The Diagnosis of Doctor Miller

THE DIAGNOSIS OF

Doctor Miller A DARK TALE

THE DIAGNOSIS OF DR. MILLER

A Dark Tale By

John-Michael Perez

ONE: “Since different regions of the brain participate in different functions, the pattern of clinical signs and symptoms that follow injury depend as much on the region of brain involved as on the pathologic process.”

PATHOLOGIC BASIS OF DISEASE 9TH ED. ROBBINS AND COTRAN

Dr. Cara Miller woke up staring at the ceiling of her vacation home, a luxurious cabin situated amid the forests high in the Appalachian Mountains with high, vaulted ceilings and an elaborate fireplace laced with wrought iron accents,. A reddish light painted tinges of dusk across the dark room.

Her back was stiff against the hardwood flooring. Beside her stood an elephantine antique mahogany table littered with blackened pockmarks of age. From her position on the floor she spotted a bright green wad of spearmint gum pressed into the cranny between the table and one of its legs.

An old memory roused. The first day, the first supper, too much wine, and a happy husband who had carried her to the master bedroom for the christening of their new home.

Dr. Miller was a surgeon. She was as organized and structured as a mathematical equation. The wad of gum she had placed all those years ago was an erroneous variable she had forgotten to extricate. Something she might have expected from her husband Alek, the philosopher and professor.

She lifted her head and saw a tall ladder looming large above her. A sudden gasp bellowed up toward the byzantine ceiling before falling mute without reverberation.

It sent chills up the spine she was sure she had severed. She kicked her legs up into the air and allowed them to fall back down. The thud carried with it a great calm as she once again lay flat in the delicate limbo between laughter and tears.

Her gaze returned to the ladder. It was tall. Fifteen feet, at least. She had been changing one of the tiny flame-shaped bulbs on the 300 pound rustic chandelier that lorded overhead. She cautiously sat up expecting to feel pain, but instead felt remarkably limber and rested.

Not a single fleck of blood marked the floor, and a quick rub of her head revealed neither laceration nor induration. Her only discomfort was an enduring rigidity across her back and down her legs.

She gingerly arose, taking one long step out from under the rusting chandelier’s girth. I’m fine. She needed to go to the hospital for a head trauma workup. A head CT scan to see if blood was collecting between her skull and brain and a neurologic

workup for signs of concussion. But she knew she wouldn’t. She was a doctor. She was fine.

She began a slow walk circumnavigating the kitchen island, one hand tracing the edge of its cold granite icing. From the other room she could hear the television. “We have breaking news on the deadly courthouse shooting in Las Vegas. We now know of a possible motive for the attack.” It was Anderson Cooper. She looked out the window over the sink. The sky was a dusky orange—about 6:30. Anderson came on at 10pm. Cara checked the clock over the stove. 2:15.

She rounded the final turn and saw a small fire shaped light bulb hovering six inches from the floor just behind the ladder. Her stiff back rounded over and she grabbed the bulb off its invisible shelf. It felt real. She tossed it into the air and watched it trace a smooth arc before shattering on the antiqued hardwood.

A bleed under the skull has nowhere to grow. A bleed above the dura (the sack which covers the brain), squeezes the brain to one side. Mounting pressure eventually crams the temporal lobe (visual memories and sensory input) down through the round hole in the skull, compressing the brainstem and the posterior cerebral arteries. She looked at her reflection off the black granite counter. Her eyes were not dilated. A good sign. I’m fine.

She strode into the main living room. Above the fireplace, two long metal screws had been used to hang her husband’s baby - an 80” flat screen TV. It sounded queer and distant. “Dollar days are back at your Honda sign and drive event…” and the screen was frozen with an image of the President speaking. She had caught the first part of this speech before changing the light bulb. The CNN ticker claimed it was 5:45pm.

She turned her head left, then right. Was one speaker louder than the other? No, one ear was quieter, perhaps damaged by her fall. She walked up to the TV and pressed her right ear directly to the speaker. The sound didn’t grow like she anticipated.

Isolate the problem. Isolate the right ear, by covering the left.

As she did, there was not the faintest reduction of volume. Her hand was air; a specter’s hand. Her right hand bolted up, and she pressed the heels of her palms firmly over both ear canals. The sound persisted and a voice spoke to her from within her head “The McRib is back for a limited time so get yours today!” It was dizzying. Dr. Miller ran out of the living room away from the sound and the frozen image of the President.

The brain on CT scan is full of minor asymmetry yet maintains clear and symmetric regional separations particularly between its hemispheres. She pictured a CT where the line between brain hemispheres swooped deep into the right, cramming the auditory cortex against her skull.

Ears still covered, she returned to the kitchen hoping to regain her equilibrium. She approached the ladder and was struck by a rich desire to climb it. She stepped onto the first rung. Then onto the second. As she stepped onto the third, she looked downward. Through the rungs, she saw a small light bulb. It was frozen in place inches off the ground again. Defying gravity. Defying her. She stepped down and looked for the shattered glass of earlier. Not a shard remained.

