My Sister's Keeper

by Jodie Picoult

  THE BRUISE IS THE SIZE AND SHAPE of a four-leaf clover, and sits square between Kate's shoulder blades. Jesse is the one to find it, while they are both in the bathtub. "Mommy," he asks, "does that mean she's lucky?"

  I try to rub it off first, assuming it's dirt, without success. Kate, two, the subject of scrutiny, stares up at me with her china blue eyes. "Does it hurt?" I ask her, and she shakes her head.

  Somewhere in the hallway behind me, Brian is telling me about his day. He smells faintly of smoke. "So the guy bought a case of expensive cigars," he says, "and had them insured against fire for $15,000. Next thing you know, the insurance company gets a claim, saying all the cigars were lost in a series of small fires."

  "He smoked them?" I say, washing the soap out of Jesse's hair.

  Brian leans against the threshold of the door. "Yeah. But the judge ruled that the company guaranteed the cigars as insurable against fire, without defining acceptable fire."

  "Hey, Kate, does it hurt now?" Jesse says, and he presses his thumb, hard, against the bruise on his sister's spine.

  Kate howls, lurches, and spills bathwater all over me. I lift her out of the water, slick as a fish, and pass her over to Brian. Pale towheads bent together, they are a matched set. Jesse looks more like me—skinny, dark, cerebral. Brian says this is how we know our family is complete: we each have our clone. "You get yourself out of the tub this minute," I tell Jesse.

  He stands up, a sluice of four-year-old boy, and manages to trip as he navigates the wide lip of the tub. He smacks his knee hard, and bursts into tears.

  I gather Jesse into a towel, soothing him as I try to continue my conversation with my husband. This is the language of a marriage: Morse code, punctuated by baths and dinners and stories before bed. "So who subpoenaed you?" I ask Brian. "The defendant?"

  "The prosecution. The insurance company paid out the money, and then had him arrested for twenty-four counts of arson. I got to be their expert."

  Brian, a career firefighter, can walk into a blackened structure and find the spot where the flames began: a charred cigarette butt, an exposed wire. Every holocaust starts with an ember. You just have to know what to look for.

  "The judge threw out the case, right?"

  "The judge sentenced him to twenty-four consecutive one-year terms," Brian says. He puts Kate down on the floor and begins to pull her pajamas over her head.

  In my previous life, I was a civil attorney. At one point I truly believed that was what I wanted to be—but that was before I'd been handed a fistful of crushed violets from a toddler. Before I understood that the smile of a child is a tattoo: indelible art.

  It drives my sister Suzanne crazy. She's a finance whiz who decimated the glass ceiling at the Bank of Boston, and according to her, I am a waste of cerebral evolution. But I think half the battle is figuring out what works for you, and I am much better at being a mother than I ever would have been as a lawyer. I sometimes wonder if it is just me, or if there are other women who figure out where they are supposed to be by going nowhere.

  I look up from drying Jesse off, and find Brian staring at me. "Do you miss it, Sara?" he asks quietly.

  I wrap our son in the towel and kiss him on the crown of his head. "Like I'd miss a root canal," I say.

  By the time I wake up the next morning, Brian has already left for work. He's on two days, then two nights, and then off for four, before the cycle repeats again. Glancing at the clock, I realize I've slept past nine. More amazingly, my children have not woken me up. In my bathrobe, I run downstairs, where I find Jesse playing on the floor with blocks. "I eated breakfast," he informs me. "I made some for you, too."

  Sure enough, there is cereal spilled all over the kitchen table, and a frighteningly precarious chair poised beneath the cabinet that holds the corn flakes. A trail of milk leads from the refrigerator to the bowl. "Where's Kate?"

  "Sleeping," Jesse says. "I tried poking her and everything."

  My children are a natural alarm clock; the thought of Kate sleeping so late makes me remember that she's been sniffling lately, and then wonder if that's why she was so tired last night. I walk upstairs, calling her name loud. In her bedroom, she rolls toward me, swimming up from the dark to focus on my face.

  "Rise and shine." I pull up her shades, let the sun spill over her blankets. I sit her up and rub her back. "Let's get you dressed," I say, and I peel her pajama top over her head.

