Seishin took up his position with Toshio at the nurse station on the second floor of the hospital. Despite not having seen use in some time, there was no color of decay or ruin to be seen. The station was made up of a napping space and a recovery room for post-operative patients' needs to be met separated by a single door.
That recovery room served Yasumori Setsuko. Until just a bit ago her husband Tokujirou was visting her but now that Tokujirou had left, Setsuki seemed to be sleeping peacefully. The recovery room had a large pane glass window in place but there was an old fashioned curtain drawn so that Setsuko herself couldn't be seen. Her outline was only seen like a shadow play upon the screen offset by the lamp.
"Word of her death will definitely come tomorrow..." Toshio murmured, sitting in a chair at the nurse station and opening a book brought from Seishin's room. He was turning the pages but his eyes weren't really on the print. "Of course there are exceptions but the sudden turn in her condition will definitely be tonight, we could say. This patient is going to suddenly get worse tonight. Something is happening at night to make the condition worse."
Seishin sighed but kept his mouth shut. He knew what Toshio was picturing but it was lacking a proper sense of reality. In any case, keeping watch like this would at least satisfy Toshio, so he felt. If Setsuko's condition worsened, that wouldn't be because of something unrealistic, he could see that the cause was something more in line with common sense, and making that clear wasn't bad for the patient in any way.
If---Seishin thought, faintly disturbed.
(If it doesn't get worse....)
If it stayed like this with nothing occurring, if Setsuko's condition didn't worsen... Then Toshio's wild delusions couldn't be dispelled but for the patient it was without a doubt even better than clarifying what it was that was making the condition worse.
"You think that bunch will come all the way to the hospital?" Toshio asked, causing Seishin to smile wryly and shake his head. He meant that there shouldn't be anything coming to visit Setsuko n the night but Toshio seemed to take it to mean something different.
"---Yeah, you're right. I had Setsuko-san hospitalized during the daytime. As long as they're not clairvoyant, they shouldn't know that she was moved here from her home." Toshio said with a fleeting glance to Seishin. "You're still making a face like you don't believe me."
"It'd be impossible to believe you," Seishin said with a bitter smile. He talked over Toshio who had started to say "Now listen," as if he found that answer unexpected. "I know what you're trying to say, Toshio. There's a disease that's thought to be spreading, and this disease has some medically strange features, is what it comes down to, right? If we think of the existence of something that defies common sense, then we preserve consistency and common sense as it pertains to diseases but we lose consistency and common sense for the world at large. ---I know what you're saying. But, I'm a layman. That this disease is strange, just how strange it is doesn't click with me. I don't see it as a phenomenon so strange that we need to rely on some preposterous existence like vampires to explain it."
Toshio thrust a finger out at Seishin. "That's right, you're a layman. And here I am, and I'm at least in theory a doctor, aren't I? And I as a doctor am telling you that it's strange. You can't have faith in that?"
Seishin smiled wryly and shook his head. "Not sincerely enough to swallow the story on your authority."
"Honestly," Toshio said clicking his tongue. "Yeah, I'm just what I look like, a country doctor with no potential for moving up in the world. I'm not a researcher, nor am I a blood disease specialist. So there're things I don't know. But, things I don't know and things thatI can't get an answer to aren't the same thing."
Saying that, Toshio thrust a mug out towards him. Seishin took that, filled it with coffee from the coffee maker brought from Toshio's room and returned it to him. "You can't get an answer? Really?"
"What else would you call having eliminated all the possibilities?"
"Can you really say 'all' definitively?"
"Seems you think I'm incredibly incompetent, huh?"
Seishin sighed. "I get it. This is clearly abnormal, isn't it? And spreading. It starts with anemia---" Seishin started to say, then tilted his head. "Normally, in the case of being attacked by a vampire, wouldn't the cause of death be blood loss?"
