The First Family

by Michael Palmer

  “They won’t listen to me,” Cam said. “They only listen to him. Maybe if those stupid tests showed something, they might change their minds.”

  Karen mulled this over. She believed Cam. The way he had been acting could support Gleason’s theory, but perhaps something else was amiss, something undetected. The president might not be open to outside consults when it came to his family’s health, but the first lady was a different story.

  Karen said, “Let’s get you to school and I’ll work on this from my end. It’s possible I can convince your parents to consider the opinion of somebody other than Dr. Gleason. Do you trust me?”

  Cam might have caught the mischievous glint in Karen’s eyes. He returned a small smile as he climbed out of bed, the blue sport coat of his school uniform now a bit wrinkled.

  “With my life,” he said with a wink.

  CHAPTER 3

  MONDAY, APRIL 17

  The half-dozen medical residents, all part of a family practice residency program, were dressed similarly in hip-length white lab coats. These were junior doctors who had graduated from medical school but had not yet completed on-the-job training. All of the residents were required to wear shorter lab coats until they completed training, at which point they’d receive a longer coat to wear. Patients at the hospital had no idea that coat length equated to doctor prestige, but the residents were well aware of the status symbol.

  Like a gaggle of geese, they followed close on the heels of their attending for the day, Dr. Lee Blackwood, a family practitioner with admitting privileges at MediHealth of D.C.—MDC for short—a renowned nine-hundred-bed hospital complex in downtown Washington. As their leader, Lee wore a white coat that went down past his knees.

  By law, all residents needed a supervisory attending for questions as they conducted hospital rounds. Thanks to Lee’s long relationship with the hospital, he and his partner, Paul Tresell, were the only family practitioners with a medical practice independent of the MDC who were allowed to serve as attendings. During contract renewal discussions, Lee would make it a point to tell the hospital administrators how he enjoyed mentoring young doctors, when the truth was more pragmatic: he needed the extra cash to help offset losses incurred in his family practice.

  Most attendings were only a few years older than the residents they supervised, but at fifty-six Lee could have been the father of these newly minted docs. He felt like the old man of the group, too, his right knee aching as they walked. He vowed not to let this lingering discomfort impact his nightly run. An undesirable HDL result from his last physical had inspired him to take up jogging late in life, and he’d learn how to run through the pain.

  Getting old was not for the faint of heart.

  Neither was family medicine.

  I should have been a dermatologist, Lee thought as he marched down a long corridor on his way to do a consult for a fellow family practitioner. Ten different family practices regularly sent patients requiring hospitalization to the MDC. Five years ago that number had been closer to twenty, before practice after practice ceased operations. Lee knew all of the local family docs, and all were hurting, but each remained committed to the tradition of caring for people soup to nuts. Which was why Lee was happy to cover for a fellow family doc on a patient who had a bad ankle break requiring surgery. If the family docs did not stick together, then the big business ethos of cutting costs wherever possible would eventually turn their profession into an anachronism.

  Lee wondered how many of the docs enjoying their morning coffee were thinking about meeting daily patient quotas, or which specialists they could direct their patients to see. Headaches to the neurologist. Asthma to the pulmonologist. It was all about the Benjamins, and these days Lee was seeing far fewer of them in his bank account.

  The residents Lee was supervising faced a seriously steep uphill climb. People wanted a relationship with their doctor—someone in whom they could confide, someone who could sense when they were truly sick. Even so, specialists would forever look down on them, while less expensive hospitalists, doctors assigned to administering general care to hospitalized patients, would continue to replace family docs in settings like the MDC. If these residents could endear themselves to their patients, prove their worth, they might be able to make a living in a dying profession.

  Lee glanced at his Timex watch that barely kept on ticking, saw he was running a bit behind schedule, and lamented the fact that most dermatologists could afford a Rolex.

  * * *

  THE FORTY-SEVEN-YEAR-OLD man, rock-jawed and preternaturally tan, was propped up in his hospital bed while an orthopedic surgeon hovered over a discolored, badly swollen ankle. The surgeon lifted his head, his eyes closing to slits as he surveyed the processional of doctors who followed Lee into the cramped hospital room.

