Black Dot Diagnosis

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@jimmywyngaarden

a short story by Jerry Zinn

“Martin?”

“Yes, Dr. Fanning?” came the prompt reply through the intercom.

“Will you page Dr. Joyce? Have her come to my office as soon as she can, please.”

“Is there anything specific you’d like me to add,” asked Martin.

“Just say it’s urgent,” said Dr. Fanning.

“I’ll send that out right away.”

Dr. Fanning waited for the light to go off. She dug her thumbs into the corners of her eyes. Fireworks exploded in the blackness. When she realized how tense her shoulders were, she had to use conscious effort to drop them. After breathing in for a count of four, Dr. Fanning held her breath for four seconds, and then released it slowly for eight.

Her heart rate went up. Briefly it dipped to 120, but she attributed that to measurement error. Dr. Fanning was skeptical about the readouts, but she found herself referencing them frequently as Gospel truth. Steadily the rate climbed closer to her orange zone. Later her watch would tell her she’d spent the morning exercising.

There were wads of paper surrounding a wire trashcan by the door. She balled up another sheet from her notebook and tossed it. Another miss. “I regret to inform you…” she scribbled. Dr. Fanning tore out the page but this time made the shot. Other than the three heartbeats of accomplishment, the make did nothing to change her outlook.

“Dr. Fanning?” said Martin through the speaker.

“Is Dr. Joyce here?”

“Yes, should I send her in?”

“Please.”

Dr. Joyce’s white coat was wrinkled, and the arms had ghost stains. But her makeup was pristine, and her dark hair neatly aligned. Dr. Fanning always admired Dr. Joyce’s eyebrows, trimmed and angular like English boxwoods. That fascinating contradiction between physical perfection and unkempt clothing created a unique effect on those around her.

“I had a feeling it wasn’t a social call,” said Dr. Joyce. She stepped over the missed shots. “Thinking of going out for the team?”

“I couldn’t have made it as a water girl for my high school team. The legal bills just to let me have a gym uniform, you wouldn’t believe. Allie, I’ve got a real patient dilemma here.”

“That’s what I love about you, Maria,” said Allie, crossing her legs at the edge of the chair. “Expert chase-cutter. No lead in, just chase. So, you’ve got a patient dilemma? Is there any other kind? I swear every patient I’ve had the last twenty-five years thinks they’ve got a new disease that requires a study and a new medication.”

Maria clicked her ballpoint compulsively.

“This is different. You’re right patients always present dilemmas, not always medical ones. But this is something else.”

“Well, now I’m intrigued. Maybe this was worth throwing away the rest of that chicken salad. It was the kind today. I still haven’t figured out which one of the chefs does it right, but the discrepancy between the good chicken salad and the bad is night and day,” said Allie.

“Remember the oath?”

“There’s a chicken salad oath?”

The oath, Allie.”

“The Hippocratic one?”

“Do no harm,” Maria replied, filling in her own blank.

“I wouldn’t be much of a doctor if I didn’t. Not that knowing it is much difference. We both know plenty of doctors that can recite it while they prescribe a toxic drug cocktail.”

“This is serious, Allie.”

“Oh, serious. OK, OK,” Allie replied, relaxing her posture.

“Would you agree that we, as doctors, have an obligation to be transparent with patients on their diagnoses?” asked Maria.

“Where is this coming from? Are you bugged? Is this some kind of ethical audit?”

“No, nothing like that. It’s just – I need to hear it from someone I respect, so I can rule out insanity.”

“That’s all well and good for you, but I don’t know if I can rule it out for me.”

“Do we have that obligation?” Maria asked, continuing to slice through Allie’s commentary.

“OK. Yes, we have an obligation to be transparent.”

“I have a patient. Physiologically, psychologically, everything, she’s got top marks. I’d trade places with her in a heartbeat.” Maria checked her wrist. Her heart rate was nearing the red zone. “Her psychologist referred her to me for an abnormality he saw in her behavior. It was a blip, but he wanted investigation. Scans of her brain, professional opinion, that kind of thing. So we did an MRI…”

“And you called me here, which means something showed up on the MRI? Does she have an abscess or a tumor or something? What was the behavioral abnormality?” asked Allie.

