Handle With Care

by Jodi Picoult

  'How is it that you came to know the plaintiff in this case?' Charlotte's lawyer asked.

  Janine leaned closer to the microphone on the witness stand. She used to sing karaoke, I remembered, at a local nightclub. She had referred to herself as pathologically single. Now, though, she wore a wedding band.

  People changed. Even the people you thought you knew as well as you knew yourself.

  'She was a patient at the office where I was working,' Janine said. 'Piper Reece's ob-gyn practice.'

  'You're employed by the defendant?'

  'I was for three years, but now I work at Northwestern Memorial Hospital.'

  The lawyer was staring off at a wall, as if she wasn't even listening. 'Ms. Gates,' the judge prompted.

  'Sorry,' she said, snapping to attention. 'You're employed by the defendant?'

  'You just asked me that.'

  'Right. Um, can you tell us the circumstances under which you met Charlotte O'Keefe?'

  'She came in for an eighteen-week ultrasound.'

  'Who else was there?'

  'Her husband,' Janine said.

  'Was the defendant there?'

  For the first time, Janine met my eye. 'Not at first. The way we did it, I'd perform the ultrasound and discuss it with her; and she'd read the results and talk to the patient.'

  'What happened during Charlotte O'Keefe's ultrasound, Ms. Weissbach?'

  'Piper had told me to be on the lookout for anything that might signify Down syndrome. The patient's quad screen had shown a slightly elevated risk. I was excited to be working with a new machine - it had only just arrived, and was state of the art. I got Mrs O'Keefe settled on the table, put some gel onto her abdomen, and then moved the transducer around to get several clear views of the fetus.'

  'What did you see?' the lawyer asked.

  'The femurs were measuring on the small side, which can sometimes be a flag for Down syndrome, but none of the other indicators were present.'

  'Anything else?'

  'Yes,' Janine said. 'Some of the images were incredibly clear. Particularly the one of the fetal brain.'

  'Did you mention these findings to the defendant?'

  'Yes. She said that the femur wasn't off the charts, that it could simply be because the mother was short,' Janine answered.

  'What about the clarity of the images? Did the defendant have anything to say about that?'

  'No,' Janine said. 'She didn't.'

  The night I'd driven Charlotte home from her twenty-seven-week ultrasound, the one with all the broken bones visible, I'd stopped being her friend and started being a doctor. I sat at the kitchen table and used medical terminology, which almost acted like a sedative itself: the pain in Charlotte's and Sean's eyes dulled as I heaped them with information they could not understand. I talked to them about the physician I'd already called for a consultation.

  At one point, Amelia had flitted into the kitchen. Charlotte hastily wiped her eyes. 'Hey, sweetie,' she said.

  'I came to say good night to the baby,' Amelia said, and she ran up to Charlotte where she sat and wrapped her arms as best as she could around her mother's belly.

  Charlotte made a tiny sound, a mewling. 'Not so tight,' she managed, and I knew what she was thinking: had this eager love broken some of your bones?

  'But I want her to come out,' Amelia said. 'I'm sick of waiting.'

  Charlotte stood up. 'I think I might go lie down, too.' She held out her hand for Amelia, and they walked out of the kitchen.

  Sean sank into the seat she'd vacated. 'It's me, right?' He looked up at me, haunted. 'I'm the reason the baby's like this.'

  'No--'

  'Charlotte had one kid who was perfectly fine,' he said. 'Do the math.'

  'This is probably a spontaneous mutation. There's nothing you could have done to prevent it.' I couldn't have prevented it, either. But that didn't keep me from feeling guilty, just like Sean. 'You have to take care of her, because she can't fall apart right now. Don't let her look this up on the Internet before you see the doctor tomorrow; don't tell her you're worried.'

  'I can't lie,' Sean said.

  'Well, you will, if you love her.'

  Now, all these years later, I wondered why I could not forgive Charlotte for following this very same advice.

  I didn't like Guy Booker, but then again, when you choose malpractice insurance providers, you're not going for the folks you want to have over for Christmas dinner. He was good at making someone squirm on the witness stand, like an insect being pinned by a collector who wanted to scrutinize it more closely. 'Ms. Weissbach,' Booker said, standing up to do his cross-examination, 'have you ever seen another fetus that had a similar finding in the measurement of the femur?'

