The First Patient

by Michael Palmer

  "The Twenty-fifth Amendment deals with the inability of the president to reliably conduct the duties of his office. . . . I want you to review the presidential law of succession and memorize the Twenty-fifth Amendment."

  "Drew," Gabe said gently but firmly, "there's something going on here with you that's not quite right."

  "Not quite right . . . not quite right." Stoddard sang the words to the tune of "lit-tle lamb, lit-tle lamb."

  Gabe felt an ice-water chill. Somewhere in the building, a military aide was approaching, bearing The Football—the buttons and codes that could, effectively, end all life on Earth, codes that could be triggered by one man and one man only. His mind struggled with only minimal success to wrap itself around the enormity of the situation. He glanced at Carol and then at Lattimore to confirm that they, too, were aware of the awesome implications of what was transpiring before them, but their expressions validated nothing.

  "Drew, is it okay if I do a little examination of you? I want to get to the bottom of this."

  "I see the answers."

  "Drew, is it okay if I check you over?"

  "The answers to all questions."

  "Is there some sort of shot you can give him?" Magnus Lattimore asked.

  Gabe stopped himself at the last possible instant from snapping at the chief of staff.

  "As soon as I know what's going on, I'll treat him," Gabe said instead. "Right now, as long as he's not in immediate danger, masking these symptoms is the last thing I want to do."

  Stoddard was perspiring profusely now, his face cardinal red. But the rocking had stopped. Still, he continued a rapid, disjointed chatter, jumping from topic to topic, laughing inappropriately, and mixing in often bizarre opinions on issues of public concern—opinions that Gabe knew were not typically held by the man. The Andrew Stoddard he had known since college was Dr. Jekyll. This was Mr. Hyde. Gabe wondered in passing what would happen if the nation's commander in chief suddenly started calling out for the military aide with The Football.

  Moving slowly but deliberately, Gabe checked his patient's blood pressure in each arm and his pulse in the neck, arms, and feet. The pressure was up—160 over 100—in each arm, and the pulse was also up at 105. Years of training and practice had kicked in the moment Gabe entered the room, and with each second he was observing, avoiding assumptions, and considering dozens of diagnostic possibilities—rejecting some, filing others away as possible, moving still others to the forefront of probability.

  Ignoring the steady stream of pressured babble, Gabe did as rapid a physical exam as he dared. There would be time for more detailed examination and testing when the immediate crisis had been dealt with. As matters stood, two things were apparent to him: The President of the United States was not having a cerebral hemorrhage or a cardiac episode and so was in no immediate danger, but also, at the moment, the man was quite mad.

  CHAPTER 8

  For the twenty minutes that followed and the twenty minutes just past, Gabe knew that the United States was without reliable leadership. He continued his evaluation of Andrew Stoddard, but Gabe's mind was spinning. Someone had to be notified, probably the vice president. Ellis Wright was an ass, but he had been absolutely justified in saying that Gabe had to become an expert on presidential illness and succession.

  But why hadn't Lattimore stepped forward—or even Carol? Why were they standing by almost calmly as one of the greatest crises imaginable evolved before them? Why had the only even slightly emotional thing either of them uttered been Lattimore's request—a request that Gabe brushed aside as bordering on malpractice—that the president be given some sort of shot to settle him down? It didn't take a formal medical education to reason out that unless a diagnosis was either known or quite obvious, giving any sort of mind-altering medication to someone with acute brain dysfunction, from either trauma, stroke, or chemical imbalance, was contraindicated.

  The president's continuous rocking had slowed, then finally stopped, and the tenor of his speech had softened somewhat. Gabe propped a pillow behind him and took advantage of the relative calm to focus his ophthalmoscope beam onto the retinas of Stoddard's eyes—the only place in the body where arteries, veins, and nerves, specifically the large optic nerves, could be directly observed.