“No, no tumor or abscess or anything like that. He didn’t elaborate on the abnormality, and I think I know why now. Actually, I do know why he didn’t say more. This patient’s brain is perfect. I don’t think she’s ever had even a minor concussion. And brain function, activation, everything is textbook.”

“But?”

“But there was a dot. On the thalamus. Here take a look at this.”

Allie rounded the desk. Three orientations of the scan filled the computer screens. Maria pointed with her ballpoint to a small black dot, so infinitesimal it could easily have been mistaken for a dead pixel.

“What is it?” asked Allie.

“Think of it like a black hole,” answered Maria.

“That doesn’t sound good.”

“No, it isn’t. This anomaly has a very unique characteristic. My choice of analogy is very deliberate. What do you know about black holes?”

“Black holes?” asked Allie, sitting on the desk and filling her cheeks with air. “Lots of gravity, no light escapes. Galaxy far, far away. None of my knowledge seems like it applies here, though. Limited as it is.”

“That’s a good enough working definition. At the moment it’s just a blip. It doesn’t do anything, symptoms will never manifest. Only a highly trained psychologist like the one this patient has, who has seen this condition before, would be capable of even identifying the possibility this may exist in their patient. In fact there are only three psychologists in the world with the experience to identify a patient who may have this condition.”

“So… it’s rare. Whatever it is? Is that what you’re saying?” asked Allie.

“Rare. Definitely. Like I said, think of this dot as a black hole. There is a mechanism that activates it. In an instant. When this process begins, or occurs nearly instantaneously, that dot will take over the entire brain. The patient will lose nearly all brain function. Interestingly, consciousness and memory are not affected.”

“So, you’re telling me they’re brain dead and fully aware of it?”

“Prisoners in their minds, yes,” replied Maria. “And from the little information I’ve seen, their brain patterns look like those of an individual experiencing a nightmare. A never-ending nightmare.”

“Jesus Christ. Well what’s the mechanism? How do you avoid the black hole and hellish limbo?”

“This is where my dilemma comes in. Take a seat, in the chair,” said Maria, inviting Allie to get off her files.

“How could it be any more outlandish than what you just told me?” asked Allie, shoving her hands into the deep pockets of her white coat.

“Trust me. You’re going to want to sit.”

“OK.”

Once her friend lowered herself nervously into the chair, Maria continued, “Awareness.”

“Awareness? I’m sorry, I don’t understand…”

“That’s the mechanism for triggering the phenomena. Awareness activates the dot . Call it the supernova moment. Dot turns to black hole.”

“Maria, I’m not following. Explain it to me like I’m a child. That shouldn’t be hard to imagine, really.”

“It’s been the case with every patient that’s been diagnosed with it. Only by developing an awareness of the abnormality, does it take over the brain. So, the prevailing theory suggests ignorance can keep it at bay. Ignorance, in this instance, might be bliss. Or at the very least it can be the difference between reality and a… ‘hellish limbo,’ as you put it. Therefore, it would appear that if I tell her what I found in this MRI, she will become trapped in the worst her imagination has to offer.”

“What would that be like? For her?” asked Allie, her jaw falling.

“Whether she lived for one more minute or forty years, it’ll feel like an eternity. And there’s nothing that could help. The brain scans I’ve seen of these patients show off the charts anxiety. They exhibit sustained stress response, extremely elevated heart rate. Sympathetic nervous system is at full bore. It’s like they’re running for their lives. And it goes on as long as their bodies can handle it. When they finally die, which this condition is ultimately fatal, they may have spent a thousand lifetimes running from something. Some fear, some deep source of terror.”

“And they wouldn’t experience any of this if they didn’t know?” asked Maria.