She jumped off the ladder and delivered it a wild kick, sending its massive wooden frame toppling over sideways, first smashing the glass paneled shelves above the stove, then smacking the granite countertop, before a thunderous clack as it met the hardwood floors, spectacularly crushing the small levitating bulb. Little tinkling noises of broken glass seemed to rain within the television’s inescapable soundtrack. The small pieces kept fracturing into smaller and smaller ones like ever shrinking chimes.

She picked up the home phone and dialed 911. She waited. The clock over the oven read 2:15. She had come home around then. For Dr. Miller, coincidence was just a word people use when they can't see the sprockets and gears turning behind the curtain.

There was no ring. She hung up the home phone and tried 911 on her cell. She dialed as she made her way to the bedroom. Again there was no ring, or perhaps the sound of the TV masked it “It seems that the attack was motivated by a previous encounter

with Judge Fujiyama.” She kicked the bedroom door closed. Once more she cupped her hands over her ears, cradling her phone trying to hear a 911 operator. “Fujiyama had sentenced the alleged perpetrator to 5 years in prison before new evidence came to light. It seems he formed a vendetta from the trial…”

The noise droned on and on, unabated. She needed out. She threw her phone at the wall and ran into her bathroom, which connected to her laundry room. The house she once loved was a sinister maze. She tripped over a laundry basket as she reached the door that reconnected to the back of the kitchen.

As she tore out of the laundry room, she stopped dead. Before her an erect ladder stood as tall and ominous as a centenarian skeleton tree. The ones behind which full moons blossomed. There was no shattered glass, nor a single hint of her assault on the ladder. A little bulb stood suspended in midair, held in place by spite, and faintly lit by the crimson light of dusk filtering through the wooden blinds.

She snatched her keys and bolted outside. She pushed a button and with a tiny beep, her Mercedes unlocked. She hopped in, slammed the door closed, and smashed the key into the ignition, trying her best to pretend that the noise in her head was just that, a noise in her head. “So what will happen if the alleged perpetrator is convicted?” “Good question Anderson, most likely a final needle to the vein, that is of course after many years of appeals.”

Her black luxury car jumped to life with a throaty growl. Ignoring her stiff back, she tore down her gravel driveway in reverse. Her tires squealed as she turned onto the dirt road sending wild vortices of dirt into an igneous sky.

TWO:

“Don’t tell me the moon is shining, show me the glint of light on broken glass” ANTON CHEKHOV RUSSIAN PLAYWRIGHT, AUTHOR, AND MEDICAL DOCTOR

Head trauma brings hallucinations, confusion, delirium. Driving is an absolute nono, but Cara couldn’t stop herself - the sound in her skull was too unnerving. Like maggots under her skin, she had to escape it, to carve them out. The moment you see them writhing under your flesh, the matter has already been decided. She pressed her foot down harder onto the gas pedal.

As the lushly wooded mountains around her unfolded, she looked for a trail, something new, somewhere she could safely escape, and mostly somewhere above it all. Gnarled trees bathed in dusk whizzed by, and in a flash she caught site of a new path. She slammed on the brakes and abruptly reversed. A long dirt pathway leading to a steep trail overgrown with Kudzu vines and small saplings. Before it was a small metal gate. A sign declared, “No Trespassing.”

Cara pulled into the path and came to a crunching halt at the foot of the trail. She left her car to open the gate but fixated on the sign. The words “No Trespassing” were clear and bright, but the words underneath it were something different, something

too foreign to comprehend. She could see the additional lines of text but couldn’t read them. They were sharp and clear, but illegible; like a Magic Eye that would come into focus if only you could look through it, not at it.

She looked up ahead at the trail leading high into the mountains. It seemed to blur into the sky. Like fire to a moth, it beckoned. She stepped through the fence and started to jog up the trail. As it got steeper, she used her hands to help her proceed.

As she ascended, the crisp leaves of the bright green trees began to lose their sharpness.

She continued upward towards the crest, and with each passing step the forest transformed into an amorphous blob of green, blue, and gray. Her world was becoming homogenous and singular. She had stumbled across a new dimension and needed to discover the secret at its end. The urge to ascend grew stronger still.

She rounded the apex and entered a grey cloud that consumed the setting sun. The grey became consummate at a sudden point. The sky, the blobs that had been trees, the road, everything, became a harmonized shade. A wave of vertigo rocked her to her knees, but they didn’t hit ground. They floated, as she was now floating, in an ocean of perpetual gray. She was about to meet God.

Then a vision of a rail-thin man, with arms as long as legs spidering off an asexual torso wearing thin gray skin, all beneath long elliptical black eyes, formed in her mind. Or was this something else entirely?

She could do nothing but stare ahead, transfixed at the gray abyss before her. It was the edge of the universe. A supernatural dimension that she happened upon. One that coalesced with the world she thought she knew so well. Her mind raced with explanations, but the brilliant Dr. Miller had nothing to offer.

She spread her arms wide and waited for the abyss to swallow her. A minute passed before her arms began to sink to her side. She glanced over her shoulder and the illusion disappeared. She saw the scene in reverse. The gray slowly yielded to the trail, which led back towards the road. As it did, it grew more clear and in focus. It grounded her and brought with it an awareness. Like an unstoppable cancer, the sound in her mind had not dissipated, “More details after the break. And coming up later, CNN’s own Dr. Sanja Gupta will give us his perspective on the mental health of the perpetrator.” Even in the vacuum surrounding her, she couldn’t escape it.

