29. high Achiever
Patient: LeíLeì
Date: 55/1/2733
Patient ID: 78367492
Presenting Complaint: Arm Pain
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Transcript
FAYE
What did we do to deserve this, Sec?
[SEC: typing on screen]
[Laugh] I don’t think I have any past lives in which I’ve pissed someone off either!
[SOUND: incoming comms call]
Ooh! Answer!
[SOUND: comms call connected]
Hi, Dr Underwood, Vesta Clinic.
VASCULAR SURGEON
. . . Right?
FAYE
Hi . . . um . . . is this the vascular surgeon on call at the Durontite Hiloovial Hospital?
VASCULAR SURGEON
. . .Uh, yes?
FAYE
Right . . . um, right. Thanks for answering my bleep.
[Pause, the VASCULAR SURGEON says nothing]
I wanted to let you know that emergency anticoagulation has been started for the patient we discussed earlier. They’re on their way to you - ETA 40 minutes.
VASCULAR SURGEON
ID number.
FAYE
Sorry?
VASCULAR SURGEON
What’s the patient’s ID number?
FAYE
Um.
[SEC: typing on screen]
78367492.
VASCULAR SURGEON
They haven’t had an angiogram.
FAYE
No - I - We discussed that - We, um - the clinic doesn’t have the capability to do that at the present time. It’s 0200 hours here and I’m the only staff member.
VASCULAR SURGEON
You need to speak to the radiologist.
FAYE
I - requested the scan?
VASCULAR SURGEON
I can’t comment on whether the patient needs clot retrieval unless I have an angiogram.
FAYE
Okay, but your department -
VASCULAR SURGEON
Lower your voice, my other head is sleeping.
FAYE
Your department has accepted the patient as a urgent transfer, I was just trying to update you -
VASCULAR SURGEON
I suggest you speak to radiology.
FAYE
Do you have a direct comms ID for radiology?
VASCULAR SURGEON
No.
[SOUND: comms call disconnected]
[SEC: questioning ping]
FAYE
[SEC: affirmative ping, typing on screen]
I wholeheartedly agree. Xaelest, you better not have behaved like this when you were a surgeon.
[SEC: typing on screen]
[SOUND: Soupy XAELEST noises]
Oh, maroon. Maroon is a guilty colour, Dr Adra!
Sec, please could you put me through to switch again?
[SOUND: outgoing comms call, hold music]
PRERECORDED MESSAGE
Thank you for calling Durontite Hiloovial Hospital. An operator will be on the line shortly.
[SEC: typing on screen]
FAYE
This music is usually better if you dance to it, but I’m way too tired for tha -
[SOUND: music stops]
SWITCHBOARD
Switchboard!
FAYE
Oh! Hello! Please could you put me through to radiology on call?
SWITCHBOARD
Sure, one second, lovely.
[SOUND: hold music restarts]
FAYE
Have you ever seen Xael on the phone to a hospital’s switchboard, Sec?
[SEC: negative ping]
She has a visceral reaction if they use terms of endearment.
[SOUND: music stops]
RADIOLOGIST
Radiology.
FAYE
Didn’t we just -? Sorry. Were we just speaking?
RADIOLOGIST
No.
FAYE
Sorry - um, hi, I’m one of the doctors calling from The Vesta Clinic about a patient who should be arriving imminently. I just wanted to check that their urgent angiogram had been vetted. Would you like their ID number?
RADIOLOGIST
What?
FAYE
Uh?
RADIOLOGIST
You’re calling to check if a scan has been vetted?
FAYE
. . . Yeah.
RADIOLOGIST
[Sigh] And you had to comms the on-call radiologist to check that, did you?
[SOUND: Soupy XAELEST noise]
FAYE
I - I don’t know? I was told to call you? Could I - maybe I could have called the scanner directly? I don’t - Obviously, I’ve never worked at your hospital.
RADIOLOGIST
Yeah, you could have called the scanner.
FAYE
Sorry? I - I was told to call you though? Um, by any chance, is your other head a vascular surgery reg?
RADIOLOGIST
I’m glad you felt the need to waste my time.
VASCULAR SURGEON
[Laughing in the background]
[SEC: questioning ping]
[SOUND: Soupy XAELEST noise]
FAYE
[Flabbergasted] I - can . . . call the scanner?
RADIOLOGIST
No. You’ve woken me up now. Hold.
[SOUND: hold music]
FAYE
Am I muted?
[SEC: affirmative ping]
What. Is. Going. On? I thought the surgeon was bad . . . but this is just - Stars, incivility is associated with poorer patient outcomes! I should tell him that!
[SEC: typing on screen]
Don’t. Don’t tempt fate. If he asks me to call the surgeon back, I’m going to lose it.
[SOUND: music stops]
RADIOLOGIST
It’s vetted.
FAYE
Sorry? Sec?
