Who Is Entity (9): The Digital Portrait

With a single strike from our hero Shiho, the truth-trolling mob guarding the ER entrance simply ceased to be.

We went straight to ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠the resuscitation room.

The moment we crossed the threshold, the other medical staff fanned out and prepared for their respective roles without a word of instruction.

Meanwhile, I pulled on the lead apron and gloves the nurses had set out in advance, then shrugged into a sterile gown.

"Professor! The patient's saturation is dropping — it's at 85!"

A nurse who had been intently watching the pulse oximeter clipped to the patient's finger shouted the number out.

I answered calmly.

"PCI is ready. Jihun — where's my arterial line?"

"Getting it now, Professor."

Jihun and I each palpated for the radial artery on either of the patient's wrists. The pulse was faint, but for two men whose entire careers revolved around finding this exact vessel, it was hardly a challenge. Almost in the same breath, we both advanced our catheters.

I addressed the room at once.

"Catheter's in. Put the monitors up, please — everyone else, step outside."

The X-ray machine whirred to life, and the staff without lead aprons filed out of the resuscitation room. What remained were me, Jihun, and the two residents assisting with the procedure.

Ah — and the patient, of course. The patient stays.

"Songwoo, swing the monitor around this way."

"Yes, Professor."

As Songwoo turned the screen, a hair-fine black line sliced across the gray field.

Cardiac catheterization. A procedure in which we thread a wire through an artery up into the heart, then punch through the blocked segment of a coronary artery. I usually explain it to families as an endoscopy for the heart — and aside from the fact that we peer inside with X-rays rather than a camera, the comparison isn't far off.

"Blood pressure 100 over 80, Professor."

"Hm… nobody drops into a stupor at a pressure like this…"

Something was off. Out of true.

People almost never lose consciousness at that kind of blood pressure. The brain keeps getting perfused even when the pressure sinks to around 80; you generally need to fall to the 70s before anyone starts debating whether a patient should be awake or not. And yet here was a patient in frank stupor with a systolic of 100. That was flatly abnormal.

"Run a full saline bolus, start norepinephrine at 0.1 micrograms. Call CS and have the ECMO team standing by. And put in a call to Neurology too — this might not be just an MI."

The treatment plan unfurled in my head and poured straight out of my mouth. The residents echoed my orders back word for word and got to work. Meanwhile, with Jihun's steady assistance, I examined the patient's heart.

"Inject."

Contrast bloomed through the vessels, and the outlines of the heart and coronaries resolved onto the monitor.

Something was wrong.

"…Inject."

Wondering if my eyes were deceiving me, I pushed contrast a second time. But no matter how I studied the images — changing angles, fiddling with every setting I had — the shapes on the monitor refused to match what I expected to see.

"These vessels are… pristine?"

The murmur escaped my mouth before I could stop it.

The right coronary artery, the one that should have been occluded, was spotless. Not even a trace of blockage. Honestly, judging by the vessels alone, this patient might be healthier than I was.

To put it plainly —

"Hey, this…"

My throat had gone bone-dry.

"This isn't a myocardial infarction."

Which meant my initial diagnosis had been wrong.

Tap tap tap.

Pausing the procedure, I drummed my fingers against the catheterization table and waited for the ultrasound machine. In the meantime, every differential diagnosis conceivably relevant was racing through my mind.

Strictly speaking, there was a term for this exact situation.

MINOCA — Myocardial Infarction with Non-Obstructive Coronary Arteries.

A heart attack with clean coronary arteries. A rare entity encountered in the field, and a notoriously difficult one to pin a cause on. When a result like this comes back, the operator halts the procedure and races to find another explanation.

And that was precisely what I was doing — waiting for the echo machine so I could hunt for that explanation.

Tap, tap…

"Songwoo. Bump the norepinephrine up to 0.3 and add dobutamine at 5 micrograms."

"Yes, Professor. Increasing norepinephrine to 0.3 micrograms and adding dobutamine at 5 micrograms."

One full minute of chemically propping up the patient's blood pressure while we waited on a machine. That sliver of time stretched out agonizingly long.

"It's here, Professor."

The moment the ultrasound machine finally arrived, I lunged for the probe. I glopped on a generous amount of gel and pressed it to the patient's chest.

On the screen, the left ventricle appeared — the heart fluttering away, alive.

"What the hell is this?"

The words tumbled out of me before I could catch them. It was a scene I could not make sense of.

The right ventricle was completely dead — its function annihilated — while every other region of the heart beat away as healthily as if nothing had happened. As though half the heart were alive and the other half dead. Normally, when one wall of the heart slacks off like that, the rest of the myocardium has to labor double to compensate. There was none of that. Nothing at all.

But there was something stranger still…

"Songwoo. What does this look like to you?"

"I'm sorry, Professor. I don't know."

"Sorry — shouldn't have asked."

Expecting a second-year resident to fully decode an echocardiogram was asking a bit much.

