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Inuyasha | Rhapsody in Eight Movements
Title: Rhapsody in Eight Movements
Fandom: Inuyasha
Universe: Alternate (Modern day Japan)
Genre: Mystery, Suspense
Rating: T
Warning(s): Mentions of death, the treatment of mental illnesses
Summary: When a mysterious man washes ashore on Halloween night, it becomes a race against time to uncover his identity – and the circumstances that left him there.
Links: DW | FF.net | AO3
This chapter might be best viewed on DW or AO3, as FF.net doesn't respect spacing - and probably made this look like an even bigger jumble than anticipated, LOL.
This is the chapter where I suspect most readers will scratch their heads and give up on this piece, for two reasons. First of all, this is the third POV change in as many chapters. Secondly, this is a medical chart, with all prescient terms and notes. It has a Flesch Reading Ease readability score of 34.6, which is basically graduate-school level (which makes sense, as it is written in the vein of medical professional notes). This shit is hard to understand - and, believe it or not, I actually tried to make it easy to read, LOL!!
Part of my current position involves reading medical charts on a daily basis. This chart is actually based assessments used at my institution - it's part outpatient, and part inpatient. The outpatient half is basically the psychology part, with the various histories, etc. The narrative is what inpatient notes generally look like, at least at my institution.
Knowing that Japan lacks HIPAA made it easier to blend the two, and make the chart more readable - and delivers the maximum dose of information possible in an authentic manner.
A couple of interesting things to note, going through this:
(1) medical decision makers ~ in cases where patients don't have available relatives or friends (or when they're not officially wards of the state, etc), basically what happens is that the hospital's ethics committee meets and assigns surrogate decision makers, usually two physicians or a doctor + another medical personnel (social worker, etc). In emergency situations, two physicians can co-sign the consent form for procedures, if the patient or their legally authorized representative is unable to do so. It's actually an interesting thing, IMO; I know the ethics committee has shown up in shows like House, but in RL, at least in my experience, its fairly rare for them to be involved, if only because the staff can usually locate someone in the patient's life.
Here, our patient has the capacity to make decisions, but is still under surrogate care of his physicians, first the medical team, and then the psychiatry team. This isn't really that far out of the realm of possibility; basically, legally, he's considered incompetent. This will become important as the story wears on.
(2) hospital course ~ this is the fairly standard hospital course, for someone who is originally admitted/transferred to the ICU at a hospital. At my institution, one of the things that prompts an ICU admission is the need for intubation, which is basically being put on the ventilator via a tube through the nose or throat. (Extubation is coming off the ventilator, in the reverse process.) Hypoxia = lack of oxygen; hypotension = low blood pressure. Pressors are used to treat hypotension. 3 is a lot to have at once, but being weaned from them quickly is generally a good thing (as is quick extubation).
Basically, our patient was held in the ICU for observation; when he didn't grow an infection and his oxygen and pressures stabilized, he was transferred to the floor under the Hospitalist (or general medicine) service to await a bed in the secure psychiatric ward. Now that he's been medically cleared, the search for his identity can resume full-stop.
(3) The whole long explanation regarding the drowning *would* appear in a resident's note (which this is), at least at a teaching hospital where residents are still students, albeit postgraduate ones :) Unusual cases such as this have these explanations noted in the chart for reference - I guess if you're going to go through all that trouble to look it up, might as well save everyone else the time, no? Heh =)
(4) Deep-water drowning was, er, interesting to look up. It started as a search query on Ask MetaFilter, and progressed from there :P Everything noted in the chart is true, at least according to this source:
Victims struggling violently to survive in water bruise or rupture muscles particularly those of the shoulder girdle, neck and chest (most often the scaleni and pectoralis major). Haemorrhages may be bilateral and tend to follow the lines of the muscle bundles. They may be present in up to 10% of cases and are strong indicators that the victim was alive in the water. In decomposing bodies these haemorrhages should be examined histologically. Uneven putrefaction can cause reddish patches to develop in muscle through haemoglibin inhibition and this may be confused with haemorrhage. Extravascular erythrocytes provides histological proof of the existence of true haemorrhage.
In the water the body floats face down with the head lower than the rest of the body so that lividity is most prominent on the head, neck and anterior chest. Lividity is often blotchy and irregularly distributed reflecting movement of the body in water. It is not intensive and appears a pink or light red colour. In cold water it can be dusky and cyanotic. It may be difficult to recognise due to swelling with water of the upper layers of the skin with resultant loss of translucency.
