“Definitively? No. But I can’t rule it out either. The tests were inconclusive.”
While seizure activity was not always related to epilepsy, as Lee had previously explained to Ellen, the symptom could have resulted from some disruption of normal brain function. Lee and Dr. Piekarski spent some time discussing Cam’s other abnormalities, including his elevated liver enzyme values and slight organ enlargement, but those seemed to have no correlation to brain function.
“I have no idea what to make of that, Lee,” Dr. Piekarski said. “Really puzzling there. What I think we should do is treat the symptoms and put Cam on a course of levetiracetam and see how he does. If he’s not waking up unusually exhausted, or wetting the bed, well, then, we can assume he has been experiencing nocturnal seizures of some sort and take it from there.”
“Sounds like a good plan. Thanks for getting this done so quickly,” Lee said.
“Hey, he’s the president’s kid. I’m supposed to wait for preauthorization from his insurance company before ordering an MRI?”
“Just to be clear, you wouldn’t say he was a depressive?” Lee asked.
“Not at all,” Dr. Piekarski said. “If you ask me, I think he’d resent being seen by a psychiatrist at this point, but I already told that to Dr. Gleason.”
Lee’s mouth fell open. “Dr. Gleason? When did you—how? I didn’t even tell him you were involved.”
“Well, somehow he found out,” Dr. Piekarski said. “He asked me not to enter any of the test results into the computer. He wanted all the records handwritten and sent to him. I guess it was a security concern. But he did say he would pass on all this information to you right away. I’m surprised he didn’t call you last night when the results came in.”
CHAPTER 21
Lee sat in his Honda Civic, letting it idle in the MDC parking lot, while he got his temper under control. In his irascible state, an errant honk from a fellow driver could lead to road rage. The only person deserving of his ire was Gleason, who would do anything, it seemed, to keep Lee in the dark about Cam.
His conflict with Gleason had overtones of the political arena into which he had been thrust. Lee hated politics, and hated subtlety. For those reasons alone, he would tell the president exactly what he thought: he could not in good conscience continue as Cam’s medical advisor without clear ground rules in place.
He tried to convince himself he’d be fine if the president fired him, but he was doing a poor job of it. He was too invested now, and Cam’s symptoms troubled him too greatly to let it go. Hopefully, Gleason would raise no objections to Cam going on the antiseizure medication, levetiracetam, as he and Dr. Piekarski both wanted. Even without an official diagnosis, they should still treat his symptoms.
Then again, anything Lee advocated was reason enough for Gleason to object. He’d probably say the EEG was inconclusive. Lee thought again of the asterisks next to Cam’s elevated liver enzyme values recorded in his medical chart. It was almost certain Gleason would come up with some equally outrageous explanation for those abnormal function tests.
What Lee needed was a clear and irrefutable narrative. For that, he decided to turn to Paul Tresell for help. When it came to stitching together seemingly unrelated symptoms, few were better diagnosticians than Lee’s longtime business partner. There was no doctor he respected more.
On the drive to his medical practice, Lee used hands-free calling to get Josh on the phone. He had thought that maybe they could still salvage an abbreviated excursion into the Blue Ridge Mountains. But the more he pondered, the more he knew such thinking was pure fantasy. He could not be without cell phone service, or even an hour’s drive away, in case the first family needed him. Dr. Gleason might not have wanted Lee around, but it would take an executive action to get him off the case now.
“Calling to cancel, Dad?”
Josh always had good intuition, except when it came to picking girlfriends.
“I can’t be far away right now. He’s the president’s son.”
“Don’t take this the wrong way, but I kind of figured we were off and made other plans.”
“What plans?”
“Bringing some army pals to camp for a few days. They want to throw me a good-bye Hannah party.”
Lee’s mouth ticked up into a smile Josh could not see.
There was some back-and-forth chitchat before Josh ended the call with a good-bye, but no “I love you.” Lee said it, though, and that was good enough for him.
