Courage

A note of warning:  This post contains the story and somewhat graphic details of a second trimester miscarriage.  Although it was important to me that this story be told, I recognize that this may be very difficult for some people to read.

-m

~ ~ ~

The triage nurse walked Olivia back to my room less then two hours into the start of my shift.  She settled her into a room, closed the door, and came up to where I was sitting.

“Whatcha got?”  I smiled up at her.  She was one of my favorite coworkers, kind and compassionate and tough.

The triage nurse sighed.  “25-year-old, G3, P0, second trimester, vag bleeding for a few hours.”

I winced.  G3P0 meant that this was her third pregnancy, but that none of the pregnancies had been carried to term.  “Miscarriage?”

“Maybe so.  She’s miscarried twice before.”

I shook my head.  “That’s no good.  Poor thing.”  The triage nurse nodded in agreement, and headed back out to the overflowing waiting room.  I gave Olivia a few minutes to get changed, and then headed in to see her.

She was young, pretty, heavyset, polite, frightened.  We chatted a little bit before the doctor came in.  She had indeed miscarried her two previous pregnancies.  She’d been bleeding, but not heavily, for about three hours.  She wasn’t passing any clots.  She wasn’t in any pain.  She’d had good prenatal care.  She was fourteen weeks along.

I started her IV, drew her blood, sent her to the bathroom for a urine sample, entered all the basic orders I knew the doctor would need.  A few minutes later Olivia’s mother came into the room, and sat down on a chair next to her bed.  The entire mood in the room changed.

“Are you losing this baby?” she asked her daughter, bluntly.

“I don’t know, mom,” she replied quietly.

“Where’s Allen?”

“He had to work today, you know that.”

“He should be here with you; it’s his baby, isn’t it?”  She didn’t even pause for breath.  “Has the doctor been in?  Have they done the ultrasound?”

“Ultrasound is on their way, ma’am,” I said, politely.  I was already plotting ways to get rid of her.

“Why does it always take so long to get something so simple done?  Isn’t this an emergency room?”  She folded her arms, and looked at me crossly.  “Do you have any juice?”

“We’re going to keep Olivia NPO for now,” I said, deliberately misunderstanding her.  Then I fired up the extra-charming smile I saved for the people I disliked the most, and left the room.

~

I managed to boot Olivia’s mother out when ultrasound came in, and then took care of my other patients until the tech finished her exam.  She wheeled the machine back out of the room and walked over to me, rubbing her hands with sanitizer.

“Well?”

She shook her head.  “No heartbeat.  Fetus looks to be about fourteen weeks, so she’s right on her dates.  Probably happened sometime in the past few days.”

When the doctor and I walked into Olivia’s room together, she knew before we even had a chance to speak.  Whether she could tell from the look on our faces, or had figured it out from the deliberately evasive answers the ultrasound tech would have given her, she knew the pregnancy was over.

She cried quietly throughout the necessary but unpleasant speculum exam, throughout the scheduling with OB/GYN for a D&C the following day, throughout the discharge teaching I did with her before we sent her home for the night.  I hugged her for a long time, told her how sorry I was, and meant it.  She hugged me back.

Then I sent her out to the waiting room to her mother, and to what would undoubtedly be a miserable ride back to her apartment.

~

Thirty minutes later, the secretary tracked me down.  “Martha, you’ve got a call on two.”

I picked it up.  It was Olivia’s mother.  “Were you Olivia’s nurse?”

“Yes, ma’am.”

“Well, I don’t know what the hell you guys did there, but it clearly wasn’t enough.”  I heard a horn blaring on the other end of the line.  “Watch it, asshole!”  Then she took another breath.  “Olivia just miscarried the baby in the parking lot of her apartment.  We’re heading back to the ER right now.”

My brain clicked into high gear immediately.  “I’ll have the same room waiting, ma’am.  You go straight to the triage nurse when you get here; I’ll make sure we get Olivia back immediately.”

“I would certainly hope so!” she snapped, and hung up.

I grabbed one of the techs.  “Get a gyn bed back into room six, and can you go find me a couple packs of disposable chux?  And the gyn cart?”  He nodded, and headed off to the storage room.  I called up to triage.

“Olivia’s on her way back — she miscarried the baby.”

“Oh, God, that poor thing.”

“Her mom’s bringing her in.”

“Oh,” the triage nurse said flatly, a wealth of meaning infused into that single syllable.

I cleared my throat deliberately.  “I think Olivia’s going to need some privacy for the follow-up care we’ll be doing.”

