Addison sits on the side of the tub and picks her hand up in his. His face is flushed and damp, erasing all the tiny lines that might show his age. Where does he hide his stress? “Do you want to go back to Seattle?” he asks. “You didn’t even try to find a job there.”
She plummets into the memory of her last lunch date with Anna at Chez Shea in Pike Place Market, the big arched window haloed with a wreath of Christmas lights. Anna. Married to Nash. She remembers joking with Anna about playing Ma on Little House on the Prairie in Hallum for a few months until Addison had time to repeat the animal trials and start another application for the human phase tests. Wishing she were allowed to say more, to tell Anna about Rick Alperts’s role in the fiasco, so she could stomp out the look of pity and doubt in Anna’s eyes. “Well,” Anna had said as she hugged Claire good-bye at her car door, “it’s all good.” Claire had wanted to lash out at her when she said it, and at the same time couldn’t blame her at all. Because it always had been good. For all of them. In one generation they had forgotten how heartless the universe could be.
A short, sarcastic laugh escapes her and she asks Addison, “If none of the clinics here would hire me without my boards, who would hire me in Seattle? Besides, we can live on half as much in Hallum. At least we own this dump.” She sees him take a breath and then quickly shut his mouth. “Sorry. This ‘graceful vintage home.’” His head falls forward at this. She takes the sharp edge off her voice and leans closer to him. “I am sorry. I’m just tired.” Drops of water have collected on his earlobes, suspended like jewels. Claire reaches up and touches one, breaks the surface tension so it runs down her finger. “You’re wearing diamond earrings.”
He looks at her, gripping the hand he still holds. “Speaking of, where is your ring?”
“Locked in the filing cabinet. Filed under ‘D’—either for ‘diamond’ or ‘debt,’ I haven’t decided. Felt funny wearing that ring to the clinic. It could buy a whole house in Mexico.” Addison nods. He looks so sad to her. So forlorn. She wants to forget every heated accusation and every splintered trust—hear them once, discuss them once, and forget them. But how do you do that? Why is it so hard to give Addison the same unconditional love she gives Jory? Is the heart for such absolute forgiveness granted only through childbirth? Instead, as always, any rub between the place they had been and the place they have arrived brings a curtain down between them. Claire is unwilling to turn from it this time. “I should sell the ring, Addison. It’s not like it was my real engagement ring. Buy me another one when you find an investor.”
He looks straight at her again, grips her hands so tight it hurts. “Please. Hang in there with me—a few more months.”
“I will. I am.” She says softly, feeling the sting of tears. “I’m trying.”
He scans her face, and she sees him looking for something there that she wants him to find. “Yeah.” He says after a minute. “Yeah. I know you’re trying.”
And she is trying, although the enemy dismantling their union is not always clear to her, leaves her wondering, sometimes, exactly what she is fighting. It is not about the loss of money, surely. She had fallen in love with Addison long before he was rich.
They’d met during her first clinical month in medical school, in the Harborview emergency room. “Initiation by fire,” the dean had editorialized with a wry smile when he read out her assignment. Addison had materialized out of the generally invisible cleanup crew in the aftermath of a multifatality car accident—materialized like a ghost in his orderly’s floppy white pants and tunic.
She was trying to write out admission orders for a patient with a hip fracture who’d been shunted to the back hall while the living were sorted from the dead. Her resident, Andy Keets, had whipped a blank order form out of a drawer behind the nursing desk and paused for a full two and a half minutes in his own scut work to bark out the orders she should use for a routine admission. Keets was a sharp, burly, aspiring surgeon who could be a comic guardian or a pitiless drill sergeant to his novitiate medical students, depending on whether he’d been allowed to wield a scalpel in the operating room or demoted to holding retractors. He terrified her. She’d scribbled the orders down in the little notebook she kept in a pocket of her short white coat, but she’d misplaced the book in the scuffle of the trauma room. Now she was lost in the middle of the sequence, somewhere between “Diagnosis” and “Vital Signs.”
