To Obey

by Mickey Zucker Reichert

  But Kendall only thrust a palm-pross into her hands, with information on a patient named Thomas Heaton. “Take a look at this one.”

  Susan scanned the information. According to the record, Thomas Heaton was a sixty-two-year-old black male with a one-year history of deterioration of mental function. The problems began shortly after an accident in which a falling stage light hit him in the back of the head while he performed his job as an orchestral conductor. At the time, there were signs of soft-tissue injury but no skull fractures or internal brain hemorrhages. He was diagnosed as having sustained a concussion, was treated with over-the-counter pain medications only, and returned to work the following day. The concerning behavior started two weeks later. Initially, it was described by family members as odd and atypical while at home, but essentially normal when at work. His wife first noticed that he quit reading entirely, avoided the Internet, and broke his palm-pross in an apparent fit of pique. Brain imaging did not show any sign of late bleeding or other problems, and neurological tests were normal. He gradually became increasingly confused and agitated until he could no longer function at work, either. For a while, he would respond positively to music, which calmed him and made him more compliant with requests. In the past month, however, even music had failed to reach him.

  Kendall took back the palm-pross before Susan could read more. “What do you think?”

  Susan shrugged. Based only on that information, she could scarcely begin to narrow down the possible diagnoses. “Let’s see him.”

  Apparently, Kendall had already done an exam, because he knew exactly where to find Thomas Heaton. He took Susan to Unit 1, the location of the newer admissions. In addition to the open common area in the center, private and semiprivate rooms branched off like spokes, more akin to a standard hospital, except the middle was not an arrangement of nursing stations and hallways but an open room, similar to the ones on the other two units. A video screen took up the entire north wall, currently showing the most recent Cocoon remake. Chairs facing the screen filled most of the area. A few patients chatted in small groups, but most stayed to themselves, watching the screen or staring off into space.

  Kendall took Susan to a slender, dark-skinned man sitting in a chair against the wall. Dressed in a crimson-and-white bathrobe, he kept his arms clenched to his chest, rocking back and forth, humming a complicated tune. He seemed not to notice their approach.

  “Mr. Heaton,” Kendall said loudly, “I’d like you to meet Dr. Susan Calvin, my partner.”

  Susan supposed “partner” worked. The words “fellow resident” might be misunderstood, especially in an institution setting. “Pleased to meet you, maestro.” Susan held out her hand.

  Thomas’ eyes rolled up to meet her gaze, but he otherwise remained exactly as he had been, rocking rhythmically with his arms folded. His expression was lax, empty, emotionally flat. His dark eyes looked watery, older than their years, and utterly devoid of passion of any kind.

  As he made absolutely no move to shake her hand, Susan retracted it.

  Kendall defined what Susan saw in medical terminology. “The poster child for flat affect.”

  “Catatonia?” Susan suggested, knowing full well it did not fit. Catatonia was most often associated with schizophrenia, which usually developed in the late teens to midtwenties. Sixty was not impossible, but extremely unlikely—a classic zebra. To ascribe other causes of catatonia meant stretching well beyond the given information.

  Kendall shook his head, then grasped Thomas’ arm at the wrist. Raising it to above head level, he let it fall suddenly. The arm flopped bonelessly to Thomas’ lap, as if it was too much effort to resist, nothing like the waxy flexibility consistent with catatonia. Those patients would leave their limbs exactly where someone placed them for hours or days on end. “Can’t find anything infectious or metabolic. Lab tests all completely normal.”

  Susan bobbed her head. Considering the prior normality and high functioning of the patient and his sudden deterioration, the medical teams must have extensively ruled out a physiological cause for Thomas Heaton’s behavior. “Anything at all on his neurological studies?”

  “Nothing.” Kendall tucked the palm-pross under his arm and headed back toward the charting area to discuss the patient in private.

  Susan followed silently, waiting for Kendall to elaborate, which he did once they stepped inside and closed the door.

