Volume 16 Number 4, SUMMER 1999

instinct

Related stories:
Writing Fiction, Exploring Reality

You enter the exam room on the right in the OB-GYN clinic at the hospital. You need an abortion within a few weeks.

You are feeling unnaturally tired, nauseated. And you're not even the patient. You sit down heavily on the stool and face your patient, Sonya, and her husband. Their five-year-old daughter plays in the corner with magnet blocks. The unit clerk, roped into playing interpreter, stands behind the door. Last week, you emphasized the need to make a decision immediately, but the couple has added an extra seven days to an already difficult procedure.

Sonya is 23 weeks and three days along in her second pregnancy. She had a glioblastoma resected from her brain two years ago back home. The tumor has returned with a vengeance and metastasized.

"You understand you have very little time left." You look toward the interpreter to make sure he is relaying the message in Albanian. "The high-risk obstetrician and the oncologist you met last time both recommend you consider undergoing radiation and chemotherapy to have an additional few months with your daughter and husband."

The interpreter speaks with many pauses, so you suspect not all the information is being conveyed accurately. There are no formal interpreters of Albanian in the hospital language bank. Fortunately, he is not related to Sonya or her husband. At least you hope he isn't.

You look directly at the clerk and then back at the couple to emphasize, "We believe you would be unable to survive the trauma of delivering this child." What you mean is she would die in childbirth, pushing until the pressure in her head becomes incompatible with life. You envision the tumor snaking around the lobes of her vulnerable brain, pulsing, hogging all the space. "If you decide to take a chance with the chemo and radiation, you'll need to have the procedure done this week." What she needs is a TAB, known euphemistically in the business as a "therapeutic abortion," right away. She should have had it done weeks ago when you discovered the mets and presented the option to them.

The husband speaks insistently in their native language to your patient. You see she has begun to cry softly. Both of them look drawn and tired in their ill-fitting hand-me-downs. They won a lottery back home for exit visas and just three months ago believed they had reached the promised land. Their second child would be born in America. They must feel cheated.

The interpreter tells you, "He says he does not want to be alone, taking care of their daughter and the infant, with her gone."

You leave them in the room for a moment to come to a decision. You feel the undercurrent of nausea more acutely as you drop off your patient's chart and walk towards the bathroom. You need to get this over with as soon as possible yourself.

You cannot believe that you are in this situation. Dirt-poor and with a chip on your shoulder, you have scholarshipped and bullied your way into medical school among the high-breeds and rich boys. You are in hock up to your neck, slogging hours in a lab, saying you're running gels because that sounds as though you are doing seminal bench DNA research, when it's really like making Jell-O. The high-breeds work for the academic thrill. Your prosperous anatomy partner works for a lab that discovers a rare mutant strain of mice useful for AIDS research. So his lab gets bought out by a venture capitalist and he gets first dibs. You dislike everything about your lab except it provides you with rent money and an excuse to leave those insufferable high-breed get-togethers when the conversation turns to lacrosse scores. "Sorry, I have to go, my gels are done." They all nod and smile with understanding. And you can skedaddle out of those uncomfortable moments.

You call on the phone in the restroom a number given to you by an old close-lipped community obstetrician. It is answered by a woman with a soothing voice, very unlike the brisk nurses in your area. You make an appointment for tonight, a safe 45 minutes away from your hospital.

When you re-enter the exam room, Sonya looks calmer. You know they have made the decision to have the TAB because the husband has visibly disengaged from the pregnancy. He is standing where their daughter is quietly playing, a good three feet away from his wife and her subtly protruding belly. The interpreter tells you they are prepared to proceed immediately.

Soon, Sonya is in a birthing bed, sitting halfway up in a hospital gown, holding her husband's hand. The nurse pulls up the gown and preps Sonya's belly with betadyne. Your attending comes in, gloves up, and pulls a foot-long needle from a sterile blue tray. She fills it with urea and hands it to you to inject into Sonya. You have already numbed her left upper abdomen. You notice on her right abdomen tiny ripples, butterfly-like flutters. The fetus is kicking. You glance up at Sonya and see that she has just felt the kicks. She starts to sob silently as your steady gloved hands guide the needle through her skin, her uterus and into a pocket of amniotic fluid.

