Deep Storm

9

Crane looked up from the digital clipboard that he'd been scribbling notes on with a plastic stylus. "And that's it? Just some pain in the legs?"

The man in the hospital bed nodded. Even beneath the sheet it was clear he was tall and well built. He had good color, and his eyes were clear.

"On a scale of one to ten, how severe is the pain?"

The man thought a moment. "Depends. I'd say around six. Sometimes a little more."

Nonfebrile myalgia,Crane jotted on the clipboard. It seemed impossible-no, it was impossible-this man had suffered a ministroke two days ago. He was too young, and, besides, none of the tests indicated one had occurred. There were only the initial complaints: partial paralysis, slurred speech.

"Thank you," Crane said, shutting the metal clipboard. "I'll let you know if I have any more questions." And he stepped back from the bed.

Although termed a "suite," the medical facility of the Deep Storm station boasted equipment that a moderate-sized hospital might envy. In addition to the ER, surgical bays, and two dozen patient rooms, there were numerous breakout areas for specialties from radiography to cardiology. There was a separate complex in which the staff had working areas and conference rooms. It was here that Crane had been given a small but well-equipped office with an attached lab.

Of all the recent complaints Dr. Bishop had described, only three had been severe enough to warrant hospitalization. Crane had already interviewed two of the patients-a forty-two-year-old man suffering from nausea and diarrhea, and this supposed stroke victim-and the fact was, neither really needed to be hospitalized. No doubt Dr. Bishop was just keeping them under observation.

Crane turned and nodded to Bishop, who was standing well back.

"There's no indication of TIA," he said as they stepped into the corridor.

"Except for the initial presentation."

"You witnessed it yourself, you said?"

"I did. And the man was clearly having a transient ischemic attack."

Crane hesitated. Bishop had said little during his examination of the two patients, but the hostility had been just below the surface. She wouldn't like having her diagnosis called into question.

"There are numerous syndromes that can present in similar fashion-" he began as diplomatically as possible.

"I did my internship in a vascular care unit. I've seen more than my share of patients stroke out. I know a TIA when I see one."

Crane sighed. Her defensiveness was starting to wear on him. True, nobody liked an interloper, and perhaps that's what he seemed. But the fact was the medical team here had only done superficial tests, treating each case as a separate event. He was convinced that if they dug deeper, ran more extensive tests, some commonality would surface. And despite what Bishop had told him, he was still betting on caisson disease as the main differential.

"You never answered my question before," he said. "There is a hyperbaric chamber here, right?"

She nodded.

"I'd like this man placed in the chamber. Let's see if repressurization and pure oxygen ease the pains in his extremities."

"But-"

"Dr. Bishop, Asher told me this Facility uses some kind of classified pressurization technology. Basically untested in the field. That makes the bends the most likely culprit by far."

Bishop did not reply; instead, she frowned and looked away.

Crane felt himself growing impatient. "Feel free to talk to Asher if you don't like it," he said crisply, "but he brought me down here to make suggestions. Now please get this patient to the chamber." He paused to let this sink in. "Shall we visit patient number three?"

He had saved the most interesting case for last: a woman who presented with numbness and weakness in both hands and face. She was awake when they entered her room. Latest-generation monitoring equipment surrounded her, bleating quietly. Immediately, Crane sensed a difference. He noted the distress in her yellowish eyes, the wasting body rigid with worry. Even without performing a diagnostic procedure, he knew this case might be serious.

He opened the clipboard, and the LCD screen sprang to life. The patient history came up automatically. Must be tagged to her RFID chip, Crane thought.

He glanced over the summary data:

Name: Philips, Mary E.

Sex: F

Age: 36

Brief Presentation: Bilateral weakness / numbness of hands and face

When he looked up from the clipboard he noticed a naval officer had slipped into the room. The man was tall and lean, and his pale eyes were set unusually-even oddly-close together. The right eye appeared to be exotrophic. Commander's bars were on his sleeves, and his left collar sported the gold insignia of the Intelligence Service. He leaned against the door frame, hands at his sides, acknowledging neither Crane nor Bishop.

Crane looked back toward the patient, tuning out this new arrival. "Mary Philips?" he asked, falling automatically into the neutral tone he'd long ago learned to use with patients.

The woman nodded.

"I won't take up much of your time," he said with a smile. "We're here to see you back on your feet as quickly as possible."

She returned the smile: a small jerk of the lips that vanished quickly.

"You're still feeling significant numbness in your hands and your face?"

She nodded, blinked, dabbed at her eyes with a tissue. Crane noticed that when she blinked her eyes did not seem to close completely.

"When did you first notice this?" he asked.

"About ten days ago. No, maybe two weeks. At first it was so subtle I barely noticed."

"And were you on or off shift when you first became aware of the sensation?"

"On shift."

Crane glanced again at the digital clipboard. "It doesn't say here what your station is."

It was the man in the doorway who spoke up. "That's because it isn't relevant, Doctor."

Crane turned toward him. "Who are you?"

"Commander Korolis." The man had a low, soft, almost unctuous voice.

"Well, Commander, I think her station is very relevant."

"Why is that?" Korolis asked.

