Shadow Command

added.

“I assume we’re all thinking of your welfare first, sir — I could be mistaken about that,” Summers said dryly. “Your life is at risk every minute you spend up there. I cannot stress that too strongly.”

“I get it, I get it, Doctor,” Patrick said. “Let’s move on past the dire warnings now. What’s the treatment for this condition?”

“‘Treatment?’ You mean, other than avoiding stress at all costs?” Summers asked with obvious exasperation. He sighed audibly. “Well, we can try beta blockers and careful monitoring to see if any electrical abnormalities crop up again, but this course of treatment is recommended only for non-syncopic patients — someone who has never passed out before from the condition. In your case, sir, I would strongly recommend an ICD — implantable cardioverter-defibrillator.”

“You mean, a pacemaker?”

“ICDs are much more than just a pacemaker, sir,” Summers said. “In your case, an ICD would perform three functions: carefully monitor your cardiac condition, shock your heart in case of fibrillation, and supply corrective signals to restore normal rhythm in case of any tachycardia, hypocardia, or arrhythmia. Units nowadays are smaller, less obtrusive, more reliable, and can monitor and report on a wide variety of bodily functions. They are extremely effective in correcting and preventing cardiac electrical abnormalities.”

“Then it doesn’t affect my flight status, right?”

Summers rolled his eyes in exasperation, completely frustrated that this three-star general wouldn’t let go of the idea of getting back on flying status. “Sir, as I’m sure you understand, installing an ICD is a disqualifier for all flight duties except under FAA Part 91, and even then you’d be restricted to solo day VFR flights,” he said, taken aback simply by the fact that anyone who had an episode like this man did would even think about flying. “It is, after, all an electrical generator and transmitter that can momentarily cause severe cardiac trauma. I can’t think of any flight crewmember, military or civilian, who’s been allowed to maintain flight status after getting an ICD.”

“But if they’re so good, what’s the problem?” Patrick asked. “If they clear up the abnormalities, I should be good to go.”

“They’re good, much better than in years past, but they’re not foolproof, sir,” Summers said. “About one in ten patients suffer pre-syncopic or syncopic episodes — dizziness, drowsiness, or unconsciousness — when the ICD activates. Three in ten experience enough discomfort to make them stop what they’re doing — truck drivers, for example, will feel startled or uncomfortable enough that they will pull off to the side of the road, or executives in meetings will get up and leave the room. You can’t pull off to the side of the road in a plane, especially a spaceplane. I know how important flying is to you, but it’s not worth—”

“Not worth risking my life?” Patrick interrupted. “Again, Doctor, with all due respect, you’re wrong. Flying is essential to my job as well as an important skill and a source of personal pleasure. I’d be ineffective in my current position.”

“Would you rather be dead, sir?”

Patrick looked away for a moment, but then shook his head determinedly. “What are my other alternatives, Doctor?”

“You don’t have any, General,” Summers said sternly. “We can put you on beta blockers and constant monitoring, but that’s not as effective as an ICD, and you’d still be restricted in flight duties. It’s almost guaranteed that within the next six months you’ll have another long-QT episode, and the odds are greater that you’ll suffer some level of incapacitation, similar or probably more severe than what you experienced before. If you’re in space or at the controls of an aircraft, you’d become an instant hazard to yourself, your fellow crewmembers, innocent persons in your flight path, and your mission.

“General McLanahan, in my expert opinion, your current job or just about any military position I can think of is too stressful for a man in your condition, even if we install an ICD. More than any treatment or device, what you need now is rest. If there is no history of drug abuse or injury, long-QT syndrome is almost always triggered by physical, psychological, and emotional stress. The damage done to your heart by your position, duties, and space flights will last the rest of your life, and as we saw, the stress of just one simple videoconference meeting was enough to trigger a syncoptic episode. Take my advice: Get the ICD installed, retire, and enjoy your son and family.”

“There have to be other options, other treatments,” Patrick said. “I’m not ready to retire. I’ve got important work to do, and maintaining flying status is a big part of it — no, it’s a big part of who I am.”

Summers looked at him for a long moment with a stern and exasperated expression. “Bertrand Russell once wrote, ‘One symptom of an approaching nervous breakdown is the belief that one’s work is terribly important,’” he said, “except in your case, you won’t suffer a nervous breakdown — you’ll be dead.”

“Let’s not get too dramatic here, Captain…”

“Listen to me carefully, General McLanahan: I’m not being dramatic — I’m being as honest and open with you as I can,” Summers said. “It is my opinion that you have suffered unknown but serious damage to your cardiac muscles and myocardium as a result of your space flight that is triggering long-QT episodes that are causing arrhythmia and tachycardia resulting in pre-syncoptic and syncoptic occurrences. Is that undramatic enough for you, sir?”

“Captain—”

“I’m not finished, sir,” Summers interjected. “The likelihood is that even with rest and medication you will suffer another syncoptic event within the next six months, more severe than the last, and without monitoring and immediate medical attention, your chances of survival are twenty percent, at best. With an ICD, your chances of surviving the next six months go up to seventy percent, and after six months you have a ninety percent chance of survival.”

He paused, waiting for an argument, and after a few moments of silence he went on: “Now if you were any other officer, one who didn’t use to date the Vice President of the United States with the Secret Service in tow, I would simply advise you that I will recommend to your commanding officer that you be confined to the hospital for the next six months. I will—”

“Six months!”

“I will still advise your commanding officer so,” Summers went on. “Whether you decide to get an ICD installed is your decision. But if you insist on not getting the ICD installed and you are not on 24/7 monitoring, you have virtually no chance of surviving the next six months. None. Do I make myself clear to you, sir?” Patrick momentarily looked like a rapidly deflating balloon, but Dave Luger could see his dejection quickly being replaced with anger — anger at what, he wasn’t quite certain yet. “It appears to me that the final decision is up to you. Good day, General.” And Summers logged out of the videoconference with a rueful shake of his head, certain that the three-star general had no intention of complying with his orders.

Once Summers left the conference, Patrick sat back in his chair, took a deep breath, then stared at the conference room table. “Well, shit,” he breathed after several long moments in silence.

“You okay, Muck?” Dave Luger asked.

“Yeah, I guess so,” Patrick replied, shaking his head in mock puzzlement. “I always thought it was Will Rogers who made that quote about mental breakdowns, not Bertrand Russell.”

Dave laughed — this was the guy he was familiar with, making jokes at a time when most sane men would be on the verge of tears. “I guess Mark Twain was right when he said, ‘It’s not what you know, it’s what you know that ain’t so.’”

“It wasn’t Mark Twain, it was Josh Billings.”

“Who?”

“Never mind,” Patrick said, turning serious again. “Dave, I need to learn everything about long-QT syndrome and treatment for heart arrhythmias before I can make a decision about what I can handle and what I can’t. There are probably a dozen companies doing research on modern ICDs, or whatever the next generation of those things becomes — I should know about the latest advances before I decide to get any old technology installed. Jon Masters probably has an entire lab devoted to treating heart disorders.”

“Excuse me for saying so, buddy, but you just had probably the best heart doc in the country on the line, ready to answer any questions you have, and you pretty much blew him off.”