She was desperate for her husband Aleksander, her philosopher, lover, light of her life. He taught a night class: Topics in Futurism. The blazing sky told her he wouldn’t be home for a while. Shortly after sunset, he would be turning on his phone. Just how long does the sun take to set? Then she knew the answer. It was obvious.

“It’s a dream.” Cara said aloud. She was napping, and the TV had found its way into her dreams. The phenomenon was called sleep paralysis. You are somewhere between sleep and dream, aware of the world, but the glycinergic and GABAergic inhibition that keeps your brain from acting out your dreams keeps you paralyzed.

You experience but cannot move. It’s the scientific explanation for legends of incubi, succubi, and the Night Hag, a supernatural being of pure malevolence who sits upon your chest while you sleep, stealing your breath to feed her soul.

It could be a dream, but it could also be a… Dr. Miller couldn’t get herself to finish the thought. She wasn’t ready for coma, but deep within, she knew it made the most sense. They were much less understood than dreams. She recalled one patient who had come out of anesthesia to recall the conversation Dr. Miller had with another surgeon during the operation. She pictured her own body at the foot of the ladder with a crimson pool suspending her head.

“The mind is capable of incredible delusions. I believe it’s a clear case of Delusional Disorder. The assailant was highly educated, a former doctor even. But even doctors are not immune to psychological disorders. Knowledge is not protective.”

“Thank you, Dr. Gupta. When we come back, Sanjay Gupta tells us more about the pressures placed on the medical community and just how that might have contributed to these tragic murders.”

She turned away from the grey, and leapt down the trail at a full sprint, the world growing clearer with each passing stride. She ran hard, yet her lungs filled with ease.

She recalled a morning during medical school where she awoke to find herself in the bottom half of an enormous hourglass. Drop by drop, her half of the hourglass flooded with water, until alas all her air was replaced with water. She had held her breath, floating just under the keyhole. An entire world was just beyond, one filled with delicious air, but her head was too large to get through the keyhole. Her lips reached towards the small pocket of air, but only pulled in water. Inches from her was an ocean of air tantalizingly close and impossible to attain. As the hemoglobin in her lungs were saturated with carbon dioxide, she became desperate to slurp the final atoms of oxygen to her lungs and pounded on the glass. A muffled scream released her lungs’ contents. Panic, born of the amygdala, forced her to inhale the water. And as she did, a peculiar thing happed; the water flowed into her lungs like air. No burning, no choking. She was breathing water. She dove back down and swam gracefully in the hourglass around her.

As she ran, she hoped she was in bed, wrapped in the arms of her husband. She would know soon enough. She jumped in the car and accelerated up the road towards Sleeping Falls, the 50-foot drop where the Chesapeake River navigated a sudden change in terrain.

As she approached the falls, she pressed down on what was left between the pedal and the floor. She careened towards the bridge. She would soon awake from a

dream or a coma. As she approached the falls she had a new thought: What if it’s not that simple? What if I’m sleep walking again? Like when I was young?

When she was 14, she once awoke in her younger brother’s room dancing ballet. She had knocked pictures off his wall and awoke to his cries of terror as he tried to make sense of the phantom frolicking around his bed.

The bridge was upon her. The speedometer read 105. Dr. Miller hadn’t sleepwalked in years, but what if today was the day her old habit reemerged? She recalled the Ambien lawsuits stemming from bizarre sleep behaviors caused by the popular prescription sedative.

What have I done? She slammed on her brake and jerked the wheel hard to the left away from the falls, but her car had lost traction and slid in a circular motion towards the guardrail. A glimpse of her dash read 85mph.

The passenger side hit the guardrail, sending the Mercedes into a side-over-side spin over the precipice. The world around her spun in circles oscillating between green and grey. A voice sang out “…Five Dollar. Five Dollar Foot, …” Cara’s car crashed into the shallow pool at the base of the falls.

THREE "I think it is true that death is the mother of beauty, and an appreciation of human suffering and our limited tenure on this Earth is essential to seeing our lives and seeing the world we inhabit."

TERRENCE HOLT MD. AMERICAN AUTHOR AND MEDICAL PROFESSOR Dr. Cara Miller opened her eyes. A bright green wad of spearmint gum was pressed onto the underside of her kitchen table. It had been a calculated risk that yielded important clues. No, it was careless. She had not been sleep walking. She hadn’t even been sleeping. Coma was her now her working diagnosis.

Her thoughts returned to her husband Alek. He had a PhD in philosophy. She wished for his calm ability to examine all sides of an issue. Nothing was black and white with him. Would he agree this was a coma? He wasn’t a medical doctor. He’d probably shrug his shoulders and say it’s all just a simulation. That was the futurist in him. To Alek, something even remotely probable became a certainty when allowing for infinite time.

She sat up and reassessed her surroundings. The ladder stood tall, and the time on the microwave read 2:15. Her back was still stiff. The TV went on and on.

