Susan’s heart rate quickened.
“Susan Calvin.” Stony gestured at her.
“All right, let’s get to work.” Susan suspected she was about to meet the side of Bainbridge that Stony had warned them about, the one that asked difficult questions and expected quick and well-considered answers. “Susan Calvin, present your first patient.”
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-
