By Arie Coleman
17 August 2015
When the Taylore case pops up through the Triage computer, it takes me five field-swipes before I steady my hand enough to cross-check the date. It’s right. My chair falls over when I throw myself from behind my desk, and I don’t even pause to set it upright as I run to my boss’s office.
Dr. Zina Bankole looks up as I barge in, a quizzical expression on her face. Charlie, her Anchor, gives her an almost imperceptible nod from across the room. Relieved that I’m actually here, Zina indicates that I should sit down.
I take the chair near Charlie. The one across the desk from Zina is both there and not-there. I know that if I try to sit in it, it will probably be solid enough; I just prefer the chair I’m sure about.
“You have to give me the Taylore case,” I say. “Iatrogenic hypoglycemia. A nurse gave a massive dose of insulin to the only non-diabetic patient at County instead of her roommate. It’s an easy intervention.”
Zina pulls up the Triage queue, and for a moment I’m sure that the Taylore case is the product of a counter-memory and not part of this timeline at all. But she starts reading, and I let out a breath. It’s a real case. And she’s considering it.
Then her head jerks toward the door, and she smiles.
“Just put it there,” she says.
Charlie shakes his head, and her face falls. There’s no one there. At least, not in the timeline Charlie’s in, which is the one we’re supposed to be focusing on. I’m happy for a moment that I didn’t see anyone there either, and then remember that something so simple is not normally a victory. Zina reorients quickly and returns to the queue.
“This case happened before the invention of the Seam,” she says. “And Triage wants a double-over. We talked about this. You were transitioning to post-Seam interventions only.”
Post-Seam cases are scut missions. I just tell someone I’m a Temporal Medicine consultant, and they do what I say, and I leave. No art, no challenge; I may as well not even be a doctor at all.
“Not yet.” I hate the tremor in my voice, and Zina’s eyes are so kind that I want to curl my hands into fists.
“You’re an excellent interventionalist,” she says. “But even I can see that you’re having trouble keeping things straight these days. I want to keep you closer to home.”
“I’m sorry, Loren, but you can’t even pick the right chair half the time.”
“Why do you even have a second chair? You were fine with just the one before the Wilson case.”
“That’s kind of my point.”
She’s not wrong. The most surprising things are popping up as counter-memories after my last intervention with the Seam. Apparently my neighbor no longer has that obnoxious dog, but that doesn’t help because I can both hear and not-hear it barking all night. The earlier the intervention, the more variabilities I experience when I get back.
I barely go out in public anymore. I hate the over-sympathetic side-eyes when I grab for nonexistent objects or talk to people who aren’t there for anybody else.
“What is it about the Taylore case, anyway?” Zina asks. “Not only is it pre-Seam, it’s a thirty-year jump.”
“It’s . . .”
“Oh,” Zina says. She’s put two and two together; I suppose I should have expected it. “It’s Press County Hospital.”
“It’s a twenty-four-minute window,” I say. “Triage wants to minimize the butterfly effect by narrowing the exposure time. I get it. But it’s Press County. That place was a shitshow.”
“Triage is recommending Dr. Ramirez.”
“Listen, not even Javi can navigate County in twenty-four minutes. When was the last time Triage recommended that he do a recon trip and then overlap himself? I did my residency there. I knew the nurse who gave the insulin dose. Put that in the algorithm, it’ll show one trip, in and out. Easiest intervention ever.”
Zina is frowning. I’m running up toward my intervention limit, but I can tell that she doesn’t want to do the double-over that Triage is recommending. Too risky, too expensive.
“You’ll minimize contact? It’s for your own good, you know.”
“Only Trina Taylore and her nurse,” I lie.
I walk out with my assignment, barely able to breathe.
Here’s the thing: doctors fuck up sometimes. You practice medicine long enough, someone will get hurt and it’ll be your fault. You do your best to protect your patients from yourself and your human failings. When you can’t, you learn how to cope with the guilt. Or you don’t, and you quit. Or you overdose and you quit forever.
Or you respecialize.
The development of Seam technology and Zina’s invention of Temporal Medicine showed up just in time to save me from a catastrophic burn-out. I took one of the first fellowships, after twenty years of whacking my head against the worst of the county hospitals. Lot of mistakes in those places. Some of them were mine.
Like Pierre Joseph, from Press County. I’ve run his case through Triage so many times that the red letters across his file may as well be stamped across my retinas: UNSALVAGEABLE. I’ve never believed it.
I’m thinking about Mr. Joseph as I lie back on the table among the Seam machines, though I know it should be Ms. Taylore at the front of my mind. One of the techs is both there and not-there as she bustles around making last-minute calculations; I close my eyes so I don’t have to look at her. Of course she’s wearing a really strong perfume and my nose can’t decide whether or not I’m choking on gardenias. Instead, I try to focus on the feel of the plastic syringe of dextrose that I’m holding in the pocket of my white coat.
