04:17 A.M.

  The emergency department was often described as a hectic, uncontrolled environment for those that happened to walk within its walls once or twice. For those that frequented the hospital - patient or worker - the department that never slept was a place that they actively tried to avoid, if only because being there too long spelled the inevitably of something happening. Nobody knew what - just that something would happen.

  During the day, the department was truly alive. Whether it was the bustle of medical students rotating through, the strut of hospital executives doing a surprise visit to verify metrics and instill new regulations, or just the hum of the medical machine trying to process the rotation of patients with as much efficiency as it could produce, there was no denying the hustle could ensnare anyone who lingered around it too long.

  At night though, the department simultaneously quieted, but truly came to life.

  There was no silence - never silence - but a sense of suspended exhaustion. Monitors continued to hum and beep incessantly; even when silenced, they found a way to break through their code, almost as if they were designed to be smug. IV pumps clicked and beeped and inevitably went missing at the times they were sought after most. Down the hall, a ventilator played a jingle that would surely play on repeat in someone's dreams that night.

  Through the fluorescent lighting that flattened everything in the same shade of pale fatigue, Dr. Louis Fleming leaned back in his chair, rotating his shoulders until something cracked with a startling pop.

  "Don't do that," a young woman with blonde hair said without looking up from her laptop. "That noise makes me uncomfortable."

  "It's either that, or I turn to stone. Your choice."

  "You're so dramatic. You're like, thirty."

  He snorted, a smirk appearing on his lips. "Thirty-two, Megan."

  "Same difference," Megan responded, the hint of amusement trickling into her words.

  The coffee cup that previously sat lazily on the desk was cold as Louis picked the cup up, frowning as he brought it to his lips. What was once a warm cup of flavor had long since surrendered its taste and comfort - now just a cold liquid that was rather unappealing in taste.

  He drank it anyways.

  Across the nursing station, Louis watched with muted interest as Fernando and Carla worked while exchanging dry sarcasm with one another, their displayed efficiency the type that only came from experience and hectic shifts. Both typed on their computers, relishing the momentary reprieve of being able to finally chart, the inevitability of bedside lingering.

  "It's that kind of night so far, huh?" Carla said, reviewing an admitted patient's chart.

  Louis's eyes slid over to his own computer, where his tracking board was already open. Twenty-seven in the department, with six admits and three of them holding for a bed upstairs that wouldn't open until morning rounds. He couldn't fight off the grin as he spun in his chair again. "Eh; feels like any other night."

  "Yeah, well, nobody's tried to fight me yet," she said with a smirk. She grabbed her phone, sighing as she began dialing. "I'm going to call report on that PCU patient. Let's see if they pick up."

  "Doubtful - we've slammed them tonight," Fernando muttered. Quietly, he counted the number of admitted patients, wincing as he neared the double digits. "It's either PCU or ICU tonight, huh?"

  "Is it always like this?" Megan asked, finally breaking her gaze away from her laptop.

  "Yes," Louis and Fernando replied in synchrony.

  Megan blinked, slowly crossing a name off her paper list. "...that's reassuring?"

  Louis glanced at her. She still carried that 'new hire nervousness' - sharp eyes, posture that was rigid, and a sense of anxious energy that somehow made him feel anxious just by proximity. He turned back to his computer, briefly opening one of his notes to review the story she'd written on his behalf, nodding once in satisfaction as his eyes skimmed the screen. "You're doing fine, by the way."

  The way her shoulders seemed to relax by a degree told him all that he needed to know.

  "I think I spelled 'tachycardia' with a K earlier. You proofread your notes, right?"

  With sarcasm only a nocturnist could produce, Louis grinned again. "Hm. Creative. Maybe I'll leave it that way."

  "Please don't joke about that," she said with a vaguely hidden plea.

  Any retort was silenced by a dull ping overhead, followed by the charge nurse's voice echoing over the intercom.

  "Medical yellow, room 40, EMS. Medical yellow, room 40, EMS in 5."

  A collective groan moved throughout the station - not dramatic, just tired.

