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  In his years as a rescue diver and a medic, he’d learned not to embrace anxiety but to focus on the job. In the medical field, this was called clinical detachment; in the military, it was called keeping your shit together. Setting himself straight in his seat, John took long, deliberate, deep breaths and counted them up to twenty-one, doing the best he could to think about nothing—usually an impossible task. He let his torso muscles relax and his attention focus on the job ahead. He would get to the victim, ensure the scene was safe, and start an initial evaluation. Megan would take the woman’s vitals, gather history from bystanders, and make sure the path out of the room was clear for transport. They wouldn’t be too far from University Hospital; the ER was just across campus, maybe two miles away and a straight shot, as long as the roads were clear. Calmer now, John watched the campus pass by.

  “KEA571 to Medic 82. Campus security advises you to use University Drive North, due to construction on University Drive South,” the dispatcher relayed.

  “Medic 82 to KEA571. We’re already on University Drive North. ETA one minute,” John replied. He turned to Megan. “Did you know about the construction?”

  “No. A woman in a lab coat was standing at the intersection and directed me this way.”

  “Nice of her to help, but she could have been wrong.”

  Megan shrugged. “Dunno. Doesn’t matter, really. We went the right way.”

  Medic 82 pulled into the driveway of building 87 and onto the blacktop emergency apron, then stopped at the front door. John called in their arrival to dispatch. Building 87, built in the 1950s, was a solid brick structure bound by sandstone. Yellow-and-black emergency fallout shelter signs hung by the entryways. A moment later, a blue-and-white University City police car pulled up behind them. The vehicle stopped far enough behind the ambulance to ensure it wouldn’t block the ambulance’s rear doors.

  A campus security guard held the building’s front door open with one hand and his radio with the other. He spoke into it; though John couldn’t hear him, he probably was telling the other units and the dispatcher that Medic 82 and the University City police had arrived.

  John and Megan easily rolled through this part of the call. They were so practiced that it was like a dance. They pulled out the gurney, dropped its legs, placed their equipment on it, and hurried toward the entryway with him pushing and her steering. When they reached the elevator, another guard held the door for them. All three boarded, and the guard hit the button labeled “1” for the second floor. The elevator was old, probably original to the building, and was cramped with the gurney and three of them in it

  “Where’s the patient, and what’s her condition?” Megan asked the guard.

  “Dr. Aida Doxiphus. She’s is in the neuroimaging lab. My partner is with her. He said she’s lying there unresponsive. We’ll turn left out of the elevator and head down the hall to room 2361 on the left.”

  “Any hazards? Chemical? Physical?”

  “No. She has some kind of brain scanning machines in there, but those are in separate rooms. No leaks or chemical spills.”

  A moment later the door slid open. Megan was out first, and the guard held the elevator door until John and the gurney were clear, then followed the EMTs, his rubber-soled shoes squeaking on the floor.

  John and Megan made their way down the hallway at a trot, guiding the gurney between them, their equipment safely cradled on it. The lab door, also original to the building, was wooden with security glass in the top half. The letters stenciled on it read

  neuroimaging/transcranial magnetic stimulation/transcranial direct current stimulation.

  John entered the lab first. Squinting his eyes against the sunlight, which poured in through the eastern wall of windows, he saw a woman, lying flat on the floor. Her legs were straight and her arms at her side, as if she’d just been standing but then decided to lie down on the cool linoleum floor to close her eyes for a few minutes. She lay in an aisle between two long lab benches that held rows of Sigma chemical bottles, a water bath, and an old stirring plate. She had long dark hair and a dark complexion. Under her white lab coat, she was dressed in an expensive-looking white silk blouse, a khaki skirt, and flats. She had the toned look of an athlete; perhaps she’s a runner, John thought.

  He looked around to get a better sense of the room. A man in jeans, a faded Red Hot Chili Peppers T-shirt, and a lab coat leaned on the lab bench for support.