Two hours later, you are called urgently to Sonya's side. She is contracting. The urea you injected has done its work and the fetus propels out of Sonya into your hands. Sonya's husband is at the bedside and sees that the fetus looks like a miniature baby. He sees that it moves its extremities while attached to the umbilical cord. You cut the cord and hand over the fetus to your nurse. She wraps it up in a cloth and sets it aside on a counter in the room. Sonya's husband looks stunned and remains quiet while you tend to her. When you are pulling off your gloves, he cannot help himself, and asks in broken English, "The baby ... move ... alive?"

"I'm sorry. But without mamma's help, the baby couldn't live." You make long gestures with your hands to indicate that the movements occurred when the umbilical cord was still attached to the placenta, which was still attached to Sonya. You make an impromptu drawing. He seems to understand. But then he asks for the clerk.

"He wants to baptize the child. He wants a Greek Orthodox priest. The closest thing to their Albanian church. He wants to name the child." On top of your exhaustion you are feeling extremely uncomfortable because your boss, the attending in high-risk obstetrics cases, wants you to ask the parents to see if the university hospital pathologist can do an autopsy to see if the cancer has spread to the fetus. You decide this is not the most opportune time to bring this up.

You clean up and change in the locker room. As you leave to get on the train, your attending comes up to you and says, "Great case, great job, Annique." You hope she does not notice the green tinge your face has taken on since your nausea has crept up again. You thank her politely.

On the train, you look around

to make sure you see no one you know from the university.

You enter a low-slung plain building and go straight along the corridor as instructed to the door at the far end. You enter the tiny reception area with a slew of women patiently waiting. The assistant with the pleasant voice looks up from her cluttered desk, smiles and asks, "Annique Wilson?" You get ushered directly into the doctor's office. Surprisingly large, it's stocked with everything you have in the ob-gyn clinic.

Dr. McCarthy looks pleased to see you. She is an older obstetrician, who works out of the community hospital. The questions she asks are straightforward. She does not assume you are a high-risk OB case.

"I have no prior medical history. I'm healthy. Except for my entrance exam to medical school, I've never had to go to the doctor," you reassure her. "I would like to have the TAB ASAP."

"Have you considered other options?" she asks.

"Of course not. I'm in clinics and you know the hours. Besides, I've never had any maternal instinct."

"What about your own family?"

"I have no family to speak of."

You vividly see images of your own mother reading paperback novels in the backyard, smoking cigarettes in the sun. A crisp image, yet obscured, removed, imbued with a discomfiting sense of distance. You do not remember ever being noticed. You ate TV dinners on a tray alone in the den while your parents ate theirs in the living room. When you asked your mother why you never went to Disneyland, she dismissed you, without any sense of maternal propriety, "Oh, we did all that with your brother."

You remember having a fever so high, seeing things, worried that you were dying, asking your mother to call the doctor. She flatly refused. Finally after repeated entreaties, she walked to the next room, picked up the phone and without dialing, began speaking into the phone, "Yes doctor, my daughter ... she'd just like to know that she'll be all right. Yes. All right? Thank you." She put the phone back onto its cradle, as if she were hanging up. You were not fooled.

These images are seared into your mind. You are defined by these moments. Having perfected that sense of distance, you are ice cold and see plainly that you are extremely good at difficult procedures.

"No, no family at all. The guy has no idea. I don't want him to know either."

Dr. McCarthy looks at her assistant, hesitates for a moment, then tells you about families wanting healthy babies. You are unbelieving, then start to listen about the private adoptions she's arranged.

"I have been speaking to a couple regularly. The husband is an extremely successful painter. The wife has been yearning for an infant but is unable to bear children. I could talk to them. They would pay for all your medical expenses, of course. But they would also pay you a lump sum. Rather generous, I should think." You cannot believe this sort of transaction still takes place. You think about the mounting bills. You wonder how much she's talking about.

