I, Robot: To Protect

Chapter 4

Susan began with one of the patients she had actually examined. “Starling Woodruff is a thirteen-year-old white female with a history of odd behavior who has been on the Pediatric Inpatient Psychiatry Unit for almost two years.”

“Odd behavior,” Bainbridge interrupted. “Is that her diagnosis, Dr. Calvin? Odd Behavioral Disorder? Isn’t that akin to diagnosing a child with a specific chromosomal deletion as having Funny-Looking Kid Syndrome?”

Irritation seized Susan, but she held her tongue. “Starling’s official diagnosis is dementia, status post A-V fistula repair.” She did not add she did not agree with the diagnosis. It would sound arrogant and ridiculous to contradict the numerous physicians who had treated her over the last two years. “Her symptoms consist mostly of memory lapses, particularly short-term, aimless wandering, lack of concentration, and confusion.”

Nods suffused the group, residents and nurses included.

Susan continued, wanting to get out the entire history before letting the other shoe drop. Going first made things so much more difficult. She had to guess how much information Bainbridge wanted, enough so he fully understood the situation but not so much it made her look incapable of sifting out the pertinent from the history. The residents’ reports at rounds might be the only knowledge Bainbridge would have of their patients.

“Starling underwent repair of a cerebral arteriovenous fistula in September of 2033. In the nearly two years since, she has developed worsening psychiatric problems, treated with various cholinesterase inhibitors. She is currently taking rivastigmine, which seems to help with memory and confusion, as well as sertraline for agitation and depressive symptoms. In addition to her psychiatric symptoms, she fatigues easily and has grown poorly for age, currently in the tenth percentile. She had previously been growing along the seventy-fifth percentile curve. On physical examination, she was pale, with remarkably cold extremities. Her pulse was thready. I could feel the liver edge, implying possible hepatomegaly, and I could hear a soft S4 gallop.”

Susan looked at the nurses, several of whom had creased foreheads. Apparently, they had never noticed the extra heart sound, which did not surprise her. It was subtle, not something expected in psychiatry, and, even under normal circumstances, required significant training to hear.

Stony pursed his lips, head bobbing. “Nice catch.”

Bainbridge looked from Stony to Susan. “Are you sure?”

“After rounds, I’ll double-check it,” Stony promised.

Bainbridge studied Susan. “What do you make of your findings, Susan?”

“Well . . .” Susan hesitated to speak. If what she believed was true, it would change the entire approach to the patient. “I don’t believe Starling has dementia per se. I think she’s actually suffering from congestive heart failure, a feature of which can be altered consciousness, especially in children.”

The nurses murmured in the background. Bainbridge nodded slowly. “Does she have a history of some sort of congenital heart disease with reparative surgery? Hypoplastic left heart? Transposition?”

“No,” Susan admitted. “But a child can develop congestive heart failure without a major defect.”

Bainbridge tried another tack. “An ASD, perhaps? A suspicious murmur?”

“No,” Susan admitted. “Prior to the A-V fistula repair, she was, apparently, perfectly normal.”

Bainbridge continued to stare. “So, then, what would cause a child with a normal heart to develop congestive heart failure after a routine neurosurgical procedure?”

Susan found herself bridling under the scrutiny and stood up straighter to buoy her confidence. The child’s life might depend on it. “Only one thing, sir. If the A-V fistula was not properly or fully repaired, it could cause a shunt that results in CHD.”

The nurses responded with a collective drawing in of breath that added up to an actual gasp. The doctors turned to face them.

“What’s wrong?” Bainbridge demanded.

The head nurse came forward. “Well, sir, the surgeon on Starling’s case was none other than Dr. Sudhish Mandar. He’s one of the greatest neurosurgeons in the world, and he personally signed off on Starling.”

Bainbridge sucked in his lips, nodding. “Well, then.”

Susan waited for his orders. It seemed impossible he would side with a first-year resident over a neurosurgeon with such stellar credentials, and she was not surprised when he did not.

Bainbridge patted Susan’s shoulder. “It was a great theory, anyway. I like to see my charges thinking in new and different ways.”

The smirks on the nurses’ faces annoyed Susan. She supposed they saw the same thing the first of every month: fresh, new residents so convinced of their own brilliance, so eager to find the instant cure so many wiser heads had missed. She supposed nearly all came with the same familiar “brand-new” approaches and ideas. She could hardly blame them for doubting her. “Dr. Bainbridge, I don’t think it would hurt anything to have Neurosurgery come down and reevaluate Starling. As far as I can tell by her chart, they haven’t seen her in at least the last eighteen months.”