She supposed there was a chance that she was in a hospital bed where Alek had left the TV tuned to her favorite news channel. But she knew intimately well what a

hospital sounded like and there was no beeping from telemetry, or the clack of nurses’ ugly clogs down hallways, or the hushed voices of doctors, nurses, and residents roaming the wards.

She went to the sofa and stared at the frozen TV screen. “Dr. Gupta, what drives a man to commit such an act?” “You see, the brain is a highly evolved organ, and we don’t truly understand much about it. What we do know is that it has evolved careful ratios of chemicals and regions that benefit most people. Sometimes however, something goes wrong. It can be from a genetic defect or even from trauma. Delusions are commonly due to physical changes to the brain”, and on and on it went in perpetuity.

She now understood what would happen any moment now and waited. Each second was one closer to discovery, or one closer to death.

After a long while she heard it: the crunching of a car in the gravel driveway. She ran out the front door onto the sunset-tainted driveway. Her Mercedes sat parked, but there was no sign of Alek’s Audi.

Then, finally, a noise. A heavy car door shutting somewhere in the distance. She looked down the road and saw no car.

Boop boop. Aleksander locked his Audi. She stood back in the doorway, trying to feel his presence as he walked past her. She heard the front door’s faint creak, but felt nothing.

There was a thump of his leather workbag hitting the floor by the front door. She pictured it in her mind and stared at the spot of wood where it had landed. It was missing an ever so slight layer of varnish.

She would give anything to hold him for what he was about to witness. To comfort him. But she was helpless. Just a wondering mind trapped inside an imagination.

“Honey?” He said cautiously, like somehow he already knew. “Hon?” He yelled a little louder.

Dr. Miller ran to the kitchen and laid down where she had awakened, hoping to feel him. There were a series of footsteps followed by a small gasp. The sound went dead, and there was an utter silence. Cara pulled her knees tight into her chest. Any second now.

Three hard footsteps getting louder one by one. Then she felt him. Actually felt his warm hands on her face. She reached towards her warming cheek trying to stroke his phantom hand.

“Oh my god. Cara?” She felt dizzy as an imaginary force gave her the feeling of being pulled upward. Her stiff back loosened and her face suddenly felt blanketed in prickly wool. She felt one big hand behind her head, another on her wrist. After a brief moment he let her wrist go and she heard three faint beeps, then a ring, and quickly a faint “911, what’s your emergency?”. For a moment Aleksander couldn’t respond.

“Hello, is someone there? Are you hurt?”

He managed “My wife…”

“What’s your address?”

Aleksander responded with heavy breathing.

“Where are you now sir?”

His voice suddenly gained focus “Uh, 163 High Valley Trail. Send someone right away. My wife fell off a ladder.”

“If you suspect any head or spinal injury, do not move her.”

“But I already did!” His voice rose.

“That’s ok sir. Just let her lie unmoved. An ambulance is on the way.”

“Hurry. Oh god please hurry. Oh god.”

Cara felt his warm hand quivering behind her head. The soft wool fell from her face and suddenly she was as before. Stiff backed, with no sensation. Only the sound of heavy rolling sobs. She felt her hand rise and could feel another gentle touch of her wrist. He was checking her pulse again. With sufficient blood loss it would be hard to feel. Would he be able to? After a very long while, his hand let go.

She longed to feel his warm sweater on her skin again, his hot breath on her face if even for a second longer. She tried to hold on to the memory of his touch, understanding if she didn’t pull through it might be their last. Come back Alek! Please don’t leave!

All she could hear were sobs so deep, they were a black abyss. She had never heard her husband utter such sounds. But even in her grief, she knew there was hope. As long as she was hearing him, she was alive. Aleksander must know that, even if he hadn’t found her pulse, he must have felt her breath, her warmth.

She could no longer hear the 911 operator, but Aleksander was still close enough to hear.

“No. I dunno. I don’t think so.” … “I don’t know how long.” … “Yes, but I can’t tell how much”

Cara returned to the sofa and buried her head in pillows. For an eternity she heard Alek pacing back and forth from the kitchen to the front door pleading for the 911 operator to hurry, until finally sirens could be heard in the distance.

“They’re here. I have to go!” His phone clapped shut, and he bounded out the front door screaming out “Over here!” She could picture him jumping and waving his arms like an inflatable tube man. She would do the same for him.

The sirens quickly grew in amplitude. There was a sudden commotion. She heard what sounded like a small team of heavy boots storm into the room.

Lots of dropped packs. Something hard and heavy hit the ground. One of them yelled in a thick southern accent “Keep ‘em back”. She felt it again. Felt her arm rise up and two fingers pressing into her wrist.

A man with a heavy southern drawl “I’m so sorry sir.”

What the hell is he talking about? “You asshole! Tell him I’m alive! You incompetent asshole!” Her words fell on ears incapable of receiving them. She was trapped. Just an invisible spectator, a voyeur.

She heard the men and Alek make their way outside. Time passed and the TV droned on and on. Finally, she heard the return of boots and a loud crinkle and felt her body rock onto its side assisted by four firm hands. When she was let back down, she could feel a cold plastic sheet beneath her.