The doctor tells you exactly how generous they would be. You are calculating, how much is a human incubator worth? You're healthy, but from all you've seen this month, being pregnant is not a benign condition. In the end, you agree to keep an open mind. You submit to an exam and lab tests, pay the fee, and climb back on the train, full of options.

Two months later,

you are working full time in the lab and have taken

a medical leave from school.

You walk into Marsha and Will's house, past the cacti garden, past the wall-sized paintings, and find yourself confronted with an entire wall neatly stacked with videos. You turn around and see another wall filled with CDs of rock and roll, jazz and classical music. Stained glass is superimposed on the patio doors. In the vast study, cubbies and shelves are crammed with books. You see the house is not childproof.

Will asks you to sit down on an overstuffed couch, and Marsha asks if you'd like some tea or juice. You decline politely and take another quick look around for photographs but see none. They start bombarding you with questions. You recall with irritation that you've already answered some, and are mildly surprised at the irrelevance of others.

"Do you like art?"

"Is your eye-hand coordination good?"

"What are you allergic to?"

"Is there any history of emotional problems in your family?"

You answer in truthful but brief responses. You want to shrink away from their eagerness, their intrusiveness, their frantic interest in you. You realize they have just asked you another question because both of them are looking at you expectantly.

"Pardon?"

"Is there something you'd like to know about us?" Marsha repeats.

You shake your head no, but of course you have a hundred questions.

Marsha continues, "Well, we realize this is quite unusual, but we think it'd be wonderful for everyone concerned if we were all open with one another, don't you?"

Will interrupts, "We plan on meeting regularly. Is that still OK?"

You nod yes, but think this is a bad idea. When the time comes, you want to hand over the kid and be done with it.

Your mind races. You're not cut out to be a mother. You have no maternal instinct. Marsha and Will want kids and have the means to take care of the kid. You need the money. It's an enormous amount of money. Finally, you reassure yourself that your life will be as planned.

Five and a half months later,

you end up at the tiny

community hospital far from your university.

After two days of unbearable pain, the placenta comes shooting out of you before the baby and you see a crowd of people moving in on you, shouting. It seems important that they get you into the operating room next door to do a C-section, but the gurney you're on is inexplicably too big for the door, they can't wheel you out fast enough, and the doctor has her hand flat against the door of your vagina, not letting the kid out or it'd die, and they end up doing an emergency C-section right there, and you scream then shut down, go numb because you feel them gutting you open like a fish and taking the baby out and away from you.

So, the first time you see the kid he is in Marsha's arms. Marsha is beaming and she leans over to stroke your arm.

"You were unbelievably courageous! Look at this beautiful child!"

You notice, though, that she's holding the kid at arm's length. You start to worry. You think about that childless house.

Two weeks go by, you cannot walk properly from healing, you lactate then you stop because there is no baby to trigger the flow, and you have a million feelings yet you don't feel anything because you are numb at what you have done. The phone rings and it's Will, embarrassed to confess that Marsha has gone over the edge and wonders could you come over to the house earlier than planned?

You take a taxi because Dr. McCarthy says you can't drive yet. Anyway the car's impounded, you have no cash left. All the money went to paying off bills. When the cab stops, you gingerly get out, careful not to split your gut up again, and Will comes out to pay the cabby.

"Oh my God! Thank you for coming! I don't know where to turn! She's gone crazy. I have no idea what's gotten into her!"

He speaks rapidly, in confidential tones as you near the door. "She's calling the advice nurse, the pediatrician every five minutes, asking the most minute questions about stooling, feeding. I have no idea what to do."

"How is the baby doing?"

"Fine, fine. The baby's fine. But Marsha doesn't believe it. She's staying up all night, reading all these books ... . Then she wakes me up, tells me all the things we're doing wrong. It's unbelievable. I don't even know who she is anymore."

