The next morning as Michael walked into the office, he found Rita waiting for him just outside the elevator.
"Drink that and follow me!" she ordered, handing him his daily green juice.
Michael could hear shouting emanating from down the hall. "Who is that?" he asked.
"That is the sound of a Tanner-Chung reunion," Rita explained, "No wonder they've avoided each other for so long. It started about as soon as they got here, and it hasn't quit! I told them they had to wait for you to see Lianne, otherwise they'd be shouting in there, too."
Rita and Michael entered the waiting room. Minnie was in a heated argument with one of her brothers, even as she was barking out orders to the other two, one of which was busy insulting Minnie's husband George.
"You go in first—no, Brian has to wait! Ethan, you go in second! Sit there! You will be at the foot of Grandmother's bed. No! You don't talk to my husband that way, Ben! Apologize, now! Straighten your tie! Tuck in your shirt! Don't spill anything! Oh!" She clapped her hand to her forehead, "I just want everything to be perfect for Grandma!"
"Minnie?" Michael asked, hoping to intervene.
The young woman turned to face him. "Oh! Dr. Holt! All right, can we see our Grandmother now?"
Michael surveyed the group. Minnie's brothers stood behind her, looking neat and tidy but also somewhat cowed and humiliated. George stood a respectful distance from them, watching Minnie.
"Sure," he told her, "I think it would be fine—as long as you are not disruptive of the other patients or the staff."
Minnie immediately turned on her men, "All right, you heard the doctor! That means no talking out of turn, no fighting, and we'll take turns going in! Ben and I will go first, then Brian and Ethan, you can join me when Ben comes out, and George comes last."
"Why do you get to stay the whole time?" Brian demanded grudgingly.
"Because I am the one who knows what Grandmother is saying!" Lianne declared.
"Excuse me," Michael interposed, "I'm just going to make my rounds now."
"All right, Dr. Holt," Minnie replied, "thank you." She returned to putting her brothers in their places.
Once Michael was finished with his morning routine at Holt Neuro, he hung his lab coat on the hook in his office and grabbed his trench coat and scarf.
"Going to pay your respects at the Clinica?" Rita asked knowingly.
Michael nodded; he glanced down the hall to the coma patient ward. Ben and George sat there, three yards apart, but not speaking a word to each other, not even looking at each other. He nodded toward them while looking at Rita.
"Keep an eye on that group, okay?"
Rita nodded, "Say hello to Kate for me."
Michael grinned, "Will do."
The Clinica lobby was as full as ever with screaming babies, dirty hoboes, and antsy children.
Anton greeted Michael when he walked in. "Good to see you, brother," he murmured calmly.
Michael grunted a quick, "Hi Anton," as he slipped on a fresh lab coat and stethoscope. It still felt weird every time Anton called him that.
Kate came out to see off another patient. She issued final instructions and turned to Michael.
"So how's Karthey?" she quipped, arching her eyebrows.
Michael smirked, "Nice to see you, too," he responded. "I'm sure she's doing just fine."
"You're sure? But you don't know that!"
Michael huffed, "Abel Medino is a good friend and a great doctor! I trust him!"
"More than you trust yourself, apparently!"
"Excuse me!" A woman's voice interrupted their subdued spat.
Kate and Michael turned to face the speaker, a tall woman in her late fifties dressed in a black pantsuit and bright, chunky jewelry. Beside her stood her husband, a clean-shaven man who had his arm around the shoulders of a young boy of about thirteen.
The woman extended her hand, "I'm Karen, this is my husband Trent, and you must be Dr. Holt. The man at the desk said you could help our son Matthew."
Michael surveyed Matthew. Other than the fact that he seemed to be the type who amused themselves by studying their shoes, there were no other visible signs of a problem. He shrugged. "Sure," he told Karen. "Follow me."
Michael was prepared to get right down to the issue with checking over his patient, but the minute he asked, "So what seems to be the problem?" it was clear that Karen, too, was prepared.
"Our son had always been a quiet child, mostly keeping to himself. He is happiest in his own little world."
"Especially if that world includes a piano," Trent muttered.
Michael noticed that Matthew was busy drumming on his knees as if he had a keyboard perched upon them. "You like the piano, do you, buddy?" he tried to engage the young man.