There was some more tugging, followed by a long zip which punctuated the texture of plastic falling over her prone body from toe to head. The sound of the TV slightly diminished. “I’ll suffocate”, she whispered feeling the plastic bag tickle her cheeks as it bellowed across them from the pitched tent of her nose.

She felt herself hoisted upward followed by the squeaking of wheels. A few bumps and two slammed doors. Alek was gone. And the home around her was blanketed in the sound of a humming engine.

Sitting in her living room, yet also lying in the back of an empty ambulance, she was alone with her thoughts. I’m going to die in a body bag.

FOUR:

“Lily’s still reaching for me, begging for a hug, but I turn away, afraid to look at her, afraid to glimpse that blue, alien stare.”

TESS GERRITSEN M.D. TAKEN FROM PLAYING WITH FIRE: A NOVEL.

There was a clatter and the slamming of heavy van doors, followed by a long sigh and the roar and rumble of a large diesel engine. A slight pull of centripetal force tugged down to her feet. She stared at the fireplace. It failed to ground her.

Vibrations and bumps coursed through her body. Crunching gravel became the loll of the hard tires on pavement.

There had to be a way to get a message across. Just how air tight are body bags?

Could she make it rise and fall with a deeper breath? That would just accelerate your suffocation.

After a while, the man with the southern accent spoke. It was only slightly muffled by the thin plastic body bag over her face “The husband looked pretty danged upset”.

What was that accent? Texan? She heard a thump and felt herself float for the briefest of seconds as she rocked back down. A pothole.

“Yeah. I’d be too. She’s smokin’ hot.” Came a second much more gruff voice.

Tex let out a little laugh “Yeah, she was smokin’ hot.”

“No. She still is hot. Being dead doesn’t make you ugly. Obviously with decay, yeah, not hot. But at first.” He paused letting it sink in. She could hear the smirk rising on his face. “Yeah, for the first hours, they can still be hot.”

“That’s pretty fucked up rookie.” Tex said with no conviction whatsoever.

“Naw man. Think about it. Paris Hilton, Angelina Jolie, someone like that. Hmm?”

“Yeah, maybe. Hell, probably.”

There was a long silence, then both men started laughing.

Gruff said, “I’ll be right back” and she heard a seatbelt unbuckle.

Tex said, “Whudya doin’ man? Sit back down.”

“I forgot to buckle the top strap and she’s flopping around.”

Tex didn’t respond.

Dr. Cara Miller stared blankly at the ceramic logs in the fireplace, immersed in the sensations overwhelming her. She heard a quick zip and the tickling on her cheeks finally ceased. She closed her eyes trying to feel every sensation.

She felt a cool breeze across her face, and with it the smell of stale cigarettes. The smell of Gruff. There was a sudden tight squeeze and the rattling in her head was diminished. He had tightened the strap.

There was a second firm squeeze, this time to her left breast. It hurt, and then she felt his calloused hands explore her nipple. Cara felt sick to her stomach, but the pervert’s excuse to violate her had provided oxygen into the body bag.

“You forget howta pull a strap?” came Tex’s voice from the front of the ambulance.

He gave her one last squeeze. “Ow!!!!” She yelled as she felt his cold hands pressed dangerously hard.

“Holy shit, she twitched” hollered Gruff.

Cara imagined the pain had caused her body to jerk, like a sternal rub. She tried to will her body to move. Imagined jerking her arms and limbs.

“Get back in yer goddamned seat.”

“She twitched man. She twitched.”

“Yeah, they’ll do that rookie.”

She heard the zip and some commotion as gruff went back to his seat. She heard a small click. She was back in her bag, and gruff was buckled in his seat. The two men fell silent, one with novel thoughts of Cara Miller.

Dr. Miller felt sick and confused but had to be strong. If she could just hang on a little longer, a medical examiner awaited her. Normally the M.E. would determine cause of death then viable organs would be harvested. Then she thought about what that entailed.

There would be an external exam, but the real diagnoses would begin with a Yincision. They would assume she was dead. There would be no anesthesia. A scalpel would pierce her abdominal cavity deep to the peritoneum (the dense connective tissue sac that lines the abdomen), and superficial to her vital organs. Just how far would the scalpel get before they realized?

FIVE “…as we drink the decoction of the living bodies at the Pump-room, we swallow the strainings of rotten bones and carcasses at the private bath…”

TOBIAS SMOLLETT (1721-1771) SCOTTISH NOVELIST AND SURGEON

Dr. Cara Miller got up off the couch and tried to ignore the sounds of the road that whispered to her. As she walked back to the kitchen, she could feel her body pull to the left. Somewhere on the highway an ambulance carrying her body raced along a hard curve.

It was a surreal living dream. She just wanted to feel normal longing for a breath of fresh air, even if it was only imagined. She made her way outside, selectively ignoring the conversation between Gruff and Tex discussing beers after work.