All the videos, CDs and books are still perfectly aligned, the edges of their place are still intact. But the center of their house and lives has shifted. There are cotton diapers, unwashed bottles, open books strewn about everywhere.

Marsha is in her bedroom, reading a book on early childhood development. She looks disheveled, distraught. She looks up, sees you, holds out her hands like a child, ignores her husband, and says to you, "Thank God. Come, please."

You avoid her embrace and look over at the baby in the crib. He looks peaceful and fine indeed. You think he doesn't look like anyone yet, and in fact looks just like himself.

Marsha says, "I know he's adorable, but I don't feel it!" She shoos her husband out the door and continues, "I can't bond with him! I know that I got to hold him in my arms right away, but I don't feel anything! It's like a huge glass wall in front of me. I laugh but don't feel anything."

You are frightened that her cold feelings are mirroring yours and ask, "Is the baby OK?"

But she continues, "I don't know how to bathe him, how to feed him properly. Will's doing everything. I'm a total failure!"

The baby sleeps for a long time. By sitting there, you allow Marsha to tell you things you are not too comfortable to hear.

"I had such hopes, such anticipation when you were pregnant, Annique. I thought I would be a wonderful mother, very present, participating in my child's life. Instead, I'm out of control! I'm shocked to see the baby when I walk into the room. What's it doing here?" She is getting hysterical, she's gesturing wildly. "Listen Annique, you won't have to give back the money. It's all hush-hush anyway. Nothing's on paper. You take him. You'll know what to do. It's natural for you. Maternal instinct."

A year and a half goes by

and you are back in the OR, gowned, masked

and double-gloved.

You are about to do reconstructive surgery on a monster. Your patient is grotesque, born without ears, without a nose and with an abnormally large mouth.

In clinic, you hide your horror and speak to his mother. You notice she has undergone multiple surgeries on her own face, but nevertheless still looks like someone with an F-U-F. You do not like to use the crude jargon of the surgeons in plastics, but you cannot help staring at her f---ed-up face, her F-U-F.

You think, what lousy genetic counseling she must have received. You know that this particular disorder has penetrance, that with each new generation, the abnormalities show up quicker, deeper, more cruel. You ask, "Did you know?"

"Yes, from the ultrasound, they could tell he had no nose or ears."

"So did they tell you the options?" She knows you mean a TAB.

"Yes, but I figured I went through all these surgeries, so I thought he could too."

You think, what kind of idiot thinks this? Then you look down at the operating table and see your intubated patient, with sterile blue cloths draped where you'll be working. The entire lower half of his face is covered in blue and you see a sleeping child with long lashes, wearing a diaper on his perfectly formed fourteen-month-old body. You are struck that he looks exactly like your own son.

You realize that no matter what your opinions are about decisions made in utero, once this kid came out of the womb, he became somebody's child. You set to work to harvest a skin graft from his upper thigh and, with a narrow endotracheal tube, you fashion a rudimentary nose for him. You take some cartilage and create ears, proportionally larger so this child may grow into them more gracefully.

While your patient is in the recovery room, his mother greets you with tears of gratitude. You tell her, "It's just the beginning. As you know, over the years, he'll have to undergo several operations." In the middle of his face, you see a flap of skin over a plastic tube, but she sees a gesture of a nose, a glimpse of normalcy for her son.

You are ashamed of your judgments. You quickly change out of your scrubs, shower, and head up to the hospital's daycare to pick up your own child, Ben. He runs to you, trusting that as his mother, you know instinctively what to do. You pick him up in your arms. You want to examine his nose, his mouth, his ears. But he looks at you with such a nakedly adoring look that you feel heat around your heart. He wraps his arms around your neck and says, "Mama!" You kiss Ben's hair and walk into the elevator where your plastics attending says, "Is this one yours? I didn't know you had kids. Cute. Hey, that F-U-F was some case, Annique. Great job." You walk off the elevator with Ben, out of the hospital and towards his favorite park. SM