The First Patient

CHAPTER 8

For the twenty minutes that followed and the twenty minutes just past, Gabe knew that the United States was without reliable leadership. He continued his evaluation of Andrew Stoddard, but Gabe's mind was spinning. Someone had to be notified, probably the vice president. Ellis Wright was an ass, but he had been absolutely justified in saying that Gabe had to become an expert on presidential illness and succession.

But why hadn't Lattimore stepped forward-or even Carol? Why were they standing by almost calmly as one of the greatest crises imaginable evolved before them? Why had the only even slightly emotional thing either of them uttered been Lattimore's request-a request that Gabe brushed aside as bordering on malpractice-that the president be given some sort of shot to settle him down? It didn't take a formal medical education to reason out that unless a diagnosis was either known or quite obvious, giving any sort of mind-altering medication to someone with acute brain dysfunction, from either trauma, stroke, or chemical imbalance, was contraindicated.

The president's continuous rocking had slowed, then finally stopped, and the tenor of his speech had softened somewhat. Gabe propped a pillow behind him and took advantage of the relative calm to focus his ophthalmoscope beam onto the retinas of Stoddard's eyes-the only place in the body where arteries, veins, and nerves, specifically the large optic nerves, could be directly observed.

The arteries appeared healthy, with minimal, if any, signs of arteriosclerosis. The veins, too, seemed normal and were free from nicking where the arteries crossed on top of them-a finding that would have hinted at prolonged high blood pressure. But most important, the margins of the optic nerve in each eye were sharply demarcated. Blurring of those edges, known medically as papilledema, would have suggested a buildup of pressure on the brain from swelling, hemorrhage, or infection.

Reflexes normal. Extremities normal. Strength and range of motion good. Cranial nerves intact. Carotid pulses strong and free of bruits-the churning sound made by blood rushing past an obstruction. Heart rate down to 88-still high, but improved. Blood pressure down to 130 over 80. Lungs clear. Respiratory rate down from 40 to 24. Abdomen soft.

Stoddard's perspiring had slowed and the redness in his face had begun to abate.

"Drew, are you with me?"

"You're the best, pal. The salt of the earth."

"Drew, I want to ask you some questions. Will you answer them no matter how silly they might seem?"

"Go for it."

"What city are we in?"

"Why would you ask me something as-"

"Please, Drew, humor me."

"Washington, District-o of Columbi-o."

"The day?"

"Thursday. Doc, this is-"

"Please-"

"August the something. Maybe the seventeenth. Isn't that right, Carol, baby? The seventeenth?"

"That's right. You're doing great, honey." She looked over at Gabe. "He's coming around."

"Drew, how much is forty times twenty?"

"Eight hundred, of course. I was always good in math."

"A hundred minus thirty four."

"Sixty-six."

The answers came out almost before the questions were finished.

"Name the first eight presidents."

"Washington, Adams, Jefferson, Madison, Monroe, the other Adams, Jackson, how many is that?"

"Enough."

"Van Buren, the first Harrison, the one who croaked after thirty days, Tyler-"

"That's plenty, Drew."

"I can do them all. The latest one is me."

"I'm glad of that. The capital of Uruguay?"

"Montevideo. What do I win?"

"Most home runs by someone who never took steroids?"

"Aaron. You thought I'd say Ruth, didn't you?"

"No, Drew. I knew you'd get it right. You're doing better, my friend. Much better."

"Doc? I have one question."

"What is it?"

"The beasties that have been flying around here-the fairies and those round hairy things with the long tails-what do you make of them?"

Gabe looked to see if Stoddard was toying with him, but there was nothing in the president's expression to suggest that was the case. He checked Stoddard's pupils again. They had initially been midsize and a bit sluggishly reactive to light. Now they were smaller and more briskly reactive. Another sign that things were getting better.

Hyperactive cardiovascular system, uncontrolled rocking, disjointed, pressured speech, excessive perspiration, inappropriate affect, visual hallucinations. What in the hell was going on?

Gabe desperately needed to speak with both Carol Stoddard and Magnus Lattimore, but there was no way at this point that he would leave his patient to do so. Lattimore saved him the anguish.

"Whatever you need to say to us, Doctor, you can say before the president."

There was no panic in his voice and little, if any, anxiety. Gabe wondered if Lattimore's odd demeanor was at least in part due to the fact that Drew Stoddard now appeared to be rapidly improving. Lattimore moved over to where Carol Stoddard stood, stroking her husband's hand. Her expression was odd-more one of annoyance, perhaps, than concern.

"Okay," Gabe said, "it's your call." He calmed himself with a deep breath and slow exhale. "To begin with, it looks like whatever is going on here is beginning to resolve. Drew's life doesn't appear to be in immediate danger. But we all know that for the last hour or so, he has not been in control of his faculties. The implications of that are obvious."

"Go on," Lattimore said, his expression unchanged.

To Gabe's left, the president had sunk down on his bed, eyes closed. His breathing was still somewhat rapid and shallow. The redness had drained from his face, which now looked drawn, pale, and utterly spent. Concerned, Gabe checked Drew's pulse and blood pressure once more.

"Fairly normal," Gabe said, shaking his head in bewilderment. "Give me a minute to draw a few tubes of blood."

"What for?" Lattimore asked.

"I'm not sure yet, but it's better to have them and not need them than to realize tomorrow I should have gotten them."

"Do you need to put them on ice?" Carol asked calmly.

"I don't think so. I'll refrigerate them in the clinic until I'm ready to send them off."

"You won't put his name on them, will you?"

"No, I promise. I'll identify them some other way."

"Honey," the First Lady said gently, her lips brushing her husband's ear, "Gabe's going to draw some blood. Is that okay?"

"Go for it," Stoddard managed, through lips that were stiff and dry.

Gabe drew three vials of blood and set them in his bag. The president barely reacted to the procedure.

"Well, there's still an impressive collection of diagnostic possibilities," Gabe said when he was done. "Some sort of atypical seizure or even unusual migraine is on the list along with a small hemorrhage in some strategic area of his brain, or a tumor-possibly one in a part of his body away from the brain that is secreting some sort of hormone or other psychoactive chemical. There are a number of possible organs in this regard. He certainly seems toxic, but unless he has some pills hidden away that we don't know about, I don't have an explanation for how that toxicity could have happened. Then there's the diagnosis that is at or near to top of the list at this point."

"Namely?" Lattimore asked.

"Namely, that the stress of the job and the reelection campaign has pushed his emotional and mental faculties past the breaking point."

"You have no idea the hours he puts in," Carol said.

"Well, it's not a physician's job to guess. So, at the moment, the field of possibilities is wide open, and we've got to get him to the hospital for an MRI and some other tests. At this moment I am quite concerned about a tumor or a small hemorrhage."

"It's not a tumor," Lattimore said. "And it's not a hemorrhage."

"How could you possibly know that?"

"Because," the chief of staff said, meeting Gabe's gaze intently, "the president's already been recently checked for those by Dr. Ferendelli. He's run every test in the book."

"I don't understand."

"Gabe," Carol said evenly, still massaging her husband's hand, "this isn't the first episode like this that Drew has had… It's at least the fourth."