The Waking Hours

The fluorescents in Trauma Bay 2 had a fault. A faint, arrhythmic pulse in the leftmost tube that June Halliday had reported three times and maintenance had fixed zero times. It wasn't dangerous. It wasn't even visible to most people. But she worked fourteen-hour shifts under those lights, and after enough hours the flicker settled into the back of her skull like a second heartbeat, just off the rhythm of her own.

She noticed details like that. It was part of what made her good.

Thirty-seven hours into a stretch that was supposed to be twenty-four, June stood at the central monitoring station in the emergency department of Hargrove Memorial and read the board. Four patients in triage. One acute abdomen in Bay 4 waiting on surgical consult. A teenager with a displaced fracture in Bay 6 whose mother kept asking when the real doctor would arrive, meaning the male one, meaning someone other than the woman in the white coat who'd already set her son's radius by feel in under ninety seconds. And in Bay 1, a fifty-eight-year-old man named Walter Torrance, chest pain, troponin elevated, EKG showing ST depression in the lateral leads.

She'd ordered the heparin drip and the cardiology consult twenty minutes ago. The drip was running. Cardiology hadn't called back. That was fine. That was normal for two in the morning on a Tuesday. She'd check again in ten.

June picked up her coffee. It was cold. She'd poured it at eleven and hadn't touched it since, which meant at some point in the last three hours she'd forgotten it existed, which meant the fatigue was past the point where caffeine was a solution and into the territory where it was a decoration. She drank it anyway. Cold coffee was still coffee.

"Dr. Halliday?"

Rena, one of the night nurses, was standing at the edge of the station with a tablet in her hand and a look June recognized. The look that said: I need you to make a decision I don't want to make.

"What is it?"

"Bay 4. Dr. Pryor says he can't get down here for another forty minutes. She's getting worse."

June looked at the board again. The abdomen in Bay 4 was a woman named Doris Keating, sixty-three, pain migrating to the right lower quadrant, white count climbing. It looked like appendicitis trending toward rupture, and forty minutes was too long.

"Page him again. Tell him if he's not here in twenty I'm opening her myself."

"You can't do that."

"I know I can't do that. That's why he needs to get down here."

Rena left. June set down the cold coffee and turned back to the monitors. Walter Torrance's vitals were stable. The teenager's films were up and the reduction looked clean. She made a note in Torrance's chart and flagged the cardiology consult as overdue and then she stood there, her hand on the edge of the counter, and felt the fluorescent tube pulse against her peripheral vision, that wrong rhythm, that second heartbeat that wasn't hers.

She blinked.

❦

Later she would try to reconstruct what happened in the gap. She would sit in the chief of medicine's office and in her own apartment and eventually in the passenger seat of her sister's car, and she would try to rebuild the missing seconds the way she'd been trained to rebuild a patient history: backwards, from the last known point of consciousness.

The last thing she remembered before: her hand on the counter. The monitor showing Torrance's rhythm, stable, unremarkable. The taste of cold coffee on her tongue. Rena's footsteps receding toward Bay 4.

The first thing she remembered after: the alarm.

Not the gradual escalation of a clinical alert. The full crash alarm, already in progress, which meant it had been sounding for long enough that someone had upgraded it. Her hand was still on the counter. The monitor in front of her was no longer showing Torrance's rhythm. It was showing a flatline, and the code team was already in Bay 1, already working, and someone was calling her name.

She moved. She was there in four strides. She called the code. She ran it clean, the way she'd run a hundred before, compressions and epi and rhythm check and shock and compressions again, the whole choreography that lives in the hands and not the conscious mind. She ran it for eleven minutes. It wasn't enough.

Walter Torrance was pronounced dead at 2:47 a.m.

June stepped back from the bed. She stripped her gloves and dropped them in the bin by the door. Her hands were steady. They were always steady. Her hands didn't know what the rest of her knew, which was that somewhere in the last fifteen minutes the ground had shifted and she was no longer standing on it.