Before Seam technology, all we could do with the excruciating clarity of hindsight was fix systems errors and try not to make the same mistake twice. We could save people in our present, and we could save people in the future.
Now we can save people in the past, too.
There’s the expected pushback about how we’re not supposed to mess with history. But when it comes down to it, there is not a single person alive who has more loyalty to subjective timeline integrity than they do to their lost children, their absent spouses, their departed parents.
Anyway, we only intervene with the medical standard of care available at the time. No future breakthroughs threaten the integrity of the past, only the benefit of hindsight. The pancreatic cancer that could have been found with a CT before it metastasized. The potassium level that came back six minutes too late to make a difference in the code. The pulmonary embolism that didn’t present classically enough to trigger clinical suspicion in time.
We save the people who never should have been lost in the first place.
The whirring of the machine ramps up, and I close my eyes against the upcoming disorientation as my table slides into the mouth of the Seam. When I open them, I’m on the floor in a supply room.
The familiar combination of dust and pungent cleaning solution still makes me sneeze. The wire racks reach up to the ceiling, stacked with plastic basins, surgical masks, central line bundles. It troubles me that every single object in this room is unquestionably existent. I’m living between so many timelines these days that it’s visiting a single one that’s the shock.
I pull myself up, shaking off the disorientation as a beep announces that someone is swiping into the supply room. I brush off my coat, sling my stethoscope around my neck, and turn my back to the door. I pretend to study the supply cabinet so I don’t have to interact with whoever just came in.
My eyes fall on a nearly empty box of arterial blood gas packets. After a moment of guilty indecision, I grab one of the ABG tests and slip it into my pocket next to the dextrose. I try not to think about the cascade of ABG-to-patient mismatches that will ripple out from this one action. I almost put it back into the exact place where it was in the box, but the nurse who just came in reaches past me to grab another ABG kit.
The difference is now locked into the timeline I’ll return to; I had better commit myself to justifying it. Steeling myself, I venture into the pandemonium of my old hospital.
I’m on Seven East, Ms. Foster’s ward. She’s the nurse who’s about to carry out the medical error that I’ll turn into a near-miss. It’ll be nice to see her again. The nurses here were always half-dead from exhaustion; she was one who still cared about the people in her charge despite her caseload.
I sit at a computer near the nurses’ station across from Room 704, where Trina Taylore is recovering from a bout of pyelonephritis. I check my Seam timer; it’ll be a few minutes before the event that I came to stop. The more time I spend here, the less I’ll have for Mr. Joseph.
He’s on Four East, practically underneath my feet. He was a forty-six-year-old man with schizophrenia who had complained of chest pain and transferred to my service from Psych. After we worked him up and found nothing concerning, Psych refused to take him back. He was undocumented, not safely dischargeable, and could not be placed in a care facility because of his social circumstances. Psych saw a chance to get him off their census, and so he got dumped on Internal Medicine.
Mr. Joseph was sweet and easygoing, and called me “sister” whenever I talked to him. Not the worst patient I’ve been turfed.
But it can be dangerous to linger on a Medicine ward if you don’t belong there. Mr. Joseph should have stayed on Psych, where no one was obsessively following labs and vitals, overreacting to any tiny waver in the values.
One evening, Mr. Joseph’s nurse told me that his oxygen level was dropping at night. I brushed her off, told her to put him on a nasal cannula while he slept. Then I boggled stupidly and fiddled with his antipsychotic dosing as he became progressively somnolent over the next few days.
A few mornings later, I arrived to find the night float team coding him for cardiac arrest. He died soon after, and despite scrutiny of the labs from the code, no official cause could be diagnosed.
I knew, though. I had missed the signs of a Pickwickian syndrome. His somnolence was from a buildup of carbon dioxide, and the supplemental oxygen had interfered with his respiratory drive. Hypercarbia had led to his cardiac arrest. I was sure of it.
If I had done an ABG test, I would have put him on a CPAP instead of oxygen. But sleep-deprived, starving, and playing high-stakes whack-a-mole with mini-emergencies from the twenty-five patients on my service, I never made the connection.
It was such a stupid way to fail a patient.
I curl my fingers around the ABG kit in my pocket. If I send it to the lab, someone on the team will see the elevated CO2 level and investigate. Maybe it will even be me. Maybe I’ll get a wavery counter-memory to soothe the guilt, one that lets me make the diagnosis and watch Mr. Joseph recover.
A raised voice catches my attention. I look up to see that a surgery intern has cornered Ms. Foster and is screaming at her. Something about a blood transfusion.Very unprofessional.
