At seventy-three it was hardly a shocking oath to swear. Marina considered the length of Dr. Swenson’s arms and legs against the width of her circumference. It did not seem possible. “Is there any way for me to help?”
“Not unless you strap me to your back. I believe I can go up but the coming down concerns me. I don’t want to get stuck up there and wind up having to give birth in this hut myself.”
“No,” Marina said, though the thought of going up there alone was not without problems.
Dr. Swenson rubbed at her temples. “What do we know for certain, Dr. Singh? I am a seventy-three-year-old woman who is pregnant and short. But women who are older and shorter and more pregnant than I have made it up and down these ladders every day of their lives, including the day of their delivery.”
The T-shirted man leaned over the floor and looked at them with expectation. “Vir! Vir!” he said.
“Oh good,” Dr. Swenson said. “He has a little Portuguese. He says we should come.” She looked up again. “I suppose we should.”
“We also know for certain that none of those women was having her first child at seventy-three,” Marina said. “They had a lifetime of experience in climbing the ladders, pregnant or not. They were used to it.”
Dr. Swenson turned to her and nodded her approval. “Well said, and I admire your willingness to argue against your own best interests. Now stay one step behind me and prepare yourself to be an ox. You are very strong, aren’t you?”
“Very,” she said. And so they climbed, Marina stretching her long arms around her professor, her hands just beneath Dr. Swenson’s hands, her strong thighs beneath Dr. Swenson’s thighs, and up they went towards the wretched weeping and the husband’s calls of “Agora.” Now!
Benoit had been sent ahead with instructions that the family should have waiting a large quantity of water that had been twice boiled and twice strained, and the first thing they saw were the buckets, which were not clean themselves, sitting in a row. Benoit, who had avoided Marina since the incident with the snake, was nowhere in evidence. The woman lay on the floor in a pile of blankets and both the woman and the blankets were so wet they looked like they’d been dredged up from the river. Spreading across the floorboards beneath her was a dark, soaking stain. Their guide was kneeling beside his wife, holding her hand, rearranging her wet hair with his fingers while the other members of the household went about their business. An elderly man with no shirt stretched out in a hammock while two small children, a boy and a girl, pushed him back and forth, laughing ecstatically every time he swung away. Three women, one with a baby on her breast, were tying strings of red peppers together while a man in the corner sharpened a knife. When Dr. Swenson arrived at the top of the ladder she was panting and they all snapped up their heads in attention. She pointed to a wooden crate and one of the younger women ran to bring it to her. She sat down and was offered a gourd full of water which she accepted. Even the woman on the blankets quieted herself to acknowledge the honor she had been shown. To think that Dr. Swenson had come to her house!
Marina didn’t know if she should first attend to the patient or the doctor, when in fact she wasn’t sure she had the skills to help either one of them. “There’s the bag,” Dr. Swenson said, and gave a nod towards the floor. “You’ll find what you need. I’ll tell you, I’m impressed to have managed this.” She covered her heart with her hand. “I haven’t gone up a ladder since this whole ordeal began.”
Marina unzipped the bag and ran her hand in circles inside, heartsick to see how little she had to work with. There was a bar of soap in a box, no scrub brush, some packaged, disinfected towels, packaged gloves, a prepackaged surgical kit, some various medications that rolled around the bottom of the case looking paltry. There were two silver shoehorns with their ends bent back. Marina held them up. “What are these?”
“Shoehorns!” Dr. Swenson reported happily. “Rodrigo got a whole box of them once years ago. They make brilliant retractors.”
Marina put the shoehorns in her lap and bowed her head. “How can I sterilize them?”
“How can you sterilize anything? You can’t, Dr. Singh. This is what it is. Go ahead and wash up in the first bucket,” Dr. Swenson said. “I’m catching my breath.”