The nurses reset the bay. Rena pulled the sheet up to Torrance's chin with the careful neutrality of someone who had done this many times, and June watched her do it and thought: I should have been the one to catch it. Three feet away. Three feet, and the monitor was right there, and the rhythm was right there, and I was right there, and none of it mattered because for two minutes or three I wasn't anywhere at all.

Afterward, in the hallway, Dr. Liao from cardiology finally arrived and stood next to her and said, "I'm sorry, June. I was in the middle of a cath. I got here as fast as I could."

June looked at him. She didn't say anything.

"The nurses said you were right there at the station," Liao said. "They said the alarm went off and you responded immediately."

"I did."

"So what happened?"

She opened her mouth. Closed it. Opened it again.

"I don't know," she said. And it was the truth, and the truth was the worst part, because June Halliday always knew what happened. That was her job. That was all her job was. Knowing what happened, knowing what was happening, knowing what was about to happen, and she'd been standing three feet from a man whose heart stopped and she hadn't seen it start.

❦

The review took nine days.

June had been through reviews before. Every ER physician had. A death in the department triggered a standard mortality and morbidity conference, and if the death involved any question of care quality, a formal peer review followed. She knew the process. She'd sat on the other side of the table twice, reviewing colleagues whose judgment she'd questioned, and both times she'd done it fairly and both times the outcomes had been defensible.

This time the question wasn't her judgment. It was her consciousness.

The review panel, three physicians and a hospital administrator, reconstructed the timeline from the monitoring system logs, the nursing notes, and the medication administration records. The cardiac monitor in Bay 1 had registered the onset of ventricular tachycardia at 2:38 a.m. The alarm had triggered at 2:39 a.m. when the rhythm deteriorated to ventricular fibrillation. A nurse had reached Bay 1 at 2:40 a.m. and found Torrance unresponsive. June had arrived at 2:41 a.m. and initiated the code.

Two minutes. Maybe three. Between the onset of the arrhythmia and the start of intervention, two to three minutes had passed in which June Halliday had been standing at the monitoring station, directly in front of the screen displaying the patient's vitals, and had not responded.

"Dr. Halliday," said Dr. Ostrander, the chief of medicine, a man she'd worked under for six years and respected and who was now looking at her with an expression that was not unkind but was no longer collegial. "Can you account for those minutes?"

"No."

"Were you distracted by another patient?"

"No. I'd just updated Torrance's chart. I was looking at the monitors."

"Were you on your phone?"

"No."

"Had you been drinking?"

"No."

"Were you asleep?"

The word landed in the room like a stone in still water. June felt every set of eyes on her. She thought about lying. She thought about saying she'd turned away, or stepped into the supply room, or done any of the hundred small tasks a physician handles at two in the morning that might explain a gap. Any of those answers would have been easier and none of them would have been true.

"I don't know," she said. "I was standing at the station. I remember being there. Then the alarm was going and the code team was already in the room. I don't remember the transition."

"A microsleep," said Dr. Ostrander. Not a question.

"Possibly."

"How long had you been on shift?"

"Thirty-seven hours."

Ostrander wrote something on the pad in front of him. The administrator, a woman named Phyllis Crane whose job was to protect the hospital from liability and who did it well, wrote something longer. The other two panel members looked at each other and then at their own pads and then at June, and in that rotation of avoidance June could see the outcome forming before anyone spoke it.

"The scheduled shift was twenty-four hours," Ostrander said.

"Wyatt called in. I covered."

"That's the third double extension this quarter."

"Because Wyatt keeps calling in."

"June." He said her name the way he said it when he was about to deliver a diagnosis the patient didn't want. "The fatigue policy exists for a reason. You know that. You helped write it."

She had. Three years ago, after a resident fell asleep during a lumbar puncture and the needle migrated two vertebrae south. June had sat on the committee that drafted the mandatory rest intervals and the shift-length caps and the reporting requirements for fatigue-related incidents. She'd argued for stricter limits than the ones they adopted. She'd been overruled by the same department heads who were now sitting across the table from her, their faces arranged into professional concern, their pens moving across pads that would become the official record of the moment her career stopped.