  John approached the man. “Hi, I’m John, and this is my partner, Megan. We’re here to treat this woman. Do you know her? Did you call this in?”

  “Yeah, she’s my boss, Aida Doxiphus. I called this in.”

  John stepped over to the woman. “Dr. Doxiphus, can you hear me?” John called out loudly, but the doctor gave no response.

  Megan tossed a pair of exam gloves to John; body substance isolation was mandatory on every call.

  Megan continued as John gloved up. “What’s your name?”

  The man nervously paused; he looked a pale and diaphoretic.

  “Megan…,” John started, but she was already moving.

  “I got him. Sir, let’s get you to sit down here,” she said. She and one of the security guards helped him to the floor. It wasn’t uncommon to respond to a call for one person and end up with multiple patients. They never knew how the situation would go on-site.

  “Bill. My name is Bill,” he finally choked out.

  “What happened here, Bill? What time did she collapse?”

  As she asked this, John’s focus split in two, one part examining the patient while the other listened to Bill for clues. He paid more attention to the first; Megan would handle Bill.

  John began his assessment, logging mental observations for later use. The patient was lying there, eyes closed; he didn’t see any obvious signs of trauma from a fall, no blood or contusions, no deformed joints or limbs. He knelt next to her and checked the left carotid for a pulse. It was there; he counted them for thirty seconds. “Sixty-five bpm, normal. Color looks good. Skin is warm and dry,” he called out to Megan. Okay, so this isn’t a cardiac call.

  “I came in right at eight a.m.,” Bill said, “and Dr. D was already here, in her office on her computer. She looked okay to me.”

  John tilted the doctor’s head back as far as possible in order to open her mouth and an airway. The visual exam of the airway looked good; he swept his index finger across the inside of her mouth and throat. Dr. Doxiphus gagged a little, but he found nothing; her airway was clear. He watched her chest rise and fall in slow, regular waves and counted the breaths as he timed out sixty seconds on his watch.

  “Respiration fourteen breaths per minute, regular and normal, clear airway, and she’s breathing on her own.” John relaxed a bit; no resuscitation was necessary.

  “I said hi,” Bill said, “and put my stuff on my desk. Then I went to go to the bathroom and grab a cup of coffee, right at ten after…”

  Megan left the now seated Bill. She had a clipboard in hand and a blood pressure cuff under her arm. “Ready for vitals, John,” she said, putting down the clipboard.

  “When I came back, at quarter after, I found her right there, just like that,” Bill said, his voice cracking.

  John opened the patient’s blouse and placed the head of his stethoscope on her chest, listening to her breathing.

  Megan, looking at the woman closely for the first time, gave a slight start. “John!” she whispered with a note of mild alarm. “This is the woman I saw, the one who redirected us to University Drive North.”

  “What?”

  “Seriously, this is her or her twin. She’s wearing the same clothes!”

  “Can’t be. It probably was just someone who looks like her,” he offered.

  “No, this is her. I’m sure of it,” Megan said as she examined the woman’s face and hesitated in bewilderment.

  “What are you talking about? I’ve been here the whole time. She hasn’t moved,” exclaimed Bill.

  “Okay, we’ll so
rt that out later. Right now we need her vitals,” John said, trying to get the call back on track.

  “Right,” said Megan, fitting the blood pressure cuff on Dr. Doxiphus’s left arm. “One ten over seventy-five,” she called out, then noted it on her clipboard.

  “Lungs are clear,” John said. “What’s her pO2?”

  “Ninety-nine percent on room air. Her vitals are all good.”

  “I went to the phone right away to call 911,” Bill continued. Although his voice was steadier now, he was blinking as though he were trying to send a Morse code message.

  John gently lifted the patient’s eyelids and flicked his penlight twice into each eye. “Pupils are equal and reactive. Pupillary response normal.”

  He moved to kneel by her head and quickly ran his hands down the back of her head and neck. No trauma; neck was supple. He continued his exam, feeling her torso, arms, hips, and legs, looking for any subtle injuries that his initial visual exam might have missed. Everything was normal, and the woman had no medical tags.