Her pen hovered above the paper. She picked up the phone to page Keets, then hung up; it was safer to scrounge around among the blood-soaked drapes looking for her notes than to catch him in a foul mood. It was three AM. Her eyes were so tired her contact lenses felt like they were glued to her corneas, and the missing orders drifted from her memory like weeds on a tide.
She heard someone talking and jumped, realized she’d nodded off at the desk. God, she’d drooled onto the page and “Diagnosis” now bled into a faint blue pool.
“IV.” It was Addison, sitting on a parked gurney next to her sleeping patient, watching her write—and sleep. Claire wiped the corner of her mouth and stared at him.
“You have to say what kind of IV fluid to run. What do you want? Normal saline, D-five-W, lactated Ringer’s?”
She felt oddly insulted that an orderly would try to tell her how to admit a hospital patient. She knew she ranked low as a third-year medical student, but she’d rather have Keets chew her out than let a janitor see how lost she was in this foreign world that was supposedly her career. But the very next thought that skittered across her fatigued brain was He won’t age very well, but he looks so young now that won’t matter for decades.
He jutted his chin toward the paperwork. “Keets tell you the mnemonic?”
Now she was flustered, as if some mortal flaw in her intelligence were being exposed to someone that mattered. She started to stand up, ready to transport her patient up to the orthopedic floor by herself and figure out the orders there. She’d copy them from some other chart if she had to.
Addison hopped off the gurney and grabbed a pen and a clean order sheet from the desk drawer, and started writing capital letters down the left margin. “ADCVANDISSLD. A: Admit to floor. What floor’s she going to? Ortho, right?” Claire nodded. “D: Diet. Is she going for a hip pinning in the morning? So she’s NPO. C: Condition.” He glanced over at the rickety woman snoring lightly into her oxygen mask after a dose of morphine, her pulse oximeter flashing 97 percent. “Stable.” He moved closer, stood just behind Claire so that she felt the warmth from his body, saw the way his forearm flexed as he scribbled down the page. He reached the final D and wrote “Date?”
Claire looked up at him. “What do you mean? Date of discharge? I don’t know yet.”
“No. I mean you and me. A date?”
He couldn’t have timed it more perfectly, which proved to be an inherent, uncanny sense he had about the world, or at least the world of biochemistry. A second sight that made him millions until he focused too far. At that instant the elevator doors opened and Keets strode over to the desk. “Why is the hip still down here? I need you in trauma two.”
Claire snatched the pen away from Addison. “I wasn’t sure I got the orders right. You want to look at them?”
“Boehning, help her out, man.” Keets jerked a thumb at Addison, “Not even a doc and he’s smarter than any of you pitiful grunts.”
Hospital orderly work was only one of the menial jobs that had interrupted Addison’s education. He had a tuition scholarship to Harvard, but after his father lost his last bet Addison didn’t get any help from home. He’d gone door to door through Newton and Beacon Hill and Back Bay with a bucket and mop, washing windows all summer to pay for books and food. One year he’d cleaned cadaver tanks in the medical school anatomy lab. Claire didn’t know about it until Addison’s mother told her. She figured he’d kept it a secret because he was embarrassed, but when she discreetly asked him how he could stand it, Addison was nonplussed. “I had to get through school. I needed work I could do around m
y class schedule.”
He spent three years at Harvard working every weekend and holiday on a farm in the Berkshires, bunking in a half-restored schoolhouse out in the middle of a rotting apple orchard with trees gone as spiny as crabs. It was the one job he’d really enjoyed. He’d made a nightly ritual of lying in a fallow field until he counted three falling stars. In wintertime he would haul out an aluminum recliner, the nylon webbing busted through at the seat, and wedge it into the snow. Focused. Waiting. Uncompromising.
