Arms Wide Open

by Patricia Harman

  It’s clear he doesn’t want to talk, but I break into his game anyway. “Jasmine came into the office today to show off her belly. She’s almost due. Remember when her mother, Dawn Otterman, had her baby? That was a scene!” Tom doesn’t answer, doesn’t even smile. He stands up and stretches his back.

  “What’s happening, Tom? Is something wrong?”

  “It’s Bobbie Boyd. She’s the pelvic-pain patient that had that bleeding problem after surgery and I had to take her back to the OR. She came into the Emergency Department in the middle of the night for abdominal pain, distention, and fever.

  “It’s been months since I operated on her, but she identified me as her doctor so now I have to go see her. What I dread is running into her husband again. I just hope her problem doesn’t require surgery.” Abruptly he shuts his computer, rises, and strides into the bedroom, emerging in shorts, a Presidente beer T-shirt from the Dominican Republic, and his weight-lifting gloves. “I’m going to the gym.”

  “Why don’t you call the ER first, see if they’ve got Bobbie’s flat-plate X-ray back? It’s their move, right?”

  “Patsy, lay off! I’m the doctor here. This isn’t a game. I’m going into the hospital after I work out. I’ll take care of it.” He stalks out the door. I recognize his anger about my medical suggestions; this is a spark, not the full conflagration.

  Tom is less resilient than he used to be. He’s grinding his teeth at night, and the dentist says he needs expensive crowns. The fear of being sued troubles us both. We cringe at each surgical setback, wait for a blow.

  Seventy-five percent of ob-gyns in the United States have been named in lawsuits. And midwives, who used to never be sued, are also hauled into court. The last student midwife I mentored has already been a defendant, and I know she was good.

  Tom used to say that the threat of being sued was the cost of doing business in health care, but since he was named in a frivolous claim last year and the insurance company settled, we wonder if that cost is too high.

  I flash back to when we lay under the full moon, near the fountain on the Ohio University campus. How innocent we were in our desire to serve the people. We had no concept of the forces that would be against us, medical-malpractice insurance companies, difficult patients, the rising costs of running a practice, shrinking reimbursements, lawyers out for a few million bucks.

  Outside the window, Hope Lake sparkles, ever changing, one day jade green, one day turquoise, the next day slate, or khaki, or shit brown. Today it’s shit brown.

  Two hours later my cell phone chirps. It’s Tom. “I’m on my way home,” he announces. “I just left the hospital.”

  “That was quick.” I picture the color returning to his face, starting pink at the neck and rising.

  “I think Bobbie’s just constipated. The X-ray showed her bowel’s full of stool. We gave her an enema. She’s resting comfortably now and her CBC is normal. The fever was only from dehydration.”

  “Want to have a glass of wine with me when you get home?” I try one more time. Tom knows the code.

  “Maybe a nap, Pats. After the ER called last night, I didn’t sleep well.”

  “All right.” My heart creeps a little farther into its cave. This is the second time he’s turned me down. Outside the corner windows, five crows have moved into the big oak by the water and they flap, like black shadows, across the yard.

  Cord around the Neck

  “You go on,” I yell, signaling my husband to pass me. It makes me nervous when he rides my tail. He speeds by on his royal blue recumbent, the BMW of low-rider bikes.

  I have the bike trail to myself this afternoon, no hikers, no joggers, and no mothers pushing strollers. It’s our first ride in many months, and the green river moves placidly along at my side. It was three years ago that this waterway flooded and, in a rage after a fight with Tom, I took a night ride through the middle of a lightning storm . . . near death by stupidity.

  Already bluebells, white bloodroot, and yellow starflowers cover the forest floor. The air is alive with birdsong, and I stop in the middle of the trail when I see trilliums, beautiful trilliums, early this year.

  My reflections are cut off as I catch sight of Tom coming back toward me. We pause to share a bottle of water. As he slugs back a drink, his cell phone goes off. “Shit. I’ve been paged twice since we started, two different pelvic-pain patients. One was Gladys, begging me for more narcotics. I told her she had been dismissed and I couldn’t help her. She should go to the ER.