[SEC: typing on screen]
Sorry?
RADIOLOGIST
It’s vetted. You can let the surgeon know.
FAYE
But - isn’t -? He can hear this conversation - ?
RADIOLOGIST
What?
FAYE
No, um, nothing. Thank you. Sorry for wasting your time.
[SOUND: comms call disconnected]
[SEC: questioning ping, typing on screen]
I know. I lost my nerve. I just don’t get it.
[SEC: typing on screen]
I know! There’s no need to be mean! I’ve had such a bad night! Did you notice as well - they were the two heads of the same Hiloovian!
[SEC: typing on screen, questioning ping]
No! I’m not calling them back! The surgeon heard the entire conversation! And they’ll find out that their patient has arrived when the ED nurse bleeps them and says ‘Get both your heads to theatre, this patient is about to lose an arm!’. No, the best thing we can do is to get a summary over to them explaining what we did…
[SEC: typing on screen]
Aw, thank you. Um. I will. Next time, I’ll give them what for. As long as they’ve already accepted the patient for transfer.
[SEC: affirmative ping]
Shall we do it?
[SEC: affirmative ping]
Date: 55/1/2733
[SOUND: Music begins]
Patient: Okay, I’m going to mess this up because we don’t really have this in quotidian, but their Hiloovian name was LeíLeì - for their left and right head respectively. They told me that they’re happy to be referred to as Lei as a whole. They’re Hiloovian.
Patient ID: 78367492
Note: The patient consent for Dr Adra to be present in the clinic room.
LeíLeì is a 15.8 Vesta year old Hiloovian who attended as an unscheduled crawl-in overnight. I was already awake, planning to attend to one of our nocturnal patients -
[SEC: typing on screen, questioning ping]
Yes, what are they called again, Grey Kawsenclan? Rai’s sangvangi with the dentures? We need to see them next.
I took one look at Lei and knew that Mr Fangs was going to have to wait.
[SEC: typing on screen, questioning ping]
That bad, yeah.
Lei was complaining of sudden onset arm pain. They were a high achiever, presenting with all six of the six Ps of acute limb ischaemia.
[SEC: typing on screen]
Pain.
[SEC: typing on screen]
Paralysis.
[SEC: typing on screen]
Pallor.
[SEC: typing on screen]
Pulseless-ness.
[SEC: typing on screen]
Paraesthesiae.
[Pause]
One more.
[SEC: typing on screen, questioning ping]
No. It’s kind of a cheat one. ‘Perishingly cold’.
[SEC: affirmative ping]
They shuffled into the clinic room and bypassed the usual social etiquette of a Hiloovian handshake in order to keep clutching their left arm into their abdominal fluff. Honestly, my stomach felt perishingly cold at the sight.
Lei works as an asteroid mining supervisor on a Venetian vessel. The crew were heading back to home via Mars and Earth - the usual suspects - when Lei developed sudden onset, excruciating arm pain and sought medical attention. Lei had been playing, um, what game was it?
[SEC: typing on screen, questioning ping]
Um, no, sorry, you’re right. It doesn’t matter.
Lei was at rest when the pain started, Leí was playing a card game with some crewmates while Leì was engrossed in some admin work.
They were in too much pain to sit still, and chose to hop around the clinic room on their large hind legs as they answered my questions, explaining to me that they were due to see their regular doctor on Venus when they got home for a repeat prescription of their blood thinner, yartrítrìfarin. Which - [laugh] - is never something you want to hear. At some point during transit, they had lost their current supply of medication.
They take the anticoagulation as they have a metallic jikoovial valve following a nasty heart infection as a nestling. Aside from the pain, they reported a tingling in their digits which morphed into a heavy numbness. They had not been able to move their arm at all for ten minutes prior to presentation.
They did not report any, um, chest pain or breathing problems. They’d had some intermittent abdominal pain over the past week but this was likely unrelated to the current presentation. Their right upper limb and both lower limbs were unaffected.
Their past medical history included the prosthetic jikoovial valve secondary to nestling endocarditis and variodepressive mood disorder.
Lei usually took prophylactic yartrítrìfarin, but reported poor compliance recently.
[SEC: typing on screen]
Don’t. Our next patient will actually end up being the ship’s navigator who’s bleeding from every orifice because they’ve been taking Lei’s blood thinner thinking it was their vitamins.
[SEC: affirmative ping, typing on screen]
Don’t, if I have to call that hospital again, I might cry. [Laugh]
Um, Lei had no allergies.
On examination, my patient was tachycardic at 101bpm with a blood pressure of 268/95. This was likely due to their pain. Lei’s other vital signs were within normal Hiloovian ranges.
The left arm was palpably cold and, brushing through the fine, stripy fur, revealed pale skin beneath with a marked black reticular rash, like the loops of a cobweb over their skin. The most distal pulse I could palpate was present in the axillo-clavic junction.