"We're recommending a leave of absence," Ostrander said. "Effective immediately. Medical leave, not disciplinary, which means your privileges are suspended but not revoked. You'll need to complete a fitness-for-duty evaluation before reinstatement. And June, I want to be clear. This isn't punitive. This is protective."

"Protective of whom?"

He didn't answer that, which was itself an answer.

She drove home in daylight, which felt wrong. She was used to driving home at dawn or after midnight, used to the particular loneliness of a car moving through empty streets while the rest of the city was somewhere else. Driving home at two in the afternoon, in traffic, with the sun flat on the windshield and the radio playing a song she almost recognized, felt like wearing someone else's schedule. She parked in her building's garage and sat in the car for six minutes with the engine off and the keys in her lap. Then she went upstairs.

❦

Her apartment was on the fourth floor of a building in the Hawthorne district that she'd chosen for its proximity to the hospital and its lack of character. Two bedrooms, one of which she used as an office. A kitchen she cooked in maybe twice a month. A couch she sat on to read journals and a bed she lay in to not sleep. She'd lived there for four years and it still looked like she was between places, which, in a way she hadn't examined closely enough, she always had been.

The first night of leave she sat on the couch and stared at the wall. The second night was no different. The third night she turned on the television and watched a nature documentary about deep-sea organisms that lived in total darkness and had evolved to generate their own light, and she turned over the phrase "generating your own light" and how it sounded like something a therapist would say and how it meant something completely different when the context was a fish with no eyes nine thousand feet below the surface.

She didn't sleep. Not really. She'd lie in bed and close her eyes and her body would settle into a shallow, gray drift that wasn't quite consciousness and wasn't quite its absence, and then she'd open her eyes and it would be four or five in the morning and she'd feel exactly the same as she had when she lay down.

The insomnia wasn't new. It had started in residency, the way it starts for most emergency physicians, as a practical response to unpredictable schedules that eventually became its own condition. She'd managed it for years with discipline and routine, melatonin, blackout curtains, the white noise machine her mother had given her as a graduation present, which June had thought was passive-aggressive until she started using it and realized it was the most useful gift anyone had ever given her. But the management had been eroding for the last eighteen months, slowly enough that she hadn't named it as a problem, and then Walter Torrance had died and the erosion had become a cliff.

She stopped going outside. Not deliberately, not as a decision, but the way a person stops doing anything that requires a reason. She ordered groceries delivered and ate them standing at the kitchen counter, usually cereal or toast, the foods that require no attention and produce no mess. The mail piled up on the table by the door. A bill from her car insurance. A credit card statement she didn't open. A flyer for a neighborhood yoga studio that promised restorative sleep in six sessions, which she put in the recycling bin with enough force to crack the lid.

She let her phone go to voicemail and then stopped checking the voicemail and then turned the phone face down on the kitchen counter and left it there. Two colleagues texted. Her sister called once, then twice, then a third time. June looked at Vivian's name on the screen and felt the specific exhaustion of someone who has been disappointing the same person for so many years that the act of answering the phone is itself an admission.

She didn't answer.

What she did, instead, was replay the gap.

She knew the exercise was futile. She'd studied enough neuroscience to understand that a microsleep wasn't a memory that could be retrieved with effort. It was an absence. The brain hadn't recorded those seconds because the brain hadn't been there for those seconds. There was nothing to remember because there had been nothing to experience. The consciousness that would have formed the memory had simply switched off, like a circuit breaker tripping under load, and by the time it came back the damage was already done.

But knowing that didn't stop her from trying. She'd lie in the gray drift that passed for sleep and she'd find herself back at the monitoring station, hand on the counter, coffee taste on her tongue, fluorescent pulse in her peripheral vision, and she'd try to push past that moment into the next one, the one that didn't exist, the dark space between her hand on the counter and the alarm already sounding. She'd push and there was nothing. Not blackness, not silence, not the absence of input. Just the complete nonexistence of a moment that should have been there and wasn't, like a stair that looks solid until your foot goes through it.