The triage nurse snorted.  “I’m sure we have some very specific hospital rules about that somewhere.  I’ll have security explain it to her mom.  From the waiting room.”

I grinned into the phone.  “You’re the best.”

I could just see her grinning back.  “I know.”

~

Neither of us were smiling when she wheeled Olivia back again twenty minutes later.  She parked the wheelchair just inside the room, flashed me a pained look over Olivia’s head, and left, closing the door behind her.  I leaned down and grabbed Olivia’s shoulders in a hug.  “Oh, honey.  I’m so sorry.”

“Martha, I’m sorry, I’m so so sorry.”  She was crying openly, but didn’t hug me back.

“You have nothing to apologize for, Olivia –”

“No, no, look, look at me!”  She was sobbing now.  I glanced down, and realized what she meant.

She was covered with blood.  Her hands, her fingers, her nailbeds, all caked with blood.  It streaked up her arms, and down both legs.  The loose skirt that had been clean when she’d left me an hour ago was now splashed with dark red stains.

And in her lap was a plastic grocery bag.

She was gasping between sobs.  “It just – it just – it just fell out!  I got out of the car, and felt a gush of blood, and then it fell — onto the pavement — and all I had in the car was an old towel and that bag — and I didn’t know what to do! –”  She broke down in wrenching cries, her whole body shaking.

I grabbed her by the shoulders, and pulled her sideways a bit until she could rest her head against my waist.  “Breathe, Olivia,” I said, quietly, repetitively.  “Just breathe for me, sweetie.  Breathe.  It’s ok.  You did fine.  It’s not your fault.  You’re ok.”

She cried and I murmured, and we stayed there for several long moments.

Finally, when she was calmer, I said, “We’re going to worry about this –” and I put on a pair of gloves and took the bag off her lap — “in just a few minutes.”  I placed it on a bedside table, and moved it to the side.  “But first we’re going to take care of you.”

She took a towel from me and wiped her face.  “I — I — I can’t really reach everywhere the blood went,” she said, her face flaming with embarrassment.  I understood what she meant immediately, and my heart broke a little more.  Due to her size she wouldn’t be able to reach the backs of her thighs, her ankles, under the folds of skin around her groin.

I crouched down beside her, and looked her in the face.  “And that’s why I’m here, girl.”  I raised an eyebrow.  “And you and I both got exactly the same business going on under our clothes, so don’t you give it a second thought.”

And for a brief, fleeting moment, she smiled.

~

Later, when we had scrubbed her clean, changed her into a fresh hospital gown, and padded the cot well with chux and peri-pads, I glanced over at the bag.  “Is it ok if I take a look?”  I needed to see if she had miscarried the placenta as well as the fetus; an incomplete miscarriage would mean she would still need the D&C tomorrow.

She nodded, and I opened the bag, and carefully pulled out the small towel.  Gently, slowly, I unwrapped the folds.  There, tucked into the center, was the placenta, the cord, the fetus, all intact, all together.  I breathed a quiet sigh of relief.  She might not need the D&C after all.

I noticed her then, leaning forward on the bed, trying to see over my shoulder.  I turned toward her a little.  “Do you want to see….?”  I trailed off.   I had no idea what word to use.  Fetus?  Child?  Baby?

I had taken care of violent psychotic criminals handcuffed to a bed, reassembled the pieces of someone’s hand after they stuck it in a snowblower, shoved someone’s guts back in their belly after their surgical wound dehisced, helped a doctor drill a hole in someone’s skull after they’d walked in front of a garbage truck going twenty miles an hour.  I had done so much shit in my years in the ER, and yet now I was at a complete loss.

Olivia threw me my life preserver.  She nodded, and said, “Is it ok?  Is it ok if I see my baby?”

“Of course you can see your baby,” I said, profoundly grateful for the noun.  I took a moment, and rearranged the tiny body so that it seemed to lay on its side.  It was impossibly small, its arms and legs no bigger than matchsticks, its head disproportionately large, the face not quite arranged in the proper order.  It was both entirely alien, and fundamentally human.

I picked up the towel, and carried it over towards her.  I paused, a few feet away, again suddenly unsure of myself.  “Do you want to hold it?”  I asked.

“No!” she gasped, almost instinctively.  “No, no.  I….I can’t.”

I felt terrible, and, hating myself for asking, rushed my words, “You don’t have to, it’s totally fine, I just wanted to be sure, I’m so sorry.”

