SAINT USANAGI'S INFERNO

Usanagi's ICU was a place of healing. It was a shining beacon of hope in a wasteland where no one cared. If you had a heart attack in Freeside, and you found your consciousness fading as life left your body, there was always hope that you might wake up alive with people ready to help you return to normal life. And if you resided in Freeside, regardless of whether you were a squatter or a local, healing services were provided free of charge.

The ICU was also hell on Earth. The lighting was stark and pale. It accentuated the ugliest parts of everyone. The floor was cracked tile, and covered in wires that went every which way. They all met in the middle, but instead of being encased in or wrapped around some sort of pillar, they were simply bundled together in an almost organic looking mass and threaded through to the solar powers on the roof. The walls had been painted white, but were often stained. It was built and run like a prison. Nothing was allowed inside. Not even sunlight was allowed inside the ICU- there were no windows on this floor. Every door and container inside was locked. No visitors could enter the ICU without intense vetting. And no one after 2100. There was always an armed guard outside. Sometimes a patient would become delirious in the middle of the night, and would have to be held down and sedated.

The patient rooms were covered with crinkly plastic curtains. Some were drawn aside, some weren't. These rooms were dark at night, and then patients inside were like ghosts. The ventilators whirred and whooshed like a cold and mechanical wind, blowing through each room and into the atrium. There were unending alarms and beeping heart monitors, going at every hour of the day and every hour of the night. Right now there were 3 ventilator alarms going off at once.

Have you ever heard the sound of three ventilator alarms going off at once? It's awful. They're so loud and so needy sounding. Especially combined with the constant, agonizing moans from bed 4, and the regular beeping from all the monitors. Usanagi glided over to the first ventilator and clicked the alarm off. The patient was fine. He was conscious, in fact, and staring at her. He had a tracheostomy, a hole in his throat that she installed for long term ventilator patients, and he was just coughing which set off the high pressure alarm. She was not able to manually adjust the parameters on that model of ventilator and she did not want to tape the speaker off. This guy was a frequent flier. He'd be okay once his respiratory infection was over, and they'd cap his tracheostomy right back off.

She moved to the second and clicked it off, just a little faster and more precisely than a normal human should be able to. That patient, a man who EMS had revived after a choking incident, was not fine, but he was going to die soon anyway. Nothing she did was working and his vitals were declining despite the use of continuous epinephrine infusion. They currently had no access to other medications to raise blood pressure, but she doubted it would make a difference anyways. These desperate efforts were like trying to keep together a snowman as the sun came up and the temperature rose. She was planning to pull the tube out of his throat and remove him from the ventilator as soon as she had time to provide appropriate pain relief and sedation so he didn't die a miserable death, with whatever mental status he had left. She hit the alarm button to silence it and then moved a little dial to turn off all his alarms.

The third alarm had been going off intermittently for hours now whenever the patient needed to be suctioned. The patient didn't make a lot of noise when they needed to be suctioned, so it was actually a useful alarm. She didn't have any sort of access valve to perform inline suctioning on this patient, so she'd have to take him off the vent for a moment. She gave the poor unconscious patient a quick flush of 100% oxygen before disconnecting the ventilator and going in for some aggressive suction down the patient's endotracheal tube. The suction machine's engine sounded like a chainsaw, the gunk made a nasty sound as it climbed up the tube. The patient gagged and retched, and his cracked lips instinctively gulped for air as he bucked his chest up. This middle aged guy had gotten his chest cut open in the OR- he should've died on that table, but he was still clinging on without epinephrine, and maybe even getting better. Crazier things had happened. He was still heavily sedated though. She turned the noisy suction machine off, and plugged the ventilator back in.

"I think the guy over there is trying to say something, dude!" said John Chevalier, one of Usanagi's med students, almost tripping over a wire as they crossed paths in the doorway of that patient's room. Chevalier was the only other personnel in tonight. He quickly corrected himself. "Uh. Doctor."

Usanagi gave a sidelong glance, first at the very noisy patient in room four, screaming behind the curtain- but then she saw that the first man, the one who kept coughing and setting off his high-pressure alarm, was waving and mouthing at her inside his dark room. Shaking his gown and blankets like that made him look like a phantom shade in the dark. She sighed and looked away.

"Get him a notepad and something to write with. If he can't write then take it out for a minute and let him cover his tracheostomy so he can talk. He'll survive. He's only on the vent for 12 hours a day right now."

