Chapter 10: Dr. Mehta

The drive to Rockland was forty minutes on Route 1, the road that followed the coast the way a rope follows a capstan, wrapping around every inlet and peninsula, every harbor and cove, the road never straight, never direct, the road shaped by the land it crossed the way the land was shaped by the water it bordered, and Eamon drove it the way he drove every road — slowly, attentively, his hands at ten and two, his eyes on the road and the mirrors and the sides, the full scan, the constant monitoring, the situational awareness that the Coast Guard had trained into him and that he had never un-trained, the habit of seeing everything, noticing everything, processing everything, because the world was a system and the system could fail at any point and the failure would come from the direction you were not watching.

Nora sat in the passenger seat. She was dressed for the appointment the way she dressed for all appointments — carefully, completely, the outfit chosen and assembled with the deliberation of a woman who understood that appearance was communication, that the way you presented yourself was a statement about the state of the self, and the statement she wanted to make was: I am fine, I am put together, I am a woman who chooses her clothes with care and attention and whose choosing is evidence of her competence, and the competence is intact, and the doctor will see it, and the doctor will note it.

She wore the blue cardigan. The gray slacks. The shoes with the low heels that she had bought in Camden two years ago and that she wore only for appointments and for the rare dinner out, the shoes that said: I have a life outside the point, I am not only the keeper's wife, I am a woman who goes places and does things and wears shoes with heels.

She had put on lipstick. Eamon had watched her do it in the bathroom mirror, the tube held steady, the line drawn with the precision she brought to everything, the line that said: my hand is steady, my eye is steady, I am steady, and the lipstick was a declaration, a flag, the same kind of flag as the possessives — my table, my kitchen — the assertion of self in the face of the self's erosion, and he loved her for it, for the lipstick, for the effort, for the refusal to go to the appointment looking like a patient.

"Turn left on Cedar," she said.

"I know the way."

"I know you know the way. I'm saying turn left on Cedar."

He turned left on Cedar. Nora navigated. She always navigated. She had navigated since the paper maps, since the atlas in the glove compartment, since the years before GPS when navigation was a skill, a partnership between the driver and the navigator, the driver watching the road and the navigator watching the map, the two of them collaborating on the trajectory, and the collaboration was one of the rhythms of the marriage, one of the patterns, the give and take of direction and execution, and Nora still navigated even though Eamon knew the way because the navigating was her role and the role was part of the structure and the structure was part of the self.

Dr. Mehta's office was on the second floor of a medical building on Limerock Street, a building that had been a sardine cannery in the 1940s and had been converted to medical offices in the 1990s, the conversion preserving the brick exterior and the arched windows while gutting the interior and replacing it with the standardized architecture of modern medicine — drop ceilings, fluorescent lights, linoleum floors, the same architecture in every medical building in every town in America, the architecture that said: this is a place of science, this is a place of diagnosis, this is a place where the body is examined and the findings are recorded and the data is analyzed and the conclusion is reached, and the conclusion is what you came for, and the conclusion is what you are afraid of.

They sat in the waiting room. Eamon sat in a plastic chair that was molded into a shape that corresponded to no human body he had ever seen, and Nora sat beside him, her purse on her lap, her hands on her purse, her eyes on the magazine rack across the room, the magazines fanned in their holder like the prisms of a Fresnel lens, each one a different color, a different title, a different promise — health, beauty, travel, cooking — the promises of a world that assumed its readers were healthy and beautiful and traveling and cooking, and the assumptions were aspirational, were not descriptions of the readers but descriptions of what the readers wanted to be, and the gap between the assumption and the reality was the gap that the waiting room contained, the gap between the person in the magazine and the person in the chair.

"Mrs. Bryce?"

The nurse. They followed her through the door into the corridor, the corridor that smelled of antiseptic and recycled air and the particular scent of medical equipment that was neither pleasant nor unpleasant but clinical, the scent of objectivity, the smell of a place that did not judge but measured, did not comfort but diagnosed, did not love but treated.

The examination room was small. An examination table with a paper sheet. A desk with a computer. Two chairs. A window that looked out at Limerock Street, at the cars parked along the curb, at the brick buildings across the street, at the ordinary world that continued outside the window while inside the window the extraordinary business of the brain was discussed.

Dr. Anand Mehta was forty-eight. He was thin, dark-haired, precise in his movements the way a surgeon is precise, though he was not a surgeon but a neurologist, a reader of the brain, a interpreter of its signals and its silences, and his precision was the precision of a man who understood that the organ he studied was the most complex structure in the known universe and that his understanding of it was, relative to its complexity, negligible, and this understanding of his own ignorance was what made him good at his job, because the doctors who were not good at their jobs were the doctors who thought they understood, and the doctors who were good at their jobs were the doctors who knew they did not.