  “The exam is good. The only sign is an AMS–altered mental status–so I’m thinking neurological or pharmaceutical,” he told Megan.

  Megan nodded. A pharmaceutical check meant looking for obvious signs of drug use. She moved to visually examine the insides of the woman’s arms, by her elbows and her fingernail beds—which she pinched to push the blood out and timed how long they took to refill—and behind her knees. “Negative exam. Capillary refill is normal,” said Megan.

  “Bill, is she on any regular medications? Does she have diabetes or a history of seizures or allergies?” Megan asked.

  “Dr. D?” he squeaked. “No, she’s really healthy, never misses a day. I don’t know about any medications, though.”

  “When you saw her, did she make any remarks about unusual smells, lights, or sensations?”

  “Uh…I don’t know. I mean, she was in the other room and looked okay.”

  John looked up to one of the guards. “I need you to check her purse for any prescription bottles. Look for Keppra or Dilantin or an insulin syringe—she might be diabetic.”

  The guard moved quickly to the office.

  “Bill, are there any drugs or chemicals in here that she might have accidentally been exposed to?” John asked.

  “Yeah, we have plenty of chemicals, but I handle them mostly, and nothin’ happens to me.”

  The guard returned. “There aren’t any medications in her bag or computer case.”

  Nothing more to do here, John thought. The patient was in neurological emergency, but the assessment was inconclusive. He had to treat this like a stroke or long-duration seizure, maybe status epilepticus. They had to transport her quickly.

  “How old is she?” John asked Bill.

  “Fifty, I think.”

  John stopped and keyed his radio to call in the assessment results and ask for orders from University Hospital ER. He was good at his job and wasn’t surprised when there weren’t any.

  “Let’s wrap her up and move her,” he said.

  He got the gurney and dropped it to its lowest level while Megan finished taking notes. They moved the patient to the gurney, laying her on her side so she wouldn’t inhale anything in case she vomited. After he placed a folded blanket under her head for support, they strapped her in and rolled her to Medic 82.

  On the way to the ER, John again took her vitals, which were steady. She was a three on the Glasgow Coma Scale, the lowest possible score, which indicated severe neurological dysfunction, and she had no response to a hard pinch of her earlobe. She was possibly in a postictal state from a seizure, though there were no signs of a grand mal, petit, or absence, and she wasn’t showing any of the expected signs of recovery. She also showed no signs of a stroke, though nothing could be ruled out with the equipment and time they had. John called this information in to the University Hospital ER.

  Despite the woman’s stability and generally sound presentation, she was in a serious situation and time was against her. If she had suffered a stroke, time was key. John checked his watch; it was 8:38. The tech had last seen her at 8:10 and called in at 8:15. So she’d been down between twenty-three and twenty-eight minutes. He checked her vitals again—no change. As he did, a thought struck him. The call from the dispatcher came at 8:25, and the lab tech said he called it in at quarter after, and he was so sure of the times too.

  John stopped himself with an audible, “Huh?” 911 never took ten minutes to tone out—verbal shorthand for dispatching—a medic. He paused, mulling this over. The timeline didn’t fit.

  2 Equilibrium and Potentials

  S itting in the third row of the lecture hall, Natalia Doxiphus yawned once, then again. Any more and she knew the professor would get irritated. Seven thirty a.m. was too damn early for the start of a summer class, and she was on her second cup of iced coffee. It frustrated her that her parents, Doctors Gregorio and Aida Doxiphus, were making her take this class at all, but they insisted that she follow the established series of coursework.

  “Talking about neurobiology at home isn’t the same as doing the lecture and lab work. You have to take these classes for the experience, besides, they’re required for your major,” was the response she had received from her parents every time she broached the subject of skipping over the introductory material.

  Thankfully the seventy-five-minute introductory biological psychology class was nearly over. Professor LaVista was rushing through the last of the material in his slide deck. They were covering resting potential—the state that neurons always return to after they’ve fired.

