Chapter 4 : My Patient

I’ve already read his preliminary results twice by the time Damian Blackwood walks back into my consulting room.

Not because I like looking at hard cases.

Because something's not right.

His ECG confirms the rhythm disturbance seen in his recent episode. That is more significant than in an otherwise healthy patient with his history of hereditary hypertrophic cardiomyopathy.

His blood work is not scary.

That’s his attitude.

He walks in without knocking.

I glance up from the file.

“You are early.”

He looks at his watch.

“You are late.”

I check the clock on the wall.

“I’m right on time.”

“Then your watch is slow.”

I look at him for a moment.

He sits down on the other side of me.

I close the file.

“Good morning to you as well.”

“Morning.”

His tone suggests that he regards the exchange as superfluous.

I take up my pen.

“You finished the tests?”

“Yes.”

“Any symptoms since your last spell?”

“Nope.”

“Chest pain?”

“No.”

“Shortness of breath?”

“Nope.”

“Dizzy?”

“Nope.”

“Palpitations?”

A silence.

“Not.”

I stop writing.

“That’s not what you said to the nurse.”

He looks at me.

“I said I didn't think they were important.”

“That was not the question.”

He sits back.

“Sometimes my heart goes racing.”

“How often?”

“Sometimes.”

“Once a day?”

“Not.”

“Several times a week?”

“No.”

“Once a week?”

He says nothing.

I wait.

“Maybe.”

“Maybe is not a frequency.”

His jaw clenches.

“One or two times.”

“A week?”

“Yeah.”

“And how long does it take?”

“Not long.”

“Thirty seconds?”

“Sometimes.”

“A minute?”

“Maybe.”

“Another?”

He looks put out.

“Why does it matter so much?”

“Because you have an inherited heart problem and have had an abnormal rhythm before.”

“I know my state.”

“You know why I ask.”

Quiet.

There it is again.

The wall.

I have seen patients like that. Smart. Disciplined. Trained to solve problems before anyone else sees them.

The difference is that most people eventually realise that their bodies don't bargain.

Damian Blackwood seems to be in a negotiating mood.

I flip a page.

“Tell me about the medicine you’re currently on.”

He hands me the list without a second thought.

Dosage.

Times.

Names.

All memorised.

I stare at him.

“You are very consistent.”

“I don’t miss my doses.”

“That's good.”

He waits.

I keep reading.

“Who's responsible for your medicine?”

“Old cardiologist of mine.”

“And how often do you see him?”

“Next month. I was due a review.”

“You were?”

“Yeah.”

“Then why were you brought here yesterday?”

His face stiffens.

“I had a spell.”

“Correct.”

He turns away.

I tap the file gently.

“Your management has been stable for a long time. Your symptoms are shifting. That is why I am concerned.”

“They’re not going to change.”

“You just told me you’ve been having palpitations once or twice a week.”

“That doesn’t mean my condition is evolving.”

“Could.”

“May.”

“Yes.”

He grins humorlessly.

“You like that word, I guess.”

“I use it when I’m not sure something is for sure,” I say.

“Most people in your line of work seem comfortable making assumptions.”

“Evidence is good.”

That grabs his interest.

He looks at me for a few seconds.

I open the preliminary report again.

“There are a few things I want to look into more.”

“I already had an ECG.”

“I know.”

“And an echocardiogram.”

“Not the new one I desire.”

His eyebrows rise.

“You want another echo?”

“Yes.”

“More blood tests?”

“Nope. Your blood work is good.”

“Then order something?”

I slide a form over the desk.

“Longer-term heart rhythm monitoring.”

He glances at it.

“How long?”

“Seven days.”

He raises his head.

“Seven days, huh?”

“Yes.”

“I don’t want that.”

“You don't know that yet.”

“I have experienced these symptoms before.”

“Never have they been monitored for seven days straight.”

“I got a business to run.”

“I’ve heard.”

He narrows his eyes.

“You know?”

“You said that yesterday.”

“I don’t remember talking about my company.”

“You didn't. Your aide did.”

He looks at the door.

Then back to me.

“My schedule is very rigid.”

“Nor is your heart.”

I can't soften them before I've spoken them.

He stops moving at all.

I do not apologise.

Not to make him angry.

Because it is.

“You want me to wear a monitor for a week,” he says.

“I’m asking for seven days of information that could tell us whether these episodes are benign or something we need to take seriously.”

“And if I say no?”

“I record that you refused.”

“That sounds like a threat.”

“It’s documentation.”

“You doctors like paperwork.”

“We like patients who don’t die because they didn’t follow directions.”

