The ER doctor at the small rural hospital continued her rounds, checking in on a toddler with the flu. The concerned mother sat next to him, her face strained, holding her phone in one hand and purse on her lap in the other. The child lay still on the exam table, cheeks flushed with fever and flattened by an invisible extra gravity. She reassured the mother about the miracle of fever and nausea reducing medication, and the ability of young kids to bounce back like rubber balls.

She left the exam room, peeling off her gloves and stashing them in a waste bin next to the door. She waved her hands under the sanitizer dispenser, which rattled in return and sprayed a thin stream of foamy alcohol. She wiped her hands as she walked to the nurses' station, her feet tapping on the polished tan tile.

She reached the small curved desk with a few computers at a bend in the hallway, and nodded to one of the nurses. "Any updates on our hitchhiker?"

The nurse nodded back. He picked up a small manila folder and handed it to the doctor. "Yeah. The driver left. Toxicology came back, positive for LSD. No infectious diseases. Her GFR is basically nothing, kidneys are shot. Bilirubin and Albumin show liver issues, too. Her blood phosphate levels are weird, too."

The doctor flipped through the pages, folding them over the brass clips and tucking them behind the folder as she read. She reached the electrolyte test and paused. The hitchhiker had severely low calcium and phosphate. "LSD? Huh. Hypocalcemia and Hypophosphatemia. That is weird. We should..."

She was interrupted by the loud, persistent beep of the hitchhiker's pulse oximeter alarm. The doctor set down the folder and walked into the patient's room, noting that her oxygen was now 86% and dropping on the red, flashing screen. She shook the patient's shoulder, and her eyes fluttered. She picked up her hand, taped over for the IV, and pinched her palm. The patient didn't respond. Her oxygen slowly dropped. 85, 84, 83.

The doctor turned her head and called out to the nurse's station, "She's a code blue! We need to get her intubated and to a level 1 trauma center. Call an airlift. I'm reading her at GCS 4, vegetative. Rapid desaturation."

The nurse picked up his desk phone and paged the intercom, trying to keep his voice level. "This is a code blue, repeat code blue. Exam room 2, code blue." He hung up the phone with a click, and then picked it up and pressed a speed dial button. He had a hushed, fast conversation with the operator.

A team of nurses helped the doctor intubate the hitchhiker, and watched as her oxygen slowly stabilized. Her chest rose and fell in small, steady motions.

The nurse walked to the doorway. "Okay, we have an airlift waiting in Arlington. They can get her to Harborview, and they'll call ahead to get her into an ICU when she gets there."

The doctor turned her head, her face and her voice muffled by a plastic face shield. "Good. Get an EMT to pull an ambulance around, so we can transfer her to Arlington."

He picked up the phone again. A minute later, the doctor walked ahead of the gurney, down the tiled hallway. She reached the sliding doors, and the small porte-cochere strobed bright red and yellow from the waiting ambulance. The lights spilled over the parking lot and the trees around, as the ambulance exhaust's fog pooled in the cold air.

Waiting EMTs lifted the hitchhiker into a stretcher. One of the nurses wheeled her IV fluids forward, and another carried the battery powered ventilator. The EMTs pushed the gurney into the ambulance, the wheeled legs folding underneath. They took the IV bags and ventilator from the nurses, placing the ventilator on the floor next to the gurney and hanging the IV bags on nearby hooks. The doctor climbed into the back of the ambulance. The driver shut the doors with a loud slam, circled around, and climbed into the driver's seat.

He put the ambulance in drive with a clunk and a loud beep, then lit up the siren. The deafening wail echoed off of the nearby hospital wall, harsh and insistent. The driver eased the ambulance around the circular driveway, then pushed the accelerator hard. The doctor held onto a grab handle to keep her balance as the ambulance rocked. The IV bags swung back and forth on their hooks, settled for a moment, and then rocked again at the next turn.

In a tense half hour, the ambulance charged toward Arlington. They parted traffic with their siren through Sedro-Wooley, then again through Burlington. Then they took a hard left turn across traffic to an on-ramp toward the interstate. The doctor fought to keep her balance as the driver rocketed around the on-ramp, pushing everyone sideways. On I-5, they flew down the left lane, cars slowing and pulling over as they passed. The doctor saw the towering smokestack at Mt. Vernon fly by, a tall shadow against the dark sky. Soon, they turned onto a state highway and then came to the regional hospital outside Arlington. The ambulance pulled past the main hospital building, glowing against the night, and continued to a round asphalt helipad behind it.