  The arteries appeared healthy, with minimal, if any, signs of arteriosclerosis. The veins, too, seemed normal and were free from nicking where the arteries crossed on top of them—a finding that would have hinted at prolonged high blood pressure. But most important, the margins of the optic nerve in each eye were sharply demarcated. Blurring of those edges, known medically as papilledema, would have suggested a buildup of pressure on the brain from swelling, hemorrhage, or infection.

  Reflexes normal. Extremities normal. Strength and range of motion good. Cranial nerves intact. Carotid pulses strong and free of bruits—the churning sound made by blood rushing past an obstruction. Heart rate down to 88—still high, but improved. Blood pressure down to 130 over 80. Lungs clear. Respiratory rate down from 40 to 24. Abdomen soft.

  Stoddard's perspiring had slowed and the redness in his face had begun to abate.

  "Drew, are you with me?"

  "You're the best, pal. The salt of the earth."

  "Drew, I want to ask you some questions. Will you answer them no matter how silly they might seem?"

  "Go for it."

  "What city are we in?"

  "Why would you ask me something as—"

  "Please, Drew, humor me."

  "Washington, District-o of Columbi-o."

  "The day?"

  "Thursday. Doc, this is—"

  "Please—"

  "August the something. Maybe the seventeenth. Isn't that right, Carol, baby? The seventeenth?"

  "That's right. You're doing great, honey." She looked over at Gabe. "He's coming around."

  "Drew, how much is forty times twenty?"

  "Eight hundred, of course. I was always good in math."

  "A hundred minus thirty four."

  "Sixty-six."

  The answers came out almost before the questions were finished.

  "Name the first eight presidents."

  "Washington, Adams, Jefferson, Madison, Monroe, the other Adams, Jackson, how many is that?"

  "Enough."

  "Van Buren, the first Harrison, the one who croaked after thirty days, Tyler—"

  "That's plenty, Drew."

  "I can do them all. The latest one is me."

  "I'm glad of that. The capital of Uruguay?"

  "Montevideo. What do I win?"

  "Most home runs by someone who never took steroids?"

  "Aaron. You thought I'd say Ruth, didn't you?"

  "No, Drew. I knew you'd get it right. You're doing better, my friend. Much better."

  "Doc? I have one question."

  "What is it?"

  "The beasties that have been flying around here—the fairies and those round hairy things with the long tails—what do you make of them?"

  Gabe looked to see if Stoddard was toying with him, but there was nothing in the president's expression to suggest that was the case. He checked Stoddard's pupils again. They had initially been midsize and a bit sluggishly reactive to light. Now they were smaller and more briskly reactive. Another sign that things were getting better.

  Hyperactive cardiovascular system, uncontrolled rocking, disjointed, pressured speech, excessive perspiration, inappropriate affect, visual hallucinations. What in the hell was going on?

  Gabe desperately needed to speak with both Carol Stoddard and Magnus Lattimore, but there was no way at this point that he would leave his patient to do so. Lattimore saved him the anguish.

  "Whatever you need to say to us, Doctor, you can say before the president."

  There was no panic in his voice and little, if any, anxiety. Gabe wondered if Lattimore's odd demeanor was at least in part due to the fact that Drew Stoddard now appeared to be rapidly improving. Lattimore moved over to where Carol Stoddard stood, stroking
her husband's hand. Her expression was odd—more one of annoyance, perhaps, than concern.

  "Okay," Gabe said, "it's your call." He calmed himself with a deep breath and slow exhale. "To begin with, it looks like whatever is going on here is beginning to resolve. Drew's life doesn't appear to be in immediate danger. But we all know that for the last hour or so, he has not been in control of his faculties. The implications of that are obvious."

  "Go on," Lattimore said, his expression unchanged.

  To Gabe's left, the president had sunk down on his bed, eyes closed. His breathing was still somewhat rapid and shallow. The redness had drained from his face, which now looked drawn, pale, and utterly spent. Concerned, Gabe checked Drew's pulse and blood pressure once more.

  "Fairly normal," Gabe said, shaking his head in bewilderment. "Give me a minute to draw a few tubes of blood."

  "What for?" Lattimore asked.