The camp Josh was planning to visit belonged to Karen. After her father died, Karen’s mother bought the property where they had vacationed for years. There were four well-maintained cabins spread out on twelve secluded acres of woodland in Caroline County, Virginia. The cabins were close to the shore of a pristine lake, and each had running water and electricity. Karen’s father was something of a sportsman and he liked his weapons, which he kept in a gun safe in the main cabin.
For years Karen’s mom had rented the place, but it was never a moneymaker. Karen inherited the camp after her mother died. The mortgage was paid off and the camp was meant for them to use as a family. After their divorce, Karen could have used the money from the sale, but her mother had loved the camp and selling it felt like uttering a final good-bye she was not quite ready to say.
These days, the cabins got little use, and Josh and his friends would probably have to do some cobweb removal before settling down with their cans of Budweiser.
A few minutes later, Lee arrived at his medical practice, located on the first floor of a four-story modern glass building in Tenleytown, a historic neighborhood in the northwest quadrant of Washington, D.C. There was a Starbucks in the building and he went there first to get a little pick-me-up for Paul. The Starbucks was busy as usual, though not many cars were parked in the spaces reserved for his practice. Even though they had convenient access to Nebraska Avenue and Yuma Street, the new location, as of a year ago, had not brought in a flood of new patients as Lee had hoped. What it did do was add new costs to a business already struggling to stay in the black.
Lee saw expenses everywhere he looked. He had to pay the salaries of the office staff, two women who handled the scheduling and billing. He had to do the same with the three nurses he employed. The four exam rooms had supplies to refill. The waiting area had to be stocked with new magazines. Someone had to foot the bill for the electricity.
Bottom line: it was up to Lee and Paul to keep the lights on, and nobody else.
Lee greeted his staff warmly, as was his norm. They had no idea of the financial pressures he and Paul faced; how dangerously close they were to selling the practice to one of the hospitals looking to establish a satellite operation.
After a quick check of the mail, and a review of his messages and patient follow-ups, Lee found Paul seated at his desk in his wood-paneled office, talking on the phone. No surprise there. It was what they did the most these days: fought to do what was right for their patients, not what was most cost-effective for Medicare or some other insurer. Every hour they could not bill, Lee knew, was an hour closer to selling the practice. And fittingly, Lee’s involvement with Cam Hilliard had so far not put a single dime into their business coffers. If his involvement went on much longer he might have to find a way to invoice the White House.
“I don’t care that I was already at the nursing home the day before,” Paul said into the phone. “I didn’t need to see that patient on that particular day. I needed to see another patient, and then the next day I had to go back there to see patient number two.” Paul fell silent as something was said. “You mentioned that already, several times in fact, but I still don’t see how that’s any reason to pay me less for the second visit.”
Over the years, stress had turned Paul from a fit and trim athlete to a man with a double chin, a bit of a paunch, and gray at the temples of his thinning black hair. In other words, this place had made him old.
“Well, please see what you can do about it,” Paul said. “I’m actually
a very nice person, but I’m afraid I didn’t pass groveling in medical school, so forgive me if I’m not doing it correctly. Yes, you too. Have a pleasant day.”
Paul hung up the phone and rubbed at his tired eyes. He was eight years younger than Lee, but it was hard to tell. A professor they both had at Duke had introduced them to each other not long after Lee moved to Washington, back when Josh was still excited to ride his bike. Paul had a three-year-old daughter and a baby on the way back then. He also had the hunger to be his own boss, while Lee had the means and the experience to help make it happen. Plans were hatched over whiskeys and burgers, a friendship blossomed, and it was not long before The Family Practice of Tenleytown opened its doors for business. The years sped by in a blur, and Lee wondered if he looked as beaten down as his good friend. He pulled a chair over to Paul’s desk, sat down, and presented the coffee he’d bought at Starbucks.
“Triple, venti, soy, no-foam latte, just the way you like it,” Lee said.
“Thanks for that,” said Paul, taking a sip without an ounce of joy on his beleaguered countenance.