  “Shortly after the accident, they did a neurological exam. No muscular weaknesses. No changes in sensation. Cranial nerves two through twelve all intact. He could name the last five presidents, count backward by fives and threes from a hundred, balance with eyes open and closed on either foot, touch his finger to his nose, name letters and numbers. And they found no papilledema.”

  A tumor, inflammation, or other obstruction could have caused an increase in intracranial pressure often visualized by ophthalmoscope as swelling of the optic discs, called papilledema. More relevant to the injury, a subarachnoid hemorrhage could also cause papilledema, but the symptoms described did not fit the picture. “And later? When the symptoms developed?”

  “Still normal on all counts.”

  “So…physiological causes completely ruled out. It’s definitely psychological.” Susan knew from experience that differentiating mechanical, physical, and biochemical processes from mental health issues could be intensely challenging. However, in the case of a man like Thomas Heaton, she knew no doctor would send him here unless all possible physical issues had been fully addressed.

  “Definitely psychological,” Kendall confirmed. “Although, for completeness’ sake, there was one finding on the head CT. One tiny hypodense area in the left occipital lobe.”

  Susan tried to seize on that, but it seemed more of a red herring than a useful fact. Light areas on CT usually indicated pus, blood, cysts, or tumors. “What did Neuro make of it?”

  “Bit of blood from the injury or, possibly, a hallucinoma.” Kendall used a slang term for an artifact, a lesion seen on a scan that does not actually exist and was usually due to a misinterpretation, a bit of misplaced material, or a smudge. “A follow-up scan six months later didn’t show it.”

  Susan suggested another possibility. “Posterior cerebral artery stroke.”

  Kendall rolled his eyes down to Susan’s, speaking with clear reluctance. “Considered,” he admitted. “I had to look that one up. How did you know off the top of your head?”

  The realization was painful, and Susan wished Kendall had not asked. “I was dating a neurosurgeon, so I brushed up on my neuroanatomy fairly recently.”

  “Right.” Focused wholly on the patient, Kendall did not seem to notice Susan’s discomfort. “They did think of posterior cerebral artery stroke, but the findings on physical exam didn’t match. No homonymous hemianopsia, for starters.”

  Practically diagnostic for posterior cerebral artery strokes, homonymous hemianopsia consisted of complete loss of either the right half or the left half of the visual field in both eyes. Patients with these less-common types of strokes often had little or no loss of speech or muscle control but, instead, ran into walls, furniture, or people that did not appear to them to exist. They could see the world from the outside of one eye and the inside of the other eye, seeming to make a complete picture, but they were entirely blind on the opposite side.

  Susan nodded, making no further suggestions and allowing Kendall to voice the next idea. She had thoughts, but nothing firm, and she did not want to steal his thunder.

  Kendall did not disappoint her. “I’m thinking the near catatonia has to stem from severe depression. He has no prior history of psychiatric disease and no manic episodes, so it’s probably a pure depression. Until we get him talking again, I don’t really see we can do much for him.”

  Again Susan nodded. Given his age, the new onset of primary depression seemed unlikely. To determine a secondary cause, whether physical or emotional, they needed the patient’s cooperation to evaluate him. “I’m assuming he’s
already on antidepressants, correct? This is Last Resortville, and I can’t see anyone sending him here until he’s failed Neurology, followed by Inpatient and Outpatient Psych.”

  Kendall hesitated, then swept a jumble of individually packaged gauze pads to the side before placing the palm-pross squarely on the desk. He pressed a couple of buttons. “Antidepressants were tried.” He sounded disappointed. “Without success.”

  Susan quoted Dr. Hansen, one of the attending psychiatrists she had worked under at Manhattan Hasbro. “Probably at wimp’s doses. We could try something that might actually work.”

  Kendall could not help laughing. “And if it’s toxic to him?”

  Susan flushed. “I’m talking high normal doses, not overdoses. And I’m not saying you should use Hansen’s approach most of the time. Not even Hansen uses Hansen’s approach on every patient. But it seems appropriate in a case like this one, where standard therapy has failed and we might have a reachable person with a treatable problem buried in an overwhelming depression. Especially here.” She waved an arm to remind him of the hopelessness of their surroundings. While a significant number of patients did leave Unit 1, the other two units were essentially long-term sentences of deterioration and death.