“If the theory is correct. And now to the central question: I have the obligation to inform the patient, don’t I? I’ve got her coming into my office at 1:00. She’s gonna want to see these scans. They are her scans. What am I gonna say?”

“Maria. You can’t tell her. ‘Do no harm.’ That takes precedence. It’s not a question here.”

“What am I going to tell her then?”

“Tell her everything’s fine. Because it is. Unless, you tell her about this dot that could become a black hole on her brain. So, you’re being honest.”

“The scans though,” said Maria.

“Show her someone else’s.”

“Allie, you know I can’t do that. That’s an insane HIPPA violation. They could take my license.”

“No, I know. I was just thinking out loud. Well, show her the real scans. She’d have to be a neurosurgeon with 20/20 vision to notice that dot. If… and that’s a big if, she even asks to see the scans. Most patients, you tell them they’re fine, they don’t ask more questions. You know that. They say thank you and goodbye.”

“So, just hope she doesn’t ask? That’s my plan?” asked Maria.

“Have the scans if she asks. But even if she looks, again, she’s not gonna notice that. And besides, if she does, tell her something else. Like it’s… like your screen is messed up or scans aren’t always perfect. That’s true. Those MRIs are good enough, but they can’t show 100%.”

“And it shows up on all three screens in the same place? I can’t lie to a patient. You know I can’t lie, period,” said Maria.

“So don’t. They only way you’d have to is if it got to that level, and it won’t,” said Allie.

“I hope you’re right, because I don’t have any other option. All those balls of paper are dead ideas.”

“I am right. She’ll thank you for it. She won’t know what she’s thanking you for. But you will.”

The intercom buzzed.

“Dr. Fanning? Your 1:00 is in the waiting room,” said Martin.

“Thanks, Martin. Dr. Joyce is just leaving.”

“Maria,” said Allie.

“Yes?”

“You’re doing the right thing.”

All Maria could do was give a vague nod. Allie left the office. She waved to Martin as she entered the waiting room. There was one chair occupied in the otherwise empty waiting room. A woman paged through The New Yorker, laughing at the cartoons. Allie couldn’t stop staring. Blissful ignorance, she thought. A landmine was planted deep in that patients brain, but she could never know, or a terrible fate awaited her. The woman looked up.

“Hello, how are you?” the woman asked.

“You’re in excellent hands, you should know. Dr. Fanning is one of my oldest friends. We went to medical school together. She’s a true gem.”

“Oh that’s lovely to hear. She seemed very nice in my first appointment. I had an MRI done, so I’m a little anxious. Of course I’m more anxious than I probably should be. I’m sure your patients always assume they have some bizarre illness! I hope she won’t mind a million questions.”

Allie felt her breathing move to her chest and her mouth run dry. “Dr. Fanning has a pediatrician’s bedside manner.”

“I’ve been studying up on brain imagery for the last few weeks. There’s an online course through Harvard Medical School. Have you heard of it?

“I’m not… sure I-”

“Well, to a doctor it isn’t much, I’m sure. What do they say about a little knowledge? Dangerous, right?”

“Yes. It certainly can be.”

Allie thought of all the ways it could be dangerous, the ones she managed to imagine anyway. She feared most those she couldn’t even conjure.

“Ms. Hansen?” said Martin sliding open the glass divider. He was kind and upbeat, completely unaware of the implications of inviting the patient past the door.

“Yes?”

“Dr. Fanning will see you now.”

Ms. Hansen set the magazine on a messy pile of TIME, National Geographic, and People. She shouldered a burgundy leather purse with a manila file peaking out. Allie imagined there were notes and images from the Harvard course. Key questions to ask, things to pay attention to. Dots to be aware of.

“It was nice talking to you, doctor,” Ms. Hansen said as she passed Allie.

“Don’t ask too many questions,” Allie replied with a forced chuckle.

Ms. Hansen gave a confused smile. Allie knew Maria better than anyone else in her life, better than she knew her own husband. And she was positive it wasn’t the good chicken salad that suddenly made her nauseous.

2 thoughts on “Black Dot Diagnosis

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