Chapter Forty-Two

Setback and Resolution

Lieutenant JG Elizabeth Cutler

Malcolm has injured his wrist.

He was being stubborn, pushing too hard and overextending himself. He looked like a wrung out old dishrag, and was as grey as one, too, as he sat there in his wheelchair, trembling with exhaustion, hair dripping with perspiration, insisting that he could do one more lap walking the length of the parallel bars and back.

I should have told him no. We spent a lot of time, Miguel and I – with input from Malcolm – planning the ideal rehabilitation program that would push him to his limits of endurance but allow sufficient time for recuperation between sessions. I don't know how she managed it, but getting him to participate in the planning, to take ownership of his own recovery, even before he started talking to her, was Ginny's first success. I still don't like how much she upsets him during their sessions – I can see his heart rate, respiration, and blood pressure go up on the monitor at the nurse's station – but there's no denying that she's helping him.

Anyway, I should have stuck to the schedule. I should have reminded him that rest is as important a factor to his recovery as exercise. I should have told him, yet again, that muscles only recover when they are at rest.

But I have never been able to refuse him, and he is all too aware that my inability to say no is more than merely a function of his superior rank.

So I conceded to just one more lap, to the end of the bars and back.

He was so spent he couldn't even muster a look of smug satisfaction at getting me to give in. He simply grabbed the bars, hauled himself to his feet by an effort of sheer will, and began plodding ahead. It was only six meters to the other end, but by the time he got there, fatigue had robbed him of his coordination. His right hand missed the bar altogether, and he was already leaning into it to help support his weight as he turned to walk back to his chair. So when he went down, he went down hard, and because he was too exhausted to catch himself he landed awkwardly on his right arm.

We were lucky. He wasn't seriously injured. It was just a mild sprain, but it did require a brace. Something about the x-ray prompted Miguel to run a full bone density scan – after reading us both the Riot Act, of course. The results of the scan weren't terrible, but they weren't good news.

Like everything else in the human body, the skeleton requires more than just an appropriate diet to stay healthy. Bones need weight bearing exercise to remain strong. The only exercise Malcolm got for most of a year was pushing himself from one end of that damned tank to the other.

When I say we were lucky he wasn't seriously injured, I mean we were lucky he didn't snap all three bones in his arm like they were so many dry twigs.

Now Miguel is angry with himself for not thinking to do the bone scan sooner, and I can't help but feel that he's taking it out on Malcolm and me just a little. Despite all our talks, and Trip's assurances that Malcolm would have the final say in all decisions concerning his care and recovery, Miguel has made unilateral changes to Malcolm's physiotherapy plan, his medication regimen, his daily schedule – as a function of the meds schedule – and even his diet.

I had to confront Miguel about his high-handed decision-making. Malcolm's autonomy is too important to his psychological recovery to just rip it away like that.

"But Malcolm doesn't even like broccoli!" I protested.

"How in bloody hell would you know?" demanded our ungrateful patient.

I rolled my eyes and looked at him. "You think I don't notice? You think I don't watch you? You never choose broccoli when it's an option and you take it down like medicine when it's put in front of you."

He gave me a slightly mortified look and muttered, "You're an uncommonly peculiar woman."

I had no idea what that was supposed to mean, so I ignored it, and told him bitterly, "Don't be an idiot. It was my job. When you first came here, you had no interest in anything except not being hurt and not being forced into anything against your will, remember? You were so angry and anxious and upset most of the time that you could hardly stand to eat. It was my job to watch and figure out what you like so we could get you to put some meat on your bones. Why do you think you get pineapple every day now? And fish and chips with an extra-large serving of mushy peas at least once a week, though God only knows why you like those awful peas so much."

He looked embarrassed then, and maybe a little flattered. "I…Thank you," he mumbled, surprising me with gratitude. "I never realised."

"I wouldn't expect you to," I told him in a huff. "Up until last year, it's been all about you for ages, to the point you don't even notice it anymore. Everybody around you knew their health and wellbeing, if not their very lives, depended on anticipating and satisfying your needs. It's not like anyone actually believes Alex chopped one of his own fingers off in a kitchen accident. There's no reason you should realize someone is actually paying attention to your likes and dislikes in an effort to make things easier for you."