Over Dr. Bainbridge’s shoulder, Stony shook his head, an obvious warning to Susan not to pursue the matter further, at least not at the moment.

A tinge of purple rose to Bainbridge’s wrinkled face, but his voice gave no sign of building rage. “Susan, when Dr. Sudhish Mandar signs off on something, it is off, finished, perfect.”

Susan wondered why she had never even heard of this so-called best neurosurgeon in the world. They had neurosurgeons at Thomas Jefferson, in Philadelphia; and she had performed her neurosurgery rotation as a medical student. She had never once heard them mention Dr. Mandar. “Fine, sir. As I wasn’t inside Starling’s brain, I can’t guess what they saw. However, I know pediatric congestive heart failure when I see it. Can I, at least, have a Cardiology consult?” No matter the cause of Starling’s heart failure, the cardiology team ought to have the expertise to control it. Perhaps they could come up with a reason for the problem that did not reflect badly on the neurosurgery team.

Bainbridge looked at Stony, as if to say he pitied the R-3 having to deal with a difficult upstart.

Stony did not seem put out by Susan at all. “How about if I examine Starling after rounds? If I also see signs of CHD, then we’ll consult Cardiology.”

That seemed to satisfy Bainbridge, who flashed Susan a sincere smile and nodded broadly. Before he could call for information about the next patient, thunderous pounding echoed across the ward. It sounded as if an entire wall had collapsed. There followed a shout, then a loud string of the dirtiest swear words in the English language in the voice of a prepubescent male. Through the one-way glass, they could see Dallas “Diesel” Moore ripping children’s artwork from the hallway walls and throwing the mangled papers at two nurses at his heels. Blood poured from his nose, gushing down the front of his shirt, but he paid it no heed.

“I hate you!” he screamed before disappearing around the corner, the nurses in tow. “I’m going to kill you! I’m going to kill you all!” He flung something in his hand that one of the nurses dodged.

Stony and several of the nurses excused themselves, darting out of the office toward the retreating figures.

“Whose patient is that?” Bainbridge demanded, watching Stony go.

Panic sparked in a few eyes. The other residents had had even less time than Susan to review and meet their patients. They might not know.

Susan rescued them. “He’s mine, too, sir.”

Diesel’s shouts wafted to them, still mostly curses. The sound of objects hitting the walls rose over the din, as well as scuffling and the softer voices of the nurses, attempting to restrain and soothe him.

Susan tried to ignore the noise as she presented the boy. When she had met him earlier, he seemed so calm, so normal, she could scarcely believe she had seen the same child. “Dallas Moore, known as Diesel. He’s a ten-year-old black male with morbid obesity, ADHD, oppositional defiant disorder, severe depression, and obsessive-compulsive tendencies, particularly in regard to food.”

The thudding sounds ceased as someone apparently restrained Diesel, but the threats grew louder and more vicious. Susan heard someone say, “Get him into the Self-awareness Room.”

Susan told the group, “He seemed quite normal this morning. I’m not sure what happened to him.”

One of the nurses, a petite blonde, spoke up. “He broke into the med room and plundered the snack cart. Ashlynn confronted him, and he just went crazy.”

Most of the nurses disappeared to the other side of the staffing area to watch through the one-way windows.

Another string of swear words rent the hallway; then came the sound of a large door closing. Silence followed until most of the nurses returned with Stony Lipschitz. Blood covered the front of the R-3’s dress polo, the stethoscope around his neck, and the papers in his pocket.

Bainbridge looked alarmed. “What happened? You didn’t have to hurt him, did you?”

Stony looked himself over. “It’s nasal blood, sir. Apparently, when Diesel gets upset, the blood vessels in his nose burst. The more he fusses, the worse it gets, and he won’t let anyone stop the bleeding until he’s calmed down. In fact, he seems to delight in spreading it as far and wide as possible.” Stony kept his hands away from his body. “Do you mind if I clean up?”

“Please do.” Bainbridge flicked a hand dismissively. “In fact, why don’t we all take a short break?” He looked at his Vox. “We’ll reconvene in an hour, at nine fifteen. Does that work for everyone?”