  "I'm not sure yet, but it's better to have them and not need them than to realize tomorrow I should have gotten them."

  "Do you need to put them on ice?" Carol asked calmly.

  "I don't think so. I'll refrigerate them in the clinic until I'm ready to send them off."

  "You won't put his name on them, will you?"

  "No, I promise. I'll identify them some other way."

  "Honey," the First Lady said gently, her lips brushing her husband's ear, "Gabe's going to draw some blood. Is that okay?"

  "Go for it," Stoddard managed, through lips that were stiff and dry.

  Gabe drew three vials of blood and set them in his bag. The president barely reacted to the procedure.

  "Well, there's still an impressive collection of diagnostic possibilities," Gabe said when he was done. "Some sort of atypical seizure or even unusual migraine is on the list along with a small hemorrhage in some strategic area of his brain, or a tumor—possibly one in a part of his body away from the brain that is secreting some sort of hormone or other psychoactive chemical. There are a number of possible organs in this regard. He certainly seems toxic, but unless he has some pills hidden away that we don't know about, I don't have an explanation for how that toxicity could have happened. Then there's the diagnosis that is at or near to top of the list at this point."

  "Namely?" Lattimore asked.

  "Namely, that the stress of the job and the reelection campaign has pushed his emotional and mental faculties past the breaking point."

  "You have no idea the hours he puts in," Carol said.

  "Well, it's not a physician's job to guess. So, at the moment, the field of possibilities is wide open, and we've got to get him to the hospital for an MRI and some other tests. At this moment I am quite concerned about a tumor or a small hemorrhage."

  "It's not a tumor," Lattimore said. "And it's not a hemorrhage."

  "How could you possibly know that?"

  "Because," the chief of staff said, meeting Gabe's gaze intently, "the president's already been recently checked for those by Dr. Ferendelli. He's run every test in the book."

  "I don't understand."

  "Gabe," Carol said evenly, still massaging her husband's hand, "this isn't the first episode like this that Drew has had. . . . It's at least the fourth."

  CHAPTER 9

  Incredulous, Gabe stared across the bed at Carol Stoddard and Magnus Lattimore.

  "I can't believe this," he said, barely maintaining control. "How many episodes?"

  "Four," Carol said. "All within the last three months. Jim Ferendelli was actually with us when the first attack occurred. It was right here in the residence. He was up here for dinner. All of a sudden Drew began shaking his head as if he were trying to clear something out of it. It turns out he was hearing voices."

  "I just can't believe this," Gabe said again, making no attempt to lower his voice. "How in the hell could Drew come all the way out to Wyoming to ask me to take over as his doctor and manage not to tell me about this? And you two. Carol, we've known each other for years. Magnus, you had plenty of chances to talk to me before I flew out here. Who in the hell do you think this man is—an organ-grinder? How can you ask me to uproot my life and come here to take care of him and then withhold information like this?"

  "Gabe, please," Carol replied. "I understand why you're upset. We debated how and when to tell you what had been happening, but with all the tests coming out negative, and no attacks for a few weeks, Drew thought we'd be better off hoping the whole matter was a thing of the past. He really needed you, Gabe. Then and now."

  "So that's why he lied to me? That's why you lied to me? Because you all needed me?"

  Gabe glanced down to see the president's reaction, but Andrew Stoddard, eyes closed, was lying motionless, breathing coarsely, and had clearly not heard a word. Reflexively, Gabe reached down and checked his pulse. One hundred and regular.

  Then suddenly Gabe found himself reflecting upon the meeting with Drew in Wyoming. There was time then, plenty of time, for Gabe to tell his longtime friend about the self-prescribing he had been doing—about the pain pills and the antidepressants. He hadn't said anything to the president for the same reason he had never said anything to his former AA sponsor—the same reason he had gradually cut back on his meetings until he stopped going altogether. He was ashamed—not frightened, not worried he was heading for an alcohol relapse like so many warned at the meetings—just ashamed of his weakness and maybe of his foolhardiness and denial as well.

