I, Robot: To Protect

Chapter 5

When rounds restarted, they naturally focused on Diesel. More confident after their conversation, Susan started again. “Dallas ‘Diesel’ Moore is a ten-year-old black male who has been diagnosed with ADHD, oppositional defiant disorder, severe depression, obsessive-compulsive tendencies, and morbid obesity.” As Susan glanced around the office, she could see the other residents looked more relaxed than they previously did. The hour off had given them more time to meet their patients and review the charts, while she had entombed herself with Diesel. Stony had changed into the blue corridor scrubs that served two purposes. First, they announced their lack of sterility, that the wearer was not headed for the operating room. Second, their bright color was a reminder not to wear them outside of the hospital.

Dr. Bainbridge studied Susan with a bemused expression. “You’re about to tell us you don’t agree with those diagnoses, aren’t you, Susan?” He already had her pegged from her presentation of Starling Woodruff. Worse, he was right.

“Well, actually, sir . . .” Susan paused, uncertain how to continue. She had not expected to get to this point so quickly and had not fully organized her thoughts on the matter. “I think it’s possible he has an undiagnosed syndrome, yes.”

Stony leaned toward her. “What are you thinking?” Less jaded than Bainbridge, he actually seemed eager to hear her theories.

“Well . . .” Susan tried to work through her thoughts as she presented them. A well-reasoned argument would speak volumes over an educated guess. “Obesity has three main causes: familial, psychiatric, and physiological. The first one is the most common, and also the most treatable. The first and second types cover some ninety-eight percent of all cases of obesity.”

“You think Diesel has the third,” Bainbridge said predictably.

Susan did not wish to couch her ideas as speculation or intuition. Those would not fly in a scientific institution like Manhattan Hasbro. “I think there’s a reasonable amount of evidence to come to that conclusion.”

“Evidence.” Bainbridge made a “come here” motion Susan took to mean he wanted more information, not for her to stand beside him.

“Neither his parents nor his siblings are obese. While there is some history of a maternal uncle who was, that’s not strong evidence for familial obesity.” Susan supposed she had not needed to present those details. That Diesel resided in the PIPU proved his previous physicians believed in a psychiatric basis for his problems, not familial or physiological. “Diesel hasn’t responded to any of the standard antiobesity drugs.” A plethora of those had emerged in the early part of the current decade, when medical research dollars had been restored after nearly two decades of attempts to balance the national and state budgets by channeling that money into medical care for the indigent. The antiobesity drugs worked for anyone with even a modicum of self-control and the desire to attain a healthy weight.

Bainbridge made a more severe gesture, as if to get across to Susan they had a limited amount of time.

“Diesel was underweight until about age two and a half, when he developed hyperphagia and put on enormous amounts of weight quite suddenly. That’s remarkably early for nearly all the psychiatric causes. He packed on the weight despite having ADHD, with an emphasis on the hyperactivity part in his case. He started walking very late. Intelligence testing reveals an enormous backward split between performance and verbal aptitude. Most children with learning problems do worse on the verbal parts, but Diesel has a profound vocabulary and the ability to use it. He has much more trouble with dexterity: drawing, writing, shoe tying. Also, he’s short for both his age and his family history, with surprisingly long arms.”

Monk Peterson blurted out, “Prader-Willi syndrome.”

It was the obvious diagnosis. Though rare, it was still the most common obesity syndrome. Even at the turn of the twenty-first century, most children with Prader-Willi died before they reached adulthood. Driven to eat, they would choke to death, poison themselves with spoiled or uncooked foods, or rupture their stomachs. Those who survived all of those things frequently still died young of complications of obesity.

In the last twenty-five years, doctors discovered treating these children with human growth hormone, consistently locking up all food storage areas, and training the families and children from infancy could help delay the development of the deadly hyperphagia and even prevent the obesity in many cases.

“Is he intellectually disabled?” Clayton asked. “All children with Prader-Willi syndrome are.”

Behind Bainbridge’s back, Monk Peterson poked furiously at his Vox. “Not all. Ten to twenty percent have normal IQs, with severe learning disabilities.”