Ms. Foster’s face looks like it’s made of stone, and as I listen to the intern it’s clear that he expects a timetable that’s just unreasonable for County. Ms. Foster is probably working as hard as she can to arrange the transfusion; knowing her, she’s already expedited it to an impressive extent. But it isn’t enough for this little asswipe intern who probably has his own little asswipe resident riding his tail for not arranging the transfusion earlier.
I glance at my Seam timer again; sure enough, the event I had come to stop is slated to happen immediately after this. Ms. Foster, like all the nurses here, had more patients than she could safely handle to begin with, and now she’d be distracted by how unfair this intern had just been. Perfect recipe for an error.
It’s time; I get up and walk into Trina Taylore’s room.
“Ms. Taylore? I’m Dr. Whittier. I wanted to say hi and do a consultation with you. Do you mind if I listen to your heart?”
Ms. Taylore puts her smartphone aside and wordlessly loosens her hospital gown so I can place my stethoscope. I ignore her eye-roll at the interruption; she has no idea I’m about to save her life. Her roommate is asleep in the bed by the window.
I’m examining Ms. Taylore’s lungs when Ms. Foster comes in with the offending insulin dose, her footsteps furious and her expression stormy.
“Hey, Ms. Foster,” I greet her. Ms. Foster blinks at me; she’s trying to place me and clearly can’t. My hair is short and completely gray these days, and I no longer wear glasses. It’s enough of a disguise, especially for someone who isn’t expecting an older version of one of her coworkers at her patient’s bedside. “You’re lucky,” I tell Ms. Taylore. “Ms. Foster is the best nurse in this hospital. I wish everyone I work with was as conscientious and careful as she is.”
Ms. Foster and Ms. Taylore smile at each other, unsure how to respond. I brace myself in case I have to snatch the insulin away from her, my other hand clutching the syringe of dextrose in my pocket. But now Ms. Foster starts chatting with Ms. Taylore and her expression is clearing. She looks down at the dose she holds, squints at it, cross-checks it with the computer. Then she carries it over to Ms. Taylore’s roommate, the patient who was supposed to get the medication in the first place.
Sometimes, that’s all it takes. Target achieved.
My Seam timer says I have twelve minutes left in my window. I tell myself it’s plenty of time, but I know that it’s going to be tight.
I’m on my way into Mr. Joseph’s room when I realize I don’t have a label for my ABG. Without one, the lab won’t be able to match the sample to the patient it came from, and they’ll just throw it away.
I throw myself in front of a computer and try to remember my old login. After three tries, the system locks me out. Panicking, I look around. Can I interrupt anybody nearby without causing a massive temporal ripple?
My eyes fall on a disheveled figure hunched over a nearby computer, and my stomach flips over. She’s in scrubs under her dingy white coat, hair unbrushed and wild, peering at the screen through thick glasses.
I quickly turn away, poking desperately at my uncooperative computer. ABG kit cascade aside, can I risk going up to her and asking her to print a label? I think about Mr. Joseph, quietly slipping away as I sit here. I don’t have the time to cajole my younger self into helping me. Mr. Joseph doesn’t have the time.
I dial the operator and report a coding patient on Four East. Just as I hoped, the me at the nearby computer is on call. She jumps up, leaving her computer open while she runs around the floor. No one knows why the code was called, and the nurses’ station clears out as everyone rushes into the patient rooms to check on their charges.
I print out an ABG label at my younger self’s abandoned computer. Five minutes.
I run to Mr. Joseph’s room. He’s gazing curiously at the flurry of activity outside, but when he sees me he pulls into a slow, sweet smile.
“Hello, sister,” he says. I pause at the doorway. There’s no way he actually recognizes me. I feel an old surge of affection for the man, along with a familiar fury. Is he actually “unsalvageable”? Or is it just that he’s poor and mentally ill and alone?
“Hi, Mr. Joseph,” I say. I want to tackle him and pull the ABG without spending precious moments on talk, but that’s assault, and anyway, it wouldn’t go any faster that way. “Can I do a blood test? I’d have to take it from the artery in your wrist, so it might hurt more than usual.”
Mr. Joseph smiles. “It’s okay, sister.” He holds out his arm to me. He moves slowly, his eyes half-closed. The stab of guilt that shoots through my stomach is enough to take my breath away.
“I’ll be fast,” I promise. I’ll have to be. I only have minutes until the Seam retrieves me back to my own time.
I steady my hands and pause to map his pulse. Better to get the artery on the first shot than to have to poke around for it. When I get it, my relief rushes through me like the blood filling the syringe.
Only a little time left. I don’t even know how much and I can’t bring myself to check the Seam timer to find out. I might not have enough, but I can’t stop myself from laying my hand on his.
“I’m sorry, Mr. Joseph,” I say. “I should have gotten it right the first time.”
“It’s okay, sister.” He closes his eyes.
I flee the room, my vision blurred by tears.