  Whatever the reason, he had lied by omission just as Carol and Latti-more had been lying since his arrival in D.C. Just as Drew had done back in Tyler. Different stripes, same zebras.

  "The episodes haven't all been the same," Carol said, maintaining her composure against Gabe's onslaught. "The second one happened at a press conference. Jim was there, and so was Magnus. The moment Drew's color changed and his speech became disjointed, they got him off the stage. The whole thing didn't last half an hour. There were more audio and visual hallucinations than there were today, but no rocking. That was when Jim had him brought to the presidential suite at Bethesda Naval. After all the tests were negative, including an evaluation by a team of neurologists, the diagnosis was made of atypical migraine. I'm surprised you didn't read about the whole thing in the papers or else hear about it on TV."

  Gabe's smile was mirthless.

  "I don't own a TV that works with any reliability, and the only newspaper I ever read is the Tyler Times. Life has been much easier that way."

  "I guess that's why you never asked us about the atypical migraines," Lattimore said.

  "I guess," Gabe replied acidly. "Drew mentioned something about migraines when he was in Tyler. Listen, you two, I don't know what's going on with him, but I do know this man is in no position to function as the President of the United States. We've got to do something, and quickly. I haven't had the chance to study up on the Twenty-fifth Amendment, but I would imagine a call downstairs to the vice president is in order."

  "Wait," Lattimore said sharply. "Please, Gabe, just wait . . . and listen. . . . Please?"

  Gabe flashed on the desert behind his ranch. The sun would be setting just about now. The perfect time for a ride.

  What in the hell was he doing here?

  "Go ahead," he said. "But you should know that I have no reason at this point to trust anything you tell me."

  "I understand. With lobbyists and spin doctors and hidden agendas on every corner, this town is justifiably famous for people playing fast and loose with the truth, and I'm afraid that as a political advisor, I'm hardly blameless in that regard myself. Even now, the guests downstairs have been apologized to and told that the president has a migraine headache, some asthma, and some sort of gastric upset, and that you're attending to him. The press will be next."

  "Go on," Gabe said, picturing the truth being batted about like a badminton shuttlecock.

  "First of all," Lattimore went on, "remember that when you first came upstairs, I asked Agent Griswold to send for the military aide who is entrusted with The Football.
We talked about The Football when you first arrived in town."

  "Believe me, I was paying attention. That sort of stuff is not easy to ignore."

  "Then I may have told you that among other things, the briefcase contains the papers necessary to hand over control of the government to Vice President Cooper. The military aide is waiting out there in the foyer right now, Gabe. Ultimately the decision as to what is best for your patient and for the country will be up to you."

  "Go on."

  "I'm sorry, truly sorry, that we weren't more forthcoming about these episodes in the first place. We had come to an uneasy agreement with Jim Ferendelli that so long as the situation didn't worsen, he would continue to try and come up with a diagnosis. Then, when he disappeared the way he did, we three have been in a quandary about what to do next. The president and First Lady felt that you were the only one who would step in and continue Jim's investigation into the situation, while at the same time giving the president the chance to be reelected."

  "Gabe, the country needs him," Carol said. "The world needs him. But not if the price of that service is his mental health."

  "Carol, if Drew was an exam question, and there was only one right answer, I would have to say that his neurological presentation today and the history you've given me add up to some sort of stress disorder. That is not a desirable condition in the man with his finger on the big, red button. It seems like with each episode he's drifting farther and farther from reality."

  "But in between these episodes," Lattimore said, "the president has been as focused and energetic as he's ever been, and I mean that. He's gotten the Koreans and Iran to back off and allow nuclear inspections. That's major. The new trade agreements with Mexico and China have already brought us the lowest unemployment in a dozen years. He knows that the only solution to the drug problem in our cities is to deliver hope for the future in the form of education, and already he's gotten more money for schools than the last two administrations combined. He's pushed through more legislation, more of the pieces of his populist agenda, than anyone ever thought he could, and with the polls predicting the shift to a friendly Congress, there's no telling what he could accomplish in the next four years. This is no ordinary man, Gabe."