Presented with Complaint

Patient File 230988: Aquella Lewis

New patient Aquella Lewis presented with complaint of localized pain in lower right leg. Bruising evident, approx. 4.5 cm. Patient indicated she “fell off bench at beach.” Inquired about trip to beach, as nearest is approx. 241 km away, and environmental impact regulations allow only two visits to High Environment Impact Regions annually. Patient said she “needed to get away,” and that the beach was “the only place she felt herself.” Confirmed this was her first trip this year. Palpitated bruising with soft articulated manipulator. Patient winced. 

Diagnosis: moderate bruising. Prescribed ice, NSAIDS. Reminded patient of one beach trip left this annum. 


Patient presented with complaint of irritation and discharge of right eye, onset 4 days prior. Patient believed it was due to smoke from fires in western hemisphere. Reminded patient that dome filters 96% of pollutants. Patient noticeably turned eyes upward and crossed arms. Body language suggested disagreement. Scanned eye with retina diagnostic laser. No evidence of irritant-induced inflammation. 

Diagnosis: conjunctivitis. Prescribed moxifloxacin eye ointment. 

Offered patient brochure: “Dome Safety and ULPA Filtration;” accepted.


Patient presented with complaint of hearing difficulty, left ear. Onset two days prior. Patient described sounds of “crackling” and “fluttering.” Fitted eye with laser otoscope for examination. Patient expressed distress. Upon questioning, patient admitted fitting of otoscope onto eye distressed her. Assured her this was normal practice. Patient submitted to exam. Discovered beetle (3 mm), inner ear. Fitted firm articulated manipulator with tweezers; removed beetle. 

Asked if patient had taken her second trip to a High Environment Impact Region, as opportunities for authentic human-insect interaction are scarce in dome. Patient looked down and away, speech paused noticeably (rated 4 on Stegman’s Dishonesty Scale). Patient indicated beetle entered ear during sleep, as patient had not traveled since last visit to beach. Did not press further. 

Diagnosis: foreign object in ear. Prescribed otic drops.

Offered patient brochure: “Robotic Nurse Practitioners and You;” declined.


Patient presented with complaint of nasal and throat irritation, insisting due to smoke from fires (western hemisphere fires are noted to be extreme this year). Informed patient that while there is some indication ULPA filters are not as efficient with current particulate levels, they are removing 89% of pollutants. Patient vocally disagreed. Patient refused examination. Reminded her non-compliance with robotic nurse practitioners is considered a level 1 transgression within the Confederated Health System of the Alliance of Western Remaining Countries, with loss of travel privileges most common outcome. Patient allowed examination, revealing mildly irritated nasal and throat passages. 

Patient asked if she could see “a real doctor.” Further questioning revealed her desire to see a human doctor. Reminded patient of Standard Ladder of Escalating Care, requiring human care only at Step 3 or higher, given both rates of infectious disease and dearth of human medical providers. 

Offered brochure; declined.

Prescribed lozenges. 


Patient presented with complaint of pain, blisters, and swelling of her lower legs. 65% of lower legs show second degree solar burns, approx. two days post sun-exposure. Patient indicated she sustained burns in garden. Reminded patient that dome blocks 90% of UVA/UVB rays; such burns are not possible in dome. Upon further questioning, patient admitted traveling to beach again, though insisted she utilized SPF 85 sunblock. Informed patient that level of burn suggests otherwise. 

Patient began crying and was unable to communicate for 2-3 minutes. During this time, I articulated appropriate burn care steps. Patient asked what level her injury was on “care ladder” [note: referring to “Standard Ladder of Escalating Care”]. Told patient this was Step 2: “moderate injury or illness, likely to resolve with appropriate robotic nurse practitioner care, and/or prescribed medications/supplies; likely requires follow up visits.”

Reminded patient she has now consumed her two High Environment Impact visits per annum. She stopped crying and indicated she received a High Environment Impact Forest Preserve pass for this year (provided to each resident once every three years). Informed patient rationing her exposure to natural landscapes is wise, given such exposure preserves her mental wellness and gives her something to look forward to, an important meta-cognitive process for humans. 

Prescribed silver sulfdiazine cream, and Noro 5/325 mg for pain, with return in three days for re-assessment.  


Patient returned for re-assessment of burns. Patient arrived 27 minutes late and presented clearly in pain and unable to ambulate efficiently. Burn site was inflamed and purulent; used olfactory sensory device to determine there was a smell of sulfur. Skin was torn and damaged in places. Does not appear patient used prescribed cream. Patient was visibly struggling to keep composure; inquired as to her use of antibiotic cream and analgesics. Patient insisted she had used both, though, per Stegman’s Dishonesty Scale (rating 7: “showing faux surprise with animations of remorse and worry”), that is highly unlikely. Patient had a body temperature of 39 C (approximately 102 F). 