She nodded, and I placed the towel and the baby at the foot of her cot.  She pulled her legs up partially underneath herself, and we just looked at it for a few minutes in silence.  Then, without looking at me, she said, “I was praying it would be a boy.  I wanted a boy so much.  I was going to name him Donnell.”

I smiled over at her.  “That’s a terrific name.”

She kept looking at the baby, and nodded.  “That was my brother’s name.  I wanted to name him for my brother.”

I closed my eyes for a moment, a chasm opening in my heart.  “How old was he?”

“Eleven.”

“And you?”

“Fourteen.”

I nodded.  I no longer needed to tell Olivia how sorry I was.  She knew, she understood how much I was hurting for her.  Repeating the words over and over again would do nothing to bring back either her baby or her brother.

Suddenly, she looked up from the bed and met my eyes.  “Can you tell?” she asked.  Her gaze flashed from the baby to me and back again.  “Can you tell at this point if it’s a boy or a girl?”

I honestly didn’t know.  I put on another pair of gloves, and gently moved one tiny, translucent leg out of the way.

And at that moment, my courage failed me entirely.  All the strength I prided myself on, the toughness, the bedrock honesty I tried to use with all my patients, all of it collapsed from beneath me in a soundless, bloodless landslide.

I couldn’t do it.  I couldn’t tell her.

I glanced up at her, and lied to her face.  “I can’t tell, hon.  It’s pretty early.  Let’s wait for the L&D nurse to get here.  I’m sure she’ll know.”

Trusting me, she nodded.

Ashamed, I turned away from her, and spent a very long time washing my hands.

~

-Yet here’s a spot.
-Hark, she speaks…
-Out, damn’d spot! out, I say!—One; two: why, then ’tis time to do’t.—Hell is murky…

~

The L&D nurse came down to the ER.  She took the baby’s feet, dabbed them with ink, and stamped the little footprints on a card that she then gave to Olivia.

And when she told Olivia that her baby was a boy, Olivia leaned into me again and cried.  I wrapped my arms around her, and even though I wanted to wipe away my own tears, I wasn’t willing to let her go.

~

Much later, I settled Olivia back into a wheelchair.  She had said her goodbyes to her son, and I had taken him away.  The OB-GYN had seen Olivia, given her the misoprostol to complete the miscarriage and lessen the bleeding, and scheduled a follow-up visit in 48 hours.  All the paperwork was done and signed, all the folders with bereavement and support-group information tucked into her belongings bag.  Olivia’s mother had gone home, and Olivia’s boyfriend was on his way to pick her up.

I sat down in a chair next to her, and took her hand.  “Can you think of any other questions?  Anything else at all that I can answer for you?”

She glanced over at me, her face surprisingly peaceful.  “Do you have any children?”

The question took me completely off guard.  I didn’t have any children; I’d never been pregnant.  When I’d ended my marriage in a cold, drafty, marbled-floor courtroom in Boston, I’d taken those quiet thoughts and sealed them safely in a box, hidden deep in the folds of the cloak of my soul.

Now, here, more than six months later and more than 3,000 miles away, I remembered its existence.  “No,” I replied calmly.  “No children.”

“Do you want them?”

I was tempted to sidestep the question with a joke, or quip, my usual method of handling this question from my patients.  But I’d lied to Olivia once that evening, and I wasn’t willing to do it again.

“I don’t know,” I said, with perfect honesty.  “Sometimes yes, sometimes no.”

Her eyes suddenly welled with tears.  “I want them.  I want them so much.  I’m so afraid to try again.  I’m so afraid they’ll all die.”

I leaned forward, and grabbed her other hand.  “Olivia, listen to me.  I don’t know if I’ll ever be a mother.  But I know – I know – that someday, somehow, you will be.  You will be.”

One tear rolled down her face.  “You think so?”

I nodded.  “I know so.  And, Olivia?”  She met my gaze again, and I smiled.  “You will be magnificent.”

~

36 hours later I stood alone on Shi Shi Beach, a bitter wind pulling my hair, tearing at my jacket, sending the thin material of my tent behind me snapping violently against the poles.  I stood at the edge of the tide, and watched the endless waves bathe the starfish, tug gently at the strands of seaweed on the rocks.  The great stone pillars in the surf stood dark against the clouds, the ocean roaring against them.

I reached deep into the folds of that cloak, found that box.  I blew the dust from the lid.  Then I opened it, and the wind rushed in.  And as it scattered those hopes and dreams across the infinite darkness of the sea, it also placed the very first ugly, awkward stitch in the jagged tear of my heart.