by D P Lyle
“Codes?” I asked.
“You know. Private signals.”
“What was your code?”
“Tugging on one ear. If either of us does that, it’s a signal that we like want to dump the guy we’re talking with and the other will come over and do the extraction.”
“Extraction?”
“Like a hostage rescue.”
I smiled. “Did she give you the signal that night?”
“No. I just thought she looked uncomfortable. It turned out she actually liked the guy. Not that she would’ve like done anything, being engaged, but a little innocent flirting never hurts.”
“Okay, so she was chatting with Mr. Wonderful. What happened then?”
“She disappeared. I went to talk with some other people and looked back a few minutes later, and she was like gone. The dude was still sitting there on the barstool. I asked him where she was, and he said she like went to the restroom but hadn’t come back yet. I went to check on her, but she wasn’t there.”
“Did he say anything about her behavior? Maybe something odd happened before she left?”
“I didn’t ask, and I didn’t see her again until early the next morning.”
“What did she say when she came home?”
“That she couldn’t remember anything that happened or where she had gone or whether she’d been with anyone or not.”
“Exactly like last night?” I asked.
She nodded.
“Did that seem to bother her? Was she scared that she might’ve done something wrong?”
“When these things started a couple years ago, she like freaked out. Now it’s like she’s used to them and doesn’t worry about it. I worry more than she does.”
“Do you think they’re getting worse? More frequent or lasting longer?”
“Definitely. I think in the first year it happened like twice. In the last six months it’s happened at least a dozen times. Not always like last night. Sometimes they only last a few minutes. But there’s been at least three or four episodes where she disappeared for hours.” She rested her elbows on the edge of the table. Her eyes glistened with tears. “What’s wrong with her?”
“I don’t know. There are several possibilities. It could be drugs.” Ashley started to say something, but I held up a hand. “I know she would probably tell you if she were, but probably is the operative word here. Many people, particularly those that have gone through any type of rehab before and were embarrassed by it, will hide any future use. Even from their closest friends. They don’t want their friends to see them as a failure.”
“No way. I would know. Nicole would like for sure tell me. There is no doubt about that.”
“There could be other causes. Some physical, some psychiatric. Some minor, some much more serious.”
“Like what?”
“I don’t think we should go into that right now. I need to talk with her, examine her, and get a few tests done.”
“Never going to happen. Her mother would hit the roof. She like refuses to even consider that something could be wrong with Nicole. Ever. Even when she went through the rehab thing, her mother refused to accept that it was drugs. She told everybody that Nicole was like exhausted from working so hard in school. Talk about denial.”
“Then I’ll need your help.”
“Me? For what?”
“Convince Nicole to get checked out.”
“I can’t do that. She’d get like mad or something.”
“You’re her best friend. Wouldn’t you do anything to help her?”
Again she twirled a strand of hair around one finger. “I suppose so.”
“Then talk to her. That’s all I’m asking.”
Chapter 15
Ashley refilled our coffee cups and then said she would go check on Nicole but doubted that she would be awake yet. Before she headed upstairs, Ellie came in. She stopped short, looked at me, at Ashley, and then back to me.
“What’s going on?”
“I’m just getting some coffee to go back upstairs.” Ashley eased past Ellie and headed out of the room, tossing me a nervous glance on the way out.
I was on my own.
“I came by to talk with Ashley about Nicole.”
Ellie poured herself some coffee and sat down across from me. She wore a light blue silk robe over a navy blue gown, her makeup perfect. She looked more like she was ready for a party than just crawling out of bed. “You’re still worried about her behavior at the party?” She added cream and sugar and took a sip.
How much should I tell her? Would telling Ellie about last night betray Nicole? Technically, Nicole wasn’t my patient, so there were no real ethical restrictions, but was that fair? And what about Ashley? Did she expect me to keep everything she had said confidential? Probably. Would she consider sharing this with Ellie a breach of that confidence or was she tired of taking care of Nicole’s secret? Did she want Ellie to know? Lift some of the burden from her?
They don’t teach you how to handle these situations in medical school. You have to unravel them on your own out here in the real world. The wrestling match in my head didn’t last long, since I knew deep down that the truth would be best and that Ellie needed to know everything. If Nicole got angry or felt that I was unnecessarily digging into her life, I’d deal with that later. Same for Ashley. Right now Nicole’s health was my major concern.
“Not just at the party,” I said. “Last night she had another episode.”
Ellie’s gaze fixed on me. “What do you mean by ‘episode’?”
“This is between the two of us, okay?”
“Hank, you’re talking about my granddaughter. My only granddaughter. The only part of this family that I truly have left.”
I let the fact that her daughter, Jackie, was still part of the family slide, and told Ellie everything that Ashley had said to me about Nicole’s spells and how they seemed to be getting worse. I told her about Nicole’s disappearance last night and her apparently not remembering any of what happened.
I could see the anguish in her face as she stared at me and said, “What does all this mean? What could possibly be wrong?”
“There are several possibilities. She should have a complete examination and have some tests run.”