“Not that I have any idea what that concoction actually means,” Lee added.
“I want to sell,” Paul said. He sounded definitive.
Lee made a grimace. “I’m pretty sure no-foam latte doesn’t mean that.”
“I’m not kidding, Lee. The MDC has courted us for years. Let’s get a message to Chip Kaplan. Tell him we’re open to a deal.”
“Our numbers aren’t that bad.”
Lee had no idea why he bothered with the lie when he and Paul shared a bank account.
“Abby is headed off to college next year, and Kyle is not far behind. I can’t afford it. I’ve tried, Lee, I’ve really tried, but this is misery.”
“Misery? I think that’s a bit harsh, don’t you agree?”
“No, it’s not harsh enough. Really. I thought I’d be practicing until they carried me out in a body bag, but this is best for us both. Everyone owns the doc now—the government, insurance companies, not to mention the hospital that actually wants to buy us. We’ve got no choice but to sleep with the devil we know. We have to sell out.”
Lee could not mask his disappointment. “When people talk about their doctor—their doctor—it’s guys like you and me they’re referring to, not some faceless hospitalist at the MDC,” he said.
“I get that, I really do. But you heard me on the phone just now. They wanted to pay me less because I made two trips to the nursing home when I could have made one. It’s out of control, and I can’t afford to be the one to fix it.”
“I hate the stupidity and paperwork as much as you do,” said Lee. “But trust me, Paul, you’re going to hate the alternative even more.
“The MDC will make us see patients every five minutes. It’ll be all bottom line, and there will be no heart left in what we do. You’re not an automaton doing just what the hospital demands. You’re the guy who does the right thing, no matter how difficult it is.”
Lee leaned back in his chair as Paul took another sip of his triple venti whatever.
“Are you through?” asked Paul.
“Yeah. How’d I do?”
“Pretty convincing that time,” he said with a nod. “But next week I’m definitely going to demand we sell, and I’m not going to be so easily swayed.”
“That must have been one heck of a pep talk,” Lee said. “Usually I only buy myself a couple of days.”
“Don’t get cocky. I’m pretty sure that’s your last one.”
“Speaking of how amazing you are,” Lee said, “Cam Hilliard’s case is troubling me.”
Lee spent the next several minutes on the details, getting Paul up to speed on everything, including his troubles with Dr. Gleason.
“I think I’m right about the seizures, but the enlarged spleen, possibly enlarged liver, and the minimally abnormal liver tests are really puzzling. Maybe I’m reaching, but I’ve never come across an enlarged spleen that’s not indicative of something more serious.”
“Are you thinking cancer?”
“Have to. He’s a young guy, so lymphoma’s a possibility. Mono spot and EB virus titers are both negative, so it’s not mononucleosis.”
“I take it his CBC showed nothing to suggest leukemia. Palpable lymph nodes?”
“Nope. And serologies were negative for hepatitis.”
“What about sarcoid?”
Sarcoidosis was a disease involving abnormal collections of inflammatory cells. Though most often located in the nodules of the lungs, any organ could be affected.
“Unlikely,” Lee said. “Cam’s chest x-ray is normal. I guess we’ll see what the liver biopsy shows.”
“Infection?”
“He’s not sick enough. No fever or elevated white count. His sedimentation rate is normal.”
“But his chess game is off.”
“Which is more mental and also plays into Gleason’s theory this is all psychological.”
Paul had to sense Lee’s frustration. Both doctors enjoyed the detective aspect of medicine in the abstract, but flailing around in the dark was a different matter entirely when a patient’s health was at stake.
“What about a metabolic disorder?” asked Paul.
“Something systemic?” answered Lee.
“Something along those lines.”
Lee gave a nod. “Could be,” he said.
Before they could discuss it any further, Karen called. She and Lee exchanged a few quick pleasantries. He was glad to hear Josh had taken the initiative to call his mother and clear his plans before actually inviting all his friends to the camp.
