Chapter nine:  Introductory Lessons

(November 19th)

Steve's first session with Marcus was devoted to diagnostic testing.  For four hours, Steve answered questions and followed instructions.  The tasks the young man asked Steve to perform were not difficult.  In fact, many of them were insultingly easy and Steve had no trouble whatsoever in doing what he was asked.

First, he pretended to perform some of the basic tasks of his morning routine.  Some of the instructions Marcus gave him were oral, and some were written, but he performed them all on command.  He mimed washing, shaving, brushing his teeth, and dressing.  He even remembered to put on imaginary deodorant and comb the hair that had not grown in yet.  Then he went on to more complicated tasks that included retelling a brief story and performing some complicated mental mathematical operations.

Next, he answered a series of yes or no questions about his own personal information.  He agreed that his name was Steven Michael Sloan and that he preferred to be called Steve.  His mother's name was Catherine and his father was Doctor Mark Sloan.  He denied that he was the Chief of Police and agreed that he was a lieutenant in the homicide division.  The questions went on for nearly twenty minutes, becoming increasingly complex, and a couple of times, he had to find a way to reply yes to one part of the question and no to another.

After the question and answer drill, Marcus assigned him a series of tasks that began simply and got progressively more difficult.  First, he separated a sack of small plastic chips by shape and size.  Then Marcus mixed them up and he divided them again by color.  Marcus mixed them again, and he sorted them by color and size, and once more, he arranged them by color, size, and shape.

Next, Marcus showed him a card with a picture of a panting puppy made from the plastic chips, and he had to reproduce it.  Then he made a train, an airplane, a house, and a tree.

"Now, make a cat," Marcus said, but didn't show him a picture to work from.

Steve made a face at him, but, with a very bored attitude, he complied.  First, he put down a large black circle for the head.  At the top of the circle, he placed two black triangles for the ears, then he placed smaller red triangles on top of them for the insides of the ears.  Dime-sized green circles became the eyes, a small gray triangle for the nose, and a little red semicircle for the mouth.

"Good," Marcus said, "but it's missing something."

"Of course," Steve said sarcastically, "my kitty needs whiskers."

Hearing the tone behind Steve's mangled words, Marcus decided this would be the last task he would give Steve with the manipulatives today.

Steve selected six long, narrow rectangles and placed them on the cat's face for whiskers. 

"Ok," Marcus said, then made a face.  "But I don't like the looks of them.  Can you choose something else?"

Steve put the rectangles back and chose six skinny isosceles triangles instead.  He put the wide ends near the nose and spread the narrow ends out.

"Great," Marcus said.  "Now, there's one more thing missing.  Can you see what it is?"

Steve started at his creation a moment.  There was something wrong, he could see that now, but what was it?  His cat had ears, eyes, nose, mouth . . . eyes!  It didn't have cat's eyes!  He chose two small, narrow ovals and placed them in the centers of the circles he'd used for the eyes.

"Purrrrfect," Marcus said.

Steve just rolled his eyes.

"Get it?" Marcus asked.  "I said purrrrfect."

Steve gave a phony grin and nodded, then rolled his eyes and shook his head no.

"Everybody's a critic," Marcus said.  "I don't get no respect."

Steve finally laughed slightly and shook his head.

"Ok.  Let's put this stuff away." 

With a huge sigh of relief, Steve started gathering up the plastic chips and shoving them into the bag.  When they had finished, Marcus said, "Ok, I am going to ask you some more questions.  I want you to try to verbalize your answers.  Do you understand?"

Steve nodded.

"I want an attempt at words, Steve.  Do you understand?"

"Yes."  Steve nodded for good measure, knowing even such a simple response would be unintelligible coming from him.

"What is your name?" Marcus asked.

Steve froze for a moment.  This was not something he could nod or shake his head to.  

Marcus let the silence stretch a full minute before he asked, "Do you know your name?"

A nod.

"Words, Steve."

"Yes," accompanied by another nod.

"Then tell me your name."

A shake of the head.

"Words."

"No," again, with a shake of the head.

"Try."

Another shake of the head.  "NO!"  He was being stubborn and Marcus couldn't blame him.  Most of his patients found it painful to be confronted with the fact that they couldn't say their own names, and the stubborn refusal to try and fail was a common reaction.

"If I say it for you, will you try to say it back?"