  “The other was Ruby. When I tried to call her back, her line was busy. That pissed me off. This cell phone is driving me crazy. It feels like a goddamned cord around my neck.”

  Tom isn’t usually so cranky. “Here, give me your phone. I’ll take the calls.”

  “Thanks.” He takes a big breath and lets it out slowly. “I shouldn’t let it get to me.” Then he pedals off and I punch in the saved number.

  “Hi Ruby. This is Patsy Harman, taking the emergency calls. How can I help you?” I emphasize the word emergency so the patients won’t call just to chat.

  “Oh, Patsy. I’m glad it’s you. I’m cramping again. My pain is real bad today. I know you said I need to wean off the narcotics, and I’ve been trying, but I just can’t make it on two pills a day. Do you think you could call in some more Percocet, so I could take three? And maybe give me one more Duragesic patch? They used to work good.” I go on alert when she mentions cramping. This isn’t an ordinary chronic-pelvic-pain patient. Ruby is pregnant.

  “Cramping, like menstrual pain?”

  “Yeah, like my period . . . only real bad. Real bad, Patsy. Worse than before.”

  “Any bleeding?”

  “No, just pain.”

  “Did you have intercourse?”

  “Not this time.”

  “When did you poop last?” I glance around to see if anyone’s passing. I’m talking about poop in public, for God’s sake.

  “Couple of days ago. Can you get me a few more patches?” The woman is persistent.

  “No, Ruby. That isn’t going to happen. I can’t give you any more narcotics. It wouldn’t be good for the baby. We have to keep to the schedule. In fact, we’ll be stepping down further next week. You need to get your bowels moving. This is a common problem in pregnancy, and it’s worse for you because narcotics slow the motility down. After you get emptied, if the pain is still bad, you’ll have to go to the ER. They’ll examine you and call us. Can you go get some Metamucil or a stool softener? Can you do that?”

  “I don’t have a car.” Ruby is whining like a six-year-old and I see why Tom gets irritated.

  “Well, call your stepmom or someone.”

  “They’re all gone to the mall.”

  “Do they have cell phones?”

  “Yeah . . .”

  “Well?”

  “OK!” This is said in a teenage-like huff. “But the Metamucil probably won’t help . . . If I try and I’m still in pain will you call in a prescription for some Oxycontin?”

  “No, Ruby. We can’t take a chance with the baby and we can’t go back up with the narcotics. You’ll manage OK. Get someone to come home and sit with you. Partly you’re afraid because you’re alone. ”

  “I guess.” Ruby disconnects without saying good-bye and I step down on the pedals. Tom is already far ahead. I can just see the red and yellow dot of his bike shirt rounding the bend.

  That wasn’t my best moment as a midwife. I was really rather harsh, but Ruby is going to be a mom. She needs to understand the personal sacrifices she’ll be making.

  I flash on something I’ve said to myself more than once: It hurts to be a mother. It hurts to give birth and it can hurt a lot more later . . .

  Spring Again

  CHAPTER 13

  Blame

  S
pring comes in a rush to Appalachia. One day you notice tiny buds on the plum tree and the next, I’m not kidding, the whole tree is a bouquet of pink. The forsythia blaze and daffodils march along the front walk, but when I get to work, the clinic feels muted and strained. I’d like to find out what’s going on, but my schedule is overbooked and I’m way too busy to investigate.

  The first thing I see when I get to my desk is a note from Dawn Otterman, Jasmine’s mother, that her teenage daughter has delivered a seven-pound baby without pain medication and has already been discharged from the Birthing Center. It was a girl, as they’d predicted. I take time to send them a card.

  Along with the usual prenatal visits, menopause problems, early OB visits, yeast infections, and annual exams, I see a twenty-one-year-old woman, Dannie, who wants to become a man. We have a long talk. Once a transgender patient would have shaken me, but after we helped a previous patient, Kasmar, successfully make the transition, my mind is more open.