He told Claire about the farm on their first date, the very last D in ADCVANDISSLD. So she had taken him home with her after dinner, shoved all the blankets from her bed through a small window onto the roof of her apartment and lain for the first time in the hollow of his shoulder, arrested, astounded by the perfect fit of herself against him. He had teased her through the lyrics of Chapin and Dylan and Waites, counted out Bill Withers’s twenty-seven “I Knows” for the first time, like a premonition. They had watched the sky for hours, Claire undeterred by the obscuring lights of Capitol Hill and downtown Seattle, until three perfect stars fell. Three perfect stars that eventually led to a perfect family of three. Jory, Claire and Addison. Falling.
• 11 •
On her fourth day, Dan puts a patient’s chart in Claire’s hands and points to the first exam room. “Think you’re ready?”
She wants to blindly assure him that this is the moment she’s been looking forward to—it is, after all, such optimistic hubris that had defined the best and brightest in medical training, herself included. But the falseness of it catches, and all she can say is, “Does she speak English?”
“Anita can translate when she’s not checking people in. You can buttonhole Frida or me between patients. You aren’t working alone.”
Claire opens the thin chart, as much to buy time as to get information. Dan watches her for a minute, then steps into the cramped office they all share and comes back with a stethoscope. He drapes it over her shoulders and says, “You look ready enough to me. Have at her.”
Elena Ynez, a twenty-two-year-old woman, is sitting on the end of the exam table. She has put her blue gown on backward, so the opening gapes in front, exposing part of her breasts and abdomen. Claire introduces herself and pulls another gown out of the drawer, holding it open so Elena can slide her arms through the slits. A toddler clings to Elena’s leg; she takes one wobbly step and slips to the floor, tipping over the waste can. The crash makes her face twist and she sucks in a deep breath, ready to wail. Claire unwraps a wooden tongue depressor and draws a puppet’s face on one end, waggling it in front of the baby until she forgets the whang of dented metal and crawls over to grasp the toy. “¿Cómo se llama su niña?”
The woman smiles and a gold-rimmed tooth gleams in the front of her mouth. She answers in rapid Spanish, gesturing at the baby and laughing, going on for sentence after sentence with barely a pause. The only word Claire thinks she understands is blanca, which may be the child’s name, or the color of Claire’s coat, or perhaps the snow, or the mountains she had crossed coming north from Mexico. Claire smiles and lifts one finger in the air. “Momentito, por favor.” She steps into the hallway and waits until Frida appears. With an apologetic plea Claire pulls her into the exam room.
Frida ends up doing almost everything except the brief abdominal exam, walking Claire through translated questions, helping her find the urine specimen cups, showing her how to spin down a test tube of the cloudy yellow fluid and prepare a microscope slide. Claire’s only contribution is the confirmation of white blood cells floating in the magnified droplet and a prescription for Bactrim, which Frida finds for her on the shelves of their small pharmacy. That and a happily distracted baby. Claire stands out of the way in the closet-sized room while Frida hunts for the Spanish language label to tape onto the bottle. “Don’t we have to send it out for a culture?”
Frida opens an under-the-counter incubator and pulls out an agar plate of culture media. “We start with this. If it’s something other than E. coli we send it out. You can at least tell if it’s resistant to sulfa in a couple of days. You’ve made a culture smear before, right?”
Claire gives her a tight grin. “Sure. In my first year of medical school. You don’t send it to the lab?”
Frida laughs. “We have a lab. And we use the hospital lab. We just don’t have any money. This isn’t the medicine you learned in your Seattle private hospitals.”
“It’s not even the medicine I learned at the public hospital.”
Frida unwraps a sterile wire loop, dips the end into the test tube and draws a wide S down the center of the gel. She carefully places the lid on top without touching the rim and puts it back in the incubator. She is about to walk out to see the next waiting patient when she stops; Claire can almost see her consciously rein in her perpetually frenetic pace, sweep her eyes over Claire’s face and hair, appraising. “Dan’s needed help for a long time. I don’t know what made him finally cave in to that fact.” She presses her lips tight for a second and goes on. “It’s not an easy job.”