His face alters.

Only a little.

I can see it.

A shadow flits across his eyes, and then the controlled mask is back.

I know something has been touched.

I don't know what.

I don't press.

Changing my voice, I say, “I don't want to run your life, Mr. Blackwood.”

“You've been telling me what to do for twenty minutes.”

“Medically.”

“That’s still being in control.”

“No. It's a duty.”

He glances at me.

The room is quiet, save for the soft tread of feet in the corridor.

“You don’t trust me,” he says.

“I don’t know you.”

“That's not the same thing.”

“Not.”

I meet his gaze.

“It is not.”

We both stand still for a moment.

Then he looks at the form again.

“What are you searching for?”

“Anything we missed.”

“Like what?”

“An arrhythmia that doesn't show during a short exam. A pattern to your symptoms. Changes in how your heart works. Anything that tells me your current therapy isn’t enough.”

His fingers tap once on the armrest.

“My current treatment has been working for years.”

“I know.”

“So why change that?”

“I haven’t changed it.”

“But.”

I meet his eyes.

“Not unless the evidence says so.”

It seems to annoy him.

Perhaps because he knows what I am talking about.

I am not promising to change his treatment.

I will follow the evidence wherever it leads me.

He takes the form.

“Fine.”

I see him sign it.

His script is very neat and precise.

Even his signature looks like a choice.

He finishes and lays the pen on my desk.

“Anything more?”

“Yeah.”

He looks up.

“You have to work less.”

His expression is instant.

“Not.”

“I’m only just getting started.”

“You don't have to.”

“You’re working too many hours.”

“I have a company.”

“You’ve got a heart condition too.”

“I know.”

“Then act like it is.”

His look hardens.

“I don't like being talked to like I'm irresponsible.”

“I didn't say you were irresponsible.”

“You said it.”

“No. Your schedule could be affecting your health.”

“I've been in good health.”

“Until yesterday.”

Silence.

That works.

I let it go.

He looks down at the papers.

“My father had this problem.”

The statement is so faint that I almost miss it.

I don't butt in.

“He did it.”

So I wait.

“He still died.”

There is no charge in his voice.

That just makes it worse.

I put down my pen.

“Sorry.”

He closes his face.

“I don’t want pity.”

“I didn't give sympathy.”

He looks at me.

“I was writing down what you told me.”

Something in his shoulders relaxes, just a little.

“My father was watched for years,” he says. “He did whatever he was told. Took all the medication. Did all they asked.”

“I hear you.”

“And it didn’t save him.”

“No,” I say slowly. “It didn’t.”

His eyes lock with mine.

“So why do you think doing everything different is going to change the outcome?”

There you go.

Not conceit.

Fear.

Underneath all that control is a man who’s already seen the ending he’s trying to outrun.

I recline.

“You are not your father.”

His face remains unchanged.

“You don’t know the half of it.”

“Not.”

I lock eyes with him.

“But that’s why we’re going to look at the evidence, rather than assume your story’s already been written.”

He utters no word.

I understand the monitoring order.

“This doesn’t guarantee anything.”

“I know.”

“It doesn’t mean you’re going to get the surgery.”

His eyes sharpen.

“I didn't ask about an operation.”

“I see.”

More silence.

I shove the order back at him.

“It means we know what your heart is doing before we decide what's next.”

He accepts it.

This time he does not argue.

He gets up.

He stops at the door.

“You're tough, Dr. Carter.”

“That’s what I heard.”

“And you like to disagree with me.”

“Not.”

He looks back over his shoulder.

“I like to be correct.”

A faint, reluctant upturn of his mouth.

It vanishes almost immediately.

“That's too bad.”

“Why?”

“Because I’m rarely wrong.”

He walks away.

The door clicks closed behind him.

I glance at his file.

He has never arrived without my mind being on his money, his reputation, the lift.

I’m thinking about the pause before he said his dad’s name.

And the possibility that the man who seems to want to control everything may be most afraid of the one thing he cannot command.

His own heart.

I take the

next report.

Then pause.

The first echocardiogram has just been uploaded.

I open it.

I read the measurements with my eyes.

One.

Two times.

My hand pauses on the mouse.

There's something different.

One preliminary report is not enough to diagnose anything.

Enough to look more closely.

I take the phone.

“Get Damian Blackwood booked in for the full cardiac assessment.”

The nurse on the other end falters.

“How soon?”

I see the numbers on the screen.

“Tomorrow.”

I put the phone down.

Whatever Damian Blackwood thinks this appointment is about, it’s not a routine one anymore.