Susan nodded, though the movement intensified her dizziness. She could function well enough, but her thoughts seemed to require extra time to form, and a permanent fog appeared to have descended over her mind. It wasn’t the first time she had pulled an all-nighter, but this time it bothered her more, perhaps because she currently wanted her thoughts to be entirely clear. The MRI findings were complicated, her theories on the situation much more so, and her relationship with her attending dicey at best. She twisted the knob and opened the door.
Without bothering to look up, Dr. Reefes waved the residents into the room. Both entered, Susan leading, and Kendall paused to shut the door behind them. The attending did not wait for either of his charges to speak. “You need to look at this MRI on Chuck Tripler.”
Susan took the chair in front of Dr. Reefes’ desk, trying not to look too smug. “We’ve seen it.”
Dr. Reefes did not seem to hear her. “Look at this. There’s a big, honking tumor at the L2 vertebral level.”
Susan clarified, in medical terminology, “Intradural extramedullary growth in the cauda equina.” She referred to the bundle of nerves that occupied the spinal column below the termination of the spinal cord, so named because of their resemblance to a horse’s tail. “Intradural” and “extramedullary” referred to the location of the tumor, within the confines of the membrane, or dura, surrounding the spinal cord but outside of the cord itself. “Almost certainly benign and, odds on, either a schwannoma, a neuroblastoma, or a meningioma.”
Dr. Reefes said irritably, “According to the radiologist’s report, yes.” Clearly, he intended to suggest Susan had taken all of her information from the report, thereby belittling all of her knowledge and research. Susan had not read the radiology report because she had discussed the matter directly with the radiologist shortly after the MRI. Apparently, Dr. Amani Sharna had used much of their conversation in her commentary.
Susan could feel her blood warming, heat rising to her cheeks, but she suppressed her anger and stepped to Dr. Reefes’ side to look over his shoulder. The screen was filled with spinal images demonstrating osseous erosions and a hypodense mass that became hyperdense on the T2 weighted images. Susan reached around him to hit the keys, bringing up some of the other MRI images until she found the brain slices she wanted in the middle cranial fossa. “The temporal horns of the lateral ventricles are disproportionately enlarged.” She highlighted them. “At least when compared to the sulci, which are normal-sized.”
Kendall took the seat Susan had vacated, the only one in the room other than Dr. Reefes’ own. “A benign tumor of the cauda equina doesn’t cause ventricular dilatation. It’s too far removed to cause direct obstruction.”
Susan fought a smile. Kendall was deliberately setting up her hypothesis. She appreciated that he was going to allow her to deliver the coup de grâce. “It has to be normal pressure hydrocephalus.” They had returned to Susan’s original point, that Chuck Tripler had one of the rare treatable forms of dementia. She did not add that the reason she knew the pressure was normal was because she had performed the forbidden lumbar puncture.
Dr. Reefes sat back, practically mumbling. He seemed to be speaking to himself more than the residents. “Tumors of the cauda equina don’t cause NPH.”
Susan knew he would not have the answer. Practically no one who had not done the research on the rare situations she had undertaken the previous night would. “But they can cause massively elevated protein levels, which increases the turbidity of the CSF. Sludging could block the ventricles and lead to NPH.”
It was not common knowledge outside of neurology, but Dr. Reefes accepted the premise without comment.
Slouching in the chair, Kendall helped Susan out again. “But what about the positive test for Lewy bodies? Are you suggesting Mr. Chuck Tripler just happens to have NPH, a tumor of the cauda equina, and Parkinson’s disease simultaneously, without any connection? That seems like an amazing coincidence.” He gave her a mock-hopeful look and a broad wink.
Susan suddenly wished she had not discussed the explanation with Kendall on the way in to work that morning. He was turning a serious medical discussion into an infomercial.
“They all have to be related,” Dr. Reefes said.
Susan considered remaining silent and putting their attending on the spot. She doubted he would come close to finding a logical explanation, at least not without scouring medical journals on the global web for the rest of the day. Even then, she did not know if he had the understanding or skill to pull it all together. However, trained to always protect the dignity of an attending, she explained, “NPH could potentially cause parkinsonism by dysfunction of the circuits linking the cortex, basal ganglia and thalamus, or due to periventricular ischemia, causing a vascular form of parkinsonism.”
