Douglas MacArdle looked at Tuisamoa Fauatea’s empty dialysis chair and bowed his head in shame.

“Just keep me alive ‘til my grandson graduates from USC, Doc,” Tui had told him a week before. “That’s all I ask. One more year. Then, if the Lord wants me, I’ll be ready.”

“I will, Tui,” MacArdle had reassured him. “I promise.”

Tui had collapsed and died while brushing his teeth that morning, one of the nurses had informed MacArdle. The visual was sickening, two hundred and seventy pounds of Pacific Islander goodness and joy toppling to the cold tile with a disbelieving rictus on his face. One of the stents propping open his diseased coronaries, probably.

He lifted his head and gazed again at Tui’s empty chair. It was located in the middle of a row of chairs strung along the northern end of the clinic, adjacent to the elaborate water purification system that was so vital in preparing the ultrapure water they needed to perform safe dialysis treatments. But what good had their impressive technology been? Tui had still died like everyone dies, in the humbling repose of death, legs splayed at an unnatural angle, his cheek smeared with Crest. Death with dignity? No such thing. A soporific trope to ease the angst of the living was all that was.

“Tofa soifua,” MacArdle said sotto voce, in the Samoan words Tui had taught him. Fare thee well my friend. He sighed and scanned the clinic he had been medical director of for the past fifteen years, seeing it as if for the first time.

Twenty dialysis stations and a glass-partitioned isolation stall (for patients with hepatitis) lined the walls of a commodious rectangular room, with a nursing desk in the center. Each station consisted of an aqua-colored chair resembling a La-Z-Boy recliner, and a futuristic silver dialysis machine, standing five feet high and about two feet in width. A display screen with an array of orange LEDs flashing real-time treatment data occupied the upper third of each machine; a roller-pump propelling blood through hollow fibers encased in a plastic cartridge—an artificial kidney—took up the middle third. An assortment of inlets and outlets bearing a tangle of blood tubing and water hoses marked the bottom third.

Patients reclined in their chairs, staring at televisions suspended in front of them by c-arms. Nurses and dialysis technicians in blue scrubs flitted amongst them, taking blood pressures, responding to machine alarms, entering vital signs into electronic charts. The patients appeared oblivious to the large-bore needles impaled in their arms like harpoons—and to the blood-sucking machines stationed next to them like metallic sentries. Given that each patient’s entire blood volume passed through their artificial kidney every twelve minutes, it never ceased to amaze MacArdle that they weren’t all bolt upright squeezing finger marks into their armrests. But like pilgrims to Epidaurus, they came in profound trust, asking only to be kept alive.

In the coming year alone, one out every seven of them would not be kept alive; by some measures, having end stage renal disease was as bad as having cancer. And with each new death—each new empty chair—MacArdle would feel shame. Shame for having failed to keep his sacred covenant. For having failed to stay a step ahead of their disease, despite his top-drawer training and considerable ken, the marvelous technology at his fingertips. Shame for failing them the way he failed Tuisamoa Fauatea.

Yet despite the sorrow his clinic was sure to endure, the sheer vastation of it, knowing, like all nephrologists knew, that death draped his every day like moist cheesecloth, MacArdle had yet to become cynical, had yet to succumb to “compassion fatigue”—a feeble euphemism for being too exhausted to care anymore. More language dilution to avoid offending anyone.

He was, he supposed, like a hopelessly addicted gambler, always believing the next hand would deal him a winner, that third ace so long overdue. In the dialysis world, winning meant keeping a patient alive long enough to get a transplant—or, for those patients who were, for whatever reason, unfit to receive transplants, keeping them healthy enough to make the rigors of dialysis worthwhile. And he had won, plenty of times. Scores of his patients had received transplants over the years, and more and more of them were surviving—thriving, even—for ten and fifteen and even twenty years on dialysis. Winning kept him fresh, vital, enthused to still be doing what he had wanted to do ever since he was twelve years old: save lives. If only for awhile.

Soon a new patient would fill Tui’s chair. Someone recently told they would die without dialysis. Someone with a spouse who still needed them, children who still loved them: grandchildren to send to college. Someone who would come in profound trust. Maybe even another Samoan with diabetes—it was always diabetes with Samoans. High-density, urban living had proved lethal to their island constitutions.

MacArdle would go over to her with his sympathetic smile and warm, welcoming handshake, say hello to her the Samoan way. “Talofa lava.” He would touch her shoulder, reassure her that everything would be okay. And the rills in her frightened brown face would disappear and her fists would unclench when he told her, this thick-set Samoan queen in her red and white sarong, with her black, braided hair and emotive eyes, that he and the nurses and techs would do everything in their power to keep her alive and well.

“I promise,” he would say. And with that it would start all over, their cage match against death.

Only then would MacArdle feel whole again.

(This story is a work of fiction, and as such is entirely the product of the author’s imagination. Any resemblance to real events, organizations, locales, or persons is unintended and entirely coincidental.)