A pause for thought, then a cautious nod.  "Yes."

"Ok.  Your name is Steve," Marcus pronounced it slowly.  "Say 'Steve'."

Tentatively, he formed the word, once silently to himself, then softly for Marcus to hear.  "Teeb."

Marcus could tell from the expression on Steve's face that the moment he heard his own voice, he knew he had said his name wrong.  He saw the man's jaw clench and noticed the irregular breathing, and his heart went out to him.  Knowing things would only get harder before they got easier, he knew he had to push now.

"Let's try once more.  I'll say it and you repeat."  He drew the word out, making each sound a plain and distinct as possible.  "Sssssteeeeve."

Steve was rocking back and forth.  Marcus imagined the motion soothed him.  After a moment, he said, "You have to try again.  Sssssteeeeve."

"I am not an idiot or a child.  Don't talk to me like I am stupid!"

After the string of unintelligible garble, Marcus weighed his options, and decided to try again.

"If you are going to learn to talk again, you have to keep trying until you get it right," Marcus would not cut this man any slack.  He knew how slim the odds of a complete recovery were, and he knew that any improvement would depend upon consistent practice and repetition.  "I am going to say your name again.  I am saying it slowly so you can hear every part of it plainly.  Then you will say it back to me, understand?"

After a moment of mutinous silence, he received a slight, reluctant nod.  "Yes," the whisper was inarticulate, but he was still trying to talk.

"Sssssteeeeve."

Steve was silent a moment as he processed the sounds, then, "Sssssteeeeb."

Steve threw up his hands and rolled his eyes, clearly aware that he had failed again and already frustrated with his limitations.

"Hold on, now!" Marcus told him.  "That was better.  You got the s in this time.  That's an improvement."

Steve said, "Pfft!" and waved his hand dismissively.

"Any improvement is a good sign, Steve.  Now I want you to try it again."

Steve shook his head.  "No."

"Yes," Marcus insisted.  "Say it.  Sssssteeeeve."

Steve closed his eyes and concentrated, clearly replaying the sounds in his mind and struggling to find a way to make his own voice reproduce them.  He rubbed his temples and began rocking again.  Finally, he spoke.  "Sssssteeeef.  Sssssteeeef."

He shook his head, angry with himself and clearly upset.  "Dammit!  Why can't I get it?" 

"Hey, man, it's ok," Marcus said, giving Steve a comforting squeeze on the shoulder when he saw him close his eyes and clench his fists.  "An f is closer to a v than the b was.  You'll get it."

Steve shook his head vehemently.

Marcus poured him a drink of water.  "Here," he said, and noticed the shaking hand as his patient accepted it.

Marcus patiently waited several minutes while Steve collected himself, then, when he drained the water and handed back the cup, Marcus said, "We will try one more time, and then we will move on, ok?"

Reluctant but resigned, Steve nodded.

"Sssssteeeeve," Marcus said.

"Ssss . . ." Steve stopped, then started again.  "Ssssteee . . ."  He stopped again and tried once more, determined to get it this time.  "Sssssteeeeve," he grinned.  "Sssteeve.  Steve!  Steve!  Steve!"

Laughing aloud and clapping his hands, Steve celebrated his accomplishment.

"Very good!"  Marcus praised him.  "Very good."

Suddenly, Steve fell silent and started chewing his lower lip, and Marcus could tell he was distraught.

"What is it, Steve?"

Steve closed his eyes and began to rock again.  Marcus waited patiently for him to collect himself and formulate his reply.  Finally regaining control, Steve opened his eyes and held up four fingers.

"Steve," he said, and counted off one finger.  Then he threw his hands up in a futile gesture and shook his head no.

"Steve," he repeated his name and the gestures.  Once more, he said, "Steve," and made the helpless gestures.

Finally, he said, "Steve," and gave the thumbs up.

Marcus thought a moment, then smiled.  "You had to try four times.  In my experience, that's not a lot."

Steve frowned and sighed.

"Look," Marcus tried to encourage him, "the first couple weeks are going to be like introductory music lessons.  Your voice is your instrument and you are learning what it can do.  Once you learn to make sounds with it, you can begin to put those sounds together and make music, and you will start to learn other sounds and words on your own."