[SEC: typing on screen ]
Mhm. Not good. They lacked gross sensation in the arm and power was 1/5.
This was . . . a . . . clear presentation of acute limb ischaemia.
Lei had quite an impressive Hiloovian hump over their back and I was concerned about a fat embolism - where the stored tissue migrates and occludes blood flow but they denied any trauma or other activity which would disturb the hump. Plus, the presence of the foreign heart valve made a blood clot far more likely.
I debated trying to locate the clot using ultrasound, but - um - but did not do this due to concerns that it would delay definitive, limb-saving management.
I gave LeíLeì a shot of opidax - 15mg - to ease the pain.
The updated Hiloovian emergency vascular guidelines were reviewed - thank you, Sec -
[SEC: typing on screen]
And they advised using anti-factor-493 as the first line drug.
Did, um, did Leí or LeÌ say anything when I left the room?
[SEC: typing on screen]
Oh, bless them. I think I’d be praying too.
[SEC: typing on screen, questioning ping]
[Laugh] No, but every little helps!
Calyxy’s gonna kill me in the morning. I turned that pharmacy store upside down trying to find this anti-factor. When I spun round far enough to face my own mess, I knew I’d done a useless 360 of the room and it was time to get back to my patient before they lost their arm for good. I scooped up the anticoagulants we did have, running back to the clinic room with a heaving sinking in my stomach and a voice in my head nattering that none of these medications were licensed for use in Hiloovian. I rushed an apology to the sangvangi, explaining that it might be a while before I could see them. Their ears twitched where they hung, and they curled upwards towards the ceiling, fanning their wings in a traditional display of respect.
I contacted the vascular team on call at the closest centre with specialist Hiloovian cover, Durontite Hiloovial Hospital on Callisto. They . . . were less convinced of my examination findings than I was and suggested that I call them back with the results of an angiogram - the scan needed to assess the vasculature of the upper limb. If a clot was present, they would accept the patient for transfer.
[Laugh] From the corner of the room, Xaelest lit up like an outraged nebula.
[SOUND: Soupy XAELEST noises]
[SEC: typing on screen]
I explained to them that the clinic couldn’t do that scan overnight. I was the only medic available and I didn’t know how. I repeatedly assured them of my clinical suspicion - no, clinical certainty of the presence of a clot. They then suggested that we anticoagulate the patient. I . . . explained that we didn’t have anti-factor-493 but talked them through the drugs we did have. As suspected, none of them would be safe or effective for use in my patient.
[SEC: typing on screen, questioning ping]
Ugh, stars. So, um, most medications, right, uh. Most, if not all, medications will have some level of distribution into fat tissues. Because Hiloovian store fat in their hump, they will also store drug there. It means that - if I remember right - most drugs meant for other lifeforms won’t reach therapeutic levels because they’re being distributed in the fat and they have much longer half-life because they’re slowly released from the fat tissue in the hump.
[SEC: typing on screen]
That’s . . . the full extent of my Hiloovian pharmacology knowledge. [Laugh]
LeíLeì stared at me with both their heads from the examination bench. Their chest-mouth frothed. The vascular team reluctantly accepted the patient for transfer but advised that it would likely be too late to salvage the limb by the time Lei arrived.
‘Is there nothing you can do?’ I was asked, ‘I’ll take one of those drugs if you think it won’t kill me!’
I explained that the drugs I had would either cause harm or simply not work. Anticoagulants tend to work on specific clotting factors and different lifeforms had different, specific, drug targets. There are very few pan-biological drugs. I promised I’d check again, in case there was something I’d missed.
I stepped out of the clinic room . . . and saw the sleeping sangvangi . . . and had the funniest little idea.
[SEC: typing on screen]
[Laugh] Yeah, I must have looked like I was losing it, walking out and straight back in again. I couldn’t ask the patient to leave the room, given how sick they were, but I did get permission to discuss something with Dr Adra with them present. I scurried over to the corner of the room where Xael wa s resting and whispered ‘There’s a sangvangi in the waiting room . . .’
I could see Xael’s thought process ripple through her membrane before settling on a swirl of jade. The coalescing form inside - her new body - shifted. Green means go.
[SEC: typing on screen]
Yeah . . . dark green has meant ‘that’s stupid’, I think. Basically, I interpreted it as ‘go ahead with your stupid idea’.
[SEC: affirmative ping]
Um, how are we going to phrase this for the letter? Um. Hm. Yes.
Unfortunately, given the relatively few Hiloovian patients and the usual level of acuity of patients at the clinic, we did not have a supply of anticoagulation suitable for use.
Yeah?