The water in the first bucket was tepid and Marina ground the soap into her skin over and over again, wondering how it was possible that she was where she was, that what was about to happen was in fact happening. Surely she had participated fully in every step it took to get to this place, agreeing whenever she had meant to decline, but still, it wasn’t such a long time ago that she was back at Vogel charting lipids and Anders was alive. She was trying to dig out the dirt from underneath her fingernails when the woman on the blanket let out such a cry she jumped. What Marina needed was to deputize a nurse, someone had to open the packages. She called to one of the three women, jerking her head until the woman reluctantly laid down her peppers and came over. Marina handed her the soap and did a pantomime of washing and opening the packages while the woman stared at her as if Marina had lost her mind. She wondered if she would have to act out every stage of the surgery, but now she was getting ahead of herself. No one had said there would be a surgery. Dr. Swenson had situated her crate next to the woman on the blankets. Marina came over with her nurse who continued to scowl at the bother of it all until Dr. Swenson made eye contact with her and the eye contact settled her at once.
Marina pulled on her gloves, got down on her knees. When the woman on the blankets looked at her, Marina pointed to herself, “Marina,” she said. The woman gave her a weak nod in return and said a name no one could hear. Having made the introductions, Marina soaped the woman’s genitals and thighs, bent up her knees and showed the nurse how to hold them. “It would be nice to have a clean blanket to put her on.”
“If you had a clean blanket you would want a sterile one, and a sterile blanket makes you think you can’t do anything without a table and a light, and from the table and the light it is a very short step to needing a fetal heart monitor. I know this. Check and see how dilated she is.”
Again, Marina looked at the woman as she slid in her hand to check the cervix. There was enough room for a well placed baby of normal size to make an easy exit and Marina felt a great wave of relief come over her. “She’s wide open.” She moved her hand around, feeling for the baby. As it happened, the basic construction of the female body had not changed since she had done this last. Having the patient on the floor made no difference: there was the baby, though she was quite certain that was not the baby’s head she was feeling. “It’s breech,” she said. It wouldn’t have been her first choice but she could manage it. “I’m going to have to try and turn it.”
Dr. Swenson shook her head. “That takes forever, causes a great deal of pain, and half the time it doesn’t work anyway. We’ll do a section.”
Marina removed her hand from the woman. “What do you mean it takes forever? Where do we have to go?”
From her perch on the wooden box Dr. Swenson dismissed the suggestion out of hand. “There’s no point in putting her through all of that if in the end you’ll have to do the section anyway.”
Marina sat back on her heels. “The point is we don’t have anything approaching sterile conditions. The chance of her dying from a postoperative infection is enough to indicate that turning the baby is worth a try. I don’t have a nurse to help me with a surgery, I don’t have an anesthesiologist.”
“Do you think we keep an anesthesiologist around here?”
“What do you have?” Marina pulled off a glove and poked through the bag.
“Ketamine. And don’t go throwing gloves away. This isn’t Johns Hopkins.”
“Ketamine? Are we planning on sending her out to a disco later? Who in the world uses Ketamine?”
“Here’s the news, Dr. Singh, you get what you get, and I was lucky to get that.”
“I’m going to try and turn the baby,” Marina said.
“You’re not,” Dr. Swenson said. “It is enough that I had to go up that godforsaken ladder. I would appreciate it if you did not make me get down on the floor as well. Even if it were possible to take my leg out of the equation, I have edema in my hands.” Dr. Swenson held up her hands for exhibition. Her fingers were swollen out straight and the skin was pulled tight. Ten little sausages.
“Dear God, when did that happen?” Marina reached up for a hand and Dr. Swenson jerked it away.
“I would have a difficult time with the scalpel. I have a difficult time with a pencil. All that said, either you are going to do the cesarean or I am. Those are the choices.”
“What is your blood pressure?” Marina asked.
“I am not your patient,” Dr. Swenson said. “You would do well to keep your attention on what is in front of you.”
The man in the gray T-shirt looked from Dr. Swenson to Dr. Singh, holding his wife’s hand. Clearly, their disagreement concerned him. It did not concern his wife, who took the opportunity to close her eyes for the two minutes she had between contractions. Had someone asked Marina whose opinion was more valuable on the question of whether or not to proceed with a cesarean—the former head of obstetrics and gynecological surgery at Johns Hopkins who had not touched the patient, or the obstetrics and gynecological surgery dropout who was touching her first patient in thirteen years—Marina would cast her lot with the former. Still, being the latter, she was sure she was right, and equally sure she wasn’t about to physically prevent her mentor from taking over the case. That left her one option. “Tell me how to use the Ketamine,” she said.