Susan envied him the ability to use the Vox. With Bainbridge’s attention on her, she did not have the same luxury. “And a ten-point split between verbal and performance portions of the IQ test defines nonverbal learning disability. Diesel has a thirty-five point split. Severe.”

Susan could see nurses whispering behind the other residents and knew they had something to say but did not have the temerity to interrupt an attending’s rounds. She addressed them directly. “Has Diesel been tested?”

One of the nurses answered quickly. “Negative.”

Monk punched more buttons. “Methylation or FISH?”

Everyone turned Monk a blank stare, and he casually hid his wrist behind his back.

“Methylation testing is a lot more accurate.”

“It was the more accurate one,” the nurse inserted. “The one that definitely ruled out the syndrome.”

“Methylation, then,” Monk asserted. “It’s reportedly nearly ninety-six percent accurate.”

That put Susan off a bit, though not entirely. She still believed she had read Diesel correctly. “There are other obesity syndromes and states. Prader-Willi is not the only one.”

Directly behind Bainbridge, Monk still worked his Vox. “There’s post-craniotomy syndrome, also known as secondary or acquired Prader-Willi syndrome. It occurs after removal of a craniopharyngioma from the brain.”

As Diesel had not had brain surgery, Susan discarded the possibility. “There are also other congenital obesity syndromes.” She desperately wished she had Monk’s freedom, stuck with racking her brain from genetics class. “There’s Bardet-Biedl syndrome, for instance.” She hoped no one asked for specifics, as she could not recall them. “Hypothyroidism, hypercortisolism, leptin deficiency.” Another thought filled her mind, a brief memory from a single class about rare syndromes. “I’d like permission to explore some of those possibilities.”

Bainbridge stroked his chin. “I see no harm in that. So long as you keep cost in mind. Start with the most inexpensive tests likely to yield the most results.”

Susan had the perfect answer. “He’s had borderline thyroid studies in the past, but it’s only TSH and T4. I’d like to add free T4. Also, how about a vision screening? With a dark room, dilating drops, a cooperative patient, and a decent ophthalmoscope, I can do it myself.”

Now, all attention in the room went to Susan.

Misunderstanding the staff’s sudden interest in her, Susan added, “I believe he’ll cooperate with me. He’s not always in volcano mode.”

Stony explained, “Susan, we’re just wondering what an eye exam has to do with physiological obesity.”

Susan had thought the connection obvious. “In Prader-Willi, the obesity is hypothalamic. The hypothalamus regulates food satiety and hunger, as well as body temperature, mood, thirst, vomiting, pain sensation, hormonal balance and secretion, and some other things I’m probably forgetting. Diesel has six obvious features of hypothalamic dysfunction.” Susan ticked them off on her fingers. “Obesity, hyperphagia, serious mood disorder, short stature, inability to vomit, and high pain tolerance.” She had learned about the last two just minutes earlier. He had directly told her about the vomiting. The high pain tolerance she deduced by his love of football and his positions, despite his squat figure.

“I’m with you so far,” Stony said. “But still not making the vision connection.”

Susan cleared her throat and looked around. Monk still furiously consulted his Vox, but he clearly had not yet found the thread of her logic. “Diesel has no history of head surgery or trauma to indicate he had damage to the hypothalamus. Monk mentioned craniopharyngioma.”

As Susan drew attention to him, Monk swiftly dropped his arm.

“But, as he said, the tumor itself rarely causes these kinds of problems. It’s when the tumor gets irradiated or surgically removed that the hypothalamus becomes damaged. Since craniopharyngiomas are nearly always benign, they have no cancer markers to attack with immunotherapy; and we still have to remove them the old-fashioned, surgical way. So, we can obviously see what causes many of the problems in Prader-Willi syndrome, and post-craniotomy syndrome, is damage to the hypothalamus.”