  "Another? That's like, the ninth one tonight," Fernando said, already pushing away from the desk. "I'm starting to feel personally attacked."

  "Flu season," Carla responded in tune. "Seems like every year we forget how bad it can get."

  Louis stood, stretching his legs with a low grunt. The way his ankles burned for a brief second, he'd nearly forgotten how much he'd been running around when he first got on shift. "It's an early start to flu season though. And surprisingly high acuity. I can't remember the last time we had this many sick people."

  "It's October, doc."

  Setting down the coffee cup with finality, Louis looked toward Carla with an exaggerated snap of the head, smiling when she cracked a grin. "It's barely October."

  Carla shrugged as she grabbed a portable computer. "Viruses don't check calendars."

  There was no denying that statement; so, Louis simply fell silent as he tossed his stethoscope over his shoulders and around his neck, rolling his shoulders in anticipation. Two medics came pacing down the hallway - not running, never running - but with as much haste as they could manage, while still somehow looking casual to an outsider.

  The waiting room had been full since sunset; according to the day team, the volume had been especially high, considering the projection of flu season wasn't supposed to hit for another few weeks. The complaints seemed to fit the bill though - fever, body aches, nausea, fatigue. All the normal flu-like symptoms. Nothing unusual in the complaints. But the volume was relentless. And the strange part?

  Everyone was testing negative on the respiratory panels thus far.

  Megan hastily stepped close to Louis, her anxious energy beginning to fill the space once more as she clumsily adjusted the laptop in her hands. He couldn't blame her, though. Most new scribes didn't get bombarded with the volume she was forced to chart for today; plus, he didn't usually work with new scribes thanks to his tendency to move fast.

  But a switched shift on his part meant that he was without grounds to complain about the circumstances. Plus, he didn't mind - she was trying, and that's all he could really ask for.

  "Another flu?"

  "Well, if I said yes, I'd be jinxing it. Plus, it would make the first."

  "Are you superstitious?"

  "Look around us," Louis said casually, as if that explained everything. "We're in the most superstitious place on Earth. There are words we've banned in this place, you know."

  A brief moment passed where Megan simply stared at him, apprehension highlighting her features. "Is that... true?"

  "Kinda."

  He didn't say anything else; he began his walk over to room 40, ignoring the glare he felt Megan giving him. The clicking of his shoes on the tile was drown out by the department around him - even in the twilight of the morning, there was patient transport wheeling around beds, environmental service diligently working to clean and restock, and radiology technicians rolling the portable x-rays down the hall with a distinctive mechanical whirl.

  As Louis reached room 40, another physician appeared at the end of the hall - her platinum blonde hair standing out as she rose her hand and pointed at the room in silent messaging. He responded by waving her off, which she seemed to appreciate, judging by the way her posture relaxed immensely. Then, like a ghost, she disappeared - probably to admit her own list of patients.

  From the other end of the hall, the EMS doors slid open with a not-so-subtle shudder, followed by the sound of a stretcher wheeling down across the tile. As the paramedics approached, Louis turned to face them, his eyes locking onto the patient in the same way they always did when he first met someone.

  The patient - a young woman, maybe in her early twenties - looked small against the sheets. Her skin was pale - or, maybe it was just her normal skin tone, but she certainly looked pale if he were the judge. Damp hair stuck to her temples as the faint shine of sweat clung to her forehead.

  The assessment began without Louis saying anything, just as it always did. Skin tone. Breathing effort. Level of responsiveness. All of his normal primary survey checks.

  And, like almost every other patient he'd seen so far, she looked like all the others.

  As the stretcher came to a halt in front of the room, one of the medics broke off from the guidance of their patient to hand Louis a strip of paper with a thin-lipped grimace. "Heya doc. Uh, twenty-three-year-old female coming from home. Three days of nausea, vomiting, fever, malaise... roommate on scene said that she's been sick the past few days but today was definitely different. Less responsive. We couldn't really get her to say anything."

  "Vitals?" Louis asked, his eyes scanning the EKG strip he'd been handed. Fast heart rate. But nothing unusual otherwise...