"Alex?" he said, puzzled.

"Your chef, Mal!"

"Ahh, of course, Alex," he muttered as if there was something significant about the name but he couldn't quite remember what it was. "I thought it was Alice…"

Miguel thought I should get clued in that now he was taking charge.

"Like broccoli or not, he's gonna have to eat it, and collard greens and cabbage and lots of other leafy greens and cruciferous veggies, along with fatty fish and canned sardines and salmon with the bones, and maybe a few other things he doesn't like! That, along with IV supplementation and a daily multivitamin, might just undo the damage in a couple of years."

"IV…Wait, years?" Malcolm gasped.

"Miguel, I thought we were a team!" I reminded him, gesturing to include our thunderstruck patient. "The three of us are supposed to figure out together what's best for Malcolm's recovery."

"Yeah, we're a team, all right," he snarled, "but lately mah quarterback's had her head so far up mah center's ass that she can only see daylight when he opens his damn mouth!" Rounding on Malcolm, he added, "An' if you don't understand the American football reference, General, Ah'll be happy to draw you a picture!"

"Look, you've made your point," I told him, weakening, "but you need to at least include Malcolm in the decision-making process."

"And I'm not agreeing to anything without Liz's approval," Malcolm added, surprising me again with the level of trust he showed in me.

Glowering, the doctor said, "Well, then, she's just gonna have to convince you to do whatever Ah say, because right now Ah don't think either one of you knows your ass from your elbow when it comes to what's good for you, General."

"Miguel, why are you doing this?" I asked plaintively. "We've worked so hard to build trust, and you have no idea how difficult that is in the Imperial Fleet and the MACOs." Leave alone in a man who's been through the things that Malcolm has.

He sighed. "That's just it, Liz. Right now, Ah don't trust either one of you to know what the right thing is. As the physician of record, his treatment and recovery is ultimately mah responsibility, so Ah need to take charge."

"You don't trust us?" I squeaked, my throat tight with hurt and outrage. "How can you say that?"

"First of all, the general here obviously doesn't recognize his own limits," the reply came with a scowl. "Or he's just incapable of accepting them. Then you got so caught up in playing nurse to your boyfriend here that you went and forgot that you actually are a nurse and abandoned all standards of professional medical practice, so you were in no position to rein him in!"

I knew exactly what he was alluding to with the word 'professional', and I couldn't help blushing a bit guiltily.

"I know my record-keeping has been a little lax," I admitted. "And I will fix that, per your orders, Doctor, but you can hardly say I've been otherwise unprofessional or abandoned the standard of care."

Miguel hasn't just made unilateral decisions affecting Malcolm. He has imposed orders on me, as well. For starters, if I want to remain in charge of Malcolm's physiotherapy and general care, I am now required to submit a daily SOAP note for my superior's approval. SOAP stands for Subjective, Objective, Assessment, and Plan. I resent this demand, but not because it's tedious and time consuming, or because it's more supervision than a nurse of my experience would ordinarily be subjected to; or even because it was incredibly condescending when Miguel actually sat me down and showed me how to write one as if I was a first-year nursing student and didn't know how. I resent it because someone actually had to tell me to do it.

Charting and documentation is as important to good medicine as the caregiver's knowledge and compassion for the patient. It's how we know what treatment the patient has received, what has worked, what has not, and how the patient is progressing. It's what allows someone else to take over in case some emergency prevents the primary caregiver from attending the patient, and, as Miguel pointed out, it's how we know when to tell the patient to slow down.

I'd had the idiotic idea that, since Malcolm was my only patient, daily progress notes weren't necessary. I see him every day. I know how he's been doing. I know him better than anyone, probably better than he wants anyone to know him. I rationalized that not keeping notes was protecting his privacy, which – if asked – I'd have argued was a psychological benefit for such a fragile, paranoid patient.

"You think you know what's going on, do you?" Miguel challenged me. "Fine then, Nurse." Turnabout was fair play and he had no qualms about using my professional title as a snide insult, as I had just used his. "Compare the patient's current condition to how he was doing two weeks ago. Identify the areas of greatest improvement, the one area – aside from his sprained wrist – that needs the most intensive therapy, and recommend three exercises to improve strength and functioning of that weakest part of his anatomy."