On the gray-and-black screen, I pointed at the right ventricle, the lone structure blazing white against the murk.

"Even you can see it, right, Songwoo? That looks like fat, doesn't it?"

"I… I suppose it does, Professor."

"What on earth could this be…"

Something itched in the back corner of my mind. A thread I could almost grasp — almost, but not quite. And then Songwoo spoke up, cautiously.

"U-um, Professor? Could it be ARVC?"

ARVC. Arrhythmogenic right ventricular cardiomyopathy — a hereditary disease in which the heart muscle is progressively replaced by fat and fibrous tissue. That was the disease he was proposing.

But his guess had a problem.

"Good thinking, but that's a reach too far. The ECG says no — and there's no arrhythmia."

ARVC shouldn't present like this. Because it's a genetic disease, it morphs the heart slowly over years, so you'd expect the characteristic T-wave inversions or epsilon waves. Above all, the mechanism by which it kills is entirely different. ARVC doesn't make the heart simply stop like this — it announces itself as an arrhythmia. In other words, it's a disease you could never mistake for a myocardial infarction.

At my explanation, Songwoo bowed his head.

"I'm sorry, Professor."

"No, no. It was a genuinely good guess. I thought exactly the same thing at first."

I waved off the apologetic resident, who kept ducking his head, and forced myself to organize the test results in my mind.

This is wrong. All of it.

None of these findings followed normal physiology. It was as if the heart had been coded by a programmer who didn't really understand hearts — an uncanny, awkward simulation of one…

Wait.

An unnatural intervention?

I spun toward the entrance of the resuscitation room on pure reflex — and shouted at the woman standing there, arms folded.

"Director Shiho!"

"Just call me Shiho. I'm unemployed now; the whole 'Director' thing is a little embarrassing, don't you think?"

"Shiho. Could you show me the Echo observation log for this patient?"

"One moment."

Shiho pulled out her phone, tapped the screen a few times, and turned it toward me. The design was different from the entity encyclopedia in the game — this looked like an official record used internally by the Management Bureau. I swept my eyes rapidly down the entity record on the screen.

The Digital Portrait.

An Echo that resonates with people who live by appearance — performers above all, actors, models, anyone whose face is their livelihood.

Those who resonate with this Echo have their looks frozen at their youngest, most beautiful moment — and the more time passes, the more beautiful they become. No matter how great the evil they commit, they can always buy forgiveness and public support on the strength of their face alone.

But the Echo exacts one price.

Every photograph of the resonant host begins to mirror the entity's inner nature — and with each evil act the host commits, their photos warp by degrees into uglier and more aged shapes.

That's it.

The moment the foggy record came into focus, the final piece of the puzzle clicked home.

"What an idiot…"

"Er — was that directed at me, Professor?"

"Sorry, Shiho. That was aimed at me."

After apologizing to the bewildered Director for the unprompted profanity, I turned back to the patient. She trailed at my heels, firing off questions.

"So, what did you figure out?"

"Yes. I understand the patient's condition now."

Our approach had been wrong from the very first step. This patient was resonating with an Echo — with a supernatural phenomenon in its own right. Forcing conventional medical common sense onto such a patient was an act of sheer stupidity.

"The patient deleted photographs with his own hands. He wouldn't have erased every photo of himself in existence — most likely just the ones in his own possession."

And that was why only part of his heart had stopped. To be exact: only the cells of the right ventricle had turned to fat.

"Which explains how one region can lose function while everything else keeps moving normally."

It also explained the ECG that mimicked a myocardial infarction. When an entire wall of the heart transmutes into a lump of fat in an instant — rather than degenerating slowly over years — of course it masquerades as an MI.

"So what you're saying, Professor, is that right now this person is in fulminant RV failure — because of the Echo?"

"…Were you, by any chance, in the medical field, Shiho?"

At my rebuttal, Shiho shook her head.

"No. I don't know any treatments — just the diagnostic side."

A thread of self-mockery had crept into her voice.

"Man a checkpoint long enough and you end up needing to know this kind of thing. The Bureau's 'Knowledge Infusion' handles it — they upload it straight into your head."

Knowledge Infusion? So medical knowledge just… installs itself in your brain with a single click?

The phrase twelve years thrown away flickered unbidden across my mind. I shook it off.

No. It's fine, Jeong-uk. Your youth wasn't wasted.

…Damn it.

"In any case — the patient's heart is partly melting into fat. That's the situation."

"Then he can't be saved?"

Tension had crept into Shiho's voice. That she could spill that much worry over a total stranger — a man she'd never met before today — was almost admirable. I shrugged at her.

"No? We know the cause now, so we can save him. Songwoo! Where's the ECMO team?"

"They've just arrived, Professor."