[SEC: affirmative ping]
Urgent transfer had been arranged for LeíLeì, but the severity of the vascular compromise made it unlikely that their limb would survive without urgent treatment. However -
[SEC: typing on screen]
I can’t believe I’m about to say this either - [breathes] However, there was - stars - there was a sangvangi present at the clinic at the time of the review. In order to feed, Sangvangi are able to inject a potent, short acting and, importantly, locally acting anticoagulant during their bite.
LeíLeì stared at me like I’d turned Hillovian and grown an extra head myself as I explained the proposed plan. I made it clear that consent would be required from both of them. Lei asked, with an unhappy slant to their chest-mouth, if it were not possible for me to extract the anticoagulant and inject it - thus avoiding the need to be bitten. I explained that the sangvangi needs to anticipate a bite in order to produce the fluid - like how a human produces more saliva when they’re hungry. They blinked at me. Like how a Hiloovian hump doesn’t open up unless it’s raining. They understood then.
‘You think it’s going to save my arm?’ They asked me, twin faces resolute.
‘I think it’s the only shot we have.’
I asked the other patient, who will remain anonymous in this letter, to join us in the clinic room and explained the situation and what we were asking of them.
‘Oh, goodness, that’s terrible.’ The sanvangi empathised. My heart melted a little and I saw something flicker in Lei’s eyes, something like surprised relief. The person about to bite them wasn’t the blood-sucking monster certain streams made them out to be.
The sangvangi explained that they’d never bitten anyone before, it was a bit of a cultural taboo. I reassured everyone that it was to treat a medical emergency and that no feeding would occur. Grey - uh, the sangvangi, was worried about hurting Lei, despite the anaesthetic they’d secrete along with the anticoagulation. It was Lei who reassured them - they were in so much pain already, they doubted that they’d even feel it.
For the letter - let’s summarise and say that the risks, including pain, excess bleeding, accidental feeding, wound complications, infection, nerve and vascular damage - and the benefits: providing anticoagulation, in the hope of saving the arm - were discussed. Verbal consent for the bite was obtained from both parties.
They sealed the deal with a one-handed Hiloovian handshake - Grey had to use their foot. I felt a bit -
[SEC: questioning ping]
I don’t know. It’s a symbol of trust and connection and it made me feel a bit emotional seeing people just being decent and trying to help others.
[SEC: typing on screen]
It just makes me happy.
Then the deed was done. The sangvangi flattened their noseleaves against Lei’s cold arm and snuffled up to just below the shoulder joint, ruffling Lei’s fine fur with their rapid sniffing. Once they were confident that they’d found the level of the clot, they murmured a brief and apologetic warning and their jaws protruded forwards. They bit down through the rough skin and muscle of the arm but did not latch on. After a few seconds, they pulled back and I staunched the minimal bleeding with gauze.
I administered further analgesia but would advise covering Lei with broad-spectrum antibiotics. . .
On reassessment post-bite, Lei’s vital signs were stable. It was not possible to say if there was any improvement in the left arm. It still may have been too late. I suspect that the first sign of improvement will be a significant increase in their pain as blood starts to flow through the ischaemic tissue once again.
Um, I prepared Lei for transfer and, with their consent, updated their Captain about the plan to move them to hospital. A thorough handover was given to the transfer team - who looked between Lei, myself and our friend in the waiting room with an incredulity that almost made me laugh. But, in fairness, I was feeling pretty hysterical at that point.
Ugh, I need to sort these medications out. And formally review Grey.
[SEC: typing on screen]
Hah. Yes. We can say with some confidence that their fangs are working well!
[SEC: typing on screen, questioning ping]
Oh, yeah! Add,I have informed the receiving team about the imminent arrival of LeíLeì and an angiogram has been booked and vetted.
[SEC: affirmative ping, affirmative ping]
I wish them all the best.
Signed,
Dr Faye Underwood
The Vesta Clinic
[MUSIC: The Vesta Clinic Theme]
This episode of the Vesta Clinic was created by AMC. It starred AMC as Faye Underwood, Dr Bestie as The Hiloovians and Sec as himself. Music by AMC and Ruby Campbell.
Please check out our show notes for content warnings, transcripts, and your prescription of: a normal interaction with a service worker.
If you enjoyed this episode and would like to help the show reach more ears, please tell someone who loves podcasts to check into the Vesta Clinic. You can also follow us on your social media of choice at @vestaclinicpod! A huge thank you to our Patreon supporters. We hope you enjoy this week’s bonus story and bloopers like this one:
AMC: This is the energy, right, this is why I knew you’d be able to bully me.
Dr Bestie: [Laugh] It’s different when you have to pretend, though.
AMC: [repeats, mocking] Come, on.
Dr Bestie: I’m being bullied into this, I’m blinking twice for help.
AMC: Hi! Is this the vascular surgeon on call at Durontite Hiloovial Hospital
Content Warnings: Rudeness from a colleague; bleeding; blood clots; biting; novel medical therapy