Chevalier raised his eyebrow. "You don't want to speak with him?"

"I don't have time to speak with him."

Usanagi danced across the dirty floor, criss-crossing between the organic network of wires. When she was in the ICU, she was more than human. She was the lord of her domain.

Usanagi rested her gaze upon her "comfort care," patients. She had two of them, right now. Blotchy gray husks lying in bed, breathing too fast, too shallow to live for long. An old woman with many years on her, who had suffered a terrible stroke, and a young man who had been smashed in the head on the outskirts of Freeside and found in a ditch. They each had a bag full of saline and high dose morphine running into their arms. Usanagi could tell looking into the dark room from across the ICU that the bags still had fluid and were still running, but she liked to double check, in case some day she was wrong. She also checked their throats for secretions, and they were good; she had been dropping tiny doses of atropine down their throats to keep down the snot and drool.

There was an occupied third bed, but she had died hours ago, and had a sheet drawn up over her. A little bit of blonde hair peeked up around the edges, and one pale arm hung slack over the edge of the bed. Her time of death was written on the coarse fabric, using black marker. Usanagi didn't remember exactly what happened to her. It was irrelevant now. All she remembered was that she lived in misery for an unfortunate amount of time, and they had harvested a significant amount of blood before she passed. There were little drops of blood on the blanket. The harvest certainly hastened her death, but she would have been euthanized anyways if she didn't pass on her own. She had enough of her organs intact that she might've lived for weeks in an almost brain-dead state, draining resources from viable patients, before she inevitably expired.

And that brought her to her next patient. She could already see the patient's stricken silhouette from outside, through the dirty plastic curtain. Twitching, rolling around in bed. She drew aside the crinkly plastic curtain and stepped inside. The patient was another young woman. She was local. Dark skinned, with a big puffy afro hairdo that had become progressively more messy and disheveled. The patient had vomited once again on the blankets. She had a tracheostomy and she was surprisingly good at clearing her own airway, so she was less likely to choke on it. But it was still a pitiful and distressing sight. Usanagi suctioned the vomit from the woman's mouth, checked her tracheostomy to make sure it was good, and cleaned up her face. She wasn't a ghoul, but her face was all scabbed up and wet. The skin was very raw to touch.

She was "recovering," with treatment. She did not require epinephrine or ventilator support to survive. The tracheostomy was just to protect her airway, for now. But she could never live on her own again. Her brain damage was too severe. She had no friends or family to take care of her- no one had come looking for her, despite the posters they'd put up. She could open her eyes halfway and moan, but she couldn't eat or drink on her own; she was being fed through an NG tube. Perhaps she could regain that ability again, eventually, but her limbs were already locked up and contracted. Her muscles were locked at unnatural angles. She'd never be able to walk or use a wheelchair without help from a physical therapist, and no one had the time or knowledge to work with a patient with this sort of extensive brain damage.

This patient could live for years with basic treatment, but there was no world where she survived outside these walls. She had been in the ICU for a month and three days. She was three days over her limit.

They'd been putting this off.

Usanagi sighed. "What is your name… Ah, Jamie." She crouched down next to Jamie. Jamie acknowledged her with what might have been brief eye contact, then went back to moaning and rolling around in bed. Usanagi took her hand and held onto it. Jamie's wrist was heavily contracted, locked up and unable to move. "Jamie, baby. I'm so sorry. This is awful. I wish we had more to offer you." She ran her fingers through Jamie's hair. Jamie didn't stop moaning or rolling around. If anything, it made it worse.

It never got easier. It was always so fucked up when she did it like this. Usanagi opened up the pouch on her belt and removed a vial of morphine. She drew up half the vial into a 10ml syringe, held Jamie's arm down, and connected it into her central line. She looked away as Jamie's half closed eyes crossed hers, and pushed the medication. Then she drew up the other half of the vial, and did it all again. It felt like snuffing someone out with a pillow when she had to draw up more than one syringe. She'd done this so many times now that even though her heart was heavy, her hands didn't even shake.

Almost immediately, Jamie started to doze off. Usanagi held her hand as her muscles relaxed and the moans petered off. Jamie rolled over onto her face, then her side, then stopped rolling. Her eyes were closed now. She started to snore. Then she stopped snoring. Her head slumped to the side. She stopped making any noise at all.

Usanagi had been preparing for all this. She drew up a vial of potassium from her pouch, and drew it up into a syringe. Jamie had gone slack now. It made it easier. She pushed it all through the IV line.