As she stepped out onto her patio, the conversation was overlaid with the sound of wind through the trees. The very sound that had first attracted her to these mountains. It was why she chose to build her cabin nestled in the woods. She took in the hills and trees that painted the landscape. The Oak and Hickory hardwoods were the most prominent. But she was drawn to the evergreens. Hemlocks, Spruce, and her favorite, White Pine, the tallest tree in Georgia. At the end of her driveway stood

an unusually tall one. The foliage was sparse and the heavy branches came almost to the ground. It would be perfect.

She jumped up a couple inches and grasped the first horizontal branch. The winter had been brutal, and the branches were brittle and lacked their usual shrubbery.

Normally it would have been a harrowing and difficult climb. Today, though, it would be relatively easy. In the coma world, ventilation and perfusion of the lungs was infinite and imagination could carry you. As she hung from the branch, she noticed she was wearing a white coat. She pulled herself up and sat a moment on the first branch. Her coat said Cara Miller. There was no MD after the name. That wouldn’t happen until after graduation. She felt the return of a deep despair that had once plagued her. 100 hour per week rotations in the hospital enduring and unabashed beratement, shaming, humiliation, and sexual advances. The thoughts of suicide, long ago quelled, once again consumed her.

She felt her body pull forward with a slight screech. She had arrived at the hospital.

Somewhere in the building a cold steel scalpel awaited her.

She grabbed a knot of the pine’s trunk and reached up for the second layer of branches as she heard a loud click of ambulance doors opening, and the long clatter of squeaky wheels across linoleum floor. She imagined First United Hospital. Her employer. Was she there? The ride hadn’t been that long though. Maybe she was at Saint Joseph’s. No one would recognize her there.

She climbed harder now, pulling herself up branch-by-branch, higher into the tree.

She was already at rooftop level, about a fifth of the way up. That’s where the cold air began to cover her. The higher she climbed, the colder is got. She could hear metal doors swinging open and closed. There was a faint whirring sound of ventilation. It seemed to come from all around as the trees and wind swirled it.

She focused all her attention on to the climb. She didn’t want to feel the scalpel dig into her. She didn’t want to know when it would come, even if it might wake her up.

As she went up, she felt her body come to a stop. The wheels of the gurney ceased their squeaking. “Leave it there,” came a deep male voice.

It? She was an it! Her whole life, her whole career, reduced to an it. Dr. Miller was in her first surgical rotation all over again, stripped of her dignity and robbed of her voice. Just climb.

She pulled upward onto yet another layer of heavy branch and foliage. As she pulled upward she heard a loud zip. She felt a freezing breeze blow in from the north. She felt her nose tickle.

“Climb, Goddamnit! Climb!” That was all she could do. She pressed on, looking only upward, counting down the rungs as she proceeded to the top. She thought of the first incision she had ever made. Her patient was a 95-year-old cadaver on table 6 in

anatomy lab. The cadaver was hard and firm, but the scalpel sliced like butter as she skated the blade from nipple to nipple.

She felt a faint tug at her white coat. Snip. Snip. Snip. Snip. Snip.

Then the cool breeze suddenly penetrated her coat and clothing, cutting straight to her bare skin. She felt her skin tighten and goosebumps blossomed over her as the frigid air covered her. Cara Miller looked at the branch above her. It wasn’t cold out here, it was cold in there. She continued her climb.

She felt warm hands grab her back and lift. The hands released, and she felt her body drop an inch or so onto cold steel. She instinctively arched her back as the searing cold bit into her back. But she never stopped climbing.

She could die any second now. Would she make it to the top before she did? She heard a click then a deep and calm voice. “Case number 418419. External exam, and invasive internal exam.”

She felt large powerful hands on her face. This wasn’t what she expected. She tried to stay calm, breaking from her pursuit to look out into the forest below.

She saw a world of grey snow underneath a dusk-like sun. Everything was frozen in place. Like a thick coat of ash, a deep and never-ending gray blanketed the trees and

rooftops. Her own roof was covered in this gray, and it seemed to melt down through her home straight into hell. It was hideous. It was beautiful. She climbed.

“Severe head trauma as noted by the large laceration exposing a fractured lambdoid suture. Subject displays a fractured orbit consistent with a counter coup injury related to the lambdoid fracture”

Dr. Miller knew what that meant. The back of her head was cracked open. The force from the blow transferred to a point 180 degrees from the injury causing another fracture around her eye.

“How is it, being a doctor?” student Cara asked wearing her short white coat.

“The pressure is too much sometimes. Remember how you thought you might like psychiatry?”

Cara nodded

“You should really consider that.” Dr Miller said to student Cara. She was both aware and unbothered by talking to herself. Instinctually she understood anoxic brain injury was fragmenting her thoughts.

She felt confident hands probing her body in a methodical manner. Her random colleague in medicine pushed and poked his fingers over her body, exploring her legs, pelvis, abdomen, ribs, breasts, neck, and face. God, had she shaved her legs? She felt her body pushed onto its side as the hands continued to probe.

All she could do was climb. She was now at least sixty feet in the air. There were perhaps thirty to go. The higher she went, the more the branches began to take on an indistinct form. Each branch she made it to was becoming less defined. They blurred as she ascended. Was she losing consciousness? Was she about to die? Had her coma taken a turn for the worse?

“Hurry!” said student Cara. They were two thirds of the way to the top, but even from here they could feel the swaying of the large trunk. It swirled like a wooden tornado.