  "Temp 38.5. Heart rate 129. BP 96 over 61." Louis suppressed a groan. Another sepsis alert. "Respirations 24. Satting 98 percent on room air. We got an 18-gauge in the right AC, and we hung a liter en route. She meets sepsis criteria by our protocol."

  From inside the room, Fernando adjusted the bed so that the gurney was at level with it, grimacing as he heard the vitals. "Just like the rest. Doc, you want more fluids?"

  "Yeah. We'll do the whole bundle - lactic acid, cultures, antibiotics. I'm not a fan of that blood pressure." He stepped into the room, setting the EKG strip near Megan as he adjusted his stethoscope. He stood next to the patient as she was moved over from the stretcher to the bed, barely reacting at all as she was gently jostled.

  Just like the rest, yet again...

  "Hi, sweetie," he said gently. "I'm Dr. Fleming; I'll be taking care of you. Can you open your eyes?"

  Her eyelids fluttered. She didn't quite focus on him immediately; instead, her gaze seemed distant, unfocused. There was a lag as her eyes lazily slid toward him - a second longer than he'd anticipated.

  "Can you tell me your name?"

  "...Hannah," she murmured.

  "Do you know where you are, Hannah?"

  Stolen from its rightful place, this narrative is not meant to be on Amazon; report any sightings.

  There was a pause.

  Her gaze shifted again - but this time, away from him, slightly above his shoulder, like there was something there. He was half-tempted to turn to see if there was something peeking behind him, but it was important to maintain his attention on her. Especially during this part of the exam.

  "...home."

  "Yeah, that's not right," Fernando muttered as he grabbed a saline flush from the bedside cart.

  Behind him, he heard the sudden pause in Megan's typing - undoubtedly confused by her statement. Louis, though, tried to keep his expression neutral. He spoke lightly, trying to keep his voice soothing for the ill girl. "Not quite. You're in the hospital. You have a fever - we're going to take care of you, okay?"

  Her fingers twitched against the bedsheet. Not a tremor, but not a simple flex, either.

  He filed it away as he popped his stethoscope into his ears, placing the diaphragm of the device against her chest. Even with gloves on, he could feel how clammy her skin was - and with a fever, he chalked up another note in his mental book. "Does anything hurt?"

  "Head," she whimpered. "Behind... eyes..."

  Carla, who had been collecting vials of blood from the IV established by the paramedics, gave Louis a look. "That'd be the fifth tonight with the exact same complaint."

  "Think it's six," Fernando supplied.

  Louis didn't comment.

  Frontal headache. Disorientation, bordering on delusions. Notable fevers. Elevated heart rate, which could theoretically be explained by dehydration and volume loss... but might also be disproportionate.

  It all fit influenza. Mostly.

  "Can you hand me that otoscope?" Louis said lowly, gesturing to the small device on the wall. Carla grabbed it and wordlessly passed it to him like she'd done a million times before. Twisting the dial, he gently raised the light to her eye, using his fingers to pry her eyelids open to measure the pupillary response. They were equal. Reactive. Slightly sluggish, though.

  Behind him, the paramedic who'd given report shuffled uneasily. "Her roommate also said she'd been... jumpy?"

  Louis paused in his assessment. "Jumpy?"

  "Like, she kept startling at small noises. I kind of figure it's nothing, but... she also seems not quite oriented, so figured it's worth passing on."

  Fernando snorted as he walked over to the portable computer Carla had brought in. "That's me every time I'm sick."

  Non-specific, Louis thought to himself. "You seem like a 'man-flu' kind of guy."

  "Please, it just hits me different."

  "Right, well, ignoring that, same thing as everyone. I'll adjust the fluids; otherwise, labs, viral panel, sepsis, and... yeah, let's see what we're working with." He handed the otoscope back to Carla, who hung it up, and gave him a thumbs up. "Also, I'll put in some meds - has she had anything at home?"

  "Not that we were told," the medic responded, finishing up documentation on his tablet. "Guessing she won't be signing... ah, can I get one of your signatures?"

