blood. We have no circulatory system, just a network of pores that diffuses nutrients throughout the body, much like mosses and fungi. Our bodies are largely self-repairing; that part isn't understood properly, but Anna found that healing times vary based on how recently a vampire had fed, and on what kind of blood. Human blood, of course, is better, but reptile is a close second.

Blood is digested by the stomach and small intestine, which are much the same as in humans. The large intestine and excretory system are no longer necessary; a vampire's digestive tract uses every part of the food. Because of this increased efficiency, and the additional time it takes to get nutrients out to the cells, it is not necessary for us to eat as often as humans. Our body temperature is usually around the same as the ambient temperature, usually a few degrees cooler since we don't hold heat very well. Variations in temperature can speed up or slow down metabolism, which is why we are less thirsty in winter.

The link at the bottom lead to a more detailed report about vampire neurology. Anna had apparently found an excuse to run herself through some fairly extensive neural imaging tests, and made a few discoveries. First, predictably, the vampire's brain is just as efficient as the body. It is constantly "sleeping" small parts of itself, which is why vampires don't need to sleep at night. We also have more activity in the sensory cortices, unsurprising given our heightened senses. The brainstem, responsible for basic functions like heart rate and temperature in a human, has about a quarter of the activity compared to a human. The hypothalamus, on the other hand, lit up on the scan like a Christmas tree, even moreso after Anna had waved a swab dipped in human blood under her nose. That, she theorized, was the source of the appetite, the lust for human blood.

Could be targeted, she's written at the bottom of the page, to curb appetites in newborns. Further research necessary. I stroked the back of Esme's head and wondered if the hypothalamus was the root of her illness. Perhaps a new type of disease had evolved that could attack vampires' brains? There were more of us that there had ever been before, and bacteria evolved quickly. Perhaps it was attacking her hypothalamus like tertiary syphilis would attack a human's brain.

Dr. Sutcliffe had basically emailed me her entire hard drive. She'd met Esme once, while we were was at a conference in England, and they might have become close if not for Dr. Sutcliffe's frequent indulgence in human blood. But there remained a fondness, and Beatrice had dropped everything once she heard that Esme was ill. I began sifting through years of notes and write-ups, mostly about giftedness in vampires, and the traits that carry over after the transformation.

The only thing that caught my eye was a few notes about some psychological tests that Beatrice had run on Esme looking for hidden abilities. The only thing she'd unearthed was what Esme called maternal instinct, and Beatrice called long-range empathic abilities. Esme, apparently, maintained a sort of connection between herself and her family, and could tell if something was wrong with me or any of the children, even over great distances. There had been, of course, no ethical way to test this ability. I smiled to myself, recalling instances when Esme had instinctively known when one of the children was upset or worried or needed our help. I'd never paid it much mind before. Why hadn't Esme told me that she was slightly gifted? Probably because she was a modest woman, and had thought it vain and presumptuous to put herself in the same class as Edward and Alice and Jasper.

I looked down at her, lying across my lap, unmoving, eyes open but not seeing. Deep in me, I nursed a gnawing worry that I'd never figure this out. One thought in particular was especially disturbing, and I'd tried my best not to entertain it until now. Whatever this affliction was, could Esme die of it?

Thank you to catharticone and everyone else who reviewed. You keep me going. (Also check out catharticone for the treasure trove of Twilight fics. They are an amazing author).