VEXAS Syndrome (1)

Hell.

That was what people ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠called our hospital's Emergency Medical Center.

And I, Han Hyeon-jae, was a creature of that hell: a first-year resident in Emergency Medicine.

Slurp—

"For fuck's sake, chew quieter. That shit looks disgusting."

"Dude, isn't it a miracle this is even going down my throat right now? Huh? I just came off thirty minutes of CPR on an MI—myocardial infarction—patient who rolled in. I should be grateful the cup ramen even tastes like beef bone soup."

My classmate Kim Ji-hoon said this through a face dripping with sweat.

We were sprawled like corpses in the corner of the on-call room, cobbling together a meal out of lukewarm convenience-store lunch boxes and cup ramen however we could.

The noise outside started to swell.

Oh, please. Don't you dare.

"Doctors! Arrest in the Resuscitation Room!"

Fuck.

"Ah, fuck, seriously."

Kim Ji-hoon spat the curse with noodles still in his mouth and launched himself off the floor.

I got up half-mechanically myself. A body that had weighed a thousand pounds a second ago now answered a single alarm like Pavlov's dog, the cursed son of a bitch that I was.

It was the only real skill I'd picked up from getting my ass kicked through this place.

The instant I kicked through the Resuscitation Room door, the air stabbed my nose: blood, disinfectant, and human despair, all tangled into one.

"Patient is a fifty-eight-year-old male! Found unresponsive! Eleven minutes since first contact, no BP, no pulse!"

"I'll push epi—epinephrine—and start compressions right away!"

"Starting compressions! One, two, three, four…"

Everything moved in perfect unison and, at the same time, in complete raving chaos. Someone had climbed onto the patient's chest and was compressing until the ribs had to be splintering; someone else was squeezing an ambu bag, jamming oxygen into the lungs by force. I stared at the scene, blank, for a moment.

A middle-aged man with his hand already on the doorknob to the afterlife. Could any of this shit we were doing actually pull him back to this side?

Doubt. Yeah, doubt. What the hell was I even doing this for?

That was when it happened.

Right in the empty air in front of my eyes, for the briefest instant, a rainbow-colored noise seemed to crackle into being.

…Am I seeing things because I'm tired?

I rubbed my eyes. It didn't disappear. The noise began to resolve into a clear shape, like one of those translucent system windows you'd only ever see in a sci-fi movie.

What the fuck was this bullshit.

I decided I had finally lost my mind. Overwork and stress had melted some particular part of my brain; that had to be it. Was I the only one seeing this?

I almost asked the nurse grabbing an IV line beside me. Excuse me, can you see that blue text over there?

That would have been a straight shot to the locked psych ward.

"Checking rhythm! It's VF—ventricular fibrillation!"

For better or worse, that ridiculous system window vanished in a second without a trace, as if it had never been there at all.

Right. Just a hallucination.

By the time I snapped out of it, the defibrillator paddles were already in my hands.

"Everybody clear! Charging, two hundred joules!"

"Clear!"

"Shock!"

Whump! The patient's body arched like a bow. The ECG tracing on the monitor was still a complete wreck. It didn't look interested in coming back. Another thirty minutes went by like that.

In the end, it was over with the attending professor's declaration that CPR would be terminated.

Sweat and effort scattered into the air, amounting to nothing.

Rest in peace.

I headed back to the on-call room.

The moment I threw myself onto the bed, the message from earlier rose up again.

Gallery Pass?

"And what exactly am I supposed to do with that."

Was this one of those web novels that were popular these days? A status window? Skills? Hunters?

On the off chance—feeling like a complete idiot—I tried shouting it in my head.

Gallery!

Nothing happened.

I let out a short, empty laugh. Right. Like I was some kind of protagonist. This was just my exhausted brain screwing with me.

I closed my eyes and tried to force myself to sleep, but my head was a mess. Gallery… gallery…. Wait. Did that word gallery mean that gallery?

In that instant, a translucent window popped up in front of my eyes again.

This time it was different. It wasn't a simple message box like before.

"…What the hell is this screen."

What unfolded in front of me was an interface that was a carbon copy of a site you'd have lurked on at least once. Dingy blue. A clumsy, slapped-together UI. And, stamped in the upper left corner, the gallery's name.