  As the medic collected the remaining information and signatures, Louis stepped out of the room, immediately eyes locking on the nearest sink to wash up. Megan followed behind, frantically typing with one hand as she walked. Water rushed over his skin as he pondered the case, reviewing the information over and over in his head on repeat.

  "Weird that so many people are a bit disoriented, right?"

  Louis stared at the stream of water, as if it might answer her.

  "Yeah..." he admitted. "I was just thinking that. Y'know, I haven't done any lumbar punctures today, but... I wonder if this is some weird viral encephalitis picture..."

  "A what now?"

  He turned off the faucet and reached for a towel. "Viral encephalitis - an inflammation of the brain, sometimes viral. Encephalitis can also be bacterial. It can cause a lot of the symptoms you're seeing so far. Things like fever, headache, confusion... behavioral changes."

  "So..." Megan paused in her typing to look up. "What does stabbing someone in the back with a needle do for that?"

  Louis couldn't help the hardy chuckle as he turned off the water and dried his hands. "It's not that the procedure does anything for them. Rather, it's a diagnostic tool - we can review the fluid from the spine to review the cell counts, and things like sugar and whatnot within to help infer whether or not there's potential pathology. That can help guide management."

  "Oh."

  A pause filled the conversation like a growing bubble, before Megan spoke up once more. "So... why haven't we been doing that?"

  It was a fair question.

  "Well, for one, I really haven't been convinced by any of the patient's we've seen today - they've been a bit out of it, but not... her," he said, gesturing to room 40. "Their stories are all over the place, but they're consistent in their complaints. She's just... the first one who really seemed off. Clinically, she's the first that might fit that picture. But, damn... that's going to be an annoying procedure."

  "Are they hard?" Megan hesitated a second, before rectifying her statement. "I mean, like, does it take a lot of time?"

  Louis ushered her toward their desk once more, seeing Carla's pointed gaze lock straight onto him. He hadn't yet put in the orders.

  "They can be - and they're time-consuming. But..." As he popped onto his chair and pulled up the medical record, his fingers slowed in typing. "...maybe it wouldn't be a bad idea..."

  "We've got a lot of patients..." Megan offered. She wasn't wrong, either. Their list hadn't quite shrunk since they'd started their shift - and, judging by the way people kept checking in, there was no end in sight. While she might not have intended it, the devil's advocacy was spot-on.

  But, staring at Hannah's chart, Louis couldn't move further. He'd clicked on all of the orders, the medications were ordered, and the labs were toggled... all except for the lumbar puncture orders. His eyes lingered over the button. It was just a click - a simple press of his fingers... and then he'd be locked in on doing it. Subconsciously, his teeth began to gnaw his bottom lip as he pondered the situation.

  She had no seizure-like activity that EMS had reported. She didn't appear to have any focal deficits. Clinically, he could just chalk it up to her fever and maybe some dehydration. But...

  You know the rule, Louis... if you think about it twice, you should just do it...

  "Fuck. Alright." Startled, Megan looked over at him suddenly as he spoke - but he didn't care. The ripple of resignation had already clawed through him as he clicked the button, signing his fate. "Maybe it's nothing, but..."

  There was a moment he simply stared at the screen, the orders already being processed. Then, from the room, Carla's voice echoed out, loud and clear: "did you mean to click CSF samples?!"

  He sighed.

  It really was that kind of night.

  Setting up for the lumbar puncture was easy enough; the pre-built kits had nearly everything needed, and anything else was paperwork-based.

  The hard part was finding the time.

  Nearly two hours had passed since Dr. Fleming had initially seen Hannah; there were still just over a dozen patients on his list, and each one seemed to require just a little more than initially expected. Most of them were being admitted. The phone calls became monotonous as he eventually ended up apologizing to the on-call hospitalist after the sixth patient, though their resigned sigh was born from a place of understanding rather than frustration.

  Between the admission calls, Louis tried to make time for the patients, and more importantly, their families. He always tried to make time for them. Early in his career, he'd learned that answering questions clearly - setting expectations honestly - made everything smoother. Fear softened when people understood what was happening.