Susan looked thoughtfully at Dr. Reefes. It was his turn to say something, to validate her actions and logic, to admit his mistake, if only on a subtle level.
Dr. Reefes rose. Without missing a beat, he turned on Susan Calvin. “Which is why, when I tell you to perform a test, you do so right away. You don’t argue with me.”
“What?” The word was startled from Susan’s mouth.
Reefes continued, his stance growing more rigid, his face purpling. “Chuck Tripler could have been evaluated by Neurology two days ago if you had done the lumbar puncture when I asked you to instead of waiting until it was convenient.”
Susan shook her head, trying to clear it. She could not believe what she was hearing, certain she had gone schizophrenic overnight, beset by auditory and visual hallucinations. This could not be happening. “I…but you didn’t…” Suddenly realizing she was about to say something vulgar, she clamped her mouth shut.
Dr. Reefes seized her by the elbow and steered her toward the door, opening it with his other hand. “I’ll be transferring Mr. Tripler to Hasbro Neurology.” He used a condescending tone that suggested he chose to do it himself because he did not trust her to do it. “Now get back to work, Susan, and try to keep on top of things.” He shoved her through the opening.
Susan stumbled once, then whirled. Rage flashed through her, igniting her blood into a bonfire. Never in her life had she so wanted to strangle somebody. Her fingers balled into bloodless fists. She would have coldcocked him had Kendall not appeared suddenly in front of her and slammed the door behind him. Even then, she raised a fist to bang on the wooden panel standing between her and the man she fully intended to kick to a painful and immediate death.
Kendall stepped between the door and Susan’s hand, catching it before it could land on the door. “He’s not worth it.”
“Shit, you mean?” Susan spat out.
“He’s not worth having to wipe off the bottom of your shoes,” Kendall affirmed, fitting eerily into her kicking-to-death scenario. “Verbally cast—” He caught himself. “—igating surgeons is one thing. Murdering an attending will almost certainly get you canned.”
At the moment, Susan did not care. She could feel her fingernails biting into her palms.
“And imagine having to look at his gloating face in a courtroom while he sues you for assault.”
That did it. Susan dropped her arm to her side, whirled violently, and stormed toward the nearest staffing area. Kendall followed her, step light and cautious, as if he feared the slightest noise or action might set her off again or turn her rage against him.
Susan threw herself into a chair, still fuming. “You know what that moron’s going to do?”
“Of course I do.” Kendall’s face twitched. He was obviously fighting a grin. “He’s going to call Neurology, present your case, and act like he came up with it all on his own.”
Susan paled. She had only been thinking he would use some unflattering comment like “lazy” on her evaluation. That would upset her, but would probably get lost among the larger number of glowing reports. Not that every superior appreciated her style. A few had labeled her “distracted” in the months following Remington’s death.
Others had referred to her as smug or overconfident, although all had appreciated her diagnostic acumen. Somewhat of a perfectionist, she found every criticism irritating, but the unjust ones gnawed at her. Dr. Reefes had no right to refer to anyone else as lazy. The realization that Kendall was right only reignited the fire.
“Then he’ll get the”—Kendall put his palms together, then tipped his head against the back of one hand and assumed a falsetto—“‘My, aren’t you just so clever.’” He batted his eyes as he spoke, then dropped his hands to his sides. “And the balloons in the hallways. And the ticker-tape parade.”
Susan wanted to slap him, but in her current mood, she was afraid she might hurt him. “Ha, ha, ha,” she said, her tone dripping sarcasm. “All that matters is Chuck getting the treatment he needs. Who cares who takes the credit?”
“Who, indeed?” Kendall had made his point, then his brow furrowed. “What the hell is ticker tape, anyway?”
Susan sat back, glad for the distraction. “It’s just confetti thrown from windows over a parade. Originally, it was bits of—” She looked up to find Kendall studying her, brows raised in anticipation. “Rhetorical?”
“Of course.” Kendall chuckled. “But leave it to Susan Calvin to have the answer on the tip of her tongue.”