  Trailing her spine, like a line of small blue jewels, are a string of bruises.

  "Anemia, right?" I ask the pediatrician. "Kids her age don't get mono, do they?"

  Dr. Wayne pulls his stethoscope away from Kate's narrow chest and tugs down her pink shirt. "It could be a virus. I'd like to draw some blood and run a few tests."

  Jesse, who has been patiently playing with a GI Joe that has no head, perks up at this news. "You know how they draw blood, Kate?"

  "Crayons?"

  "With needles. Great big long ones that they stick in like a shot—"

  "Jesse," I warn.

  "Shot?" Kate shrieks. "Ouch?"

  My daughter, who trusts me to tell her when it's safe to cross the street, to cut her meat into tiny pieces, and to protect her from all sorts of horrible things like large dogs and darkness and loud firecrackers, stares at me with great expectation. "Only a small one," I promise.

  When the pediatric nurse comes in with her tray, her syringe, her vials, and her rubber tourniquet, Kate starts to scream. I take a deep breath. "Kate, look at me." Her cries bubble down to small hiccups. "It's just going to be a tiny pinch."

  "Liar," Jesse whispers under his breath.

  Kate relaxes, just the slightest bit. The nurse lays her down on the examination table and asks me to hold down her shoulders. I watch the needle break the white skin of her arm; I hear the sudden scream—but there isn't any blood flowing. "Sorry, sugar," the nurse says. "I'm going to have to try again." She removes the needle, and sticks Kate again, who howls even louder.

  Kate struggles in earnest through the first and second vials. By the third, she has gone completely limp. I don't know which is worse.

  We wait for the results of the blood test. Jesse lies on his belly on the waiting room rug, picking up God knows what sorts of germs from all the sick children who pass through this office. What I want is for the pediatrician to come out, tell me to get Kate home and make her drink lots of orange juice, and wave a prescription for Ceclor in front of us like a magic wand.

  It is an hour before Dr. Wayne summons us to his office again. "Kate's tests were a little problematic," he says. "Specifically, her white cell count. It's much lower than normal."

  "What does that mean?" In that moment, I curse myself for going to law school, and not med school. I try to remember what white cells even do.

  "She may have some sort of autoimmune deficiency. Or it might just be a lab error." He touches Kate's hair. "I think, just to be safe, I'm going to send you up to a hematologist at the hospital, to repeat the test."

  I am thinking: You must be kidding. But instead, I watch my hand move of its own accord to take the piece of paper Dr. Wayne offers. Not a prescription, as I'd hoped, but a name. Ileana Farquad, Providence Hospital, HematologyI Oncology.

  "Oncology." I shake my head. "But that's cancer." I wait for Dr. Wayne to assure me it's only part of the physician's title, to explain that the blood lab and the cancer ward simply share a physical location, and nothing more.

  He doesn't.

  The dispatcher at the fire station tells me that Brian is on a medical call. He left with the rescue truck twenty minutes ago. I hesitate, and look down at Kate, who's slumped in one of the plastic seats in the hospital waiting room. A medical call.

  I think there are crossroads in our lives when we make grand, sweeping decisions without even realizing it. Like scanning the newspaper headline at a red light, and therefore missing the rogue van that jumps the line of traffic and causes an accident. Entering a coffee shop on a whim and meeting the man you
will marry one day, while he's digging for change at the counter. Or this one: instructing your husband to meet you, when for hours you have been convincing yourself this is nothing important at all. "Radio him," I say. "Tell him we're at the hospital."

  There is a comfort to having Brian beside me, as if we are now a pair of sentries, a double line of defense. We have been at Providence Hospital for three hours, and with every passing minute it gets more difficult to deceive myself into believing that Dr. Wayne made a mistake. Jesse is asleep in a plastic chair. Kate has undergone another traumatic blood draw, and a chest X ray, because I mentioned that she has a cold.

  "Five months," Brian says carefully to the resident sitting in front of him with a clipboard. Then he looks at me. "Isn't that when she rolled over?"

  "I think so." By now the doctor has asked us everything from what we were wearing the night Kate was conceived to when she first mastered holding a spoon. "Her first word?" he asks. Brian smiles. "Dada."

  "I meant when."