  Unfortunately, the most common question was the one he couldn't answer.

  "When is this going to go away?"

  As the clock neared 7 a.m. - and subsequently, the end of the shift - Louis finally found a block of time that he really wanted to use for charting. He was at least 29 charts deep and hadn't signed a single one.

  Instead, with a quiet sigh, he wandered over to the storage room and grabbed a lumbar puncture kit, before heading over to room 40. Close behind, Megan matched his pace, almost giddy with excitement.

  "You're okay with me watching? You're sure? You won't get nervous?"

  Louis gave her a tired smile. "I promise, it's fine. But you understand that if there's something bacterial, you may need to take antibiotics just by having been in the room?"

  "Yes! I've never been able to see this before - and, you know, I really want to go to med school, so I'll be exposed to all this stuff, and --"

  "Alright, alright," he interrupted gently. "It's not that exciting, anyways."

  He pushed open the door, taking a deep breath in just before he entered.

  On the bed, Hannah was on her side, curled into a ball. Whether or not that was intention, or if it was because Carla had been generous enough to try and position her pre-emptively, he didn't know or care - he was simply appreciative.

  "She's still febrile," Carla mumbled as she adjusted the bag of fluids that was nearly done running. "Her heart rate is a bit improved... 110."

  "Any change in responsiveness?"

  "About the same."

  Louis crouched down to Hannah's level. "Hannah?"

  Gently, her eyes fluttered open. And, just like before, there was a hesitation in her tracking, where she stared forward, but nowhere. Then, her pupils fixed on him, though her fatigue didn't vanish. He nearly winced - but kept it under wraps. "It's me again. I think we need to do a procedure known as a lumbar puncture."

  He paused, allowing her the opportunity to respond. But, as she blinked slowly, he realized he wasn't going to get any type of response. So, he continued.

  "It's where I take a needle and insert it into your back - and I check your spinal fluid for signs of infection. Is that okay?"

  There was no nod. No response. No questions. Just her staring back at him blankly. It was difficult to tell if there was even any thought behind those tired eyes; the way she focused on him, he was almost positive that she was hearing him - but he couldn't gauge if she understood, or if she was just... hearing him. He glanced toward Carla, who gave him a small shrug and grimace.

  "Sweetie, I need to know if that's okay."

  Still nothing.

  Louis gave it a moment before standing straight again, sighing as he ran a hand through his hair. "Well, that's... something. She's responsive...ish. CT was clear for anything - so, we're clear to go from a medical standpoint... but we need to get her consent. Should we... call fam-"

  "...don't like that..."

  Louis went silent, realizing the soft voice had come from below. He crouched down again, locking eyes with Hannah. Her eyelids drooped as she sniffled once, her whole form looking fragile.

  "You don't like that?"

  Her eyes looked glassy. Exhausted.

  "No..."

  "I don't blame you... it's not very fun. But... I'm worried about you. Are you okay if we do that procedure?"

  "...okay."

  His gaze flickered upward to Carla, who nodded once. The room was silent, aside from the beeping of the bedside monitor and the very subtle buzz of the lights overhead.

  "...alright then," Louis said with a sense of finality. He watched her to see if there was any resistance. "We proceed forward."

  Wordlessly, he opened the kit and pulled out the gown, carefully donning it as he'd done so many times as a resident. Carla took a moment to adjust the bed and rails so that there was nothing in the way, but also so that he had the most space to work - something he appreciated immensely as he offered her a quiet 'thanks'. Megan watched silently, poorly concealed anticipation in her gaze, as Louis gently set the sterile material around the bed. He gently pressed on Hannah's skin, feeling the exact space he'd need to enter in her spine, then donned his sterile gloves.

  "Alrighty; cleanse time and... let's hope for a good first try," Louis muttered, more to himself than anyone. With his iodine, he meticulously cleaned the skin, before dropping the sterile drape over her back so that a hole looked back at him - the same place he'd be entering with the needle.