A red and white airlift helicopter waited, engines idling with a loud whine, lit up in flashes by the ambulance lights. The EMT switched off his siren then turned and backed the ambulance over the curb, down the grass, and to the helipad. Two airlift responders climbed out of the helicopter, wearing navy blue flight suits and helmets with headset and microphones. They unfolded a bright yellow stretcher with practiced efficiency, and wheeled it across the pad to the ambulance. They worked with the EMTs to move the hitchhiker to the new stretcher, and hand off her ventilator and IVs. The airlift responders quickly wheeled her stretcher to the open helicopter door and loaded her inside. The hitchhiker's head rolled side to side passively.

The ER doctor strode over to the helicopter. The pilot opened his door and waved her around to the other side. She climbed inside and buckled the complicated five-point harness. The pilot wordlessly handed her a headset, then reached down and flipped a series of switches. The engine whine intensified and raised in pitch, deafening now. The doctor put on her headset and adjusted the microphone.

The doctor keyed his microphone, his voice calm and slow. "We'll be wheels up in about thirty seconds. Team, you settled back there?"

An EMT nodded, strapped into a jump seat next to the gurney. "Ready."

The pilot eased the speed of the rotors up, and they lifted gently off the small asphalt pad. The ambulance turned on their siren, and started turning around. Then the helicopter banked and turned, the bright hospital and retreating ambulance growing smaller and spinning underneath them, soon lost in the lights of the small city.

The pilot keyed his mic with a burst of static. "November niner five zee-ro alpha romeo, we are en route to Harborview hospital." He checked his chunky black flight watch. "Current time zero-one sixteen hours, ETA 27 minutes."

The helicopter dropped its nose forward and picked up speed, and the city fell away, replaced by quiet farm fields. Small patches of porch light surrounded the farm houses, and were swallowed by their dark fields. Rows of windbreak trees stood like quiet sentinels, dividing the houses.

Soon the lights of Seattle and Bellevue appeared. First as a diffuse glow and the twinkle of outlying neighborhoods, then taller buildings took form in the dark. The lights spread out and reflected over the calm water of Lake Washington. The pilot eased over the north end of the city, skirted the lake, and approached Harborview. The helipad came into view, a series of three white circles on the roof of a parking garage.

They touched down quickly, and saw a team of nurses and doctors from Harborview waiting at the fringes of the helipad. As the rotors slowed, they jogged forward with a gurney, ducking their heads in the rotor wash. The flight crew opened the door and quickly unbuckled their stretcher from the floor. They climbed out and pulled the stretcher out behind them, the wheels deploying with a loud clatter against the wet concrete. The two teams worked quickly to transfer the patient to the waiting hospital gurney, then wheeled her through a small elevator lobby and across a ramp to the front door of the hospital.

A Harborview doctor fell in behind the group, matching his pace with the ER doctor. "You must be the transferring doctor?"

She nodded. "She came into the ER at our community hospital in Burlington. She was hitchhiking, and passed out. Driver dropped her off. We arranged the airlift when she desaturated on the highest supplemental oxygen we have."

"Got it." They walked through the sliding doors at the hospital entrance, greeted by a bright lobby. The new doctor squinted. "What were her symptoms?"

"She came in barely conscious, I read her at a GCS of 10. The driver reported she was itching, vomiting, and delirious. When she desatted again, she was a GCS 4, not responsive. She has jaundice, edema, hypotension, hypocalcemia, and hypophosphatemia. Toxicology came back positive for LSD.'

The new doctor's eyebrows shot up. "LSD? Huh." He kept walking for a moment, in thought. "Where did the driver pick her up?"

"Highway 20, Cascades."

He nodded a few times, thinking. "Did you check for transaminases?"

She pulled the manila folder from her lab coat and flipped the page. "Yep. Bilirubin, albumen, transaminase are all high. Why?"

They came to an empty ICU room and the team started to transfer her to a new ventilator. The doctor turned to the team. "We need to get dialysis up here, right now." He turned back to the ER doctor. "Amatoxin poisoning."