  'Of course.'

  'Do you happen to know the outcome?'

  Charlotte's lawyer stood up. 'Objection, Your Honor. The witness is just a technologist, not a physician.'

  'She sees this every day,' Booker countered. 'She's specially trained to read sonograms.'

  'Sustained.'

  'Well,' Janine said, miffed. 'For your information, it's not so easy to read the results of an ultrasound. I may just be a technologist, but I'm also supposed to point out things that might be problematic.' She jerked her chin toward me. 'Piper Reece was my boss. I was just doing my job.'

  She did not say anything more, but I could hear it all the same: Unlike you.

  Charlotte

  S

  omething was wrong with my lawyer. She was fidgeting; she kept missing questions and forgetting answers. It got me wondering: Was doubt contagious? Had Marin sat next to me all day while I fought the urge to stand up and put an end to all this, and then awakened this morning with the same gut instincts?

  She had called in a witness I did not know - Dr Thurber, who was British but had become the head of radiology at Lucile Packard Children's Hospital at Stanford before moving to Shriners in Omaha and applying his knowledge as a radiologist to OI kids. According to the endless list of credentials Marin had led him through, Dr Thurber had read thousands of ultrasounds during his career, had lectured throughout the world, and donated two weeks of his vacation every year to provide care to expectant mothers in impoverished countries.

  Basically, he was a saint. A really smart one.

  'Dr Thurber,' Marin said, 'for those of us who aren't familiar with ultrasounds, can you explain the technology?'

  'It's a diagnostic tool, in terms of obstetrics,' the radiologist said. 'The equipment is a real-time scanner. Sound waves get emitted from a transducer, which is placed against the mother's abdomen and moved around to reflect the contents of the uterus. The image gets projected onto a monitor - a sonogram.'

  'What are ultrasounds used for?'

  'To diagnose and confirm pregnancy, to assess fetal heartbeat and fetal malformations, to measure the fetus in order to assess the gestational age and growth, to see the location of the placenta, to determine the amount of amniotic fluid - among other things.'

  'When are ultrasounds traditionally performed during pregnancy?' Marin asked.

  'There's no hard-and-fast rule, but sometimes scans can be done at about seven weeks to confirm pregnancy and rule out ectopic or molar pregnancies. Most women have at least one ultrasound performed between eighteen and twenty weeks.'

  'What happens during that ultrasound?'

  'By then, the fetus is large enough to check out the anatomy and to look for congenital malformations,' Dr Thurber said. 'Certain bones will be measured, to make sure the baby is the right size based on the date of conception. They'll make sure organs are in the right place, and that the spine's intact. Basically, it's a confirmation that everything's where it's supposed to be. And of course, you get to go home with a picture that stays taped to your fridge for the next six months.'

  There were a few laughs on the jury. Had I had a picture of you, from your ultrasound? I couldn't remember. When I think back to that day, I only feel this great tidal wash of relief, from the moment Piper
told me you were healthy.

  'Dr Thurber,' Marin asked, 'did you have an opportunity to review the eighteen-week ultrasound that was performed on Charlotte O'Keefe?'

  'I did.'

  'And what did you see?'

  He glanced at the jury. 'Based on the ultrasound, there was definite cause for concern. Normally when you do an ultrasound, you're looking at the brain through the skull, so it's usually a little fuzzy, a little bit muddy and gray, because of reverberation artifacts from the side of the skull that the ultrasound beam first hits. In Mrs O'Keefe's sonogram, however, the intracranial contents were crystal clear - even that near field of the cerebral hemisphere, which is normally obscured. This suggests a demineralized calvarium. There are several conditions in which the skull presents undermineralized, including skeletal dysplasia, and OI. One then has the obligation to look at the long bones, and in fact femur length is a part of every obstetric ultrasound. In Mrs O'Keefe's case, the femur was also measuring a bit short. The combination of the short femur and the demineralized skull is strongly suggestive of osteogenesis imperfecta.' He let the words hang in the courtroom. 'In fact, had the technologist pushed down on Mrs O'Keefe's belly as she was doing the ultrasound, she would have been able to watch the screen and see the skull of the fetus being squashed out of shape.'