“There is nothing wrong with my daughter.”
The voice was harsh and angry. I turned to see Jackie standing in the kitchen doorway. She wore knee-length black formfitting pants and a white T-shirt beneath an unzipped two-toned purple hoodie, each sporting the Nike swoosh. An iPod was strapped to one arm and earbuds hung around her neck. Looked like she was going for a walk or maybe to the gym. Disturbingly, her face appeared tight, jaw set, and her hands were squeezed into fists at her sides.
“Jackie,” Ellie said, “don’t get all wound up. Just hear what he has to say.”
“I don’t care what he has to say. He’s got you fooled but not me.” She looked at me, her eyes dark and angry. “I know about you. How you neglected and killed that man. How you fled out here to the Hamptons to prey on old women.”
Ellie stood. Now her hands were balled into fists at her sides. “Don’t you dare. Don’t you say one more word about Hank. If it wasn’t for him, I’d probably be long dead.” She leaned forward, flattening her hands on the tabletop, and looked Jackie directly in the eye. “Or maybe that’s what you want? Can’t wait to get your hands on all the money.”
Jackie’s anger vibrated through her entire body. “Mother, how could you say that? Just because I’m worried that some quack has you fooled?” She looked back at me. “But he doesn’t have me fooled. And he absolutely will not touch my daughter. Not now. Not ever.”
This was getting uncomfortable. I wasn’t sure what to do. Something else they don’t teach you in med school. Maybe get up and run out the door. But leaving Ellie to fight my battle didn’t seem right.
One thing I did know was that illness, even the prospect of illness, can bring out the good, the bad, and the very, very
ugly in some people. Most are quietly brave, but some, like Jackie, become volcanic. Usually the best way to defuse these people is to agree with them.
“Mrs. Crompton,” I said, “you’re right. I did lose my job. Not for the reasons you imagine, but I lost it nonetheless. I didn’t want to be here doing this, but here I am. I do know what I’m doing, and just as important, I care about the people I see. Including your mother. But right now, I’m more concerned about your daughter.”
“Nicole is none of your concern and she never will be.”
“Then have her see someone else. I can suggest an excellent internist.”
“She does not have a problem. She’s just stressed from the wedding and all the plans.”
“That’s entirely possible,” I said. “But there are other possibilities.”
Jackie crossed her arms over her chest and jutted her chin toward me defiantly. “Okay, Doctor, what did your infinite wisdom tell you the problem is?”
“I’ll tell you what any physician would tell you. When a young woman Nicole’s age begins to exhibit abnormal behavior, drugs are commonly the cause.” Jackie started to say something, but I went on, cutting her off. “To be honest, I don’t believe that’s the problem. Neither does her friend Ashley, and she knows Nicole better than just about anyone.”
“I know darn well it’s not drugs and I will not have my daughter treated like a junkie.”
Okay, agreeing with her didn’t seem to help, so I decided to go in another direction. Fear. The greatest motivator and most sobering emotion humans possess. “There are a few other important considerations.”
Jackie walked toward the counter, spun, and rested against it, her arms still crossed over her chest, her face even tighter. “Let’s hear them.”
“She could have a brain aneurysm or a tumor. She could have an encephalitis . . . a brain infection. Maybe some hormonal problem with her pituitary or thyroid. Maybe she has diabetes and her blood sugar is all over the place. Each of these can cause erratic behavior.”
“What erratic behavior?”
“Aren’t you aware she’s been having episodes of confusion and disorientation? Loss of memory?”
“Oh, please.”
I nodded. This wasn’t going anywhere.
“Nicole doesn’t have a brain tumor or that encephalowhatever,” Jackie said. “She’s just stressed.”
“Maybe. But these things must be ruled out. Mild schizophrenia or some other psychiatric disorder, too.”
Jackie came off the counter, her face contorted in anger. “My daughter is not crazy. My daughter does not have a psychiatric problem. No one in our family has ever had a psychiatric problem and she is definitely not the first.”
“Mrs. Crompton, you’re missing the point here. There are many things that could cause Nicole’s odd behavior, and whatever it is, it needs to be evaluated and corrected. Not necessarily by me, but by someone. Doesn’t that make sense?”
“What makes sense is for you to leave my daughter alone.”
“You don’t have to like me,” I said. “You don’t have to think I’m a good doctor. What you do have to do is pay attention to your daughter. Get this looked into because whatever it is, it’s probably not going to get better on its own.”
My cell phone buzzed. I looked at the screen. It was Divya.
“I need to take this.” I stood, walked past Jackie, out of the kitchen, and into the foyer. I flipped open the phone. Divya told me that Mrs. Maria Mendez called about her husband, Oscar. Said he was more confused than usual and that she was headed over to see him. I needed to get away from Jackie, give her time to think about what I had said—if she would, that is—so I told Divya I’d meet her there.