"Nora," he said. "Eamon. Please sit down."

They sat. Dr. Mehta sat at the desk. The computer screen was on, the screen showing something — a chart, a graph, a record — that Eamon could not read from his chair and did not try to read because the reading of the data was the doctor's job and the receiving of the interpretation was the patient's job and the patient's husband's job, and the division of labor was clear and the roles were defined and the room was arranged to enforce the division, the desk between the doctor and the patient, the desk a border, a threshold, a line between the person who knew and the person who was about to know.

"How have you been?" Dr. Mehta said, and he was speaking to Nora, not to Eamon, because Nora was the patient and the question was directed to the patient, the data coming from the source, unfiltered, uninterpreted, raw.

"I've been well," Nora said. "Some days are better than others."

"Can you describe a not-so-good day?"

"I forget things. Words, mostly. The names of things in the kitchen. I know what they are, I know what they do, but the name — the name goes away and comes back and goes away."

"How often?"

"Every day. Several times a day."

Eamon looked at her. Several times a day. He had not known it was several times a day. He had known about the colander and the whisk and the spatula because she had said the descriptions aloud — the thing with the holes, the thing you flip with — but there were other times, times when she had not said anything, times when she had reached for a word and found it gone and had simply not spoken, had simply continued without the word, and the silence where the word should have been was invisible to him because silence was the absence of information and you could not observe the absence of something you did not know was supposed to be present.

"What about names?" Dr. Mehta said.

"Names."

"Do you have trouble with people's names?"

Nora was quiet. Eamon could feel her calculating, not in the mathematical sense but in the strategic sense, the calculation of how much to reveal, how much truth to release into the room, because the truth, once released, would become data, and the data would become a chart, and the chart would become a diagnosis, and the diagnosis would become a trajectory, and the trajectory would become a decision, and the decision was the thing at the end of the chain, the thing that waited at the bottom of the truth like rocks at the bottom of a cliff.

"Sometimes," she said.

"Can you give me an example?"

"I called my husband by his brother's name. Once. A few weeks ago."

"Once," Eamon said, and then he stopped, because the correction would have been to say that she had also called Colleen by her sister's name, multiple times, and the correction would have been accurate but the correction would have been his data entering her narrative, his observation overwriting her account, and the account was hers to give, and the giving was her right, and his role was not to correct but to witness.

Dr. Mehta looked at Eamon. The look was professional, calibrated, the look of a doctor who understood that the patient's account and the caregiver's account were two instruments measuring the same phenomenon and that the instruments might not agree and that the disagreement was itself data.

"Eamon," Dr. Mehta said. "Can you tell me what you've been observing?"

"The word-finding difficulty, as Nora described it. The name confusion — she's called me by my brother's name, and she's called our neighbor by her sister's name. She gets disoriented sometimes. Early morning. She went outside a few weeks ago, to the rocks, at dawn, and she wasn't sure why she was there."

"How often does the disorientation occur?"

"Two or three times a week. Maybe more. It's hard to know because I'm not always there."

"Where are you?"

"In the tower. The lighthouse."

"Every morning?"

"Every morning."

Dr. Mehta wrote something on his pad. The pad was paper, not a tablet, not a screen, and the writing was by hand, by pen, and Eamon felt a kinship with this, with the man who wrote by hand in a world of screens, the man who kept a paper record, who trusted the pencil and the page over the keyboard and the server, and the kinship was irrational but real, the kinship of two men who believed that what was written by hand was more real than what was typed, that the physical act of writing inscribed the information not just on the paper but in the mind, and the inscription was deeper, was more permanent, was more true.

"I'm going to do some tests," Dr. Mehta said. "Nora, these are the same tests we've done before. They're not difficult. Just answer as best you can."

The tests were the tests. Eamon had sat through them three times now, and the sitting was its own form of endurance, the watching of his wife being tested, the watching of her intelligence — the real, substantial, formidable intelligence that had taught third grade for thirty-one years and had raised a marine biologist and had maintained a sourdough starter and had navigated with paper maps and had known the difference between a Daboll trumpet and a diaphone because her husband had told her and she had listened and she had remembered — the watching of that intelligence being measured by tests that asked her to count backward from a hundred by sevens and to draw a clock and to remember three words and repeat them five minutes later.

She counted. Ninety-three. Eighty-six. Seventy-nine. Seventy-two. He heard the number and thought of the steps, the seventy-two steps, the same number, and the coincidence was not meaningful but it was there, the number connecting the test and the tower, the counting and the climbing, and Nora was climbing and the numbers were the stairs and the stairs were getting harder, the treads less certain, and at sixty-five she paused and the pause was a step that was not there, a tread that the foot reached for and did not find, and she said, "Fifty-eight," and Dr. Mehta wrote on his pad and said, "That's fine, let's move on."