Marcus was totally unprepared for the reaction he got.  Steve looked suddenly stricken.  He drew his knees up to his chest, wrapped his arms around them, hid his face against his legs, and began to rock.  When he heard the distinctive sound of tears being barely held at bay, Marcus put a hand on Steve's arm and was brushed off.  Hoping he was doing the right thing by being persistent, he decided to put an arm around Steve's shoulders.

"Get off me!" Steve yelled and shoved him away.  "Just go away and leave me the hell alone!  Just GO dammit!"  He pointed to the door.

Marcus knew he was being ordered away, be he chose to defy those orders.  Instead, he sat on the edge of the bed beside his patient, and told him, "I don't know what I said to upset you, Steve, but you know I didn't mean to.  I realize you can't explain to me what's wrong right now, and I am not sure you would if you could.  I am sure, if you want me to know what's wrong, you will try to tell me if and when your are ready, but right now, I think you just need some time to gather your thoughts."

Steve tried to push him off the bed, but Marcus braced himself by pushing his toes against the floor.  He gripped Steve's upper arms firmly and said, "Look at me."

Steve shook his head no.

"Look at me, Steve.  I'm not going anywhere until you do."

After a long, silence, Steve looked up, and the pain Marcus saw in his eyes was shocking.  He knew Steve was in no shape to continue testing right now, but he also knew how important it was to get started on Steve's speech therapy as soon as possible.  He didn't want to push the man to the breaking point again, but he knew they had to continue soon if they were to finish the diagnostic tests today.

"I am going to leave, Steve, but I will be back in five minutes, and we will continue."  With that, Marcus got up and left.  He had barely cleared the doorway when he heard the bedpan slam against the wall and clatter to the floor.

Five minutes later, Marcus returned to find Steve red-eyed and shaken, but ready to continue.  He didn't ask if Steve was all right, thinking it might drag him down again.  Instead, he crossed the room and picked up the bedpan, placed it back on the bedside table, and then went into his backpack and pulled out a deck of cards.

"Ok," he said, "these cards have pictures illustrating four well-known fairy tales.  I want you to sort them and then sequence them so that they correctly tell the stories."

It took Steve less than five minutes to perform the task.

"Excellent," Marcus said.  "Now, tell me the names of the stories."

Steve gave Marcus an inquisitive look and refused to answer.

"Oh, you want to know why?"

Steve nodded.

"Words, Steve."

"Ye-eh."

"Good!  You're getting it!"

Steve grinned.

"Ok, why do you have to name the fairy tales?"

Steve nodded, "Ye-eh."

"Alright, this takes some explaining, so hang with me, ok?"

"Ye-eh."

"Aphasia encompasses a lot of things.  The size of the affected area of the brain and the severity of the damage have a lot to do with the problems an aphasia patient experiences.  Are you with me so far?"

Steve nodded.  "Ye-eh."

"Some patients have trouble comprehending language, others can comprehend but can't respond properly to instructions.  There are people who can respond to yes or no questions but not much else, and there are those who can follow simple step-by-step instructions but cannot undertake a complicated task where they have to organize information and decide what to do about it.  The problems are as unique and complex as the patients themselves.  Understand?"

"Ye-eh-ss."

"Hey, you added the s!  Great job!"

Steve beamed, and Marcus continued.

"The questions we started with showed me that you can comprehend and respond appropriately to questions of fact.  The plastic manipulatives proved that you still understand size, shape, and color relationships and that you can sort correctly.  You can recognize similarities and differences among objects.  Making the pictures showed me that you can reorganize information to mimic a model, and making the cat told me that you can synthesize information into something new and original.  Telling you the cat was purrrrfect showed that you still understood humor, even if you didn't like the joke.  Still with me?"

"Ye-ehs."

"Good.  Putting these cards in order shows me that you can reassemble familiar information.  Naming the stories will tell me if you can recall familiar names, and in a few minutes, when I have you retell one of the stories, I will know just how well you can describe familiar events."

"But I can't talk right," Steve said.  "How will you know I'm telling the stories properly?"

"Steve, you know I have to guess at what you just said, right?"

"Ye-ehs."

"I'll bet you want to know how I will know what you said."

"Ye-ehs."

"Same way I just did with the question.  I will repeat what I think you said, and trust you to confirm it for me, ok?"

"'Kayyyyy."

"Now.  Will you name the stories for me?"