  By four, I’m at my desk attacking a two-foot-tall stack of charts. Across the hall, I hear the name Ruby mentioned in a low voice by one of the nurses, and I briefly wonder if it’s Ruby Tuesday, my OB patient, but go back to my tasks. Within an hour the office is empty. No one even stops by my door to say good-bye.

  As I review and sign my last lab report, I dial Tom’s cell. “Hey, where are you? You up for a bike ride?”

  “Just down the hall.” I smile to hear his voice from both the receiver and the other side of the clinic.

  “I haven’t seen you all afternoon. I thought you were in the OR.”

  “No, I came back to the office an hour ago.”

  “So, you want to go riding?”

  “Nah, Pats. I don’t feel like it. You heard what happened . . .”

  “No . . . What . . .”

  “Come over here; I don’t want to talk about it on the phone.” This sounds serious. I snap the cell shut and take the shortcut through the lab.

  “What? What’s up?”

  My partner leans forward on his desk, Beatles tie pulled loose from his shirt collar. He runs his hands over his head and across his face. “It’s Ruby. She’s dead.”

  I back away from him. “Pregnant Ruby?” I know very well whom he means; I just don’t want to believe it. He nods.

  “But I just talked to her a few days ago. I told her to go to the ER if her pain got worse. She wasn’t bleeding or anything. What happened . . . ?” I’m thinking of a pulmonary embolism or maybe a blood clot in her groin.

  “Dr. Wheaton called from the University Hospital ER. He’s pretty sure it was a drug overdose. Her body’s been sent to Pittsburgh for an autopsy.” My husband pushes a chair toward me and I fall into it. “But I just talked to her. I told her we couldn’t give her more narcotics. We were weaning her off . . . She can’t be dead. Was it my fault? I just talked to her . . .”

  “No. You did the right thing.” We look at each other, both wondering what the repercussions will be. Will the coroner call for an investigation? Will the state Board of Medicine get involved? But mostly we’re just sad for Ruby, silly, selfish, once alive, beautiful Ruby.

  Somewhere far out to sea, Tom and I bob alone, up and down, on the lead gray waves.

  Silence

  Breathe in. Breathe out. I’m sleeping alone again, in Zen’s old room, and the worry about Tom curls around me like snakes. Since Ruby died, he isn’t himself. Neither of us are . . . but we can’t comfort each other.

  My husband comes home later and plays video games longer. We never make love. Yesterday I saw he’d left his wedding ring in the bathroom, and when I asked him about it, he said his hands were swelling. It crossed my mind that he could be having an affair. There is silence between us. The silence is cold.

  Earlier tonight, lying in bed with him, getting ready to read a chapter of a mystery together, I tried talking, thinking that if he could express what’s bothering him, he might feel better.

  “These last few months have been hard,” I begin obliquely. “I’ve been worried about morale at the office, the staff aren’t getting along, and the boys never call . . . There’s just been so much going on with the chronic-pain patients, and now Ruby . . .” I want to take off my armor, tell him I’m also concerned about us, about our relationship. He cuts me off at the first sentence.

  “You stick your nose into other people’s business too much, Pats. That’s your problem.”

  There’s silence again, this time from me. Screw you, I think, and snap the silver vest plates back across my chest.

  “Maybe I’ll go downstairs and sleep in Zen’s old room.”

  “No you won’t.” Tom grabs my arm hard. “Let’s read.” And so we do, and my blaze of resentment banks into coals.

  In the night, for the third time in two weeks, I move downstairs anyway.

  Breathe in and breathe out, I tell myself. Stop thinking. Stop picking at your worry and grief and guilt. It spreads into your soul like poison. Just breathe and find your calm center.

  In the deep night I wake, dreaming of Ruby and Aran. Aran was my friend Trish’s daughter. The nineteen-year-old died when she was only a few months postpartum, another narcotics overdose; this one by street drugs. Tom had delivered her baby. I was her midwife. I should have known she was in trouble . . .