Crane looked back at the patient. She returned his gaze anxiously. The last thing he wanted to do, he decided, was increase that anxiety. He motioned Commander Korolis in the direction of the hall.

"We're performing a diagnostic procedure," he said, in the corridor and out of the patient's earshot. "In a differential diagnosis, every fact is relevant. It's quite possible her work environment is in some way responsible."

Korolis shook his head. "It's not."

"And how do you know that?"

"You'll just have to take my word for it."

"I'm sorry, but that's not good enough." And Crane turned away.

"Dr. Crane," Korolis said softly. "Mary Philips works in a classified area of the Facility on a classified aspect of the project. You will not be permitted to ask work-specific questions."

Crane wheeled back. "You can't-" he began. Then he stopped, forcing down anger with effort. Whoever this Korolis was, he clearly wielded authority. Or thought he did. Why all this need for secrecy, Crane wondered, at a scientific establishment?

Then he paused, reminding himself he was the newcomer here. He didn't yet know the rules-overt or covert. It seemed likely this was a battle he couldn't win. But he'd sure as hell bring it up with Asher later. For the moment, he'd just have to diagnose this patient as best he could.

He stepped back into the hospital room. Dr. Bishop was still beside the bed, her expression studiously neutral.

"I'm sorry for the interruption, Ms. Philips," Crane said. "Let's proceed."

Over the next fifteen minutes, he performed a detailed physical and neurological examination. Gradually, he forgot the watchful presence of Commander Korolis as he grew absorbed in the woman's condition.

It was an intriguing case. The bilateral weakness to both the upper and lower facial muscles was marked. When tested for pinprick sensation, the woman demonstrated significant impairment in the trigeminal distribution. Neck flexion was intact, as was neck extension. But he noticed that the sensation of temperature was greatly reduced across both the neck and upper trunk. There was also-surprisingly-noticeable, and apparently quite recent, wasting of the hand muscles. As he checked the deep tendon reflexes, then the plantar responses, a suspicion began to take root in his mind.

Every physician dreams of stumbling across a particularly rare or interesting case, the kind one reads about in the medical literature. It rarely happened. And yet, in all observations so far, Mary Philips was presenting with precisely such a condition. And Crane, who often stayed up late catching up on medical journals, thought perhaps-just perhaps-he had just identified such a case. Maybe there is a special reason I'm here, after all.

On a hunch, he examined her tonsils: markedly large, yellowish, and lobulated. Very interesting.

Thanking the woman for her patience, he stepped away, picked up the clipboard, and glanced at the blood work:

White-cell count (per mm):3,100

Hematocrit (%):34.6

Platelet count (per mm):104,000

Glucose (mg/dl):79

Triglycerides (mg/dl):119

Erythrocyte sedimentation rate (mm/hr):48.21

He withdrew to speak with Dr. Bishop. "What do you think?" he asked.

"I was hoping you could tell me," she replied. "You're the expert."

"I'm no expert. Just a fellow doctor looking for a little cooperation."

Bishop simply looked back at him. Crane felt the anger returning, stronger now: anger at all the inexplicable secrecy, anger at the meddling Commander Korolis, and particularly anger at the unhelpful, resentful Dr. Bishop. He'd take her down a peg, show her how much he did know.

He closed the clipboard sharply. "Did you think to do any antibody tests, Doctor?"

She nodded. "Viral hepatitis A and C, sulfatide IgM. All negative."

"Motor-conduction studies?"

"Normal bilaterally."

"Rheumatoid factor?"

"Positive. Eighty-eight units per milliliter."

Crane paused. These were, in fact, the tests he would have performed next.

"There was no history of arthralgia, anorexia, or Raynaud's phenomenon, for that matter," she offered.

Crane looked at her in surprise. It wasn't possible the same exotic conclusion had occurred to her as well. Was it?

He decided to call her bluff. "The incipient wasting of the hand muscles would seem to suggest syringomyelia. So would the loss of sensation in the upper trunk."

"But there's an absence of leg stiffiness," she replied immediately, "and little to no medullary dysfunction. It isn't syringomyelia."

Crane was now even more surprised by the depth of her diagnostic technique. But it couldn't hold.

Time to lay my cards on the table, he thought. "What about the sensory defects? The neuropathy? And did you notice the tonsils?"

Bishop was still staring at him, her face expressionless. "Yes, I did notice the tonsils. Enlarged and yellowish."

There was a silence.

Gradually, a smile crept over her features. "Why, Doctor," she said. "Surely you're not suggesting Tangier disease?"

Crane froze. Then slowly-very slowly-he relaxed. He found that he couldn't help smiling back. "As a matter of fact, I was," he said a little ruefully.

"Tangier disease. So, what: now we've got a hundred rare genetic diseases floating about this station?" But her voice was mild, and there was no hint of reproof that Crane could detect. Even the smile, he decided, might be genuine.

At that moment a series of alarms sounded, loud and fast, cutting through the wash of classical music. An amber light snapped on in the hallway outside.

The smile left Bishop's face. "Code orange," she said.

"What?"

"Med-psych emergency. Let's go." She was already running toward the door.