Immersion in water produces progressive maceration of the skin which becomes blanched, swollen and wrinkled. It is first apparent in the skin of the fingerpads and then appears on the palms, backs of the fingers and back of the hand in that order. When fully developed it is most striking on the palms and soles. In water 50-60°F early changes can be seen within an hour. Generally there are obvious changes within 24-48 hours but the process may be delayed for several days in winter. With developing putrefaction the epidermis including the nails peels off like a glove or stocking. Fingerprints may be easily prepared from the glove; reverse fingerprints may be prepared with some difficulty from the exposed dermis. The wrinkling and blanching of water-soaked skin in reflected histologically in water uptake with swelling of the epidermis progressing to epidermal detachment from the dermis.
Having sunk to the bottom, a body drifting along the water bed will sustain a pattern of injuries reflecting its head down floating position (see above). Abrasions are typically found over the prominent points of the face, anterior trunk and extremities. (source)
I don't remember exactly how I made it from AskMeFi to this article, but yeah. Suffice to say, I refrained from eating while I hunted down this answer :P
(5) cognitive testing ~ a very basic part of a psychological workup is cognitive testing, which would reveal a general fund of knowledge from which doctors could extrapolate a possible education level, etc. This can be specially requested by a psychiatrist, and I think in this case, with so little information to go on and the mystery of why the patient isn't speaking, it would be a very probable step. The Mental Status Exam is such a test, but definitely not the be-all end-all.
(6) the safety monitoring plan has a name ~ this is fairly standard in most institutions; there are certain protocols that have been developed to deal with certain aspects of medical care, and safety is one of those. It's sometimes called suicide-prevention, especially for psychiatric patients.
(7) Full Code ~ this is the default resuscitation status, at least at my institution; it means that any and all life-saving measures will be undertaken in the event of an emergency.
(8) As you can see, two more characters have been introduced! Kagome is a doctor - more specifically, a level-four resident, which is basically the last year of residency. I decided to make Mushin her attending physician (or her supervisor). I thought it was an interesting role to give Mushin, a rather minor character, considering how he cared for and looked after Miroku in the canon. I have him a first name, "Masao," as a nod to his place in the canon; according to my baby-names book, it means righteous or holy.
This is definitely the hardest chapter to get through, but I thought it a unique way to convey a lot of information, including how frustrating the search for our mystery man's identity is, even a week in...
no subject
I haven't seen a hospital chart in ages, so I won't speak to authenticity, but knowing that you do this as a part of your job, and seeing the work you've put into researching this, I'll trust you.
In any case, I really love this and the unique way you're progressing the story. I'm very much looking forward to future chapters.
no subject
I basically wrote this in exactly the same vein as the charts I read - and, you know, it varies from institution to institution. This is based on an outpatient form that is still widely used where I am, and seems to be the best of the lot, at least locally. In a way, I'm glad that I had the chance to work with inpatient records before I decided to publish this, because the original note was...well, not good :P
I love researching for my stories - I think I like it better than actually writing them sometimes! - so I'm pleased to hear it helps as much as I like to think it does :P
I really love this and the unique way you're progressing the story
:D Honestly, I've been pleasantly surprised with the level of interest in this story, considering its so very not the norm (and considering that crazy review I received on a similarly experimental fic, LOL!). I guess IY fandom has mellowed out more than I give it credit for... =)
no subject
You made Mushin work in psychiatry... That's not quite what I was expecting. :D
Though I'll have to assume that he at least won't be as drunk as his canon self. ;)
Is he related to Miroku in the same way as in canon?
The chart was okay. Whatever vocabulary I didn't know, I let my nifty little firefox addon translate and explain to me. The abbreviations were a little harder, but I decided that the few I didn't get weren't THAT important. The gist of it still made it through to me. :)
Just one question: If our patient has no memory and is answering only in the barest manner, how did they find out he's got a brother?
In any case, this makes me question the identity of Miroku's colleague again, though I have no idea who else to assign to that role from your AO3 character list. Hmmm...
no subject
No, Mushin & Miroku are not related in this universe =)
I'm glad you were able to get through the chart! The abbreviations are pretty minimal; compared to the records I go through. Quickly looking over this chapter...
SA = substance abuse
UDS = urine drug screen
PMH = previous medical history
FPP/RBC = fresh packed plasma/red blood cells (so, basically a blood transfusion)
w/wo contrast = with & without radioactive constrast
US abdomen = ultrasound of the abdomen
If there are any others you're curious about, just let me know, hehe =)
If our patient has no memory and is answering only in the barest manner, how did they find out he's got a brother?
The key here is dissociation, not amnesia.
ETA: Ugh, IE, WTF >:(
no subject
Uh oh, what happened?
Yay, I guessed the latter 2 of the abbreviations right. :D
Looks like every job is now abbreviation-riddled. Whenever I hear family and friends talk about their jobs (even those who work in production), they use abbreviations that make all they say sound like a different language altogether, that's how much I get what they're doing.
Fun fact: In my job, we know what the abbreviations mean, but we often don't actually know what the letters stand for. :D