As Susan explained her theory, she began to realize she had previously jumped several steps. As she filled them in, she saw how she had lost her companions along the way. “So, if I assume Diesel has hypothalamic damage causing his symptoms, and it didn’t come from surgery or head trauma, it has to be something he was born with, right?” She looked around at her fellow residents, the nurses, and Bainbridge. They all still seemed attentive to her. No one wore the “aha” expression of someone who had just figured out something that had previously eluded him.

“The hypothalamus forms during weeks four to six of embryonic development, the exact same time and place as the optic nerve.”

Now, Susan saw a few heads begin to bob.

“Unlike the hypothalamus, which is deep inside the skull, we can actually view the optic nerve directly. We don’t need an MRI or anything fancy. If he has abnormal optic nerves, it would indicate some sort of mishap in weeks four to six of fetal development and would help substantiate my hypothalamic obesity argument.” The coup de grâce delivered, she looked around at her fellow residents.

Stony spoke first. “But if Diesel has abnormal development of the optic nerves, wouldn’t he be blind? Or, at least, wear glasses?”

“I’m not sure,” Susan admitted.

Monk launched into his Vox. Having edged behind Bainbridge, Nevaeh did the same.

Diesel’s nurse, a large man with brown hair and a thick mustache, said, “I’ve often wondered if he didn’t need glasses, but he won’t cooperate with chart vision testing.”

Susan still believed she could get Diesel to allow her to examine him.

Monk finally came back with an answer. “Congenital abnormalities of the optic nerve can result in blindness, decreased vision, loss of snippets of visual field, or even normal or near-normal vision.”

Bainbridge nodded thoughtfully. “Definitely sounds worth pursuing vision screening and the free T4 level. We may also need to consider a growth hormone and cortisol stimulation test.”

Susan smiled, appreciating his new faith in her. With a glance at his Vox, Stony tried to move things along. The longer rounds took, the less actual work got done. Susan knew from her experiences as a medical student that the first rounds of the month usually took much longer, as residents and the attending learned the new patients. Later, it would dwindle to things that had happened the previous day, changes in treatment plans, and discussion of new discharges and admissions. “Susan, do you have any patients without underlying undiagnosed medical problems requiring immediate attention?”

Susan laughed. “Two. Monterey Zdrazil.” She stumbled over the last name. “Zzz-drah-zil.”

“It’s Zdrazil,” one of the nurses corrected, pronouncing it “Dray-zull.”

Susan practiced the pronunciation. “Monterey Dray-zull is a twelve-year-old white female with post-traumatic, hysterical mutism times six years.”

“Six years?” Bainbridge could not help cutting in. “I’ve never heard of such a thing, at least not outside of a soap opera.”

Susan could only nod. Her limited research the previous night had not gotten her far. Normally, mute children came in three varieties: deaf-mutes, selective mutes, and post-traumatic mutes. Monterey had spoken normally for the first six years of her life and had passed hearing tests in the newborn nursery and at school. Selective mutes, by definition, spoke when relaxed but refused to talk in anxiety-provoking situations, such as school.

By report, Monterey had not spoken a single word since a car accident six years ago, which put her clearly in the category of post-traumatic mute. However, she did not fit those criteria well, either. In most cases, post-traumatic mutes had serious head trauma affecting the midbrain area, and they recovered speech function gradually in days to weeks. Hysterical mutism fit her better, as she met the criteria of sudden onset after a stressful event and absence of a causal organic disease. However, Susan could not find any other cases of conversion reactions of any kind occurring before age ten.

“And it’s definitely psychiatric this time,” Susan said without a hint of doubt. “She’s had the most complete workup for medical illnesses I’ve ever seen in my life. They’ve tried every antianxiety drug ever invented, including some so old we didn’t learn about them in school. Her brain looks perfectly normal on MRI, even in the speech areas. On the other hand, the mutism started when she was involved in an auto accident that killed her father. No one knows exactly what happened, but she was firmly buckled into her booster and he . . . was not.”

Stony’s eyes glimmered. “So, what’s your theory, Susan?”

Susan had nothing to add. “I agree with everyone else. She suffered a major trauma, and the mutism is a conversion reaction. Somehow, not speaking binds her anxiety and guards her against future pain. It’s rare in children but not unheard of.”