“We’re all tied up moving Cam from the MDC back to the White House, so I don’t have even a minute to come by and see you,” she said. “But I wanted to tell you about what I learned at the TPI.”
Karen recounted her time with Yoshi Matsumoto and what Dr. Hal Hewitt had told her. Lee ended the call with a promise to get together soon to discuss her findings in more detail. He was most struck by what she told him last, and for Paul’s benefit conveyed what Karen had said.
“These kids are taking nootropics? Why on earth would their parents allow that?” Paul sounded incredulous.
“Obviously it’s not mandatory, but according to Karen, most parents chose to opt in. The drug maker runs some sort of neurofeedback testing to measure brainwave activity. Apparently the results have been impressive. Improved memory. Improved concentration. Improved focus. No reported side effects.”
“Makes sense,” Paul said, sounding a bit dismayed. “Soon as one group of kids has access to something potentially beneficial, parents get competitive about that. They want their kids to have those benefits, too.”
“Studies say these nootropics are safe,” Lee said, recalling what little he knew of the industry. “But I don’t like giving them to young people.”
“No doubt, their brains are still developing,” said Paul. “Then again kids as young as five are taking ADHD meds these days.”
“And nootropics are marketed like vitamins and nutritional supplements more than the cognitive enhancers they are,” added Lee.
“What’s the company?”
“ProNeural,” Lee said.
Paul did some Google searching.
“Good gracious,” he said, skimming some Web page. “They have millions in VC backing from Silicon Valley. When did high tech get into the supplement business?”
“Probably when they realized there were big dollars to be had.”
“So the TPI kids are taking nootropics. What does that mean for Cam and his symptoms?” asked Paul. “Obviously what’s happening to him isn’t a widespread problem, otherwise there’d have been an uproar.”
“Cam told me he wasn’t on any prescription medication, but I’m willing to bet Gleason is the one doling out his daily dosage of ProNeural.”
“And he has been acting very protective of Cam,” Paul said, hitching onto Lee’s train of thought.
“Oddly so,” said
Lee. “It’s hard to explain Cam’s dip in mental acuity, and there’re no widely reported problems with ProNeural, as you said. Karen thinks he’s been taking the nootropics for years. So why would he suddenly start having issues now?”
“Are you thinking what I’m thinking?” asked Paul.
“That’s right,” answered Lee. “Poison.”
CHAPTER 22
FRIDAY, APRIL 21
The signs posted at the E Street entrance to the White House read NO STOPPING and AUTHORIZED VEHICLES ONLY. Lee stopped anyway. He was authorized.
Karen stood near the guardhouse waiting for him. She waved to Lee as he drove up. Standing behind Karen, a stern-faced uniformed guard, white shirt, no tie, kept a close watch on Lee. With a glance Karen got the guard to relax.
“Don’t you look dapper,” she said, leaning into the open window of Lee’s car.
For his meeting with the first lady, Lee had selected his best suit from Brooks Brothers, and did an extra-careful job with his morning shave.
“Thank you,” he said. “I actually tried.”
“How come you never dressed like that when we were married?” she asked playfully.
“I did. You were never home to notice.” Lee said this with an equally playful wink.
Karen, who wore her usual attire—a navy blue pantsuit and durable shoes, good for chasing down wall jumpers—facilitated the ID check. She climbed into the passenger seat of Lee’s Honda, directing him to the next checkpoint, where a bomb-sniffing dog, sleek and muscular, waited for work.
“Speaking of home, Josh is with me for a few days,” Karen said.
Lee raised an eyebrow. “I thought he was going to the camp.”
“He is, but I guess his plans got delayed for some reason, and he didn’t offer to explain.”
“The less you probe, the better.”
“My thoughts exactly,” said Karen.
Lee noticed the time on the car dash. “I have to be at the MDC for morning rounds at eight thirty. Do you think I’ll be late?”
“Ellen is about the most directed and task-oriented person I know,” said Karen. “I’d be surprised if your meeting lasts more than five minutes. Are you going to talk to her about the nootropics?”
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