She heard the voice again “External exam complete. No other abnormalities found. I will now begin the internal exam.”

As she reached up for the next rung of the tree, she felt it. A fire blossomed in the center of her chest. It seared its way down towards her pelvis where it made a quick detour around her navel.

The blade was not cold. It was hot and excruciating. She screamed out over the forest. She was now higher than all the hardwoods, clinging to the trunk as a child would their caregiver. Her scream went flying into the open space before her, where it would fall on the gray which was setting in from all directions. The gray was brain damage. She was almost dead.

With a pressure that felt like an anvil, two more slices tore from her shoulders to the center of her chest. The Y incision. She cowered down onto the branch, still hugging the tree trunk in an upright fetal position. A stream of tears blew off her face into the swirling wind as the scalpel clinked back down onto the instrument table.

“I’m alive!” She screamed. “Please, don’t you see that I’m bleeding! Corpses don’t bleed! Please!”.

There was a click and a high-pitched whine. She knew this sound well from many surgeries she had performed. A bone saw.

The squeal of the saw changed pitch ever so slightly as it hit her ribs. She could feel the vibrations down her body and imagined the marrow that must have been pouring out from the fresh cut. “Jump, Dr. Miller. You have to jump!”

“We tried that, remember? It doesn’t work like that.” Dr. Miller looked over and saw that student Cara’s face had turned gray. In fact, she was having trouble

remembering why this student was shadowing her. No one told Dr. Miller about the assignment.

There was a little girl too. A ballet dancer in white slippers with a grey face and body. It was funny, Dr. Miller had also loved ballet when she was a child. Who was this child?

Words came out of the small ballerinas distorted gray face masked by the sound of the bone saw. There was a sudden stillness and the whining pitch of the saw wound itself down to a silence.

She felt hands reach deep into her chest. There was a tremendous upward force, with a pressure so intense she thought she might explode. Then she heard a series or chalky snaps.

“Chest cavity now open for the thoracic exam.”

She felt thicker, could feel her ribs held open like saloon doors. But she would climb.

There were several shadows following her. All familiar, yet strange and foreign to Dr. Miller. They were her past. They were part of her memories, inventions of her imagination, representing pieces of a fractured mind.

She grabbed the next branch and pressed onward. She felt hands curl under the flaps of skin on her chest. Hands burrowed deep inside her body. The pain was red hot, like a battalion of fire ants gnawing away at the fascia beneath her skin. Then she felt a piercing sensation to her right upper quadrant. Her liver.

“Warm and stiff.” Came the voice.

She looked down at the mottled world below. Whisps of gray swirled around her.

She was almost to the top, and climbing branches that looked like ghost arms. If she climbed high enough, would she reach heaven? Would a light pierce the grey and unveil expansive gates of pearl?

Warm and stiff. Where had she heard that before?

She was at the final couple of tree rungs. She had only ever seen these from below one or twice. The trunk swung wildly in increasing concentric circles. The cold was biting yet did little to numb her pain.

At last, she pulled herself up the last branch. It was elastic. She stayed close to the trunk, which was only about three inches in circumference. Her weight atop the narrow canopy made the tree swing around wildly. It was dizzying.

“We made it! ” Dr. Miller looked down, but she was alone. Who was she talking to?

All that remained now was one final leap. The final leap to jolt herself awake and be discovered alive. One last chance to hold Allen again. To feel his loving arms around her. No, it was Alek she missed. Who was Allen? She thought of her family, but was having a hard time remembering who they were. She imagined amyloid plaques and fibrillary tangles filling her brain like an Alzheimer’s patient . Would she forget Alek?

It was now or never.

“Three. Two. One…” She was interrupted.

“Algor mortis rates of the liver, and rectum are consistent with a 4:00pm time of death on January 15, 2019. In addition, a broken wristwatch seems to confirm this.

The face displays 3:55. It likely broke during the fall. Damage and fractures consistent with a fall of well over 6 feet. There are no viable organs for donation.

Fate of body to be determined by surviving family.” Click.

SIX: “In the long run, you’re dead” GOBIND SINGH M.D. EMERGENCY MEDICINE SPECIALIST

Dr. Cara Miller had her arms around the swaying tree trunk. She looked around at the gray ocean that lay before her. Warm and Stiff. Now she remembered. Warm and flaccid meant death happened less than 3 hours ago. Warm and stiff meant death occurred 3-8 hours ago. Cold and stiff, 8-36 hours. Cold and flaccid was greater than 36 hours.

The cold air. The cold table. The taped monolog. She was at the medical examiner’s office. She was dead. She had been the whole time.

She heard some more squeaking, then came to a halt. She closed her eyes trying to visualize where her body was. She heard a loud drawer slide open in a long and heavy motion. Heavy hands lifted her onto an even colder surface. Her body vibrated as the drawer marched closed. There was a loud click, and all was silent.

She was in the morgue.