During assessment of burns, patient asked if this was “Step 3.”

Upon lengthy questioning, patient revealed she had deliberately caused burns and neglected their care to advance to Step 3.

Questioned patient about deliberate self-harm; indicated given disregard for self, recommendation for revocation of High Environment Impact Forest Preserve pass is possible. Patient said, “everything is burned anyway.” Informed her that while the fires in the western hemisphere exceeded typical annual estimations, they would be contained and abated, and some forest preserve saved. Indicated that there would be something for her to visit, should she maintain the requirements for her pass. While fires this year are statistical outliers, threatening much of the forest preserve, hope is an important cognitive element for humans. 

Patient cried but nodded agreement. Completed Visual Assessment for Mental Health; patient scored 7 (likely in need of immediate mental health care). 

Completed form 33N1, “Escalation of Patient Care for Mental Health Reasons.” Declined form 72-E, “Revocation of Travel Privileges for Medical Reasons,” as humans are goal-oriented and patient’s next caregiver may require such a goal for successful care. 

Left patient in secured room. 

Heather Ryan

3 Questions for Heather

What was your process for creating these pieces?

“Admit It” came after I told a friend that part of me was glad that the West was seemingly always on fire because it felt, for the first time, that maybe the rest of the country would start to take the impending climate apocalypse seriously. In the West, we’ve always had wildfire, but it’s been getting worse since I was a kid, but getting a lot of people to understand that has often felt impossible. The piece came out in blur in about an hour and with minimal revision—something that almost never happens for me.

“Presented with Complaint” was something I wrote when I was part of a writing group in 2018. The “rules” for the group were that each of us would write a flash fiction piece every month, email it to each other by the last day of that month, then vote on our favorite without any discussion. All four of us had been in the same MFA program some years earlier, and it was a way for us to commit to a writing practice with a small amount of accountability to each other. We did this for a year, and it was a tremendous way to keep writing and to generate a lot of flash fiction, something I’d never really tried my hand at before. This piece in particular was one the group liked a lot. I wrote the piece one month, submitted it, then put it away for a while. This was a few years before Covid, so I wasn’t even considering that we might, in our immediate lifetimes, experience limited human contact the way Aquella does. When I read it again a year after the first lockdown, I was struck with the echoes of what we’re going through now.

What is the significance of the forms/genres you chose for this work?

My current work explores how forms considered outside the normal bounds of literature can be used to create story and narrative. I initially became interested in this idea when texting a close friend. We, like all friends who text regularly, had created a language of emoji particular to our friendship. I thought a lot about the life in those texts and the way the form we were using shaped our relationship (since all language shapes the way we conceive of the world). So much of our lives are dictated by forms, especially in our current landscape, yet those forms aren’t allowed much space in literature. I started wondering what parts of our lives aren’t reflected in the art we consume. This seemed worth exploring, since so many of the ways we communicate and make meaning remain unexamined within that art. The trick is giving the form muscle in the story, which takes a lot of work. Sometimes I start with a particular form and idea, then find that the story doesn’t need it and so abandon the form. But other times, it becomes indispensable to the story I’m telling.

What is the significance of this work to you?

Both stories are essentially about the climate apocalypse and its effect on us. I find climate-related disasters increasingly entering my work, even when I don’t mean for them to. I’ve only every lived on the West Coast, so I remember being a child in northeastern California and watching in my front yard, through binoculars, a wildfire consuming the forest. I was afraid then, even though my parents insisted that the fire was far away. Of course, it never got close to us, but I often think of that now and wonder how much more would that fire burn if it started now in these new conditions. Would it have made it to our house? I live in north central Washington state now, and that reality in our little town is ever-present during fire season, and with that is a specific body of knowledge: what Level 1 Evacuation means versus Level 3, how to make a go-bag and what to put in it, what kind of mask to wear when the AQI is terrible. Until recently, I don’t think people outside the West fully understood what it is like to live in wildfire country. These stories come out of the desire to show that reality.

Heather Ryan earned an MFA in Fiction from the University of Oregon in 2006. Her creative non-fiction has been published in the Los Angeles Review, Salon and NPR, among others. Her fiction has been published in the Western Humanities Review and the Southern Humanities Review. Her essay 'En Passant' was short-listed for the Best American Essays anthology in 2016. She teaches college writing at Wenatchee Valley College in north central Washington State and, like everyone in the state, loves hiking and gardening.

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