Appalled to realize that because of my complacency this was information I simply didn't have, I just stammered at him. "I…I don't know."

The admission didn't placate him. "Well, make somethin' the fuck up, then!" he sneeringly encouraged me. "Without your notes, hell, Ah won't know if you're lyin' or not!"

When I finally got his point – when I understood what it meant to keep good records even in this situation, not just professionally, the way they taught us in training, but practically, in terms of the quality of care I was able to give my patient – I just wanted to crawl away somewhere and sit and cry in the dark. Without a reliable, documented patient history, I couldn't do my job properly. Worse still, it shouldn't have taken Miguel calling me out to make me realize it.

When Malcolm saw how upset I was, he became incensed. I saw his shoulders stiffen, saw his fingers curl around the ends of the chair's arm-rests. "If you don't ease up, Doctor…"

"You'll what?" Miguel interrupted, probably deliberately to piss Malcolm off because he'd learned by then how much he hated being interrupted. "The best you can do right now is to spit at me, an' if Ah back up another five feet, why, you can't even manage that!"

"I won't always be bed-ridden, Doctor." I'd seen this so often, the way the eyes almost seemed to change color, to go shades lighter and infinitely colder. My spine crawled as I heard that mildly polite tone that anyone who knows him understands is so much more dangerous than any shout could be. "When I'm up and about again…"

"You'll do nothing, Mal." I could risk cutting him off, because honestly, I didn't really care if he threatened me or what he could do to me in the future. Maybe I am as screwed up as everybody thinks, but the most important thing to me is him. "Because he's right. It doesn't matter how much I help you or what I do for you, if I'm not keeping proper medical records the plain truth is that I'm failing you, professionally and ethically. That makes me no better than Phlox."

"Well, Ah wouldn't go that far," Miguel said, in a more conciliatory tone. He'd never met Phlox personally, of course, but he must have gleaned plenty of pointers towards the Denobulan's particular set of medical ethics.

Malcolm, however, was gaping at me. "Are you out of your bloody mind?" he snarled. "Phlox was a fucking sociopath, Liz, or have you forgotten that? He vivisected sentient creatures. He was going to operate on me without an anaesthetic! I know I've been a hateful bastard for as long as you've known me, but even I had a greater purpose to my cruelty than just wanting to hear something scream!

"...Most of the time," he had the grace to add, a little wryly. The whole Empire was made to bear witness to the time he didn't.

"Be that as it may," I told him, warmed to the core by his defense of me. "I've only been doing half my job. Miguel is right, and he shouldn't have had to point it out to me. I want your word that you won't ever retaliate for what he did today."

His resentment, once earned, was slow to dissipate. He gave Miguel a dark look. "Fine," he grumped eventually, clearly hoping I'd accept that word as his word.

"That's not good enough," I insisted, knowing to do so would leave him the loophole of saying he never actually swore to anything. "I want a promise. You may be a lot of things, hateful bastard included, though I really don't think so, but you've also always been a man of your word. Promise me you won't retaliate."

He didn't like being backed into a corner – literally or metaphorically. It had been a long time since he'd given me that chilly, measuring look, but within a moment he hooded the gray stare and shrugged, glancing at the doctor as though suggesting he should be thankful I was there to plead his cause.

"Malcolm, this matters to me."

"Fine," he said again, now turning on me a narrow-eyed glare like that of an angry teenager being told he wasn't having any fun anytime soon unless he did his homework and chores. "I promise I won't retaliate for his telling you off."

"Or anything else he does as your doctor," I added, "because he really is trying to help you and if anything ever happens to him, you'll have me to answer to."

Scowling first at me and then at Miguel, he didn't even bother to question what I could possibly imagine I might do to him in that eventuality. Somehow, without the words ever being said, we have established that I, of all people, am the one person in the universe whose opinion matters to him. It is enough that I would be displeased to learn that he has hurt Miguel.

Sometimes this development hits me so hard that I literally stop in my tracks. It's like having my own pet Tyrannosaurus Rex allow me to stroke his nose and give him orders.