Karen leaned forward and tapped the edge of the table next to Matthew. In rhythm with her hands, she prompted in a singsong voice, "Answer the man, please, Matthew."
Matthew, to Michael's surprise, responded in kind, replying in his own melody without missing a beat. "I love the piano; it's my favorite instrument!"
Michael watched this exchange with interest. "Well," he remarked when Karen sat back, "His vocabulary is strong enough."
"Trent and I have ensured that he has not lacked anything in the way of education," she said with certainty, "even if the tutors had to come to our house, and be able to play the piano in order to get him to listen. He is a brilliant musician, our little musical protégée," she pronounced the malapropism with finesse, unaware that the correct term was "prodigy," "and we hoped to send him to Carnegie-Mellon, where I'm sure he'll do famously, but—" she frowned, "we can't get him to concentrate long enough to get his grades up. We've tried intensive tutoring, advanced placement, accelerated classes, even, but nothing works." She gazed sadly at her son, "It just burns me up inside to see such a marvelous talent go to waste. Do you know of anything that could help him behave normally? Is it ADD, do you think?"
Michael watched Matthew for a long time. He was still drumming away, oblivious to the people around him—but sitting very quiet and very still. A child with attention deficit disorder would be roaming the room, looking for something to catch their attention, if even for a moment. Matthew, on the other hand, seemed fixated on one thing alone.
Michael turned back to Karen. "Have you considered that Matthew might have autism?"
Karen seemed horrified at the suggestion. "Are you implying that our son is mentally deficient? I assure you, when the tutors are working with him he does phenomenal schoolwork. Matthew is not handicapped!"
Michael sought to reassure her, "I never said he was. Studies have shown that autistic individuals are only lacking in some social skills. Mentally, they can often be brilliant, especially if their fixation involves some sort of skill…such as music."
Michael saw Karen look at her son very differently. Instead of anxiety, he saw curiosity. He felt like a hero as he stood. "Well, since we've diagnosed the problem, let me tell you how we can help: I'm going to send you to Autumn, who is a social worker, and she can recommend some tutors and programs specialized for autistic kids, and they will help Matthew flourish within his condition." He walked the family out of the room and waved Autumn over.
Karen turned to him, "Thank you so much, Dr. Holt!" she gushed.
He smiled. "Don't put away those dreams of Carnegie-Mellon just yet," he encouraged. As the family left, he checked his watch. "All right," he told a harried Kate as she passed, "I'm out of here; good luck on the rest of your day!" he traded the lab coat for his overcoat.
Kate rolled her eyes and did not respond.
The rest of the day was as smooth as Michael could wish. The Tanners and the Chungs left around three-thirty, and Michael performed three minor cranial operations over the course of the evening without missing a stitch. At the end of the day, he hung up his lab coat and relaxed at his desk, mindful of a day well-spent. Michael noticed that his inbox held and e-mail from Dr. Medino. He opened it.
Attached were the contrast-MRI scans. They confirmed that flow through the brain was sluggish in some areas, backed up in others.
Dr. Holt, the e-mail read, Attached you will see the scans from Karthey D., the patient you referred to me yesterday. A lumbar puncture, administered with the patient laying prostrate, revealed about 53 cmH2O in Karthey's spinal cord. Such inordinate pressure, as you know, would require immediate surgery. I met with the mother and daughter after the puncture to discuss treatment options.
The first option I gave was an endoscopy. Further inspection of the MRI image may indicate stenosis of the aqueduct between the third and fourth cranial ventricles. An endoscopic ventricular bypass of the fourth ventricle, creating a new pathway from the third ventricle straight to the spinal cord, could solve this issue. However, as I expressed to Karthey and her mother, such a procedure runs the risk of disrupting the hypothalamus and also carries the risk of short-term memory loss.
The second option is to install a new cerebral shunt, if indeed an effective drainage system is what she needs. I communicated the necessary risks and projected failure rate with complete honesty. They said they would discuss the options, as neither sounded very pleasant at first, understandably so. I anticipate reaching a decision in the next couple weeks. I did warn them that whichever procedure they chose, Karthey should not leave Manhattan for at least a month….
Michael shook his head as he finished the e-mail. Something told him he would be getting a call from either Martha or Karthey the next morning, for sure!