  “Can I help you?”

  Lee had met this surgeon before, but was not surprised by the man’s lack of recall. Staff at the MDC changed with the tides, and learning names was often wasted effort.

  “Dr. Lee Blackwood,” said Lee. “I’m here to do a consult for Dr. Anthony Gavin.”

  The patient, Wendell Prichard according to the medical chart, brightened at the mention of the name.

  “Hey! How is Doc Anthony doing? I thought he was coming to see me.”

  Doc A, like all of us, is drowning in a sea of paperwork, trying to keep his business afloat, thought Lee glumly.

  “He got caught up with something and couldn’t get to the hospital today. He knew I was escorting these fine residents on morning rounds, and asked if I’d stop by to check on you pre-op as a favor. Hope that’s okay.”

  Lee thought he saw the surgeon’s eyes roll, if only slightly, as he reapplied the patient’s air splint. He could guess what the surgeon was thinking: a family doc consult would be as useful to Wendell Pritchard as a treadmill.

  “Exam away,” said Wendell. “But be sure to tell Doc A that the only thing really hurting is my ego.”

  Lee checked the medical chart on his clipboard and saw that poor Wendell had hurt his ankle falling down a flight of stairs, hence the bruised ego.

  “You can always say it was a skydiving accident,” said Lee.

  Wendell returned a hearty laugh, while his surgeon did not so much as crack a smile.

  “We’re doing him tomorrow morning,” the orthopod said flatly. “Just make sure he’s stable for surgery, take an admitting history, whatever you need to do. You can have me paged if you need.”

  But you won’t need me, the man’s eyes said. Because you take throat cultures and placate worried moms all day.

  “Thanks,” said Lee, addressing the surgeon’s back as he departed. The residents moved aside to let him through and reformed as a group at the foot of Wendell’s bed.

  “Do you mind if there’s an audience while I do my exam?” asked Lee. “This is the future of family medicine right here, and I’m sure they’d appreciate the learning opportunity.”

  “Also fine,” said Wendell, his smile surprisingly congenial for someone who had to be in a good deal of pain.

  Lee passed around Wendell’s medical chart, which showed a low dose of Ancef to fight infection and included results from various labs and blood work. No alarming finds in those pages. He doubted the residents would learn much from this exam, but they were his charges for the day and every moment could be a teachable one.

  Wendell gave Lee his general medical history, including the few prescriptions he took for various aliments, none of which would cause problems for tomorrow’s surgery. Overall, Wendell appeared to be the picture of good health, minus his badly injured ankle.

  “Anything else troubling you?” Lee asked, using an ophthalmoscope to peer into Wendell’s eyes. “Even something from before the accident?”

  “No, not especially. Except maybe a little shortness of breath.”

  Lee stood back and appraised Wendell thoughtfully.

  “Tell me more,” he said, feeling the residents closing in, perhaps sensing somet
hing might be afoot.

  “I dunno,” said Wendell with a shrug. “I’m super tired all of the time. Before the injury I would get winded just walking my dog.”

  Lee placed his fingers on Wendell’s wrist and measured the radial pulse. It was dramatic, brisk—a water hammer pulse. Next, he checked Wendell’s blood pressure. The result, 150 over 50, indicated a wide pulse pressure of one hundred.

  “Wendell, do you mind if I share my findings with the residents so they could benefit?”

  Wendell gave his permission.

  “The patient’s blood pressure is one fifty over fifty,” Lee announced, “and his radial pulse is a bit dramatic and brisk. What should we think about?”

  Dr. Cindy Lerner, a stylish young woman in her second year of residency, lowered her horn-rimmed glasses to the tip of her nose.

  “That’s a wide pulse pressure,” she said. Lee acknowledged her acumen with a nod. “The difference between a systolic and diastolic blood pressure should be around forty, more like one twenty over eighty. A wide pulse pressure suggests he has hyperdynamic circulation.”