A tangible wave of relief flooded through the residents as they realized they could continue studying and examining prior to presenting their patients. They scattered in an instant. Susan hesitated, watching a janitor appear to clean up the blood-splattered hallway and the torn hunks of paper scattered in Diesel’s wake. She wondered what had come over him. She could scarcely imagine the stout, quiet little boy becoming a terror in an instant, as though he had swallowed Dr. Jekyll’s potion. She wondered what it must be like to live with a child so volatile, to be his parents or, worse, his younger sibling.

Curious, Susan followed the blood trail to the massive white door reading SELF-AWARENESS ROOM in bold black letters. Two male nurses stood there, one peering through a small but thick polycarbonate window.

“May I see him?” Susan asked.

The nurse stepped aside wordlessly.

Susan leaned into the glass. Diesel stood near the door, bashing his head against the padded walls, leaving smears of blood and snot that betrayed his tears. He wore a T-shirt, cut in the latest triangular-sleeve style, and olive green sweats with the trendy T’chana label and its signature parrots. Short and round, he looked more like a bowling ball than a child, especially bouncing from wall to wall.

“I’m going in,” Susan said, her hand on the knob before anyone could stop her.

“You can’t — ,” one nurse started.

“It’s not allowed,” the other said simultaneously.

Susan pretended not to hear them, turning the handle and opening the door. It was heavy, thicker than she expected, and also covered with padding.

Diesel ignored Susan, banging his head repeatedly against the wall, nose blood splashing in surreal patterns each time he did so.

The door closed behind Susan. She could see one nurse watching them through the window, and she guessed it had less to do with curiosity and more with protocol. The rules, perhaps state or national law, demanded someone placed in isolation be watched every moment. Susan imagined the other nurse running for assistance. In the end, she doubted anyone would bother her. To do so would only agitate Diesel, and the purpose of the Self-awareness Room was to give him a safe place to vent and calm himself.

Susan approached the boy. “Diesel?”

“Leave me alone,” Diesel growled. He stopped banging, grinding his head into the padding.

“Okay.” Susan stepped back, then sat cross-legged on the floor. She retrieved a wad of tissues from her dress pants and laid them in a dense pile beside her. She also had some Slookies, hard sour candies; but she knew better than to offer them to an obese patient on a strict diet.

The blood from Diesel’s nose dripped onto the floor beneath him in a steady patter, no longer squirting. Apparently, he had calmed a bit, at least enough to drop his blood pressure to a more normal level. She took that as a positive sign.

“What do you want?” Diesel said into the padding.

“Nothing.” Susan tried to keep her voice absolutely neutral. She had no idea what might calm Diesel and what might provoke him into another wild tantrum. “What do you want?”

Diesel hesitated. He seemed as uncertain as she about how he felt like behaving next. “Got any tissues?”

“Right here.” Susan patted the floor beside the piled tissues. “Come join me.”

Diesel turned slowly, studying the situation as if he expected her to leap up and net him. Finally, he came over, picked up the tissues, and clamped them to his nose. Tears and blood streaked every part of his face.

Susan’s training rushed to the fore. She should be wearing a gown and gloves and staying as far as possible from a biohazardous patient. It helped that she knew from his chart he did not carry hepatitis, HIV, or CIV; and she was legally vaccinated against everything contagious and known to science. “Sit,” she said, not expecting him to obey. “Please.”

To her surprise, Diesel sat. He kept the tissues clamped to his face with one hand, the other flat on the floor. He also sat cross-legged.

For several moments, they sat quietly on the floor together, neither saying a word. Susan kept her gaze from the window. Whether or not Diesel knew they were being watched, he did not need to be reminded of it. She let him speak first, knowing instinctively anything she said would only inflame him. Through the years, he had faced the inquisition whenever he acted in an irrational manner: “Why did you do this? Are you insane? What were you thinking?” She wondered what he might say if he had the opportunity to get in the first word.

“I’m a monster,” Diesel said softly. “I hate myself, and I want to die.”

And there’s the depression part. Susan wished she had had more training. Her immediate thought was to disabuse him of such a terrible notion, to assure him he was a sweet boy with a problem, not a monster, that killing himself would only create more problems for all the many people who loved him. But she was sure he had heard it all before, and anything she said in this vein would only shut down a conversation that had just begun, one she suspected had the possibility of yielding important information. “Why do you say such a thing?”

“Because I am. And I do.” Diesel hid behind the wad of tissue, not bothering to look at Susan.

That was useful. Now, Susan worried she had not only shut down the conversation, she had also left him believing she thought him a monster who ought to kill himself. What made me think I could handle this? Susan tried again. “Tell me more. What kind of monster are you?”