Chapter 16
The shaded walkway that led from the street to the home of Oscar and Maria Mendez was uneven and cracked from the tree roots that twisted beneath it. That was the only bit of disrepair visible; the remainder of the property was meticulously groomed. By Maria. That was her nature. The house was a light green stucco with white shutters, and the odor of fresh paint greeted me as I knocked. Maria answered. Inside it was as orderly as outside.
I found Oscar sitting on the sofa, with Divya next to him. She appeared to be completing her neurological examination as she tapped his patellar tendon with a rubber reflex hammer.
“His neurological examination is unchanged from my last exam,” Divya said. “I found no evidence that he’s had another stroke.”
Oscar Mendez was well-known in the Hamptons. He’d run a bicycle-repair shop for many years, catering to everybody from weekend pedalers to hard-core racers. He reputedly could make any bike smoother and faster. Until his first stroke three years earlier. It didn’t do much physical damage in that he could still use all his extremities, but mentally he didn’t fare so well. His confusion and memory impairment forced him to sell his shop and retire. A year later, he had a second stroke and his dementia worsened.
Maria was as steadfast a spouse as anyone would ever want. She doted on him and took his episodic confusion, crying jags, and temper outbursts in stride. She had seen them before in her father, and she knew that none of this was personal but rather the broken wiring of a strokedamaged brain.
“He’s been so confused the past couple of days,” Maria said. “His ups and downs seem worse. He constantly sleeps or gets agitated and cries. He can’t remember how to make coffee.” She wound a handkerchief into a knot around one of her fingers. “What’s wrong?”
I knelt on the floor in front of Oscar and looked him in the eye. “Oscar, how are you doing today?”
He stared at me blankly for a minute and then smiled. “Dr. Lawson, what are you doing here?” He then looked at Divya. “Divya, you, too? I get to see both of you today?”
Then I saw the spark of realization in his face as he suddenly remembered that Divya had been there for a while. He closed his eyes and swallowed hard.
“It’s okay, Oscar,” I said. “Sometimes I forget Divya’s around, too.” I gave her a quick wink. She smiled, knowing what I was doing.
If you can’t fix it, make it seem less serious.
This is the tragic part of dementia. Contact with reality comes and goes, in an almost cruel manner. Sometimes I believed it would be better for the person to remain confused all the time. That way he would never know he was confused. But these moments of lucidity, where everything suddenly, if briefly, makes sense, must be maddening. That’s what I saw in Oscar’s face. The frustration of knowing that something had happened and yet he was completely unaware of it. I knew his days were likely filled with such episodes.
I reached out and touched his hand to bring his attention back to me. “I’m going to ask you some silly questions, but I want you to answer them as best you can.”
I began a mental-status exam, asking his name, the date, where he was, and the name of the president. He answered all the questions perfectly, proving he was oriented to time, place, and person. I evaluated his memory by asking what the name of his old bicycle shop had been and then saying five words and asking him to repeat them in the proper order. He aced it. I asked him to repeatedly subtract seven from one hundred. He stumbled on a couple of the numbers. To test his cognitive abilities and abstract thinking, I asked him to explain what is meant by “A penny saved is a penny earned” and “Don’t cry over spilled milk.” He didn’t do so well. Not uncommon in multiple-stroke dementia.
Oscar took two meds for high blood pressure and an SSRI for his episodic anxiety. A year earlier, he had accidentally doubled up on his blood pressure meds and ended up on the floor. When I saw him, his blood pressure was down to seventy, but a few hours in bed and avoiding those medications for twenty-four hours resolved that issue. After that, Maria took over dispensing his meds.
I asked Maria, “He’s been taking his medications regularly, hasn’t he?”
“Oh, yes. I have one of those weeklong pill containers and every Sunday I set up his medicines for the week. I keep the bottles
locked up like you told me.”
“His vital signs are normal today,” Divya said.
I stood and motioned for Maria to follow me. I led her into the kitchen, where I sat down at the table. She sat across from me.
Concern etched her face as she asked, “What is it? What’s wrong with Oscar?”
It’s always best to have these types of discussions out of earshot of the patient. Even those that are the most demented and confused often hear and understand bits and pieces of what is said. In their scrambled and often paranoid reasoning, such shards of information can be misinterpreted and this can induce fear and panic, and even aggression, meant to be self-protective.
This conversation was for Maria only.
“I think it’s simply his dementia worsening,” I said.
She wound the handkerchief into an even tighter knot. Tears collected in the corners of her eyes. “He’s been doing so well. It’s just the past couple of days that he’s been out of it.”
“That can happen. Remember when I told you things would wax and wane, but they would soon begin doing more waning than waxing? I’m afraid that’s what’s going on here.”
“There’s nothing you can do to help him?”
“Unfortunately there isn’t. We just don’t understand this disease very well. Not yet anyway.”
She dabbed a tear from one eye with the wadded handkerchief. “I don’t know what I’m going to do.”
“We discussed the options.”
“Go to one of those places? Oscar would never do that.”
“You could have someone come and help you at home.”
“We can’t afford that. Besides, I can take care of him myself.”
“For how long?” I reached across the table and took her hand. “You’re not twenty anymore. This will take a toll on you.”