Kendall had become Susan’s closest friend, and she wondered why she so often felt like doing him grievous bodily harm.
“So.” Kendall flopped down into the chair beside Susan. “The good news is, when you’ve started the morning with a superior taking credit for your hard work, then upbraiding you for not doing exactly what you did, nothing worse can happen to you the rest of the day.”
Susan nodded at the new twist on the Mark Twain quote about eating a live frog. “What’s in store for us?”
“Two new admissions.” Kendall tapped some keys on the nearest palm-pross. “You want the young newbie? Or the old woman who keeps bouncing in and out of here every few months?”
Susan had learned the previous year to let others do the choosing. She tended to cure her patients and cared little for the innuendo that she selected them solely to make herself look more competent than her peers. In some cases, she had gotten lucky, but, mostly, she had a keen eye and ear and knew how to put knowledge and diagnostic details together. “You pick.”
Kendall shrugged. “Fine. I’ll take Barbara Callahan. She’s the bouncer. Reefes put up a fight about taking her at all, and you don’t need any more confrontations with him.” He shoved a palm-pross toward Susan. “You get Jessica Aberdeen.”
Dutifully, Susan typed in her identification and passcode. “We came in together. How did you find out about the new patients?”
“Musica filled me in.” Kendall gestured randomly, but Susan knew he meant one of the young nurses. “I went to check on Thomas Heaton first thing, and she corralled me.”
Susan teased, “Maybe she has a thing for you.” Her conversation with her father two nights ago flashed to the fore. She had mentioned to John Calvin that she had never seen Kendall date anyone. Now the reason became instantly clear. Within two weeks of their first rotation, Remington had died and Susan wound up in intensive care. Kendall partially blamed himself, and it made sense he had not resumed whatever social life he might have had prior to starting his residency. She had not had any interest in pursuing a relationship since the trauma, either.
Kendall did not hesitate. “I doubt it.” He twirled a lock of his ginger hair around his index finger. “Lots of men have a thing for redheads, but women…” He shrugged. “Especially when you have freckles, they see you as a romantic prospect about as serious as Howdy Doody.”
Susan’s brows shot up. “Ticker-tape parades? Howdy Doody? Have we been transported back a century? And how do you expect women to take you seriously when you’re always joking?”
Kendall ignored the last part of her point for the first. “This place is getting to me,” he admitted. “Immerse me in a world of senile ninety-year-olds, most of whom are still living in the 1960s, and my references get a bit…stale.”
Susan was pretty sure real ticker-tape parades and Howdy Doody predated the sixties, but she did not argue. “And the constant joking?”
Kendall shrugged. “A great sense of humor tops nearly every list of what women want in a man.”
Susan could not help ribbing. “That’s assuming your joking around is actually funny.”
“Oooow.” Kendall clutched his chest and screwed up his face. “You’ve shot me right through the heart.”
“Sorry,” Susan said, knowing she did not sound it. Though they had put the morning’s events behind them, they still colored her thoughts and actions. She typed “Jessica Alberdine” into her palm-pross and gleaned nothing. She showed the error message to Kendall.
“Aberdeen,” Kendall corrected. “No l, and ‘deen’ with two e’s.”
Susan retyped the name, and a description in medical terminology, written by the transferring doctor, popped onto the screen: “J.A. is a forty-four-year-old white female with progressive memory loss and disorientation six months post skull fracture with complete recovery.”
Susan assumed the referring physician meant Jessica had completely recovered from the skull fracture, not from the progressive memory loss and disorientation. She continued reading: “Family history positive for breast cancer in the maternal grandmother, mother, and paternal aunt. There is also a strong family history of early-onset Alzheimer’s disease in paternal grandfather and two uncles, one of whom died in his late thirties. Social history negative for smoking, alcohol, or illicit drugs. She takes no medications. Brain MRI shows generalized mild atrophy, with no discrete lesions. Alpha-synuclein test is negative, ruling out parkinsonism or Lewy body dementia. Diagnosis: early-onset Alzheimer’s versus post-traumatic dementia. Treatment: transfer to Winter Wine Dementia Facility.”