Diesel rolled an eye in Susan’s general direction. “I’m a food-hogging monster. If I could, I’d eat Tokyo.”

Susan could not help laughing. “What part of Tokyo?”

Diesel slipped into baby talk. “All of it. Da cakes. Da pies. Da can-dee.” He paused. “Da bui-dings, da people, da can-dee.”

“You said ‘candy’ twice.”

Diesel managed a smile around the tissues. “That’s my favorite.”

Susan could not resist. She slipped a Slookie into his hand and whispered conspiratorially, “Careful how you put that in your mouth. And don’t tell anyone I gave it to you.”

Apparently, Diesel did know about the nurse observing because he peeked sideways at the object, then made a casual motion of moving the tissues and sneaking it into his mouth. “I’m hungry all the time, Dr. Susan. I’m hungry right after dinner. I’m hungry in my sleep. I’m hungry while I’m still eating.”

Susan thought of all the psychiatry she knew about hunger. Most believed it a substitute for something missing, usually love. Nothing in Diesel’s chart suggested inadequate parenting. He had a married mother and father, at least one of whom visited him at every opportunity. They had cooperated in every way with his therapy. They had two other children, an older boy and a younger girl, who seemed normal in every way. From his dress and vocabulary, it was apparent he did not lack for attention, money, or education.

“If I ever threw up, I think I’d be hungry doing it.”

“Gross.” Susan managed to chat even as she mulled the pertinent.

“You’ve never thrown up?”

“I once broke into the freezer and ate three boxes of Popsicles, two things of ice cream, a cake, a loaf of French bread, and a package of shredded cheese in less than five minutes. They said I should be puking all over the place, but they couldn’t even make me.” Diesel seemed almost proud of the accomplishment. “I don’t throw up.”

Susan suspected if she had eaten all that, she would be in a coma. “Wow.” She could think of nothing else to say.

Diesel loosed a raw, honest belly laugh so fun and contagious Susan could not help joining him.

She finally managed, “I’ll bet you could eat Tokyo.”

Diesel laughed again, and Susan realized she loved that sound. She bet people did silly things just to elicit it.

Having stopped his nosebleed, Diesel turned to wiping blood, snot, and tears from his face.

Susan could not help wondering if someone took pleasure in Diesel’s overeating. Perhaps he or she encouraged it, either intentionally or subconsciously. More than one person might be to blame. Maybe even me. She felt a sudden pang of guilt at having slipped him a candy. She wondered how many people had tried to win his trust that way and vowed she would never do so again. “So, how’d you get the nickname Diesel?”

Diesel actually smiled. “Football. I plow through the other line like an old-fashioned diesel truck or train.”

“You’re a lineman?” Susan guessed. She hoped her ignorance of football did not show too much. When she took her pediatrics rotation, she remembered one of the residents telling her the smartest thing a pediatrician could do was to keep up with the trends in gaming, music, and play. Nothing impressed a child more than a doctor who knew the hip shows, the names of the newest characters, or could keep up with him in a game of I-Star.

“Nose guard,” Diesel said. “And center on offense. Right smack dab in the middle of the line.”

Susan looked him over. Though notably short for his age, he was built like a tank. “So, I bet you love the Giants.”

Diesel wrinkled his nose. “I like college. Longhorns.”

“Texas?” Susan asked.

Diesel looked at her as if she had gone mad. “No, the Pennsylvania Longhorns.”

“Pennsylvania?” Susan realized he was teasing her. “Funny.” Of course Texas, you moron. “What do you like about them?”

“For one thing, they’re good. Ten and oh last season. For another, they send a lot of guys to the pros. Especially quarterbacks.”

Susan made a mental note to study up on football, especially the Longhorns. “You think you’re calm enough to go back out there?”

Diesel sighed. “And apologize. Yeah, yeah. I know the drill.”

“Good, because I have to get back to rounds.” Susan looked around the room at the blood-splashed, padded walls. “And someone is going to have to clean up in here.”

Diesel followed Susan’s gaze as if noticing the mess for the first time. Only then, he studied himself. He looked as if he had gone ten rounds in an ultimate fighting ring.

Susan rose, walked to the door, and knocked politely.

It swung open immediately.

“We’re ready to come out,” she announced to the waiting nurse, who gave her a gaze that spoke volumes. Susan had a feeling she was about to face a punishment worse than Diesel’s own.

To her surprise, she did not care.