Reaching Down the Rabbit Hole Read Online Free Page B

meetings when she had to deliver bad news. She had turned out to be one of our strongest clinicians.
    Although she hails from the Midwest, Hannah Ross has a northernEuropean flair, somewhat Dutch, in that she is tall, lithe, wears fashionably businesslike glasses, and seems indifferent to the possibility that anyone might appreciate the effort she has made in choosing her look, probably because the effort is now merely a habit. She moves swiftly from room to room, from pod to pod, from the nurses’ station to the rolling laptop cart, where she displays an instantaneous command of electronic medical records, and can bring up an MRI scan and zoom in on a tumor or a cerebral hemorrhage with no wasted effort.
    “What are you watching?” Hannah asked Vincent, in an inflection she would later inform me was Kansan rather than Missourian.
    “The Bunkers.”
    “Do you mean All in the Family ?”
    “Yes, yes, . . . the Bunk . . . Yes.”
    Vincent’s form of speech difficulty, known as Wernicke’s aphasia, sounds like gibberish, but not pure nonsense. It can include halting phrases that almost make sense, echolalia (repeating someone else’s just-used words), perseveration (giving the same answer to a succession of different questions), and play association (cracking wise). While he knew the answers to many of our questions, most of his responses didn’t come out quite right, yet he seemed unaware and unconcerned.
    “What’s your name?” Hannah said.
    “Vincent.”
    “Good. Where are we? What place is this?”
    “Vincent . . . uh, yeah . . . Vince.”
    “What day is it?”
    “Avince . . . Vince.”
    “Okay. Look at my hand. Now follow my thumb.”
    “Gee, you’re so dumb.”
    Gilbert, the medical student who had made the initial exam, recorded this as “orientation times one.”
    “To one what?” I later asked him.
    “To himself,” he said.
    “Have you ever met a patient who wasn’t?”
    “I don’t think so.”
    “No, you haven’t. It doesn’t exist.”
    The phrase A and O times three means “awake, oriented to self, oriented to place, and oriented to time.” Some people add a fourth: oriented to situation. The problem is that everybody is “oriented times one” unless they are hysterical or dead.
    Vincent knew who he was. He was sharp enough to find himself amusing. Did his colonoscopy earlier in the week bring this on, or, more to the point, did the anesthesia bring it on? My guess is that it was just a coincidence. A straw poll of the team leaned toward a diagnosis of tumor, possibly stroke, maybe a seizure, but they were basing their guesses on Vincent’s MRI. I had seen the scans and knew they did not hold the answer. On the other hand, Vincent’s wife, who was sitting in an armchair at the foot of his bed, did.
    “He had a bad headache from the beginning,” she told me, “and a fever.” The residents had neglected to mention this, but it was important.
    “How about a virus?” I suggested. “I think this is probably an infection.” Herpes encephalitis was my hunch. It would connect the headache and low-grade fever, neither of which fit with a tumor or a stroke. “Ignore the scan for now,” I told Hannah. “When there’s nothing obvious there, it can be a distraction. Stick with the patient’s story and the bedside exam.”
    We started him on acyclovir, an antiviral medication, and he soon improved. Five days later, Vince was discharged, talking normally again, and, for better or worse, just like his old self.
    “I just ran into your Mr. Talma in the elevator lobby.” Elliott, a colleague who seems to keep closer tabs on my patients than I do, had buttonholed me in the corridor outside of the ward. “When I gave him a shout-out,” he said, “you’d think I’d asked him to put up bail for the Unabomber. The guy comes in here a pussycat, and when youfinish with him he’s Mr. What’s-It-To-You-Pal. No more smiles, no more jokes. What did you do to him?”
    “We