Claire nods, wondering if she wants Frida to finish the thought still working its way forward.
“You expect you’ll be staying in Hallum?” The gold and bronze glints in Frida’s eyes darken a little when she says this—not in any offensive way, Claire thinks. More an honest reflection on the energy everybody here is putting into making this, her role here, work.
Claire feels her face flush, stumbling over the obvious fact that the chaos in her own life could infect everyone she tangles up with along the road home—wherever home ends up being. “Well, I guess you could say we’re in transition right now.” She is about to tell Frida how deeply grateful she is for this job and scoot out from under the harder question, can almost sense Frida is expecting such evasion, poised to pull back and define their relationship through it. Claire pauses, decides without conscious thought to say exactly what she is thinking. “I don’t know how long we’ll be here. But I won’t leave you in the lurch. I promise.”
Frida presses her lips tight once more and then beams her enormous smile onto Claire. “Well. Glad that we have that out of the way.”
Over the next weeks Claire feels like the practice of medicine is a language she once knew fluently, but which has now receded so deep into the corners of her memory she only vaguely understands it, no longer speaks it. Symptoms, terms, signs and syndromes rush back to her after examining a patient and slip away a second later, leaving her tongue-tied in front of Dan—all the parallel but imprecise words proving inadequate. She is only beginning to recognize what most doctors discover while still in their twenties: the gap between theory and truth is wider than it looks. You can pass a test with honors in medical school, but patients do not come with multiple-choice bubbles lined up below their complaints. The possible diagnoses must be winnowed out of hundreds floating in the thin air of recalled symptoms and diseases. It is perspective, in the big picture of life and death, that medical school can only get you ready to learn. The relativity of outcome that patients need, more than anything, can only be learned through years of experience.
So she discusses every patient with Dan. She presents cases as if she is back in medical school, sounding as stilted and awkward as when she presented to attendings in her early clinical training. “This is a thirty-seven-year-old Hispanic female, G8P6AB2 with a history of gestational diabetes presenting with polyuria and a positive pregnancy test, LMP approximately four months ago.” “A seventy-six-year-old Hispanic male, status post-MI times two, with a history of poorly controlled hypertension and medical noncompliance presenting with new onset occipital headaches and photophobia.” “This sixteen-year-old Caucasian female was in apparently good health until January twenty-third, when she developed intermittent lower abdominal pain associated with purulent vaginal discharge.”
Dan listens with his slow, serious nod, his eyes focused at a point near her feet. His expression seems simultaneously distracted by some imponderable inter
nal question he finds mildly amusing and intently focused on Claire’s descriptions. He Socratically asks her opinion about the most likely diagnosis or her first treatment choice. And when she outlines her differential and the blood work or CT scan or MRI that might distinguish them, he looks up and his eyes narrow, just a bit, a half-worked grin playing at the edges of his mouth. “And let’s say you order this thousand-dollar MRI, or the three hundred dollars of lab work, what do you anticipate they’re going to show you?” After she answers, no matter what she answers: “How would you treat him if you couldn’t get that test?” And, after a few more guiding questions: “What would you guess the harm to be in trying that treatment first? Then, if he’s no better, then we choose one test.”
“But you’ll end up treating the wrong thing, at least part of the time.”
“You will. And the first rule is ‘Do no harm.’ But the second rule, in this clinic, is ‘Money wasted is lives lost.’ We have funds, and we have patients, and if we run out of funds somebody farther down the line gets no care.”
Anita, who manages the accounts, is blunt about the budget. “I should just make it up every day—fake names and fake insurance. Fake social security numbers paying real enough tax dollars to the U.S. government and we don’t see a dime of it! The only thing you can count on by closing time is that we lost more money.” When Claire offered to help her with the books she had rolled her eyes. “You want to help me? Go take care of my kids. Go clean my house. Go yank the beer bottle out of my good-for-nothing husband’s mouth.” But then she had burst out laughing and patted her expanding abdomen. “Pregnant ladies get to say whatever they want.”
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