"Fuck it all," he muttered. "Fine. As long as he has your support, he's safe from me, you have my word – but if you ever question his motives, all bets are off, got it?"

I nodded. "Fair enough." Then, turning to Miguel, I asked, "Now, do you think instead of prescribing a menu you could offer some dietary options and let Malcolm pick the foods he would prefer?"

The doctor was still pissed off. Glaring at me he said, "Next week, if the two of you show me you can manage to follow doctor's orders this week."

"Look, Miguel…" I tried to plead.

He wasn't having any of it. He looked at both of us from behind firmly-folded arms. "Or you can find another doctor."

I looked to Malcolm. Every time there has been a decision to be made, I have advocated for him to make the final call. That's how I try to give him back some of the dignity that was so brutally stripped from him back in Sickbay.

He shrugged again, as if he couldn't care less.

"I've had to follow unpleasant orders before," he said with a smirk. "If feeding me broccoli is the worst he can do to me, I'm sure I'll survive."

"All right then," Miguel said, eyeing him.

"Fine," Malcolm agreed, more or less, returning the eye.

I'm smart enough to know when I'm in the middle of a pissing contest. Not wanting to get all wet, I guided Miguel to the door.

"Perfect. We'll see you next week then, Doctor," I told him. "And I'll transmit my daily progress notes starting tonight."

"That'll be fine," he agreed. "Ah'd appreciate it if you sent them every evening after he's down for the night. Then the next day can start with a report of overnight activities and how he slept."

=/\=

As it turns out, Malcolm only had to eat broccoli once. Miguel left Elaine a list of menu options and let her know what I'd told him about broccoli. He just wanted to know that Malcolm would follow medical orders for his own wellbeing.

I've been submitting my SOAP notes religiously, both for physiotherapy and for Malcolm's general progress. The subjective component is still a bit of a struggle because, while he has no problems reporting positive progress, Malcolm has been so heavily conditioned to conceal any vulnerabilities that he sometimes seems to lack the vocabulary to talk about the areas where he feels he's struggling. I've found some assessments in the Defiant's medical database to help with that, though. All he has to do is check boxes or circle something, and though even these small admissions probably take some effort, I can use them to guide our conversation.

The objective component is nothing more than a record of Malcolm's vitals, input and output, diet, medication, activities, and the number of sets and reps of each exercise he completes in physiotherapy and how much weight he uses with the weight-bearing exercises. I complete most of my assessment while he's doing his exercises, unless he needs hands-on attention to stabilize him or guide his limbs through the correct motions so he doesn't twist or bend awkwardly and strain his joints. He rarely needs me to push him to work harder. More often than not once he gets the hang of an exercise, I find myself warning him to dial it back a notch or two.

At the end of every session we discuss together what he should try to do in the next one. I'm determined to give him as much autonomy as possible in this. He always kept himself in fantastic shape on Enterprise, and at the beginning of the project, I could tell he had continued to do so afterward. He always seemed to enjoy working out, and really, any exercise in moderation will benefit him right now. Unless he asks my input for a specific purpose, I mostly just write down whatever exercises he suggests and remind him that he needs to include balance, flexibility, and range-of-motion exercises along with the strength and stamina building. It's been three weeks, and so far, Miguel has approved every note as written.

So, things are going well, for the most part. Malcolm is on target with his physiotherapy. I am doing my job properly now, and Miguel has stopped riding herd on us as if we were a couple of irresponsible teenagers.

The problem now is, he just can't sleep.

As long as I've known him he's been a light sleeper, but this is different. His eyes may close, but his body never relaxes, his breathing doesn't deepen, and he tosses and turns throughout the night, kicking away his blankets and fidgeting with the splint on his arm.

I've tried everything. Maybe he's too cold, add a blanket. Too warm? Take one away. Hungry? Try a bedtime snack. Too full? Eat an hour earlier. One evening I spooned with him, to no success. Another night, Ginny came by and talked him through a breathing exercise that I could have predicted wasn't going to work because even the mention of her name when I'm taking his vitals makes his pressure and heart-rate increase. In desperation, I tried a hot toddy one night, made with his preferred whiskey instead of bourbon, and only just a drop of it, and the next night I offered to increase his pain meds.