"If it's in a horror movie. They lose all their blood without a drop left, they say, but. ---But, I wonder about that, if you're thinking about it as a real world problem." Toshio brought the mug to his mouth. "Just what is a vampire anyway? Are they a group that doesn't have a body like ghosts, or do they have a body of some type or other? The village folklore "Oni" have the risen corpses of the dead. If we go by that, then a vampire's body would be structurally not too different from a human's."
"Aa."
"A person's blood volume is approximately eight percent of their body weight. If they're a full grown man weighing 70 kg, their total blood volume would be about 5,600 milliliters. Another way is to estimate 70 milliliters per kilogram. In that case it'd be 4900 milliliters. It's easier to round that to about 5 liters but that's five one liter packs? Like they can suck in that much in one go. By the way, even in patients with severe stomach dilation, the most the stomach can hold is 4 liters, but."
Is that right, Seishin murmured. Certainly, he didn't think that the folklore about the body being drained of blood without a drop left was very realistic.
"But death by blood loss isn't something that only happens when all of the blood has been lost, is it?"
"Of course not. I can't say precisely how much blood you can lose before you die but if you lose about fifty percent of your circulating blood, the heart will stop. If you think of the full blood volume as 5 liters, that's 2.5 liters. Even if that's half, that's a lot of blood."
"...Certainly."
"Thinking about the cases up to now, it's not like they've been taking their victims in one go. People who've lost 20 percent of their circulating blood would present with signs of shock but with this disease there's only enough time for anemia to present. If the blood volume is 5 liters, twenty percent would be one liter. One time doesn't mean one liter. At most it's 500 milliliters, or maybe less---" Toshio gave a faintly cynical smile as he held out the mug. "They have about two of these for a meal, in other words."
Seishin drank down the bitterness. Two cups worth of blood; the image brought forth an unexpectedly raw sense of disgust.
"If we estimate one time being about this much blood, by a simple calculation, by the second attack they fall into shock. On the fifth attack, the heart stops, is what it'd come down to."
"Several times...."
"Not bad. In reality, it's probably not that simple, but. ---Immediately after the first attack, red blood cells and extracellular fluid shift from extravascular to intravascular. Blood cells made by the bone marrow compensate for the lost blood. Living beings have faculties to manage blood loss. The blood gets deluded, and since the immature blood cells are released early, reticulocytes that can't carry as much oxygen are high. So anemic tendicies would appear but for the time being the body's fixed the problem. If this were the only attack, then the victim certainly wouldn't die."
"But, the attacks continue....?"
"They continue. By the second or third time, the body's management capacities are past their limit. If it goes past that, then they go into full-blown oxygen deficiency. The cells are screaming. Mediators are activated to save them. That causes the blood vessel permiability to rise, and water leaks from blood vessels in between cells. Even under normal circumstances, the insufficient blood count would become even lower. With the water content decreased, the blood becomes more concentrated, and at a glance it may even seem like the anemia's abating but the activated white blood cells attach to the blood vessels easily. Neutrophils start to migrate, consuming anything they can make contact with. The body goes into panic as a defense mechanism, and as a result of the defense system activating, the body starts to harm itself. Once this happens, it gets worse, building momentum like it's rolling down a hill. Once the waterline's crossed, the body will destroy itself even if they're not attacked again."
"To a certain extent the defense mechanisms sustain the patient, past that certain extent the defense mechanisms accelerate the damage to the patient...."
"That's what it comes down to. Whether it sustains them or quickens it, it's plus or minus zero; after a certain number of attacks it's a sure out. Within a few days of the outbreak. ....The balance sheets even out."
Seishin wordlessly shook his head. Not caring about that, Toshio continued.
"Once the defense mechanism runs wild, if there's something wrong with the body, it would strike directly at that. The fight would be over that quickly. After that it's a mater of luck. In any case, it gropes around trying to attack the problem. ----Multiple Organ Failure."
"I can't accept that," Seishin said, Toshio raising a brow as if it were an unexpected answer.
"Why?"