I looked toward the entrance and spotted the thoracic surgery team wheeling in the ECMO cart. I walked over to Professor Kim Kyungchul of CS, who was leading the team, and gave him a quick rundown of the patient's state. He tilted his head at first — but when he heard the word entity, he grimaced and reluctantly accepted it. I understood. Asking a thoracic surgeon to mount an ECMO on vague, unprovable grounds is a heavy burden on its own; and with the insurance service chomping at every opportunity to slash ECMO reimbursement, the burden only compounds.

Even so, Professor Kim got straight to work setting up the circuit.

While he cannulated, he threw a jab my way, grinning.

"Hey, Professor. I'm mounting this on my faith in you and nothing else — so if we get our reimbursements gutted again this month, what do I get out of it?"

"Shall I buy you dinner?"

"Save it. I'm not about to start mooching meals off some bright-faced junior at my age~"

Amid the old professor's grumbling, the thoracic surgery team ran the ECMO. Meanwhile, I retreated to a corner of the resuscitation room and peeled off my sweat-soaked gown. Shedding the lead apron made my shoulders feel pounds lighter.

"Songwoo."

"Yes, Professor."

"Let's prep for the next procedure."

Songwoo looked at me, puzzled.

"I'm sorry — once the ECMO's on, aren't we done?"

"We would be, if this were ordinary right heart failure."

ECMO is a technology that lets a machine do the heart's work so the heart itself can rest. It buys time for a heart like this one — a ventricle half-melted into fat — to recover. Looked at that way, one could argue that once the machine was running, our job here was done.

But that logic only holds for ordinary heart failure.

"Is this patient going to spend the rest of his life hooked to an ECMO? He'll wake up eventually. And you're the one who said this looked like ARVC, remember? The heart turned to fat — so what complication comes with that?"

"Ah — arrhythmia."

"What kind?"

"AV block, Professor."

"Good. So for a high-risk arrhythmia patient who's already lost consciousness once — what do we have standing ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠by?"

"A temporary pacemaker. It has to be exchanged for a permanent one before discharge."

"There we go. Our Songwoo's been studying. Set the temporary pacemaker at the head of the bed. If the arrhythmia hits, we go in immediately."

While I wiped the sweat from the back of my neck with a gauze pad, our second-year shot out of the resuscitation room like a bullet.

Sorry, Songwoo. Third-years are like soldiers in their final service year — I don't work them unless it's a Code Black. Being a second-year in this era of all eras — you drew the short straw, kid.

If you stay at the hospital, I'll make it up to you.

Not that he'd want to stay. God knows.

With the resident dispatched, I let out a long breath. Everything within our power was done. All that remained was to hope the patient could fight through it.

Just then, Shiho — who had been standing in silence by the entrance — came to my side. Her footsteps were startlingly quiet.

"Did you save him?"

"I didn't remove the Echo. I only bought his life back. Honestly, if I were a better doctor, we wouldn't have needed to come back around like this — I'd have fixed it on the spot."

Of course, in real modern medicine, differentiating a disease like this from a myocardial infarction without ever running a catheterization is flatly impossible. But if the ones on duty had been geniuses like the Department Chair ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠instead of a mediocrity like me, the outcome would have been better. The clinical front line always leaves nothing behind but regret.

"Frankly, I still don't know why he's in a stupor, and I don't even have a guess as to how to remove the Echo."

The limits of modern medicine. A supernatural phenomenon wouldn't be called supernatural if science could explain it — and an Echo is no different. Playing by the rules of modern medicine, I'm powerless against these things. The best I can do is grab a patient by the collar as the waters of the River Styx close over his head and haul him back up.

"…"

At those words, Shiho stared at my face, unblinking.

"Was there something you wanted to say?"

"Just as I thought."

"?"

"I think I picked the right person."

"What do you mean by that?"

Shiho turned her gaze toward the patient lying on the table, draped in a thicket of ECMO tubing — Gu Jihye.

"That patient. I actually stumbled across her in an online community myself."

Her voice dropped lower.

"Anyone could see she was turning into an entity. And nobody lifted a finger to help her. I couldn't stand watching it, so I used Bureau equipment to trace her down to her address — but the problem was…"

She paused.

"I know how to filter entities out at a checkpoint. I don't know how to save a person."

"…"

"And then I remembered a video of you I'd seen on NewTube. So I brought her here."

"I'm not that remarkable a doctor."

"After I got out of the Bureau—"

Shiho smiled, a lonely little smile.

"—I looked around, and you were the only person in this going-mad world who actually knows how to save people, and actually tries. That was enough for me."

"It's a shabby kind of hypocrisy."

"Then I'll turn it into the real thing."

Shiho jerked her chin toward my pocket.

"Open the app."

"Which app would that be?"

"Which do you think? The game. Go check the in-game mailbox."

Brow furrowed, I launched Paranoid Institute. While the loading bar crawled toward full, an awkward silence settled between us. Unable to bear it any longer, I tried to strike up a conversation.

"So, um, by any chance…"

But before the words could leave my mouth, my ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠eyes locked onto the screen. The instant the mailbox opened, a message I could not possibly ignore was waiting inside.