Jamie convulsed, then went still again. After roughly a minute, Usanagi placed her finger on Jamie's neck. There was no pulse. Standing back up, and sighing a deep, deep sigh that contained many emotions at once, Usanagi unwound the cable from the cardiac monitor, and placed the suction cups on Jamie's slack limbs. She turned on the screen. It showed a logo of the vitruvian man, his arms spread and his expression solemn, before turning into a rhythm. The rhythm was a choppy, coarse line, which gradually flattened out, until it appeared almost flat if you were to squint at it hard enough. Jamie didn't move at all through all of this.

Usanagi checked the clock on her pip boy- the little guy in the vault suit grinned and winked at her as she scrolled to the stats page. The whole process had taken 20 minutes. Too much time- she should've had Chevalier do this. But he wasn't up to the task. Not yet.

Still, Usanagi had to get ready for lectures in the morning, which meant recording a holotape handoff report to whichever student would be taking over for her. She hated leaving med students in charge of the ICU, but she held her lectures just downstairs, and they could get her if something was really wrong. Doctor Usanagi drew a sheet over poor Jamie's corpse and wrote the time of death on the sheet using a thick black marker. She straightened out her coat, pushed back her hair, and strolled out of the room. She was greeted once again by the hissing and whirring of the ventilators, and the beeping of the monitors. One of the ventilator alarms- from a room she hadn't visited yet, started going off too, as she tried to gather her thoughts. Someone tapped her on the shoulder.

"What is it, Chevalier?" She asked. John looked a little bit upset.

"You were gone for 20 minutes dude! What gives?" Usanagi removed the empty potassium vial from her pouch, and held it up in the fluorescent light for him to see. It took him a moment to process, but then he backed up and stared at the ground. "Oh. I'm sorry dude. I mean doctor."

"Dude is acceptable. And there's nothing to be sorry about," said Usanagi, wearily. She put the vial back in her pouch. "20 minutes is rough, I know. And it's been a long night. I have to record my report- Take care of that alarm in room five for me. If you can't handle it, call me back."

Usanagi walked over to her desk. She had a rolling stool, but she never used it. If she sat, she'd lose energy, which she couldn't afford to do. She had to keep going, no matter what. She snatched a holotape off the desk and popped it into her pip boy. She scrolled to "items." Clicked on it. She wiped the data. It made a satisfying clicking noise, a soft whirring sound, and then another click.

Success.

Usanagi cleared her throat and put the mic closer to her mouth. She clicked on the button to record. It made the sound again. She licked her lips and sat in awkward silence as she waited for the static.

"Doctor Usanagi, September 1st. Time is 0532 at the time of recording. I hope you're having an awesome morning. I'm giving the handoff report for receiving care team, so get ready to take notes…" She watched Chevalier in room 5, turning the patient over and moving him so he wouldn't get bed sores. Chevalier was so innocent. All the med students were so innocent. They were all so good. How could she expect these kids to do the things she did? To make the decisions she did? "We've lost a few over the night. A few more are expectant. We have two right now in palliative care, bed P1 and P2, who may be dead by the time you see them. Both too acidotic to harvest blood. Receiving standard comfort care measures. Atropine to dry secretions as needed, standard morphine dosing and IV fluids. Be aware bed P2 has family who will want to claim her body for burial. Bed P3 is dead and hopefully the body will be moved shortly. Continuing with palliative care, Bed 2 suffered an anoxic brain injury after cardiac arrest secondary to choking. EMS resuscitated him in the field. He's been steadily declining. He has been on a dirty epi drip, 20ml/min, but I'm planning on cutting that before I leave. If I don't, please do that ASAP. Pull the endotracheal tube and move him over to palliative care. He has a relative who will want to claim the body." She paused. There was a sinking feeling in her stomach. "I… also euthanized bed 4 just before recording this report using morphine, and potassium. I know this'll be hard to hear for some of you who have been taking care of her for the last month and hoping for her recovery, but it was time. At this time, no one has claimed the body."

Usanagi cleared her throat again. A lot of thoughts went through her head. She wanted to justify herself. She wanted to talk about how bad she felt, or reflect on her own doubt regarding the morality of euthanasia. She wanted to say sorry…

No. This was her job. She had nothing to apologize for. Nothing to explain. 'Saint Usanagi' did this so no one else had to. She leveled out her voice and continued on. "Well. That was our palliative care and deaths. Now, for some patients who are potentially good news!..."