“So.” Bainbridge sounded relieved the department seemed to have this patient in hand. “What are we going to do with her?”

Susan sighed. Monterey was not the uncomplicated patient she initially seemed.

Nevaeh stepped into the fray for the first time since rounds began. “What about homeopathic treatments? She might benefit from acupuncture or something naturopathic.”

Sensing another tirade from Dr. Bainbridge, Susan jumped in swiftly. “Monterey’s mother shopped her from healer to healer. She’s tried the whole gamut: faith, herbal teas, acupuncture, hypnotists, aminconmi, random ingredients of the Krebs cycle, mega doses of indiscriminate vitamins, Scientology, soul whisperers, psychics, you name it. When she started experimenting with toxic comas, child protective services stepped in and brought her here.”

The tirade came from Nevaeh instead. “Lots of natural products work, with no impurities and fewer side effects.”

Dr. Bainbridge’s cheeks purpled. “Sure they do. Some of the most potent drugs in history were natural: digitalis from foxglove, aspirin from willow bark, curare, muscarinic mushrooms, rattlesnake venom. Unfortunately, they were also all deadly poisons, most even at low dosages.”

Kendall could not help butting in. “I consider death a pretty significant side effect, even if it’s the only one.”

“Exactly.” Dr. Bainbridge launched into what Susan had tried to avoid. “We eventually discarded all of them for safer and more effective alternatives; yet people still insist on self-medicating with arbitrary doses of unproven plant substances, believing them safer.” He shook his head. “In the public mind, anecdotal ‘evidence’ and false promises trump science every time.”

Stony gave Susan a pleading look. She alone could get the proceedings back on topic, by applying them to Monterey Zdrazil.

Trying to remain diplomatic, without antagonizing Bainbridge, Susan cut in. “The technique we’re planning to use on Monterey isn’t terribly scientific, either. We’re trying to get permission for old-fashioned ECT.”

That shut down the discussion.

Nevaeh finally broke the silence. “So, we’re denigrating a few harmless herbal treatments; but we’re perfectly fine with frying a child’s brain?”

Stony’s eyes went round as coins. Nostrils flared all around the group. No one spoke to an attending like that, short of another attending.

To Susan’s surprise, Bainbridge did not fret over Nevaeh’s verbal attack, though he did give Stony a significant look. Apparently, he expected the R-3 to lecture the R-1s on appropriate behavior after rounds. “So, it’s perfectly fine to stab a child with pins and needles of no known benefit, fill her full of untested poisons, or bleed her with leeches; but using an effective, studied, painless technique is ‘frying her brain’?”

Apparently realizing her mistake, Nevaeh tried to fade into the background. Her defense came from an unlikely place.

“In all fairness,” Stony said, “ECT isn’t harmless.”

“I didn’t say ‘harmless,’ ” Bainbridge pointed out. “I said effective, studied, and painless. The decision is whether it’s worth a bit of potential memory loss to regain a life for this child.”

“Assuming it works,” Stony said. “Otherwise, it’s potential memory loss in a child for no gain at all.”

Stony had had a bit more time to consider the situation, having come on service a few days earlier. “I’m not saying I’m for or against it in this case. Just that there is an argument for both sides.”

Susan did not feel as neutral about the situation. “We’ve wasted six years already and tried everything else known to man, including much less tested and effective therapies. It’s not as if Monterey is a busy mute with an otherwise active life. She’s one step from catatonia, and she’s only twelve years old. She’s lost half her life to this already. This obviously isn’t going away by itself. We have to do something, and ECT appears to be all that’s left.” She glanced at Nevaeh. “At least all that’s logically left from a medical standpoint.”

Bainbridge smiled. “Let’s do it, then.”

Stony shook his head, and Susan knew where he had to go next. “We can’t. There’s a legal injunction against us.”

Bainbridge stared. “After trying everything else, her mom’s fighting this?”

“Not her mom. The Society for Humanity. The SFH.”

Bainbridge groaned. “Those god-awful ignorant protestors?”