  "Oh." He frowns. "I think she was just shy of one."

  "Excuse me," I say. "Can you tell me why any of this is important?"

  "It's just a medical history, Mrs. Fitzgerald. We want to know everything we can about your daughter, so that we can understand what's wrong with her."

  "Mr. and Mrs. Fitzgerald?" A young woman approaches, wearing a lab coat. "I'm a phlebotomist. Dr. Farquad wants me to do a coag panel on Kate."

  At the sound of her name, Kate blinks up from my lap. She takes one look at the white coat and slides her arms inside the sleeves of her own shirt.

  "Can't you do a finger stick?"

  "No, this is really the easiest way."

  Suddenly I remember how, when I was pregnant with Kate, she would get the hiccups. For hours at a time, my stomach would twitch. Every move she made, even ones that small, forced me to do something I could not control.

  "Do you think," I say quietly, "that's what I want to hear? When you go down to the cafeteria and ask for coffee, would you like it if someone gave you Coke, because it's easier to reach? When you go to pay by credit card, would you like it if you were told that's too much hassle, so you'd better break out your cash?"

  "Sara." Brian's voice is a distant wind.

  "Do you think that it's easy for me to be sitting here with my child and not have any idea what's going on or why you're doing all these tests? Do you think it's easy for her? Since when does anyone get the option to do what's easiest?"

  "Sara." It is only when Brian's hand falls onto my shoulder that I realize how hard I am shaking.

  One more moment, and then the woman storms away, her clogs striking the tile floor. The minute she is out of sight I wilt. "Sara," Brian says. "What's the matter with you?"

  "What's the matter with me? I don't know, Brian, because no one is coming to tell us what's wrong with—"

  He wraps me in his arms, Kate caught between us like a gasp. "Ssh," he says. He tells me it's going to be all right, and for the first time in my life I don't believe him.

  Suddenly Dr. Farquad, whom we have not seen for hours, comes into the room. "I hear there was a little problem with the coagulopathy panel." She pulls up a chair in front of us. "Kate's complete blood count had some abnormal results. Her white blood count is very low—1.3. Her hemoglobin is 7.5, her hematocrit is 18.4, her platelets are 81,000, and her neutrophils are 0.6.

  Numbers like that sometimes indicate an autoimmune disease. But Kate's also presenting with twelve percent promyelocytes, and five percent blasts, and that suggests a leukemic syndrome."

  "Leukemic," I repeat. The word is runny, slippery, like the white of an egg.

  Dr. Farquad nods. "Leukemia is a blood cancer." Brian only stares at her, his eyes fixed. "What does that mean?"

  "Think of bone marrow as a childcare center for developing cells. Healthy bodies make blood cells that stay in the marrow until they're mature enough to go out and fight disease or clot or carry oxygen or whatever it is that they're supposed to do. In a person with leukemia, the childcare-center doors are opened too early. Immature blood cells wind up circulating, unable to do their job. It's not always odd to see promyelocytes in a CBC, but when we checked Kate's under a microscope, we could see abnormalities." She looks in turn at each of us. "I'll need to do a bone marrow aspiration to confirm this, but it seems that Kate has acute promyelocytic leukemia."

  My tongue is pinned by the weight of the question that, a moment later, Brian forces out of his own throat: "Is she… is she going to die?"

  I want to shake Dr. Farquad. I want to tell her I will draw the blood for the coag panel myself from Kate's arms if it means she will take back what she said. "APL is a very rare subgroup of myeloid leukemia. Only about twelve hundred people a year are diagnosed with it. The rate of survival for APL patients is twenty to thirty percent, if treatment starts immediately."

  I push the numbers out of my head and instead sink my teeth into the rest of her sentence. "There's a treatment," I repeat.

  "Yes. With aggressive treatment, myeloid leukemias carry a survival prognosis of nine months to three years."

  Last week, I had stood in the doorway of Kate's bedroom, watching her clutch a satin security blanket in her sleep, a shred of fabric she was rarely without. You mark my words, I had whispered to Brian. She'll never give that up. I'm going to have to sew it into the lining of her wedding dress.

  "We'll need to do that bone marrow aspiration. We'll sedate her with a light general anesthetic. And we can draw the coag panel while she's asleep." The doctor leans forward, sympathetic. "You need to know that kids beat the odds. Every single day."