  I folded my hands over my stomach, as if you were still inside.

  'If Mrs O'Keefe had been your patient, Doctor, what would you have done?'

  'I would have taken more images of the chest - looking for rib fractures. I would have measured all the other long bones to confirm that this was a generalized short-bone condition. And at the very least I'd have referred the case to a center with more experience.'

  Marin nodded. 'What if I told you that Mrs O'Keefe's obstetrician did none of those things?'

  'Then,' Dr Thurber said, 'I'd say that physician made a very big mistake.'

  'Nothing further,' Marin said, and she slipped into the seat beside me. She immediately let out a heavy sigh.

  'What's the matter?' I whispered. 'He's very good.'

  'Did it ever occur to you that you're not the only one with problems?' Marin snapped.

  Guy Booker got up to cross-examine the radiologist. 'They say hindsight is twenty-twenty, don't they, Dr Thurber?'

  'So I've heard.'

  'How long have you testified as an expert witness?'

  'For ten years,' the doctor said.

  'I'm guessing you don't do this for free?'

  'No, I'm paid, like all expert witnesses,' Thurber replied.

  Booker looked at the jury. 'Right. There sure seems to be a lot of money flying around these days, isn't there?'

  'Objection,' Marin said. 'Does he really expect the witness to answer his rhetorical questions?'

  'Withdrawn. Doctor, isn't it true that osteogenesis imperfecta is very rare?'

  'Yes.'

  'So a small-town OB, for example, might go through her entire professional life without ever seeing a case?'

  'That's true,' Thurber answered.

  'Isn't it fair to say that only a specialist would have been looking for OI on an ultrasound?'

  'There is the old medical saying about hearing hoofbeats and assuming it's a horse instead of a zebra,' Thurber agreed, 'but any trained obstetrician should be able to look at an ultrasound and spot red flags. She might not be able to identify what they signify, but she would know them for their abnormality, and would recognize that the patient's care needs to be taken to the next level.'

  'Is there any condition other than osteogenesis imperfecta that can give you such a clear image of the near field of the brain during an ultrasound?'

  'The lethal form of congenital hypophosphatasia, but it's extremely rare and it still wouldn't have changed the need for the patient to be referred to a tertiary-care center.'

  'Dr Thurber,' Booker said, 'do you ever get a particularly clear image of intracranial contents of the skull . . . on a healthy baby?'

  'Occasionally. If the plane of the ultrasound on a particular image happens by chance to go through one of the normal cranial sutures, instead of bone, the interior of the brain will be shown clearly. However, we take multiple pictures of the brain looking at different intracranial structures, and the sutures are very thin. It would be virtually impossible to see multiple pictures of the brain for multiple projections where the transducer manages to hit a suture every single time. If I saw one image that showed the near field of brain very clearly but the other images did not, I would assume that single image had been taken through a cranial suture. In this case, however, all of the images of the brain show the intracranial contents unusually well.'

  'How about that femur length? Have you ever measured a short femur during an eighteen-week ultrasound and then seen a perfectly healthy baby delivered?'

  'Yes. Sometimes the technologists' measurement can be off by a hair because the fetus is moving around or in an odd position. They measure two or three times and take the longest axis, but even being a whisker off at eighteen weeks - we're talking millimeters - can drop the percentile significantly. Many times when we see a borderline-short femur length, it's just undermeasured.'

  Booker walked toward him. 'As useful as ultrasound technology is, it's not an exact science, is it? Certain images might be clearer than others?'

  'The clarity with which we see all structures in the fetus is variable, yes. It depends on many things - the size of the mother, the position of the fetus. There's a continuum, really. On any given day we might not be able to see them well, or conversely we might be able to see everything clearly.'

  'At an eighteen-week ultrasound, Doctor, can you definitively say that a child is going to have Type III OI?'

  'You can tell that there's something wrong skeletally. You can see indicators - like the ones that were in Charlotte O'Keefe's file. As the gestational age increases, if you see broken bones, you can generally guess that the fetus has Type III OI.'