"I'm not in any pain," he insisted. "And I don't want to be drugged any more than necessary!"

"I won't give you anything," I promised him. "Not without your consent."

"Are you sure you don't want more pain medication?" I ask again tonight as he fusses with his splint.

"No! I told you before, I'm not in pain. It just bothers me," he snaps.

"Is it too tight?"

"No."

"Too loose?"

"No."

I'm running out of options a bit here. "If it's sewn together with nylon threads, having the end of one of them poke you can be pretty irritating…."

"No kidding?" The dry tone and the look he shoots me in the dim light from the various monitors sends a very clear message.

"Ok, I know where I'm not wanted," I tell him resignedly. "If you think of anything I can do to help, just buzz me. I'll be out at the nurse's station."

"No, Liz, please." The whimpering tone was all I needed to hear, as humiliating as it must be for him to use. "I know I'm a pain in the arse, I'm just so bloody tired!"

"All right, if you want me to stay, I'll stay."

Actually, there are two problems. If Malcolm can't sleep, neither can I.

So I sit there on the foot of the bed, massaging his feet, which he really enjoys, and watching him watch me because he's just so tired but can't seem to close his eyes. As I massage deeply into his arch, he groans softly and smiles a bit, then frowns and turns his wrist.

"Malcolm, I'd like to try something," I say.

"Haven't we already tried everything?"

"Not this. I want to take the splint off your wrist."

"I told you it wasn't bothering me."

"I know, but humor me."

"Oh, fuck it all," he moans. "Do what you want. I'm too tired to care."

I'm seated by his left foot. I have to go halfway around the bed to remove the splint from his right wrist. I'm not even back to my seat when I hear the deep regular breathing of sleep. All the monitors confirm it: he's out.

I give him about five minutes and then gently and stealthily slip the reversible splint onto his left arm.

Almost instantaneously the slow, even brainwave patterns are disrupted. Less than a minute later he snuffles and snorts and he's awake. And even before he can be really conscious, I see the familiar reflexive jerk of his forearms.

"Noooooo," he moans so plaintively I think he may be close to tears. I feel bad, but I had to do it. "I was asleep! I finally got to sleep!"

"Yes, you were," I call from the other side of the room where I'm rummaging about for an elastic bandage.

"Er, it's on the wrong wrist." He sounds adorable in his groggy confusion as he squints from one arm to the other.

"I know. I was checking something out."

He groans out loud. "Couldn't you have just let me bloody sleep? I was so enjoying that!"

I refrain from pointing out that when you're asleep you don't know enough about your mental state to be enjoying it, but I know what he means: sleep is so vital for the proper functioning of the brain that not getting enough of it is literally torture, and if prolonged enough can lead to breakdown and ultimately madness. It's also essential to physical health. Children require naps because most of the hormones required for growth are released during sleep. As he's been regaining strength, we've worked two naps a day into Malcolm's schedule because those same hormones are necessary to trigger damaged adult bodies to repair themselves. Being finally 'plugged into the mains' for his mental batteries to recharge themselves must have been like drinking water when you're dying of thirst, and he needs to get plugged back in again as soon as possible.

"Give me five more minutes, and then I think you'll be sleeping in tomorrow." I remove the brace from his left arm and wrap the elastic bandage around his right ankle, taking pains to be sure it's not tight.

For the next ten minutes, he's miserably awake and his right foot is never still as he keeps rolling his ankle.

"It is the brace," I tell him as I pull a spare pillow out of a cupboard and tuck it in beside him. "But it's not pain or discomfort. It's muscle memory."

"Eh?"

"Your body thinks that a brace is a restraint holding you down." I say as I take his right arm and he lets me gently move it onto the pillow. "Anything around your wrist would have had the same result: a watch, bracelet, rubber band, even a snug shirt sleeve. Your body associates the feeling with being strapped to a table, your stress and anxiety go up, and you can't sleep."

"Really?"

"Yes, really. Maybe that's something you could talk over with Ginny," I suggest as I move to the bottom of the bed and remove the wrap around his foot. "Meanwhile, I'll discuss an alternative to the brace with Miguel for the times you need to sleep."

He doesn't even hear me mention Miguel. He's already out.

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