She drew the clock. The circle was round, which was good. The numbers were placed correctly, which was good. The hands — she was asked to draw ten minutes past eleven — were close, were nearly correct, the hour hand on the eleven and the minute hand on the two, but the minute hand was shorter than the hour hand, the proportions reversed, the small error that was not a small error but a sign, a reading, a data point on the chart that Dr. Mehta was building, the chart that described the trajectory.

She was given three words: lighthouse, bread, harbor. She repeated them. She was asked to remember them.

Dr. Mehta talked to her for five minutes. He asked about her daily routine, her cooking, her garden, her reading. He asked about sleep, about appetite, about mood. She answered correctly, completely, the answers detailed and coherent, and Eamon listened and thought: she is fine, she is herself, she is answering every question with the full weight of her intelligence, and the intelligence is there, the intelligence is present, and the tests are tests and the tests do not capture the person, the tests capture the deficit, and the deficit is not the person.

"Nora," Dr. Mehta said. "Can you tell me the three words I asked you to remember?"

She looked at him. The look was the look of a student who has been asked a question she knows the answer to, the look of confidence, of competence, of the teacher turned student who will demonstrate that she has learned what was taught.

"Lighthouse," she said.

"Good."

"Bread."

"Good."

She paused. The pause was not like the pause in the counting. The pause in the counting had been a momentary gap, a stumble, the foot missing the step and recovering. This pause was longer. This pause was a search, a reaching, the hand extending into the dark for something that was there a moment ago and was not there now, and the reaching was visible on her face, the effort of it, the strain of it, the concentration of a mind working at the edge of its capacity, trying to retrieve the word that had been placed there five minutes ago, the word that was in the room, in the air, in the context, the word that should have been available, should have been easy, should have been as automatic as the name of the colander or the spatula or the husband, and the word was not there.

"The third word," she said. "I know I know it."

"Take your time."

"It's a place. It's a — it's where the boats are."

"That's right."

"The boats come in and they tie up and the water is calm and the — the place where the boats are."

"Harbor," Eamon said.

He said it without thinking, said it the way he would have handed her the word if it were a tool she had dropped, a thing she needed, a thing that was hers that had fallen from her hands, and the handing-back was instinct, was reflex, was the keeper's reflex, the response to a signal that said: something is wrong, something needs attention, something needs to be restored.

"Harbor," Nora said. "Of course. Harbor."

Dr. Mehta wrote on his pad. He did not look at Eamon. He did not need to look at Eamon because the look was unnecessary, the message was clear, the data was the data, and the data said what it said, and what it said was that the three words — lighthouse, bread, harbor — were the measure, and two out of three was the score, and the score was lower than the last time, which had been three out of three, and the trajectory was the trajectory.

They sat in Dr. Mehta's office afterward, the examination over, the tests scored, the data recorded. Dr. Mehta sat behind his desk with his pad and his pen and his face that was kind but not sentimental, professional but not cold, the face of a man who delivered news that he had delivered many times and who had not become numb to it but had learned to deliver it with a precision that was its own form of compassion, the precision of a man who understood that the truth, delivered cleanly, was less painful than the truth delivered poorly, the way a clean cut healed faster than a ragged one.

"The progression has accelerated," Dr. Mehta said. "The medication is working, but the disease is outpacing it. This is not unusual. This is the expected course."

"Expected by whom?" Eamon said.

"By the disease. By the neurology. The early stage is ending, Eamon. What we're seeing now — the word-finding difficulty, the name confusion, the disorientation, the memory loss — these are the markers of the transition to moderate stage."

"Moderate."

"Moderate. Which means more frequent episodes. More significant memory loss. Difficulty with complex tasks — cooking, managing medications, navigating. Possible personality changes. Possible behavioral changes. And the wandering — the incident on the rocks — that's a safety concern."

"I'm addressing the safety concern."

"How?"

"I'm there. I'm with her. I check on her. I monitor."

"You're also in the lighthouse every morning at five a.m."

"I can adjust my schedule."

"You can. But the question is whether adjustment is sufficient or whether the level of care she needs exceeds what one person can provide, regardless of how dedicated that person is."

Nora was sitting in the chair beside Eamon. She was listening. She was present, was engaged, was following the conversation the way she had followed it in the examination room, with the full attention of a woman who understood that the conversation was about her and that her presence in the conversation was important and that her absence from it — her silence, her passivity, her allowing the men to discuss her fate without her input — would be a surrender she was not prepared to make.

"I'm sitting right here," Nora said.

Dr. Mehta turned to her. "I know you are, Nora."