  “The sodium-potassium pump, here at point one of the diagram, moves three sodium ions out of the neuron for every two potassium ions it moves into the neuron.” As the professor droned on, Natalia’s eyes glazed over as she stared at the projected slide. I know this stuff. This is so boring. No wonder I can’t stay awake.

  She drew zentangles on the border of her notebook page, and her mind drifted while the professor spent the next few minutes discussing the sodium-potassium pump. Despite her best intentions, Natalia’s eyelids started to slide down. They snapped open when the professor said, “The sodium-potassium pump runs all the time, even in a sleeping brain”—he looked right at her— “and is responsible for a large amount of the brain’s energy consumption.”

  He was just too damn awake for Natalia’s liking, but then Uncle Tony always had been a morning person.

  “Any questions?”

  “I’m unclear about one thing, Professor,” blurted out a biology major from the front row, for the ninth time this morning.

  “Steve,” acknowledged Professor LaVista, trying not to let his irritation show, and modestly succeeding.

  “Since the pump is always moving sodium ions out of the neuron, and the cell membrane is selectively permeable to potassium only, how did the sodium get into the neuron in the first place, and why doesn’t it get depleted?”

  “That’s a reasonable question but a little ahead of where we are. Anyone have any thoughts?”

  No one immediately volunteered, not that the professor would have noticed, as he was ignoring Steve and focusing on his slide notes. After a few beats, and still without looking up, he called out, “Natalia, would you care to help Steve out?”

  Natalia groaned inwardly. Not again, not today. I hate talking in class. I’m a junior. Let the kiss-ass senior figure it out for himself. But Uncle Tony had asked, so she put on a good face and turned toward Steve. After stifling a third yawn, she explained in an authoritative tone.

  “The sodium ions enter when the neuron is propagating an action potential,” she told Steve, who looked puzzled. She decided to take pity on him. “When the neuron is exposed to enough depolarizing stimuli, its resting potential—that’s the electrical charge difference between the interior of the cell and the extracellular space—starts to move in the positive direction, toward the threshold. When it reaches the threshold, which is about minus thirty to minus forty mV, the polar
ity of the cell changes briefly and the voltage-gated sodium channels open for about a millisecond, allowing a rapid influx of sodium ions into the cell’s interior down the sodium concentration gradient. The potassium channels close during this time. This activity is the generation of an action potential in the neuron. Then the charge-gated sodium channels close, and a combination of the work of the sodium-potassium pump and the reopened potassium channels restore the neuron to its resting state, or resting potential, so it’s ready to fire again. That’s where the sodium comes from.”

  Natalia finished and hoped the professor wouldn’t ask her to use the Nernst equation to predict the balancing point between the electrostatic pressure and the concentration gradient for potassium.

  “That’s exactly right, Ms. Doxiphus. Thank you,” Professor LaVista said, beaming. Steve looked sheepish; Nat gave him a weak smile and turned back to the front of the room.

  “That’s it for today. Your last tests have been graded, and the scores are available on the website. Be prepared for next time. We’ll be covering action-potential propagation.”

  There was a general thumping of books and closing of laptops as the class rose as one from their seats.

  “Natalia, do you have a second, please?” Professor LaVista asked.

  “Sure.” She walked to the podium, hoisting her messenger bag on her shoulder and clutching her tablet.

  He glanced up to make sure no one else was within earshot, then continued in a softer voice. “What do you think of Steve? He applied for a TA position.”

  “After a question like that? From a senior in a science major? I don’t know. This isn’t hard stuff, Uncle Tony.”

  She had grown up knowing this man as Uncle Tony. He was her godfather, her mother’s peer, and a longtime friend of her parents; he had known her from birth and had been over to their house for formal departmental dinner parties every few months and for more relaxed meals, birthdays, Christmas, Easter, and all the other holidays for as long as Natalia could remember.