I snorted out a laugh before I could stop myself.

Dead medical scholars? Ah, so that was the gimmick? My brain had officially gone off the deep end. For a delusion cooked up by an overworked, bottom-rung doctor's brain, it had a pretty convincing B-movie sensibility.

Fine. So my brain was throwing a full-blown tantrum. Alright then—try solving this one.

A patient who had just arrived at the ER came to mind. He'd been running a high fever of unknown origin for days, bounced from hospital to hospital until he landed here. The bundle of outside records a nurse had handed me a little while ago was plastered with every test under the sun, and every last one of them said some useless variation of "no significant findings."

I had flipped through the chart myself, thought Hmm, nothing weird here, and moved on.

How do I even write a post? Do I just imagine typing on a keyboard?

I mimed tapping a keyboard in my head, and as if it were the most natural thing in the world, letters began filling in the compose window floating in front of me. Oh, fuck. This was real.

That should be enough. I submitted the post by thinking about the submit button. Now, who in this insane delusion was actually going to reply?

That thought didn't survive a second.

I had to admire the dedication—the reply led with an insult before anything else. It even showed an IP address. A delusion with that kind of detail. 118.235—that was a Korean IP, wasn't it.

But VEXAS?

"What the fuck is VEXAS."

It was a disease name I'd never heard in my life. Gotta hand it to my brain, inventing something like this.

I let out a hollow laugh at the sheer absurdity of it, but my fingers were already, without my say-so, picking up my phone ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠and opening UpToDate, the closest thing doctors have to a bible.

I typed "VEXAS" into the search bar.

And the moment the results appeared on the screen, I heard my heart hit the floor with a thud.

I stopped breathing. The words on the screen and the contents of the chart I had skimmed past so carelessly began to slam together in my skull like a storm.

There was an erythematous rash on the patient's face.

The CBC was normal across the board—except the red cell ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠count was just a little low. Mild anemia.

And he'd complained that the cartilage in his ear was red and swollen.

Fuck.

Fuck.

Fuck!

There wasn't another word in my head besides cursing. The letters VEXAS Syndrome on my phone screen were so sharp they felt like they were burning into my retinas.

And the thing that had told me was a raving delusion in my skull called the Dead Medical Scholars Gallery.

I grabbed the internal phone immediately. The patient's attending wouldn't be me from Emergency Medicine; it would be Internal Medicine, once he was admitted. A rare case like this obviously had to go through IM.

The procedure was clear. Internal Medicine general on-call: R3—third-year resident—Nam Seunghyun.

A guy famous even on a normal day for being prickly and a complete asshole.

A neurotic voice tore through the receiver.

"Who is this."

"Ah—Doctor! Good evening! This is Han Hyeon-jae, first-year Emergency Medicine!"

I dropped my voice as low and polite as it would go, with the exact heart of a private on the phone with a division commander.

"EM? At this hour? Get to the point."

"I'm calling to request a consult on an FUO patient who just came into the ER. He's a sixty-eight-year-old man, and looking at the outside hospital records together with our initial findings…"

I swallowed once, and said it.

"VEXAS syndrome is strongly suspected."

Silence spilled through the receiver.

One second. Two. Three.

That brief stretch of time felt like forever. Then Nam Seunghyun let out a scornful little laugh.

"What? What did you just say?"

"VEXAS syndrome, Doctor. That's what I said."

"Hey, Han Hyeon-jae. You fucking with me right now?"

His voice sank, gone ice-cold.

"So this is the crazy bastard who reads some weird-ass case report and decides to call me. Ha, fuck. Unbelievable."

"But Doctor, the patient's symptoms are textbook. Recurrent high fever, a skin rash, mild anemia, and the cartilage—"

"Hey!"

Nam Seunghyun cut me off. His voice was thick with undisguised contempt.

"Bastards like you are the real problem. You don't even have the basics down, and you're out here picking up rare disease names and writing novels about patients. You so much as run your mouth like that to the patient's family. Start by ruling out basic infectious disease again. Rerun the viral markers and the autoantibody panel, and call me when those come back. No. Don't call me. Just drop a note on the sign-out sheet. I'm hanging up."

"Doctor, wait, looking at the previous hospital's chart—"

The phone went dead, one-sided.

"…Fuck."