It was time to jump, but Dr. Miller knew it wouldn’t do any good. She sat down straddling the branch underneath her. From the seated position she felt more secure. She looked down at her white coat, which now read Dr. Cara Miller, MD. It wasn’t soaked in blood, or ripped open. But by the way she ached, it should have been. Her entire body felt crushed and rotten. The pain remained so intense, but she held focus. As in all physicians, there was a scholar within her teeming with curiosity. She was experiencing The Question. And it was worse than she ever could have imagined.

This wasn’t purgatory, or hell. It was natural. She had always been taught that death occurs when brain activity has ceased. But she could clearly see that was inaccurate.

Science had been wrong. Religion even more wrong. And there was no way for her to ever warn the world just what death held for every soul that walked towards it.

She pictured her mind as a computer hard drive. It had no power, but the information was still housed within it, where it would remain until it degraded enough to become non-existent. Her confusion, perhaps hallucinations, and failing memory were due to decay. Stuck in a freezer though, she wouldn’t keep degrading.

She was trapped. The neurons in her brain weren’t firing, but they still touched each other. They were passive conductors. In death there were no longer electrical cords, instead they were water faucets filled with stagnant water.

She understood that every living creature would endure this, but only humans drag it out for so long. Within an hour the dead squirrel is covered in ants or minced in the beaks of buzzards. But people, they are subjected to autopsies, embalming, and prolonged storage. And often a fiery last hurrah into carbon ash. She cringed and considered her will. What had she chosen?

The wind swept sheets of gray around her. Was her mind decomposing? Was she losing clarity as it did?

She looked down onto the woods around her, and onto her house, which seemed all too tiny from here. The heavy coat of darkness chewed away at everything. She had never seen her home or these woods from this perspective. That’s it, she realized.

Perspective.

She imagined the No Trespassing sign from before. She had passed it a thousand times on her way to the house, but she had never read the note below it. Her dead brain couldn’t see it either. Instead it saw what she had seen as she passed by. A blurred mess.

The trail she had walked down wasn’t a portal or some magical place, it was simply a spot she had never been before. Her brain lacked imagination. It was passive now.

What she hadn’t seen, couldn’t be seen. She was limited to the knowledge held deep

in the circuitry of her brain. The green gum on the table was what she saw the last time she ever looked at the bottom of the table.

She retraced her steps. She had come home after a half shift. She came into the kitchen and looked up at the microwave. It had read 2:15. The last image of it had become frozen in her mind.

She had taken a nap, and when she awoke she found herself watching the president’s speech. She noted the time before she headed out to the garage to get the ladder. The last image she had seen on the TV had remained frozen.

So this is what happens when you die? She was certain it was. But now what?

She waited. She shivered. She burned with pain. Time stood still, but the swirling of the tree helped comfort her. She dreamt of ways that she could warn the world, but none came. She replayed the memories that remained. Mostly of her husband Alek, but also many mistakes she had made over the years, errors in surgeries early in her career. Over time the pain in their chest became background noise to the frigid cold that forked its way into them. Every passing minute it got colder as she equilibrated to the freezer she lay within. Hours became days, and days felt like weeks, watching a sun that never set.

She wouldn’t jump though. She would wait for all her memories to fade or for the world to turn black. Or gray. Or whatever the end brought. She could only hope that it would come soon.

After some amount of days or weeks, she heard noise and felt her body slide out of her compartment on its sliding drawer. She felt her hand lift and there was a hard tug on her finger. She felt her wedding ring slide off. A comforting blanket of warmth wrapped its way around her. She basked in it. The forest took on a summery feel. A warm wind seemed to hold her above it all. Let the decay begin! She craved an end.

She was transferred to what she could only assume was a funeral home. There was a sequence of foreign noises, and without warning the air around her felt blazing hot.

She watched the 360-degree view around her catch fire. The trees were suddenly ablaze. Fire consumed everything but the gray spaces. She watched her skin catch fire, and as it burned it seemed to flake away like snow flakes in a blizzard.

It wasn’t peaceful. She writhed in pain, scratching at her skin. Her body felt like it was both melting and freezing itself stiff. Her burning carcass released its grasp on the tree and spilled fourth into the inferno. She collided with heavy branches and landed with a hard thud onto a blanket of incinerating grass. She curled herself into a ball.

This was cremation.

Enormous plumes of smoke swirled haunting images as the forest burned above her.

Small spots of grey began to grow in tendrils, like a fungus invading the structures around her. The depths of it began to turn black. There was fire, there was grey, there was an impending blackness, but mostly there was pain.

She was close. Would the pain ever abate? The nerves in her skin were burning off, but why did it hurt so bad? Victims of deep burns do not feel pain, why did she? She curled ever tighter into a cocoon of melting flesh with fire coursing through her veins. From the horizon, a raging white wind tore over the forest, parting the smoke, and vomiting snow. She still burned. But not with fire. With something else entirely.

The Devil. And his bitter cold burnt worse than any fire ever could.

She heard him speak, “Preservation fluid administered and ready for cryo.”

A vague memory was suddenly resurrected.

A 10-year anniversary, a gift from her husband.

A quick signature, too many cocktails.

A pamphlet, Cryogen Corp

The caption, The Hope of Forever Through Human Cryogenics.

The frozen winds continued piercing her, invading every cell in her body.

END