  "Okay," Brian says. He claps his hands together, as if he is gearing up for a football game. "Okay."

  Kate pulls her head away from my shirt. Her cheeks are flushed, her expression wary.

  This is a mistake. This is someone else's unfortunate vial of blood that the doctor has analyzed. Look at my child, at the shine of her flyaway curls and the butterfly flight of her smile—this is not the face of someone dying by degrees.

  I have only known her for two years. But if you took every memory, every moment, if you stretched them end to end—they'd reach forever.

  They roll up a sheet and tuck it under Kate's belly. They tape her down to the examination table, two long strips. One nurse strokes Kate's hand, even after the anesthesia has kicked in and she's asleep. Her lower back is bared for the long needle that will go into her iliac crest to extract marrow.

  When they gently turn Kate's face to the other side, the tissue paper beneath her cheek is damp. I learn from my own daughter that you don't have to be awake to cry.

  Driving home, I am struck by the sudden thought that the world is inflatable—trees and grass and houses ready to collapse with the single prick of a pin. I have the sense that if I veer the car to the left, smash through the picket fence and the Little Tykes playground, it will bounce us back like a rubber bumper.

  We pass a truck. Batchelder Casket Company, it reads on the side. Drive Safely. Isn't that a conflict of interest?

  Kate sits in her car seat, eating animal crackers. "Play," she commands.

  In the rearview mirror, her face is luminous. Objects are closer than they appear. I watch her hold up the first cracker. "What does the tiger say?" I manage.

  "Rrrroar." She bites off its head, then waves another cracker.

  "What does the elephant say?"

  Kate giggles, then trumpets through her nose.

  I wonder if it will happen in her sleep. Or if she will cry. If there will be some kind nurse who gives her something for the pain. I envision my child dying, while she is happy and laughing two feet behind me.

  "Giraffe say?" Kate asks. "Giraffe?"

  Her voice, it's so full of the future. "Giraffes don't say anything," I answer.

  "Why?"

  "Because that's how they're born," I tell her, and then my throat swells shut.

  The phone rings just as I come in from the neighbor's h
ouse, having arranged for her to take care of Jesse while we take care of Kate. We have no protocol for this situation. Our only baby-sitters are still in high school; all four grandparents are deceased; we've never dealt with day care providers—taking care of the children is my job. By the time I come into the kitchen, Brian is well into conversation with the caller. The phone cord is wrapped around his knees, an umbilicus. "Yeah," he says, "hard to believe. I haven't made it into a single game this season… no point, now that they've traded him." His eyes meet mine as I put on the kettle for tea. "Oh, Sara's great. And the kids, uh-huh, they're fine. Right. You give my best to Lucy. Thanks for calling, Don." He hangs up. "Don Thurman," he explains. "From the fire academy, remember? Nice guy."

  As he stares at me, the genial smile sloughs off his face. The teakettle starts to whistle, but neither of us makes a motion to move it off the burner. I look at Brian, cross my arms.

  "I couldn't," he says quietly. "Sara, I just couldn't."

  In bed that night, Brian is an obelisk, another shape breaking the darkness. Although we have not spoken for hours, I know that he is every bit as awake as I am.

  This is happening to us because I yelled at Jesse last week, yesterday, moments ago. This is happening because I didn't buy Kate the M&Ms she wanted at the grocery store. This is happening because once, for a split second, I wondered what my life would have been like if I'd never had children. This is happening because I did not realize how good I have it.

  "Do you think we did it to her?" Brian asks.

  "Did it to her?" I turn to him. "How?"

  "Like, our genes. You know."

  I don't respond.

  "Providence Hospital doesn't know anything," he says fiercely. "Do you remember when the chief's son broke his left arm, and they put a cast on the right one?"

  I stare at the ceiling again. "Just so you know," I say, more loudly than I've intended, "I'm not going to let Kate die."

  There is an awful sound beside me—an animal wounded, a drowning gasp. Then Brian presses his face against my shoulder, sobs into my skin. He wraps his arms around me and holds on as if he's losing his balance. "I'm not," I repeat, but even to myself, it sounds like I am trying too hard.