  In the dream, it is storming. Aran and Ruby are calling for me from an old rusted car down by the lake. By the time I get there, the car is under water.

  CHAPTER 14

  Circle

  Eleven strong women sit in a bright contemporary living room near Shepherdstown, West Virginia, discussing the state of childbirth in the United States. This is over on the Eastern Panhandle, where Pennsylvania, Virginia, Maryland, and West Virginia all come together in a tangle so confusing you wonder if the surveyor, maybe George Washington, might have been drunk.

  The women in this circle come in all shapes and sizes. Most are dressed in slacks and sweaters. The grandmother next to me, with frizzy gray hair that sticks out around her head like a halo, wears an elegant brocade jacket that I especially admire. The young midwife across the room, with a seventeen-month-old baby, sports a blue T-shirt that says MIDWIVES HELP PEOPLE OUT.

  We eleven represent the rest of the fifty nurse-midwives in the state. The others are at home today . . . birthing babies, or on call, waiting for babies.

  In this circle of midwives, some work in large groups, some in small, some with state agencies, some with ob-gyns, some with family docs. A few of us own our own practices, but more are employed by hospitals or physicians. Only one of us doesn’t deliver babies: me. What we have in common is a passion for treating women with respect and a devotion to childbirth as a normal physiological event, not a disease.

  “My goal,” says Gerri, a small woman with straight short hair who sits against the wall on an ottoman, “is simply for my patients to have the kind of birth they want.” Her voice is soft and her eyes luminous.

  I think about that as I stare out the floor-to-ceiling windows, across the sunny high plateau toward the Appalachian Mountains. Not every woman does get—even with a midwife like Gerri at her side—the birth she wants . . . That would be, let’s face it, a two-hour painless labor with our loved ones around us, no episiotomy, a vagina that immediately goes back to shape, breasts that spurt milk, and no postpartum depression. But I know what Gerri means. She wants to support the women wholeheartedly in their goals. Again, it comes down to respect.

  “I had a patient the other day,” I tell the group, “who asked me if I thought any of the docs in town would support her in having a C-section without labor. It took me aback because I’m very much against C-section on demand, but for the first time, I wondered if she had a point.

  “She was a skinny little thing, thirty-five years old. Weighed about ninety pounds, with hips like a twelve-year-old boy. Her sister
had had one of those labors where she lay for three days . . .” The group laughs.

  “Why is it always three days?” Nicki asks. “Never four or two days . . . it’s always the same. It’s like they all had the same labor!”

  I smile, raising my eyebrows. Nicki’s right . . . It’s always three days.

  “Anyway,” I go on, “she told me about her sis and I went over the risks of cesarean section, how it’s major surgery. Even in the best of hands, there are dangers . . . infection, hemorrhage, and, rarely, death. I asked her how many children she wanted and explained that the scar tissue after C-sections can lead to pelvic pain, more miscarriages, and even increased incidence of fetal loss . . . but she only wants one baby and then wants her tubes tied.

  “I looked at her little bony body and thought . . . maybe she has a point. It might make sense, but I told her to wait until the end of her pregnancy and make a decision with her doctor and midwife. If the head is really low and the baby is small, she should give it a shot.”

  The conversation drifts to health-care reform and how badly we need it in West Virginia. What I’d really like to talk about is Ruby’s death, how it has affected Tom and me, but something holds me back. Maybe I’m afraid of litigation, maybe I believe we should have known the repercussions when we started the pelvic-pain clinic and the narcotics program . . . maybe I just sense that these women, who deal with the happy part of midwifery, wouldn’t understand what it’s like to wonder if you are responsible for the death of a mother.

  We hear updates from each practice, go over our new chapter bylaws, and eat pie. Then the sun, stretching low on the carpet, tells us it’s time to go home. Before the women gather their things, I ask that we hold hands.