Richard Powers - The Echo Maker

When the firemen arrived, they had to burn their way through a roof post with an acetylene torch. Weber pictured the scene: police lights strobing across frozen fields, flares circling the truck where it lay flipped in the roadside ditch. Uniformed people, their breath steaming, moving about in dreamlike, methodical activity. When the firemen at last torched through the roof post, the wreck shifted and the truck settled. The body crumpled on itself. The firemen scrambled under the wreck and drew the body clear. Mark Schluter briefly regained consciousness in the ambulance. The paramedics raced him to Kearney, the only hospital within six counties with any shot at keeping him alive.

Hayes proceeded to the medical charts. White male, twenty-seven, five ten, 160 pounds. He had lost considerable blood, most of it from a gash between his right third and fourth ribs, where he’d impaled himself on the spike of a metal model Prussian helmet fastened to his truck’s gear shift. His front scalp and face were heavily abraded. His right arm was dislocated and his right femur fractured. The rest of his body was badly scratched and bruised, but he was otherwise astonishingly intact.

“We use the word miracle a lot out here in the Plains States, Dr. Weber. But you don’t often hear the term thrown around a Level II trauma center.”

Weber studied the images that Hayes clipped to the light box. “This one qualifies,” he agreed.

“The closest thing to a Lazarus walk-away I’ve ever seen, even in my residency days in Chicago. Eighty miles an hour, on an icy country road in the dark. The man should have been dead, many times over.”

“BAC?”

“Funny you should ask. We see a lot of that, in the Kearney Emergency Room. But he came in at.07. Under the legal limit, even in the Cornhusker State. A few beers in the three hours before rolling his vehicle.”

Weber nodded. “Was he on anything else?”

“Not that we found. The ER attending logged him in at a Glasgow solid ten. E3-V3-M4. Eyes opening to speech. Withdrawing from pain. Some verbal response, although mostly inappropriate.”

Eight was the magic number. After six hours, half of all patients with Glasgow Coma Scale numbers of eight or lower gave up and died. Ten was considered moderate injury. “Something happened to him after admission?”

Weber was just playing professional detective. But Hayes grew defensive. “They stabilized him. All the protocols, even before determining whether he was insured. We have one of the highest rates of medical indigence in the country, out here.”

Weber had seen higher. Half the country couldn’t afford insurance. But he murmured approval.

“It took the paper-pushers an hour before they could locate his next of kin.”

Weber studied the paperwork. The victim’s pockets contained only thirteen dollars, a knock-off Swiss Army knife, a receipt for a tank of gas at a place in Minden dated that afternoon, and a single cyan-colored condom in a transparent package. Probably his good-luck charm.

“Apparently, his license flipped up under the dash when the truck rolled. The police found it while searching the vehicle for drugs. They located the sister up in Sioux City, and she gave phone consent for anything we needed. The trauma service got him going on mannitol, Dilantin…You can read everything. Pretty standard fare. Intracranial pressure steady at around 16 mm Hg. We got a little improvement right away. Motor response climbed. Some increase in verbal. Marked him up to a Glasgow twelve. Five hours after the admit, I would’ve told you that we were heading out of the woods.”

He took the file back from Weber and searched it, as if he still had a chance to head off what happened next. He shook his head. “Here’s the note from the next morning. ICP up to twenty, then spiking even higher. He had a small seizure. Some delayed bleeding, as well. We went to a ventilator as soon as we could. We decided to drill. Tracheotomy clearly indicated. His sister was here by then. She approved everything.” Dr. Hayes scoured the papers, looking for some shred that refused to come forward. “If you’re asking me, I’d say we caught everything as it arose.”

“It seems like it,” Weber said. Only, intracranial pressure had to be caught before it arose. Dr. Hayes blinked at him, perhaps resenting the national celebrity brought in to aid the poor locals. Weber stroked his beard. “I can’t imagine doing anything differently.” He glanced around Dr. Hayes’s office. All the right journals on the shelves, up to date and orderly. Framed diploma from Rush Medical and Nebraska Board Certification. On the desk, a picture of Hayes and a slim, honey-haired model, shoulder to shoulder on a ski lift. A world inconceivable to Mark Schluter, before or after his accident.

“Would you say that Mark shows any tendency toward confabulation?”

Hayes followed Weber’s glance, to the picture, the beautiful woman on the lift. “Not that I’ve noted.”

“I tried him on a battery of the standard tests yesterday.”

“Did you? I gave him everything, already. Here. Any scores you might need.”

“Yes, of course. I didn’t mean to suggest…But some time has passed…”

Dr. Hayes measured him. “He’s still under observation.” He offered Weber the folder again. “The data are all here, if you care for a look.”

“I’d love to see the scans,” Weber said.

Hayes produced a series of images and clipped them to his light box: Mark Schluter’s brain in cross section. The young neurologist saw only structure. Weber still saw the rarest of butterflies, fluttering mind, its paired wings pinned to the film in obscene detail. Hayes traced over the surreal art. Each shade of gray spoke of function or failure. This subsystem still chattered; this one had fallen silent. “You see what we’re dealing with, here.” Weber just listened to the younger man step through the disaster. “Something that looks like possible discrete injury near the anterior right fusiform gyrus, as well as the anterior middle and inferior temporal gyri.”

Weber leaned toward the light box and cleared his throat. He didn’t quite see it.

“If that’s what we’re looking at,” Hayes said, “it would fit the prevailing understanding. Both the amygdala and the inferotemporal cortex intact, but a possible interruption of connection between them.”

Weber nodded. The current dominant hypothesis. Three parts needed to complete a recognition, and the oldest trumped all. “He gets an intact facial match, and that generates the appropriate associated memories. He knows his sister looks exactly like…his sister.”

“But no emotional ratification. Getting all the associations for a face without that gut feeling of familiarity. Pushed to a choice, cortex has to defer to amygdala.”

Weber smiled, despite himself. “So it’s not what you think you feel that wins out, it’s what you feel you think.” He fiddled with his wire frames, feeling out loud. “Call me archaic, but I still see some problems. For one, Mark doesn’t double every person that he cared for before the accident. He should still be able to draw upon auditory cues, behavioral patterns: all sorts of identification tools other than facial. Can flattened emotional response really defeat cognitive recognition? I’ve seen bilateral damage to the amygdala — patients with destroyed emotional responses. They don’t report that their loved ones have been replaced by impostors.” He sounded too effusive, even to himself.

Hayes was ready. “Well, you’ve heard of the emerging ‘two-deficit’ theory? Perhaps insult to the right frontal cortex is impeding his consistency-testing…”

Weber felt himself turning reactionary. The odds against multiple lesions, all exactly in the right place, had to be enormous. But the odds against recognition itself were even greater. “You know he thinks his dog is a double? That seems like more than just a rupture between the amygdala and the inferotemporal cortex. I don’t doubt the contribution of lesions. Right hemisphere damage is no doubt implicated in the process. I just think we need to look for a more comprehensive explanation.”