“They’re defining it as torture and experimentation on a little girl.”

Bainbridge groaned louder. “So, what are we doing about it?”

“Fighting it legally. Looking for precedent for using ECT on a child.”

“So, in the meantime, she languishes here.”

“Apparently.”

As there seemed nothing more to say about Monterey, Susan moved on. “My last patient is Sharicka Anson, a four-year-old female of mixed race with juvenile conduct disorder.”

Bainbridge held up a hand. “Did you say ‘fourteen-year-old’?”

“Four-year-old,” Susan repeated.

“Four-year-old.” Bainbridge shook his head. “Four? As in baby?”

“Four, as in preschool. Definitely no baby.” Susan quoted from the chart, as she had yet to meet the child. “Three purported attempts at murder, two of them on the unit, and possibly more.”

“At four years old.” Bainbridge seemed incapable of getting past that point. “What kind of history does she have?”

“Adopted as an infant into a doting, professional family. Met milestones shockingly early. Sat up at two months, talked at six months, put words together by twelve months, carried on full conversations with adults before the age of two years.”

“That certainly doesn’t sound like an environment ripe for abuse.” Bainbridge shoved his glasses up his nose. “Though you never know.”

“Never missed a well exam. Got all her vaccinations on time. No documented injuries or bruises. Proud parents bragged about her early accomplishments, chalked them up to a lot of attention and reading to her every night. No history of questionable visits to the ER. Two older siblings, both adopted, with no difficulties at home or school. Child protective services noted some hostility from the parents, but not until the third thorough investigation.”

Kendall winced. “Which I imagine could make a saint turn hostile. Strangers with the authority of the state behind them grilling your children, your doctors, your school, your family and neighbors. Every little thing you’ve ever said or done scrutinized. Suspicions planted in the minds of all your acquaintances who figure CPS wouldn’t be investigating for no reason.” Kendall rolled his head. “That has to suck.”

Susan had to agree. “Everything came out clean on investigation. No founded abuse.”

Bainbridge only nodded thoughtfully. “Halfway into the 2030s, and people still want to believe all children are sugar and spice. Physical diseases, cancer, asthma, metabolic syndromes, those are sad accidents of fate. Anything that goes wrong mentally has to be the parents’ fault.”

Sable finally spoke up. “Doesn’t heredity have the greatest influence on personality?”

“Bingo.” Bainbridge jabbed a hand toward Sable. “There’s no question babies come with a preformed personality. What do we know about the biological parents?”

Susan wished she had had time to dissect Sharicka’s enormous chart. “I’m . . . not sure. I’ll have to check on that.”

Bainbridge looked around the nurses. “Anyone?”

For several moments, the nurses looked among one another until one finally spoke up. “Dr. Bainbridge, I don’t mean to be obstructionist, but we’re not sure about Sharicka’s diagnosis.” She glanced at her colleagues for support, and several of them gave strong nods of agreement. “She really is a darling little girl, and we think she might do fine in the right environment.”

Susan could scarcely believe what she was hearing. The doctors’ notes had clearly documented a long history of violent acts and an obsession with drowning and other forms of murder. “Didn’t she attempt to drown another patient in the toilet?”

The nurse’s pale cheeks acquired a reddish hue. “Well, yes. But we don’t know exactly what happened there. We think the other child might have baited her into it.”

Susan had read about the incident. Not only had Sharicka not denied being the aggressor, she had explained her intent to drown the other child with a smile plastered on her face. The other patient told a story of being lured to the bathroom with the promise of seeing a tiny alligator in the bowl. “And didn’t she assault a staff member and beat her head against a window?”

The cheeks turned even more crimson. “I wasn’t here when it happened, but the staff member quit soon after. She wasn’t well liked, and we think the staff member exaggerated what happened. Other than those two incidents, which have other plausible explanations, she hasn’t done anything bad here.”

Bainbridge had a thoughtful smile on his lips. “Does that ring a bell for any of you?” He looked around the residents, brows inching upward.