Outside at the nurses’ station, all patients have been accounted for and the other me is back at her computer muttering a low string of curses at the interruption.
I glance at the Seam timer and my heart falls through my chest. Fifty seconds.
I don’t have time to think. I run to the younger me, drop the ABG in her lap, and run. I feel her future shatter before her into thousands of possibilities, but I don’t turn back.
County blinks out of existence around me and is replaced by the landing zone of the Seam room.
I stagger sideways, assaulted by the sudden reappearance of temporal instabilities. I’m swimming in contradicting memories, hands that are there and not-there grab at me from every direction, there’s a wash of voices that I’m not certain are real. The chaos is swallowing me; I can’t even hear my own voice as I shout.
“Stop, just stop, just stop!”
Everything freezes for a moment, all timelines surprised into pause.
Things are always screwy after an intervention; I just have to focus on what is real, like the chair in Zina’s office. The sensory riot begins to calm as I sort memories from counter-memories, take stock of what is temporally stable in the timeline I’ve chosen to inhabit.
Zina’s face is in front of me now, rock-solid and full of concern. I focus on her, on the Seam room. Charlie lurks like a shadow; I’ll decide later if he actually exists.
“I’m all right,” I say. Zina is not convinced. “Where’s the computer? I need to document.”
The temporally unstable tech is no longer temporally unstable as she guides me over to the PanMed database. I have no idea how that might have happened, but I am definitely choking on gardenias now. I mentally tally my off-mission interactions starting at the ABG kit, but once I hit the false code I decide it’s useless. So many people were affected by that decision, so long ago. . . . I’m shocked the Seam facility itself withstood the temporal ripples.
The key field is there and not-there, but I assume that they wouldn’t sit me in front of it if it didn’t exist, so I start typing. The screen is at least solidly present.
I enter my report for the Taylore case into the PanMed database. This note will be the only record of the disaster that no longer happened. Despite my uneasiness about how far the effects of my intervention have spread, I can’t help but smile at the long list of Ms. Taylore’s subsequent appointments when they march and don’t-march down the screen. The most recent record is and is-not from last week.
Even though Zina is looking over my shoulder, I can’t keep from pulling up the file for Mr. Joseph. I’m already picturing a long list of doctor’s appointments and social work notes, wavering in and out of reality.
That one red word feels like a knife in my chest. I stare at it, unwilling to believe.
I can’t understand. I have so many counter-memories that everything I thought happened during that trip must have happened. Had Past Me not sent the ABG to the lab? Wouldn’t it be fitting if we both failed Mr. Joseph again?
But my panicked scrutiny of Mr. Joseph’s PanMed file shows that the ABG was there after all. It had been analyzed; I could see my own signature on the results. I have a fuzzy counter-memory of the confusion I felt as I watched my older self’s retreating back.
I can’t tear my eyes away from the CO2 value on the screen, even though my counter-memory knows what it says.
Mr. Joseph’s carbon dioxide level had been completely normal when he coded.
Zina’s voice breaks through my trance. I forgot she was even there.
“Mine was a sepsis case,” she says.
“I went back for him on my first intervention, when we were just starting to test the Seam. That was before Triage; I must have tried dozens of interventions before I realized that he was too far gone by the time he presented.”
“I was so sure.” My voice is a whisper.
Zina lays a hand on my arm, and the surety of it alerts me to the fact that I’m not positive about the chair I’m sitting on. Or my shirt. I bite my lip and concentrate on what she’s saying.
“Sometimes you open your veins and bleed for your patients, and then they die anyway.”
“Zina, I . . .” I can’t finish the sentence. I’m ashamed how afraid I am to leave the Seam room.
“It’s okay, Loren,” she says. I look over to Charlie; Zina knows exactly how adrift I am. “I’m going to assign you an Anchor. And you’re done with interventions. Even post-Seam.”
I nod. I can barely focus. Mr. Joseph is still unsalvageable, and now he’s out of my reach forever. My vision blurs, and I blink to clear it.
“We’ll set up a rotation of people whose existence you trust. They’ll help you deal with the disorientation, and you’ll get used to it after a while.” She smiles at Charlie. “I did, at least.”
“I don’t want to leave Temporal,” I say.
“Don’t worry about that right now. We’re not kicking you out; we just need you to get yourself together a bit. Then, we’ll talk about your place in the department.”
I run my fingers over the screen where Mr. Joseph’s file is displayed. UNSALVAGEABLE. But there’s new information in it now, information that hasn’t been run through the case-selection algorithms.
“I could work Triage,” I say.
“We’ll talk about it,” Zina says.
It’s not a no.
She’s right: the worst part about practicing any medical specialty is that sometimes Mr. Joseph dies no matter what I do to save his life. But I know that he will still be there, smiling sleepily through his spot in history, when I finally find a way.