  “Which makes you think of what?” Lee asked, arching an eyebrow.

  “Well, aortic valve insufficiency would be my guess,” she offered, ignoring or not seeing the mildly alarmed expression that appeared on Wendell’s face.

  Again, Lee nodded.

  “Heart pumping blood, but leaking back into the body because of a damaged valve,” he said. “So if he has an aortic valve insufficiency, we should hear a diastolic heart murmur. Let’s have a listen to his chest.”

  Using his stethoscope, Lee gave a brief listen to all five precordial landmarks.

  “To save time,” he said, “I’ll tell you there’s no heart murmur, nothing to suggest a leaky valve. What else?”

  “How about anemia?” Cindy Lerner was not going to give up so easily.

  Lee appreciated her doggedness. “But the blood count is normal,” he advised.

  “How about hyperthyroidism?” The new voice belonged to a Korean fellow with a head of moppish dark hair.

  “Observation is key,” Lee reminded him. “There is nothing physical about the patient’s appearance that should make you think of that. But it’s something to consider, and we should double-check the blood work. There is something else observable about Wendell, something we should all be paying attention to. Anybody?”

  No one spoke.

  “Watch his head,” said Lee, pointing. “He’s nodding it slightly. It’s his wide pulse pressure being reflected in his head. Wendell, were you aware your head is bobbing?”

  Wendell looked perplexed. He had no idea.

  At that moment, Lee was feeling mildly stumped himself. Wendell was right. Someone in his physical shape should not be so easily fatigued, constantly winded. Lee conducted a differential diagnosis in his head, running through the symptoms and various possibilities with the speed of a supercomputer, arriving at an unusual idea.

  “May I ask something about your past history?” he asked Wendell. “It might seem a little out of the blue, but indulge me.”

  “Shoot,” answered Wendell.

  “Actually, that’s my question,” said Lee. “Have you ever been shot?”

  Wendell’s face flushed with sudden embarrassment.

  “My wife says I’m accident prone for good reason,” he answered sheepishly. “I got shot in the leg last year. Hunting accident. At least that’s what my brother called it. He’s the one who shot me. All kidding aside, it was an accident. No charges filed.”

  “Mind if I take a look at the scar?”

  Wendell winced with discomfort as Lee lifted his leg, the same leg with the injured ankle. Pushing aside the hospital gown, Lee revealed a quarter-shaped scar behind Wendell’s thigh. Placing his stethoscope directly over the scar, he gave a listen and heard a distinctive whoosh whoosh sound indicative of the exact issue concerning him. One by one, each resident used their stethoscope to listen as well.

  “Any thoughts?” asked Lee after the last resident took their turn.

  Cindy Lerner appeared ready to speak up, but retreated into herself. Lee was mildly disappointed. He viewed her as the sharpest of the lot and would have preferred she take a guess, show her thinking rather than hold back.

  “It’s all here,” Lee said after a moment of silence. “Brisk radial pulse, head bobbing, wide pulse pressure, shortness of breath, fatigue, gunshot wound, and a prominent murmur of blood rushing between a major artery and vein. I’ve put it all on the table. All you have to do is put a name to it.”

  The room remained silent, so Lee settled his gaze on Cindy, trying to encourage her.

  “Could it be … be an arteriovenous fistula in his leg?” she said, uncertainty leaking into her voice.

  Smart as these docs were, they hated to be wrong in front of their peers. It was Lee’s job to push them out of their comfort zone.

  “No, it couldn’t be that,” Lee said, holding a grim expression, watching Cindy’s face fall. “Because it is that, no question. Blood is flowing directly from an artery into Wendell’s vein because he got shot and that’s how it healed. Well done, Dr. Lerner.”

  Cindy’s crestfallen expression brightened.

  “But here’s the thing,” Lee continued, holding up a finger for emphasis. “If the surgeon were to fix Wendell’s ankle tomorrow, this fistula would cause some serious complications. Not only would the wound not heal properly, but they’d have a dickens of a time controlling the bleeding.”

