Michael Palmer: The First Patient

Carol Stoddard returned with her hands full of pill bottles, plus an inhaler, and passed them over. Gabe scanned them one by one, setting each on the bedside table. None of them differed from what he already knew Stoddard was taking.

With Ellis Wright's words booming in stereo in his brain, Gabe moved cautiously toward the bedside opposite where Carol was standing.

"The Twenty-fifth Amendment deals with the inability of the president to reliably conduct the duties of his office… I want you to review the presidential law of succession and memorize the Twenty-fifth Amendment."

"Drew," Gabe said gently but firmly, "there's something going on here with you that's not quite right."

"Not quite right… not quite right." Stoddard sang the words to the tune of "lit-tle lamb, lit-tle lamb."

Gabe felt an ice-water chill. Somewhere in the building, a military aide was approaching, bearing The Football-the buttons and codes that could, effectively, end all life on Earth, codes that could be triggered by one man and one man only. His mind struggled with only minimal success to wrap itself around the enormity of the situation. He glanced at Carol and then at Lattimore to confirm that they, too, were aware of the awesome implications of what was transpiring before them, but their expressions validated nothing.

"Drew, is it okay if I do a little examination of you? I want to get to the bottom of this."

"I see the answers."

"Drew, is it okay if I check you over?"

"The answers to all questions."

"Is there some sort of shot you can give him?" Magnus Lattimore asked.

Gabe stopped himself at the last possible instant from snapping at the chief of staff.

"As soon as I know what's going on, I'll treat him," Gabe said instead. "Right now, as long as he's not in immediate danger, masking these symptoms is the last thing I want to do."

Stoddard was perspiring profusely now, his face cardinal red. But the rocking had stopped. Still, he continued a rapid, disjointed chatter, jumping from topic to topic, laughing inappropriately, and mixing in often bizarre opinions on issues of public concern-opinions that Gabe knew were not typically held by the man. The Andrew Stoddard he had known since college was Dr. Jekyll. This was Mr. Hyde. Gabe wondered in passing what would happen if the nation's commander in chief suddenly started calling out for the military aide with The Football.

Moving slowly but deliberately, Gabe checked his patient's blood pressure in each arm and his pulse in the neck, arms, and feet. The pressure was up-160 over 100-in each arm, and the pulse was also up at 105. Years of training and practice had kicked in the moment Gabe entered the room, and with each second he was observing, avoiding assumptions, and considering dozens of diagnostic possibilities-rejecting some, filing others away as possible, moving still others to the forefront of probability.

Ignoring the steady stream of pressured babble, Gabe did as rapid a physical exam as he dared. There would be time for more detailed examination and testing when the immediate crisis had been dealt with. As matters stood, two things were apparent to him: The President of the United States was not having a cerebral hemorrhage or a cardiac episode and so was in no immediate danger, but also, at the moment, the man was quite mad.

For the twenty minutes that followed and the twenty minutes just past, Gabe knew that the United States was without reliable leadership. He continued his evaluation of Andrew Stoddard, but Gabe's mind was spinning. Someone had to be notified, probably the vice president. Ellis Wright was an ass, but he had been absolutely justified in saying that Gabe had to become an expert on presidential illness and succession.

But why hadn't Lattimore stepped forward-or even Carol? Why were they standing by almost calmly as one of the greatest crises imaginable evolved before them? Why had the only even slightly emotional thing either of them uttered been Lattimore's request-a request that Gabe brushed aside as bordering on malpractice-that the president be given some sort of shot to settle him down? It didn't take a formal medical education to reason out that unless a diagnosis was either known or quite obvious, giving any sort of mind-altering medication to someone with acute brain dysfunction, from either trauma, stroke, or chemical imbalance, was contraindicated.

The president's continuous rocking had slowed, then finally stopped, and the tenor of his speech had softened somewhat. Gabe propped a pillow behind him and took advantage of the relative calm to focus his ophthalmoscope beam onto the retinas of Stoddard's eyes-the only place in the body where arteries, veins, and nerves, specifically the large optic nerves, could be directly observed.

The arteries appeared healthy, with minimal, if any, signs of arteriosclerosis. The veins, too, seemed normal and were free from nicking where the arteries crossed on top of them-a finding that would have hinted at prolonged high blood pressure. But most important, the margins of the optic nerve in each eye were sharply demarcated. Blurring of those edges, known medically as papilledema, would have suggested a buildup of pressure on the brain from swelling, hemorrhage, or infection.

Reflexes normal. Extremities normal. Strength and range of motion good. Cranial nerves intact. Carotid pulses strong and free of bruits-the churning sound made by blood rushing past an obstruction. Heart rate down to 88-still high, but improved. Blood pressure down to 130 over 80. Lungs clear. Respiratory rate down from 40 to 24. Abdomen soft.

Stoddard's perspiring had slowed and the redness in his face had begun to abate.

"Drew, are you with me?"

"You're the best, pal. The salt of the earth."

"Drew, I want to ask you some questions. Will you answer them no matter how silly they might seem?"

"Go for it."

"What city are we in?"

"Why would you ask me something as-"

"Please, Drew, humor me."

"Washington, District-o of Columbi-o."

"The day?"

"Thursday. Doc, this is-"

"Please-"

"August the something. Maybe the seventeenth. Isn't that right, Carol, baby? The seventeenth?"

"That's right. You're doing great, honey." She looked over at Gabe. "He's coming around."

"Drew, how much is forty times twenty?"

"Eight hundred, of course. I was always good in math."

"A hundred minus thirty four."

"Sixty-six."

The answers came out almost before the questions were finished.

"Name the first eight presidents."

"Washington, Adams, Jefferson, Madison, Monroe, the other Adams, Jackson, how many is that?"

"Enough."

"Van Buren, the first Harrison, the one who croaked after thirty days, Tyler-"

"That's plenty, Drew."

"I can do them all. The latest one is me."

"I'm glad of that. The capital of Uruguay?"

"Montevideo. What do I win?"

"Most home runs by someone who never took steroids?"

"Aaron. You thought I'd say Ruth, didn't you?"

"No, Drew. I knew you'd get it right. You're doing better, my friend. Much better."

"Doc? I have one question."

"What is it?"

"The beasties that have been flying around here-the fairies and those round hairy things with the long tails-what do you make of them?"

Gabe looked to see if Stoddard was toying with him, but there was nothing in the president's expression to suggest that was the case. He checked Stoddard's pupils again. They had initially been midsize and a bit sluggishly reactive to light. Now they were smaller and more briskly reactive. Another sign that things were getting better.

Hyperactive cardiovascular system, uncontrolled rocking, disjointed, pressured speech, excessive perspiration, inappropriate affect, visual hallucinations. What in the hell was going on?