  Kendall chewed his lower lip and followed her gesture with a roll of his eyes that did not appear to take in anything. He was clearly deep in thought, if evidenced only by the fact that his mouth remained closed and no jokes emerged. Susan suddenly realized his wisecracks had become fewer and farther between since Remington’s death, and, to her surprise, she missed them.

  “Some might argue Hansen’s approach is wiser because of the risk of extrapyramidal side effects. Maybe it brings them out early, instead of waiting until a patient’s been on the drugs for years, when the effects are more persistent. When caught early in treatment, those side effects almost always subside with simple discontinuation. When they develop years later, tapering the drug can actually make the condition worse.” It was an argument Susan had considered many times since Hansen had presented it. She shrugged. “Hansen’s no spring chicken, his patients love him, he’s respected in the field, and he has no lawsuits against him. That’s anecdotal, but it does suggest his approach is not the catastrophe many of our professors believe.”

  Few things happened quickly in medicine. Cowed by regulation and lawsuits, companies put new procedures and drugs through rigorous testing in multiple stages. Doctors worried to change established practices because “deviation from standard of care” was the gold standard for malpractice litigation. Even if correct in every way, a bold doctor risked losing everything: his reputation, his possessions, his livelihood.

  Susan often wondered if balance was even possible.

  Kendall caught and held Susan’s gaze, as if watching for some evidence of approval or indication he had made a mistake. “So, we bombard Mr. Heaton with Hansen’s doses of one of the fourth-generation antidepressants and see if we can bring him around enough to find the root cause of his mood issues.”

  Susan forced a grin. Those also came few and far between in the last year. “That sounds like a perfect plan.” Then, as Kendall still seemed to be studying her, seeking reassurance, she added, “Exactly what I would do.”

  That seemed to satisfy him at last. He let out a pent-up breath, and the corners of his mouth twitched upward. “So it is written; so let it be done.” He turned to his palm-pross, typing in new orders for Thomas Heaton. “What do you think of getting some earphones on him playing symphonies? As he comes out of his depression, music may reach him quicker than anything else.”

  Before Susan could reply, a solidly built nurse whose name she had not yet learned approached. Susan turned her attention to the woman, encouraging her to speak.

  “Chuck’s results are back. I thought you’d want to look at them right away.”

  Susan nodded with a smile. “Thanks. I do.” She hooked another palm-pross with her index finger and pulled it in front of her. Quickly, she typed her code and brought up Chuck’s information. The results from the lumbar puncture were on the first page. The official reading confirmed xanthochromia, a yellow tinge to the fluid. The cause was immediately obvious: a protein level of 3280 mg/dl, while the normal range was 15 to 60. Few things could explain a level that high, and only one seemed plausible.

  Kendall’s fingers froze on the keys, and he turned in Susan’s direction. Apparently, she had made some sort of sign or motion, because he crooked one eyebrow and said out of the side of his mouth, “Raining in paradise?”

  “Chuck Tripler needs an MRI.” Susan looked at her Vox, which already read 5:07 p.m. She doubted an after-hours expensive test would go over any better than her earlier suggestion. She rose, determined despite the attending’s negativity, despite the hour, despite her irritation. She looked at the nurse, who still stood there, awaiting her decision. “And he’s going to get it ASAP.”

  “Dr. Reefes has gone home,” the nurse informed Susan.

  “Hang Dr. Reefes.” Susan meant the words more literally than she ever had in her life. “I’m authorizing it, and I’m going with him.”

  A grin wreathed the nurse’s face. Though it flew fully against regulations, undermining the chain of command, she made no protest. “I’ll call Hasbro and Transport. Realistically, it’ll probably take forty-five minutes to get everything arranged and moving.”

  “That’s fine,” Susan said. It took her a moment to think like a person accustomed to regular hours. The shift change would occur at seven, which meant someone would either have to stay late for several hours or the MRI order should not go out until after six fifteen. Based on their earlier conversation, Susan knew that paying overtime wages would not please Dr. Reefes.