  Wendell’s eyes widened with alarm. “For real?”

  “I’m afraid so, Wendell,” said Lee. “We’ll have to fix the fistula before tackling the ankle.”

  Lee turned his attention to the residents, his eyes beaming with delight. “This is what I love about medicine.” He pumped the air with his fist for emphasis. “In a way, we saved this man’s life by taking a good history and doing a good physical examination. I hope today gives you as great a feeling as it gives me.”

  Before anyone could respond, a man appeared in the doorway. He was tall and clean-shaven with short, dark hair only a hint longer than what the marines might allow, dressed in a charcoal gray suit, white collared shirt, and bold red tie.

  “I’m looking for Dr. Lee Blackwood,” the man said in a steely voice.

  Lee stepped forward. “I’m Dr. Blackwood.”

  The man removed a badge from the inner pocket of his coat and flashed it at Lee. He was intimately familiar with the brass engraving of an image of the White House below a blue circle surrounding the presidential seal.

  “I’m Special Agent Stephen Duffy with the United States Secret Service. I’m going to need you to come with me, Doctor. Right now. It’s urgent.”

  The words “imposing” and “hard” came to Lee’s mind and he made a quick determination about this special agent. Stephen Duffy was not someone who would take no for an answer.

  CHAPTER 4

  Lee and Duffy had a private chat in the hallway. He was worried about the residents he had to oversee. Duffy stood ramrod straight, and Lee wondered if the agent’s rigid shoulders ever slumped.

  “The hospital CEO arranged for another doc to take your place,” he said. “You’re ours for the day.”

  “She put you up to this, didn’t she?” asked Lee.

  “Who?”

  “Karen, my ex. Is this about her?”

  “All I know is that I’m to bring you to the White House. It’s not an invitation many people pass up.”

  Before he agreed to leave, Lee had the orthopedic surgeon paged. Over the phone, he divulged the discovery of Wendell’s fistula. It would have been more satisfying to see the man’s disbelieving expression, watch him squirm with embarrassment at having a family doc save the day, but there was no time for ego boosting. Next, Lee checked with the hospital CEO, Dr. Chip Kaplan, and confirmed that another attending would supervise his residents for the day.

  “So why does the Secret Service want you, anyway?” Kaplan asked. “Have
you been making threats against our president in your off hours, Lee?”

  “Funny, Chip,” said Lee. “To be honest, I have no idea why they want me. But I’ll let you know if I can.”

  Lee followed Duffy out the front entrance, leaving his car parked in the employee lot out back. The sun shone brightly off to the east and wispy clouds looked brushed upon a sparkling blue sky. A massive Suburban the color of midnight idled curbside, with windows tinted so dark it was impossible to see inside.

  Duffy opened the rear door and Lee climbed in. He sank into the plush leather interior, inhaled the new car smell, and caught a whiff of perfume in the spotless gray carpeting. The car was stocked with plenty of snacks and bottled water, and lots of napkins and glasses, all adorned with the presidential seal.

  E Pluribus Unum. Out of many, one.

  Duffy introduced the driver, a tall, lean gentleman, handsome as a movie cowboy, as Woody Lapham. Judging by the suit and dark glasses, Lee guessed Lapham was also Secret Service. Both men reminded Lee of the boys he used to play basketball and football with—athletic, strong. Though he knew it was petty, Lee felt a pang of jealousy over their youth and vigor.

  Lee had managed to keep his body in relatively decent shape, though now in the middle of middle age he could feel it starting to slip. Every slice of pizza these days seemed like the metabolic equivalent of half the damn pie. But Lee was still strapping at six foot two and a healthy 215 pounds. His firm jaw jutted out slightly and complemented a natural smile bracketed by a pair of dimples. A broad, flat nose fit his face just fine. Arresting hazel eyes might have been his most notable physical trait were it not for his wavy, reddish hair, which he kept well trimmed and always cut above the ears.