He was sedated when I met him. I had no way of knowing he was a neo-Nazi. It was my first year of cardiology fellowship, 2 weeks into the electrophysiology rotation and we were consulted for heart block. He had suffered a perioperative inferior ST-segment elevation myocardial infarction after brain aneurysm clipping and had incurred atrioventricular node ischemia. After several days of persistent block, watchful waiting for atrioventricular node recovery turned to recommendations for permanent pacemaker implantation. He was awake and extubated by then and had begun meaningful, but limited interaction, brashly requesting a Coke from the ancillary staff. He was a war veteran, only a few years older than I. In all my visits to his room, asleep or awake, he had been supine or at most at a 301 incline. He was generally uncooperative. The moment I asked for his consent was the first time I had seen him sitting upright. As I helped him up, his loose hospital gown fell freely to his waist, exposing his torso and upper extremities. It bore no consequence on him, as he made no adjustments and asked me where to sign. I, however, was frozen, speechless as his passive disrobing revealed a swastika in the piercing grip of an eagle, unashamed and intentional, brazen across his left upper arm. He was expecting my pen, now suddenly cooperative and compliant, unaware of my palpitations. He gave consent. I reluctantly took my pen back and left the room.