It did for Susan. During the summer breaks between her years of medical school, she had worked at a veterans’ psychiatric institution. She had met a patient there who had made her feel competent beyond her years. He had convinced her that she alone had broken through his desperation and loneliness, that only her brilliant diagnoses and soothing manner had worked for him. Later, she had learned about his borderline personality disorder and the ability these patients had to manipulate those around them, especially caretakers. The patient had won over every one of the nurses the same way, each believing his or her special manner and expertise had brought about remarkable changes in the patient. All of them had petitioned for extra favors, treats, or services for him.

Before Susan could speak, Nevaeh took a reasonable guess. “Schizophrenia?”

“Schizophrenia.” Bainbridge fixed his gaze fanatically on Nevaeh.

“In schizophrenia, it’s the patients who have the delusions.”

Everyone chuckled nervously at the obvious joke, which clearly insulted someone. Susan realized he aimed it at the nurses who defended criminal behavior, but they might see it as referring to the parents and alleged victims of Sharicka’s antics. Susan gave the correct answer: “Antisocial personality disorder.”

Bainbridge tapped his nose and pointed to Susan suddenly, like a game show host. “Definitely a personality disorder. Most likely antisocial type. Another possibility.” He whirled abruptly, and Monk Peterson guiltily hid his arm behind his back. “You, there. The one named after a television character.”

“Monk.” The R-1 chewed his lip as he sorted through the information in his mind. “Um . . . fetal alcohol syndrome?” He waited tensely for a reaction.

“Is that a question? Or an answer?”

“Fetal alcohol syndrome,” Monk said more confidently.

“Good thought.” Bainbridge whirled back to Susan. “History of alcoholism in the mother?”

Susan shook her head. “Sharicka was adopted as an infant. Her parents gave up all social drinking when they first started trying to get pregnant, fifteen years ago. There’s no alcohol in the house. Birth mother denied alcohol or drug use during the pregnancy, but nearly all of them do, whether or not it’s true.” Susan could understand a birth mother lying in order to ensure her child the best possible placement. “When I examine Sharicka, I’ll watch for small palpebral fissures and indistinct philtrum.”

“And flattened cheekbones,” Monk added.

“And flattened cheekbones,” Susan agreed. “But even without any of those features, she could still have all the behavioral and emotional disabilities. ARND.” Susan carefully remembered the individual words of the acronym. “Alcohol-related neurodevelopmental . . .” It seemed as if it ought to have another letter.

“Disorder,” Monk finished.

“So far,” Susan said, “treatment has focused on controlling Sharicka’s behaviors and getting her home, not on the cause of those behaviors.”

Bainbridge gave Susan a stern look. “And, yet, the cause is important to know. Why, Susan Calvin?”

Susan was up to the task. “Because it can make a difference in our treatment, Dr. Bainbridge. Or explain our failures. For example, fetal alcohol and ARND still have no known effective treatment. Nevertheless, it’s becoming far less frequent due to prevention, prenatal testing, and educational programs.”

“Good.” Bainbridge finally took his intensive focus completely off Susan. “Now, who would like to present his patients next?”

For the next two hours, the other residents described a fascinating parade of juvenile patients with diagnoses ranging from uncommon psychoses to exceptionally rare organic forms of dementia. Some were newly diagnosed and still being evaluated, while working treatments were still being sought for the more chronic patients.

Of the sixteen other patients, four had severe forms of schizophrenia, including one who was so catatonic that she had not moved or spoken in almost a year. Three had temper dysregulation disorder, previously called childhood bipolar syndrome, and another suffered from psychotic depression, as did Diesel. Two had brain damage from tumors, two from drug use, and one from serious trauma. Susan found the last three most interesting. A patient of Kendall’s had terminal primary liver cancer. Sable had a patient with an uncontrollable epileptic syndrome that kept her so sleep-deprived that she had lost touch with the real world. The last was Monk’s patient, a seven-year-old boy with an, as yet, inexplicable dementia.

Susan left rounds energized about helping her own patients as well as looking forward to the next day’s rounds and finding out what her companions had done for theirs. She had a feeling she was in for a difficult, but fascinating, ride.