  "Head... hurts..." Hannah's muffled voice came through, her arms covering her face.

  "I know, sweetie. We're going to do our best to help you."

  I promise, he added silently.

  With careful movements, Louis grabbed the lidocaine that came in the package, quickly inspecting the outside. Then, he drew it up in a syringe and entered the skin. As he aspirated, he spared Carla a glance, who was at the head of the bed, near Hannah's head where she was gently whispering encouragement to her.

  She hadn't moved at all when he'd inserted the first needle. He wasn't sure if he liked that or not.

  Once he'd injected the numbing medicine, he withdrew the needle and changed to another type; then, he paused for a brief moment, steadying his breathing. "Alright, Hannah. Little pressure, okay?"

  She was silent, just as she'd been.

  With little resistance, he guided the needle forward, feeling the resistance build as he met the tough ligament of the spine - then, a pop as he breached through, followed by the sudden dripping of clear liquid. A grin flickered across his face momentarily, satisfaction filling his being, before he squashed the feeling down. He'd have time to feel boastful later - right now, he had a job to finish.

  He grabbed a manometer from the kit and balanced it, removing the needle but leaving the catheter within. Then, he adjusted a stopcock to the tube, blocking the drainage of any further spinal fluid.

  "What's that?" Megan's voice came suddenly, breaking the silence.

  "This is for measuring the opening pressure," Louis responded evenly. "It's... normal. That's a good sign."

  He adjusted the stopcock, draining the manometer into the first tube, and then allowed the fluid to continue to drip into the tube. Then, he changed tubes once, twice, and a third time - until he had four filled tubes. Finally, he removed the tube, removed the catheter, and bandaged the site. A sigh of relief - a breath he hadn't even realized he'd been holding - came out as he finally pulled off his gown.

  Grabbed one of the tubes, he inspected the liquid, nodding slowly as he did so.

  "It's... clear."

  "Is that... is that good?" Megan asked slowly.

  "Yes." Louis felt another wave of relief - this one, for Hannah's sake. "Yes, that is. Cloudy is bad. Clear is a good start."

  Then, there was a gasp. Louis quickly turned to Hannah, who had pulled her arms from in front of her face. Her eyes - slight red, possibly from the fever - locked onto Megan with focused intent. But she didn't say anything. She didn't move. She simply stared.

  "Hannah...?"

  Louis didn't dare move; the way her gaze hung on Megan was almost calculating.

  "...too loud..."

  Louis and Megan exchanged a glance, something cold and unspoken passing between them. "Alright... we'll give you some quiet..."

  It wasn't a request or a suggestion - it was an escape for the duo. Louis gave Carla a purpose glance as well, as if to say, 'give her some privacy'. The woman gently whispered something in Hannah's ear, gave her shoulder a gentle squeeze, and then left the room with the duo, ensuring that the door clicked closed quietly, yet somehow louder than it should have.

  Carla turned to Louis immediately, her brow furrowed. "That was..."

  "Weird?" Louis offered. "Bizarre? Atypical?"

  "Yes... to all of those."

  "Sorry." Both turned to Megan, who seemed a bit smaller than normal. "I didn't mean to be so loud..."

  "Megan, no," Louis began, gently placing a hand on her shoulder. "You didn't - or weren't loud. I... that wasn't... I'm not sure what to make of that, but you didn't do anything, alright?"

  It was clear to him that she wasn't convinced. If anything, she looked even less confident now than when she'd first begun the shift. Louis's frown deepened, wondering how he could cheer her up.

  "So..." he transitioned casually, "was that cool?"

  A flicker of a smile appeared on Megan's lips. "...yeah. That was pretty cool."

  "C'mon, I'll show you how to chart that," Louis said, guiding her back to the desk with a smile.

  But, as he walked back toward the desk, his eyes flickered back toward the room - and the young woman the rested within.

  The spinal fluid was clear. The opening pressures were appropriate. She was still relatively stable, despite her lingering fever and elevated heart rate. It was the end of another shift, he'd done his job, and that was all he could do.

  So... why did he feel like something was so wrong...?