Steve pointed to one set of cards and said, "No Aiiiii."  The next story was, "Guddyoxen Da Dee Bahs."

Steve stopped and Marcus watched as he took a deep breath and tried to control his frustration.

"You're doing fine, Steve.  Remember, today, I just need to know what you can do.  Tomorrow we will work hard on improving your speech."

Steve nodded, "'Kayyyyy."  He pointed to the third set of pictures and said, "Leen Booee."

He paused a long time before he named the last one.  Marcus waited patiently and watched as he tried several times to form the words.  Finally, slowly, they came out, "Yil Weh Wy-een H-oot."

"Ok, Steve, that was good.  Now, I think I understood you, and I think you got all four right, but just to make sure, I am going to say the names of the stories for you.  I want you to point them out and say the titles back to me, ok?"

"'Kayyy."

As they went through the stories again, Steve listened carefully to Marcus' pronunciation.  Snow White went from 'No Aiiiii' to 'No Waiiii-T.'  Goldilocks and the Three Bears was now 'Guldyox Inna Fwee Baws'.  Sleeping Beauty was 'Sleen Bootee,' and Little Red Riding Hood came out, 'Yil Wed Wydeen Hoood.'

"Very good, Steve," Marcus praised him.  "Now, pick one of the four stories to tell me."

Steve thought a moment and decided he had mauled Sleeping Beauty the least.  Pointing to the correct set of cards, he began, "Wus ponna tie . . ."

Thirty minutes later, the bedpan and urinal were on the floor under the vacant bed again.  After several false starts and long pauses, Steve, frustrated almost to the point of tears, sent the cards flying off the table with a sweep of his arm and, finally said, "Dee Und!"

Marcus looked for a moment at the cards scattered on the floor, then he looked at Steve.

"I'm going to collect the cards, and leave you for a few minutes.  We both need a break.  Then I will come back, and you will have to try to write for me.  That will be the last of my tests.  Then, I will leave you alone for the day."

"Fine!  I'm getting sick of you anyway," Steve grumbled.

Marcus had no idea what Steve had said, but he knew it was an insult.  He also knew better than to take it personally.  Without a word, he collected his cards and walked out.

"So how's he doing?" Mark asked the young man as he approached the nurse's desk.

"Well, right now he's pretty pissy," Marcus said, and when the doctor raised an eyebrow, he hastened to add, "which is understandable.  He's had a rough day.  The good news is he's making progress already."

"Any idea what his prognosis might be?"

Marcus hid a smile.  The worried parent was hiding behind medical jargon.

"It's too soon to tell, Dr. Sloan.  You know that.  Ask me again in a month, and I might be able to tell you more."

Mark just nodded and said, "Tell him I'll see him at dinner, ok?"

"Ok, I'll do that, Sir."

Mark turned and walked away, and Marcus returned to his patient.

In less than ten minutes, the writing test ended with Steve throwing pencil and paper across the room and shouting, "I can't do it!  I know the damned alphabet, but I just can't say it, let alone write it down.  I can't spell my own name, and I sure as hell can't write a letter!  Are you satisfied?"

"Ok," Marcus replied gently, "we're done for the day.  Your dinner will be arriving within the hour, and your dad asked me to tell you he'd see you then."  Marcus pressed the button that lowered the bed.  "Until then, I want you to take a nap."

"I am not a child.  I do not need a nap."

"You need to rest now, Steve," Marcus replied, as if he had understood every word, though Steve knew he hadn't.  "You have just spent four hours working very hard to redevelop skills you no longer possess."

"I am not tired," Steve insisted.

"Right now, your brain is trying to repair itself.  When you sleep, your body releases low levels of growth hormone to aid in cellular repair.  If you rest now, chances are, at least some of what we have done today will be 'rewired' into your brain as it repairs itself."

Steve gave him a doubtful look.  "I don't believe you."

Marcus shrugged.  "The body repairs itself in sleep.  We know the brain can be 'reprogrammed'.  The rest is just a theory of mine, but it stands to reason, and a little more rest won't hurt you, so humor me, ok?"

Steve sighed, rolled his eyes, and since he was flat on his back now, he rolled over, pulled up the covers, and closed his eyes. 

By the time he had his gear collected and put the bedpan and the urinal back where they belonged, Marcus could hear his patient snoring softly.  He smiled, and turned the light out as he left.