"I'll accept that the balance sheets even out. But, between the numerous attacks, why does the victim stay quiet? Never mind the last stages of the attacks, at first aside from the anemia, they aren't that gravely injured by any means. If someone who was supposed to be dead attacked you, why wouldn't you bring that up?"
Toshio made a grimace. "That's a weak spot for you to poke at in this. But, they can't say it---or rather, there's probably something not letting them say it. The obvious affects of the patients with an outbreak are anemia and blunted emotions. Trying to make communication with them is abnormally difficult. Thinking about it now, it was too early for them to have altered consciousness. Never mind if they were in the more advanced stages of shock, that their consciousness would be that low with just anemia is strange. They're doing something. That's the only thing I can think of."
"But---"
"It might be like some insects do, injecting a drug-like substance when they're sucking blood. Even if that's not it, they can make their victims act according to their will. It'll be strange if they can't. Of the victims, every single one of them without exception quit their jobs just before death. Without a doubt the person themselves quit but why did any of them do such a thing? I can't think it was their own will. Of course they're making them do it."
Seishin was silent. Did the classic vampire lore have anything to it like that? The attacked victims moving according to the vampire's will. To come to the very window still if called, away from all protection.
"They use the bunch they attack as their own personal puppets. If that's not it, then the consistent behavior doesn't make sense, and that's why they leave their victims alive."
"Leave them alive?"
"Isn't that what they're doing? I don't know just how much blood they're really sucking per attack but if we assume they're doing it at least more than once, they're not draining to the point of heart failure in one go, are they? Is that because they don't want it to look suspicious, or because they want to use them while they can be puppeteered, or maybe a little of both. In any case, they don't killing their victims."
"Whatever the case is," Toshio said idly picking at the medical charts. "The symptoms are incredibly consistent. After the first attack, the patient isn't aware of anything. The people around them don't notice it either. At most, their emotions become blunted, they're hard to communicate with, and so because of that there's a washed out feeling to them, like they're being plugged up but no particular symptoms appear. ---Ah, they might be thirsty and want water, or something like that. Since they're compensating for the reduction in circulating blood."
"If the attacks continue, their blood is diluted and anemia occurs?"
"That's what it comes down to. Likely, even if a blood test was done directly after an attack, it wouldn't show anemia. Since it's the blood volume itself being decreased, there wouldn't be a change in the hemoglobin per unit volume. Since the ratio compared to the red blood cells shouldn't change. But all the same, since the volume of circulating blood is decreased, the living organism tries to maintain this by starting to supplement it with extracellular fluid. Since the blood becomes diluted, the blood cell count per volume lowers. But since the reticulocytes are increasing, the blood volume---not just the hematocrit, but the hemoglobin values are down. The patient clearly shows anemia."
"And in the meantime, the defense mechanisms can't keep up? So circulatory failure occurs."
"Right. Since the heart rate falls, the pulse and blood pressure decrease. If you try to take a pulse, it's weak and hard to feel. It looks like their level of consciousness has fallen because of the brain also becoming ischemic. Since there's not enough blood flow to the kidneys, less urine is produced, and sometimes BUN levels rise."
"BUN?"
"Blood uea nitrogen. Amino acids in tissues and proteins are deaminated in the body. Ammonia is produced as a result but it's synthesized into uremia in the liver. Urea released into the blood is filtered by the kidneys but a part of it is reabsorbed. Not all of the water filtered through the kidneys is released as urine. Reabsorption occurs but if the body is suffering dehydration at this point, with the body trying to make up for the shortage of moisture, it reabsorbs too much."
"Ah---so if the circulating blood volume decreases, they'll also fall into a state of dehydration."
"That's what it means. When it's reabsorbed, the urea is also reabsorbed, so the urea levels in the blood rise. This amount of urea will also increase when the kidney's ability to filtrate is weakened. So BUN is one important took for measuring kidney function but when reabsorbtion is spurred on, creatinine levels don't rise. Creatinine is another thing the body needs that it generates inside of itself. Just like urea, it's filtered out by the kidneys to be expelled but unlike urea creatinine isn't reabsorbed. So reabsorbed creatinine levels don't rise. They only rise when the kidney's filtration functions are failing."