  Chuck Tripler had waited years for this diagnosis; he could certainly last an additional hour. Yet Susan’s conscience and curiosity could not. “I’ll go with him. We won’t need any staff, just a driver.”

  With barely a nod, the nurse rushed from the staffing room to make the appropriate calls.

  Kendall had had plenty of time to read the results of the cerebrospinal fluid analysis. “Tumor, huh?”

  Susan nodded dully. “Obviously slow growing. Probably benign.”

  “So…how do you explain the Lewy bodies? The parkinsonism? The NPH symptoms?”

  Susan had a theory, but she wanted to search the literature, make sure it made logical and coherent sense before presenting it to Dr. Reefes. “I’m…not sure. I want to see what the MRI shows first.”

  “The forbidden MRI,” Kendall reminded her unnecessarily. “How are you going to get that past the powers that be?”

  Susan smiled. “I don’t think I’ll need my rapier tongue for Reefes. The MRI will say it all.”

  “Let’s hope so.” Kendall slammed shut his palm-pross.

  “See you tomorrow?” Susan planned to finish up her charting while waiting for the transport shuttle and driver.

  “Tomorrow!” Kendall gave a greatly exaggerated look of effrontery, hands mashing his narrow waist, arms formed into indignant triangles. “Did you really think I’d let you have all the fun? I’m coming with you.”

  Susan might have protested had she not so much appreciated his company.

  Chapter 5

  Arranging the MRI, meeting with the busy on-call radiologist to go over the results, and returning Chuck Tripler to Winter Wine Dementia Facility had taken until the wee morning hours. Susan and Kendall had spent the night at Kendall’s apartment, only a three-block walk from work. There he had collapsed, fully dressed, onto his bed, while she spent the next several hours researching, on his palm-pross and her Vox, the findings on Chuck’s MRI and how they might mesh with the history and physical examination.

  So Susan found herself exhausted and fuzzy-headed when Dr. Mitchell Reefes finally arrived the following morning and sequestered himself in his office. Rereading the same page of the palm-pross for the fourth time, Susan glanced toward Kendall, who gave her a sheepish shrug. “Tim
e to face the music, Calvin.”

  With a sigh, Susan rose. “You coming?”

  Kendall consulted the whiteboard in the Unit 1 staffing area, which contained a new name: Jessica Aberdeen. He looked back at Susan and smiled. “I wouldn’t miss it for the world.” Leaping to his feet, he followed Susan toward Dr. Reefes’ office.

  The short journey took longer than it should have, and Susan realized she dreaded the confrontation. She stopped to examine her Vox twice, to ascertain it still held the tiny image of Chuck Tripler’s MRI.

  The second time, Kendall glanced over her shoulder. “It hasn’t miraculously flipped to your grocery list or the doggy-style porn network, has it?”

  Startled, Susan glared at him. “There’s a network?”

  Kendall rolled his eyes. “How would I know? Do I look like a pervert?”

  Susan declined to answer, but she paused long enough to indicate the possibility might have crossed her mind. “I’m just…”

  “Stalling?” Kendall suggested.

  Susan had been about to say “making sure,” but she realized Kendall was probably right. “Fine, I’m stalling. Sue me. I don’t want a bad review, but I can’t help loathing the man.”

  “And you’re afraid you might castrate him.” Kendall nodded thoughtfully. “I could see where that might just get you a bad review.”

  “Whatever.” Susan crossed her arms over her chest, then rechecked the Vox, concerned she might have pressed buttons with her gesture; but the MRI picture remained. “Could you stop referring to my verbal altercations as castration? People will get the wrong idea.”

  “Not the ones who know…either of us.”

  “They’re not the ones I’m worried about.” Susan recognized even this conversation as a delaying tactic. “Now, let’s get this over with.” Raising a hand, she knocked at the door.

  “Come in.” As always, Dr. Reefes sounded distracted.

  When Susan did not immediately obey, Kendall nudged her. “You okay?” he asked softly, so his voice would not penetrate the door.