"Then talk to me. Not about me. To me."

"You're right. I apologize."

"What are my options?"

"The medication adjustment I mentioned. A higher dose of the donepezil, which may slow the progression. And I'd like to add memantine, which works on a different pathway. Together, they may give us more time."

"More time before what?"

"Before the disease progresses to the point where independent living is no longer safe."

"I don't live independently. I live with my husband."

"I understand that. But there may come a time when Eamon needs help. Not because he's not capable, but because the care you need is more than one person can provide around the clock."

"You're talking about a facility."

"I'm talking about options. A facility is one option. In-home care is another. A combination is another. The point is to plan now, while you can participate in the planning."

Nora looked at Dr. Mehta. The look was the look she had given Eamon in the kitchen after Patrick's visit, the look that was clear and present and fully Nora, the look that said: I am here, I am myself, I understand what is being said to me, and I will respond to it with the full authority of a person who has earned the right to decide her own fate.

"I want to stay in my house," she said.

"I understand."

"I want to stay with my husband."

"I understand."

"And I want to decide. When it's time. I want to be the one who decides."

Dr. Mehta nodded. "That's why we're having this conversation now."

They drove home. Route 1, the coast road, the wrapping around the inlets and the peninsulas, the road that never went straight, and Eamon drove and Nora navigated and the navigation was correct, every turn correct, every direction precise, and the correctness was the proof, the correctness was the evidence, the correctness was the data that said: she is here, she is present, she knows the way, she knows the road, she knows the turns.

"Turn right on Shore Road," she said.

"I know."

"I know you know."

They passed Colleen's house, the small Cape set back from the road with the lobster traps stacked in the yard and the truck in the driveway and the boat on the mooring visible in the harbor below, and Nora said, "We should have Colleen for dinner," and Eamon said, "We should," and Nora said, "I'll make chowder," and Eamon said, "Good," and the conversation was the routine, was the script, was the structure, and the structure was the thing that held, the thing that did not deteriorate, the thing that persisted despite the trajectory, despite the markers, despite the score of two out of three.

They reached the point. Eamon parked the truck in the yard. The lighthouse was there, white, vertical, solid, the lens catching the afternoon light at the top, and the keeper's house was there, white, horizontal, solid, the kitchen window reflecting the sky, and the bay was there, blue, wide, moving, the lobster buoys dotting the surface in their colors, and the whole of it — the tower, the house, the bay, the buoys, the sky — was as it had been that morning, was as it had been for twenty-six years, was as it would be tomorrow and the day after and the day after that, and the permanence of it, the persistence of it, the sheer granite-and-brass stubbornness of it was a comfort, was a handhold, was the railing on the staircase that the hand gripped when the steps were steep and the footing was uncertain.

Nora got out of the truck. She stood in the yard and looked at the lighthouse and the house and the bay, and her face was the face of a woman who was seeing these things and knowing these things and claiming these things — my lighthouse, my house, my bay — and the claiming was fierce, was defiant, was the claiming of a person who had been told that the thing she was claiming might be taken from her, not by a person but by a process, and the process was relentless and the process was impersonal and the process did not care about claims.

"I'm going to make bread," she said.

She went inside. Eamon stood in the yard. He stood in the yard and looked at the lighthouse and thought about Dr. Mehta's words — the early stage is ending — and the words were data and the data was the data and the data said what it said, and what it said was that the fog was thickening, that the visibility was decreasing, that the conditions were changing, and the keeper noted the conditions and wrote them in the log and prepared for what was coming, because that was what a keeper did, the keeper prepared, the keeper maintained, the keeper kept watch, and the watch was not over, the watch was never over, the watch was the life.

He went to the tower. He climbed the seventy-two steps. In the keeper's office he sat at the desk and opened the log and wrote:

1430. Clear. SW 8-12. Temp 61. Barometer 29.88. Visibility unlimited. Medical appointment, Rockland. Medication adjustment pending. All lighthouse systems satisfactory.

He looked at the entry. The lighthouse systems were satisfactory. The lighthouse systems were always satisfactory. The lighthouse systems were the one thing he could make satisfactory, the one thing his skills addressed, the one thing his maintenance maintained, and the entry was true, and the truth was the truth as far as it went, and it did not go far enough, and it never went far enough, and the pencil could not write what the heart held, and the log could not record what the life contained, and the format was insufficient, and the format was all he had.

He set the pencil in the groove. He closed the log. He went to the house, where his wife was making bread, the flour on the counter and the starter in its crock and the scale set to grams and the salt — the salt measured and ready, measured and present, the salt that she had forgotten twice and that she had not forgotten today — and he stood in the doorway and watched her and the watching was the keeping and the keeping was the love and the love was the light and the light was still on.