Toshio had noticed it right away. Creatinine wasn't rising, only the BUN was. He'd thought this was because of the decrease in circulating blood volume but he couldn't find the all important spot where the blood was being lost at.
"Anyway, with this summer being as hot as it was and all..." Toshio said with self-derision. "I figured it was due to evaporation. They had cotton mouth after all and I couldn't find any traces of internal bleeding. Then after that kidney function declined. This was a sign of MOF but actually I thought tht it was more strange that creatinine levels weren't higher. Was it just an odd matter of timing when the levels were in flux? Originally, in order to get a grasp on the real state of the kidney functions, we'd conduct a creatinine clearance test. We'd collect a day's worth of urine, then compare the creatinine values in the blood and the urine. If they were in-patients, we'd have tried it right away. But, since I couldn't hospitalize the patients, there wasn't enough time to try the clearance."
Seishin remained quiet and listened. Toshio didn't like to make excuses like this. It wasn't that he wanted to make excuses now, and he couldn't go without speaking out and saying how much he regretted it even now.
"The blood is diluted and anemia appears. The organs experience oxygen shortages, and compensation mechanisms are activated. In order to maintain blood pressure, sympathetic nerves are strained. Respiration and pulse increase and the blood vessels constrict. Because of that cutaneous respiration causes the external temperature to fall, with a distinct difference between internal and external temperatures. The limbs feel abnormally cold, and a cold sweat often breaks out. Blood is centering on the insides. The blood is partitioned out to the vital organs. Because of that, blood shortages to less vital organs becomes even more prominent. So, the face and limbs become pale. ---By this point, the people around them finally start to notice. Their color is poor, their breathing is hectic, and because of the stress on the sympathetic nervous system, the digestive organs aren't getting enough blood and they have no appetite. It's like they're tired, worn out. They wonder if they're worn down or if they've caught a cold."
Seishin couldn't help nodding. Indeed that was the nature of the disease that, ever since summer, had been carrying on throughout the village.
"But, since those symptoms are trifling enough, the people around them ignore it thinking they can sleep it off. In the mean time, they give them cold medicine, thinking having them sleep is the most they can do. But the situation becomes even worse. The anemia gets worse. With the decreased blood flow and lowered hemoglobin levels, the cells become oxygen deprived. Saturated oxygen levels fall. Because of that, the body switches to anaerobic metabolism. Excessive lactic acid is formed, the pH level of the blood falls, and since the body's unable to produce bicarbonate ions metabolic acidosis occurs. If this goes on, arrhythmia occurs, blood pressure drops, and their level of consciousness is effected."
"Oh...."
"Essentially, if there is metabolic acidosis, you'll know as soon as you do a blood agent analysis, and if you do a medical examination you'll know it's what caused their cardiac stroke volume to decrease. But, at the same time as this, microphage and other parts of the complement system activate, cytokines are induced and neutrophil is activated. The capillary walls here and there start to take damage. The respiratory organs are no exception and this is when lung failure presents. With lung functioning damaged, respiratory acidosis occurs. Once you end up knowing how it works it's all clear but when you don't know what's happening, you just end up lost on what could be causing the acidosis."
"The cause and the effect become muddled."
"Right. Anyway, something's wrong, so the body's trying to somehow defend against it. All kinds of mediators are activated but with the causes and effects muddled, the body itself doesn't know how or what to rescue itself from. It tries to take defensive action against anything it can reach and starts invading the tissues. ---SIRS. The body is clattering apart inside itself. Blood vessel permeability rises, moisture flows from the vessels to the cells. With the cells being invaded, the capillaries are getting damaged one after another. The platelets form together and decrease. Lung injury, renal failure, ischemia of the heart lead to reduced heart function. From there it devolves to cardiogenic shock, and with the decrease in blood platelets, the blood clotting factor activates, which is like a direct hit to the coronary arteries. In other words, because of that blood clotting agent, fibronolysis is activated, and extreme hemorrhaging can start to occur. The body completely loses its ability to maintain itself. As a result,"
"---MOF."