Susan sat back, her encounter with Dr. Mitchell Reefes receding to the back of memory, an irritation lost beneath consideration of her new patient. Nothing in the presentation suggested Jessica Aberdeen would not take her proper place among the residents of the dementia facility, moving from one unit to the next as the years passed. Neither early-onset Alzheimer’s nor post-traumatic dementia had viable treatments. She would go on the usual assortment of cholinesterase inhibitors and NMDA receptor antagonists until they no longer helped to slow the process; then it would take her like all the others.
Susan sighed heavily, suddenly wishing she had chosen the older patient. The horrors of dementia, the desperate slide into oblivion surrounded by hopeless patients upset Susan enough without having to visit with one so inexplicably young. Jessica would not be the youngest patient at Winter Wine; Unit 3 had a twenty-seven-year-old with variant Creutzfeldt-Jakob disease, and Unit 2 held a nineteen-year-old with Neimann-Pick. Still, the idea of giving up on a forty-four-year-old woman rankled. Maybe, just maybe, I’ll see something on physical examination that gives me hope for something treatable.
Susan shoved the palm-pross aside, sighed, and rose. She glanced around, but Kendall had already left to tend his own patients. Susan headed for Unit 1. The board indicated Jessica occupied private room number 8, so Susan headed for the door and knocked.
To her surprise, a happy female voice sang out, “Come in!”
Surprised to find any patient here so lucid, Susan opened the door to discover a skinny, middle-aged woman propped in the bed, and the young nurse they knew as Musica arranging a portable dining table. Apparently, it was the nurse who had responded, because Jessica barely acknowledged Susan’s presence by rolling her eyes in the doctor’s direction. Musica, however, greeted her cheerily—“Good morning, Dr. Calvin”—in the same cadence as the earlier communication. “I was just about to serve Jessica some lunch. Would you like me to wait?”
Susan’s gaze drifted to the tray, which contained a series of plastic containers that did not resemble the standard hospital-issued items. “Did she pack it in?”
The nurse hesitated a mom
ent, then followed the direction of Susan’s gaze. “Oh. No, of course not. She’s on a special diet.”
Susan continued to study the containers. One held a white liquid, apparently milk. The other was a bowl filled with some sort of casserole. Susan could make out green beans, mushrooms, and wide noodles. She could not, however, fathom the nurse’s words. As Jessica’s physician, Susan would specify the woman’s diet when she wrote the rest of her orders. “Special diet? Who authorized this?”
The nurse set her jaw, but her gaze dodged Susan’s. “I…Dr. Reefes…said it would be…all right.”
At the moment, Susan did not feel kindly disposed toward her attending. She wondered why he had decided to involve himself in a patient’s food preferences when he rarely bothered with anything else about them, including appropriate care. “Where did this food come from?”
“Her father brought it.” Musica shifted from foot to foot, clearly uncomfortable. “He’s a naturopath. The whole family’s vegan, and he was quite insistent…” She finally looked directly at Susan.
Susan did not mean to intimidate the nurse. “Okay.” She had nothing against vegan diets, in principle, although she could not help thinking of her militant colleague, Nevaeh, who considered anyone who ate meat a murderer. Realizing that her irritation with Dr. Reefes had probably entered her tone and manner, she tried to soften them. “So, what’s on the menu for Jessica?”
Musica managed a smile, pointing to the objects on the tray. “Vegetable noodle casserole, a slice of zucchini bread, and a nice, cold cup of soy milk.” She indicated each object in turn. “And I get to help her eat it, but not until after you’ve examined her, if you prefer.”
Susan considered taking the offer; doctors’ schedules usually took priority over the ancillary staff. Here, however, Susan felt like the interloper. Given Dr. Reefes’ mostly hands-off approach, the nurses performed most of the patient care, suggesting courses of action he normally simply okayed, often without bothering to examine the patient, at least not the ones on the higher-number units. Besides, Susan suspected vegetable noodle casserole would taste a whole lot better still warm. “No, you go ahead.” She waved at the food and turned to leave. Then, a thought came to her, and she stopped midstride. “Don’t we have other vegetarians in the facility?”
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