  'Doctor, if Charlotte O'Keefe had been your patient, and you'd seen the results of her eighteen-week ultrasound, and there were no broken bones, you would have recommended she have follow-up care?'

  'Based on the short femur length and demineralized calvarium? Absolutely.'

  'And once you saw broken bones on a subsequent ultrasound, would you have done what Piper Reece did: immediately refer Mrs O'Keefe to a maternal-fetal-medicine practitioner at a tertiary-care center?'

  'Yes.'

  'But would you have conclusively diagnosed Mrs O'Keefe's fetus with OI at eighteen weeks, based solely on that first ultrasound?'

  He hesitated. 'Well,' Thurber said. 'No.'

  Amelia

  S

  ometimes I wonder what really constitutes an 'emergency.' I mean, every teacher in my school knew about the trial and the fact that both of my parents were not only in it but squaring off against each other. The whole state knew, and maybe even the whole country, thanks to the newspaper and television coverage. Surely even if they thought my mother was insane or moneygrubbing, they felt a smidgen of sympathy for me, being trapped in the middle? And yet, I still got yelled at in math for not paying attention. I had a huge English test tomorrow, vocabulary, on ninety words that I was most likely never going to use in my life.

  To that end, I was making flash cards for myself. Hypersensitive, I wrote. Too too too sensitive. But wasn't that the point? If you were sensitive, weren't you bound to take things too seriously in the first place?

  Trepidation: fear. Use it in a sentence: I have trepidations about taking this stupid test.

  'Amelia!'

  I heard you calling, but I also knew I didn't have to answer. After all, my mother - or maybe Marin - was paying that nurse who smelled like mothballs to watch over you. This was the second day she'd been here when I got off the bus, and to tell you the truth, I wasn't impressed. She was watching General Hospital when she should have been playing with you.

  'Amelia!' you yelled, louder this time.

  I scree
ched the chair back from my desk and thundered downstairs. 'What?' I demanded. 'I'm trying to study.'

  Then I saw it: Nurse Ratched had barfed all over the floor.

  She was leaning against the wall, her face the color of Silly Putty. 'I think I ought to go home . . . ,' she wheezed.

  Well, duh. I didn't want to catch the bubonic plague.

  'Do you think you can watch Willow till your mother gets back?' she asked.

  As if I hadn't been doing just that my whole life. 'Sure.' I hesitated. 'You are going to clean it up, first, right?'

  'Amelia!' Willow hissed. 'She's sick!'

  'Well, I'm not going to do it,' I whispered, but the nurse was already heading to the kitchen to mop up her mess.

  'I still have to study,' I said, after we were left alone. 'Let me go up and get my notebook and flash cards.'

  'No, I'll go upstairs instead,' you answered. 'I kind of want to lie down.'

  So I carried you - you were that light - and settled you on the bed with your crutches next to you. You picked up your latest book to start reading.

  Scrutinize: to observe carefully.

  Stature: the full height of a human.

  I glanced at you over my shoulder. You were the size of a three-year-old, even though you were six and a half now. I wondered how small you'd stay. I thought about how there are kinds of goldfish that get bigger when you put them in large ponds and wondered if that would help: what if, instead of sitting in this bed, in this stupid house, I showed you the whole wide world?

  'I could quiz you,' you said.

  'Thanks, but I'm not ready yet. Maybe later.'

  'Did you know Kermit the Frog is left-handed?' you asked.

  'No.'

  Dissipated: dissolved, faded away.

  Elude: to escape from. I wish.

  'Do you know how big a grave is when it's dug?'

  'Willow,' I said, 'I'm trying to study here. Could you just shut up?'

  'Seven feet, eight inches, by three feet, two inches, by six feet,' you whispered.

  'Willow!'

  You sat up. 'I'm going to the bathroom.'

  'Great. Don't get lost,' I snapped. I watched you carefully lever your crutches so that you could hop your way off the bed. Usually Mom walked you to the bathroom - or, really, hovered - and then privacy kicked in and you booted her out and closed the door. 'Do you need a hand?' I asked.