Toshio nodded. "Once SIRS starts to occur, even I don't know what's happening what to where. What I do know is that everything everywhere goes bad. Even getting test results back, with the toll it's taking on the body telling cause in cause and effect is difficult."
"Like when it's metabolic acidosis or respiratory acidosis?"
"Right. So you can't help trying a symptomatic approach but by the time the patient shows up they're already being carried in, and on top of all of this, with one attack after another, the condition worsens so quickly you can't even think to combat it before it becomes irreversible." Honestly, Toshio mumbled with a huge sigh. "...There's not a damn thing I can do."
Seishin remained silent. He couldn't think of any words appropriate to offer to Toshio's sense of helplessness.
"If only I'd given the relevant treatments sooner. Full blood transfusions, or Ringer's solution transfusions, just something to compensate for the circulating blood volume, something to stabilize it before the defense system started running wild, and keep it that way. To say it another way, that was the only treatment worth giving. Actually, there were results from the full blood transfusion. Out of all the methods tried, that was in fact the only one that had any effect at all...."
For a time, silence filled the nurse's station. Toshio remained sullen, staring fixedly at the single bed. From the recovery room itself there was no presence nor sound.
"Anyway, I think I know the way to handle this. Since there is a case of it being effective, I'll assume it will be from here on, too. But, the Gyouda's Baa-san still died even with that. You could say she held up well for her age but even so, it only held her out for another one or two days. If they aren't cut off from the attacks then there's no way for them to recover."
"And that's why you had Setsuko-san hospitalized?"
Toshio nodded.
"That's right. I pestered the contracting firm during the daytime to have her brought in. The thing attacking Setsuko-san will probably lose sight of her. And to begin with," Toshio said, sounding bitterly pained. "Even if she were taken to Mizobe's hospitals, there are cases that couldn't be saved. Mikiyasu is the main example of that. An ambulance was called to take him to the National Hospital in the middle of the day but in the end he still died. It's possible he was already in a state where there was nothing that could be done for him but it's also possible that wasn't the case."
"There's the possibility that they followed Mikiyasu as far as the National Hospital. In that case, they will come here." Seishin turned his eyes to the recovery room door without thinking. The building was neither silent nor was there sound, beyond that of the Momi firs swaying in the wind. That noise managed to sneak even into the building, with nothing to muffle the sound leaving it to echo as if amplified within here. "Did you lock up?"
It wasn't as if he particularly believed Toshio's excuses but Seishin couldn't help but ask that.
"I did, naturally. And not just for today. We've got strong drugs in here. I don't usually confirm that the main wing's locked up or anything, but the hospital itself is completely locked down. There are the iron bar lattices installed in the parts that would be easy to overlook, too." Saying that, Toshio's gaze went to the recovery room. "Just like the room over there, there are a lot of rooms where the windows don't open enough for anybody to get in."
Seishin nodded. The recovery room had a window but the glass window only pivoted so far to open in either direction, and it was probably impossible for a person to fit through it. ---But, Seishin thought. It was probably the same in the hospital in Mizobe. If it was an inpatient facility, it also had to be locked up tightly, and during that period they must have had somebody doing night rounds as well, so it shouldn't have been easy to sneak in. If there were something that followed after Mikiyasu, didn't that mean that that something was able to attack even in an environment just like this?
Seishin had thought that far when, aware of his own unease, he realized that at some point he had presupposed accepting the existence of an attacker. Disturbed by that, he looked up only to find Toshio looking at him knowingly. Seishin let out a sigh, but what it was towards, he himself didn't know.
Toshio gave a faint smile and stood, peeking into the recovery room next door. Setsuko was sleeping. It was a quiet night, with no abnormalities or changes.