The Ketamine was put in a syringe, which, once the needle had been inserted into the vein, was taped to the inner arm so that it could be slowly tapped in as needed, and with that tapping the patient ceased to whimper. Marina washed and dried the woman’s belly, straightened out her legs, and, putting on clean gloves, showed her nurse how to hold the skin taut. She had her nurse’s attention now. The woman was wide-eyed and still while Marina slid the scalpel into the skin. Once she felt the knife insert, it occurred to her that this was not her first surgery after so many years. It wasn’t a week ago she had cut through the snake. The subcutaneous fat welled up through the line of the incision like clotted cream dotted with the first bright beads of blood.
That cut, which passed without a sound save a small gasp from the husband, drew the sudden attention of everyone in the hut. Even the old man pulled himself out of the hammock and brought the two children over to see. The other two women, and the man with the knife, all gathered round for the show, leaning forward and pushing a little to get the best view. Marina felt someone’s knees against her back. “This isn’t helping,” she said.
Her nurse, hands steady on either side of the incision, barked out an order, and the circle immediately took one big step back.
“Now we’re looking for the fascia,” Dr. Swenson said. “I didn’t bring my glasses. Do you see it there, under the fat?”
“I’ve got it,” Marina said. She took the nurse’s hands and put a shoehorn in each one. She dug the horns into the incision and showed the woman how to pull. There was the uterus. Despite the drowning flood of adrenaline she recognized it all—bowel and bladder, it was perfectly familiar. Why was that so surprising? She had given up her profession, not her knowledge. Marina, half blinded by her own sweat, turned her face to Dr. Swenson who picked a shirt up off the floor and wiped her down. Dr. Swenson then leaned forward and blotted off the face of the nurse, who was wrestling mightily to keep the cavity open wide with her shoehorns.
“Now take the bladder down,” Dr. Swenson said. “Don’t nick it. You see the bladder, don’t you?”
“I do,” Marina said. It was a miracle to see anything without direct light. She cut into the uterus carefully, avoiding everything that was not meant to be cut, and the blood boiled up into the cistern of the belly. Blood, combined with the great slosh of amniotic fluid, made a dark and raging ocean Marina could not get past. The hot liquid broke over the floor and pooled beneath the doctor and her patient. “How in the hell do you do this without suction?”
“There’s a bulb in the bag,” Dr. Swenson said.
“I need another set of hands.”
“You don’t have them. Make do.”
Marina grabbed at the bulb which shot out of her bloody glove and skidded across the floor where it was caught, like all balls, by a five-year-old boy loitering nearby. “Christ!” Marina said. “At least get somebody to wash it off.”
And Dr. Swenson, without a word, motioned for the bulb to be run through the bucket with soap and water and so it was returned to Marina who used it to pull up a half pint of liquid that she then shot onto the floor beside her. She did it again. There, beneath so many layers, she could see the baby face down, feet to the head, bottom lodged firmly in the pelvis. Marina tried to sit the baby up but it was stuck.
“Lift the breech,” Dr. Swenson said.
“I’m trying,” Marina said, irritated.
“Just tug it up.”
Marina moved the shoehorns to the inside of the uterus and motioned for the nurse to pull, to really pull, which this woman who was herself doomed to a lifetime of constant reproduction did with all her might while Marina reached in and tried to pry the baby out. It was wedged into the mother like a child who had shoved himself into the tiniest cabinet during a childish game and could then not be coaxed out. The muscles in Marina’s shoulders and neck strained, her back pulled. It was a physical test of strength, 142 pounds of Marina Singh against six pounds of baby, and then with a great sucking sound the baby dislodged. The man with the knife put his hand on Marina’s back to keep her from falling over. Red and white and shining, one entire boy flipped over on the mother’s chest.
“Look at that. Could that have been easier?” Dr. Swenson gave a single, decisive clap. “Give the baby to them now. They know all about this.” No sooner were the words spoken than the slippery child was out of her hands, the thick liver of placenta going with him. The entire crowd bore him away, the old and the young made off with the astonishingly new. They had proof of something spectacular happening now. As many births as there had been no one was completely inured to the charms of infants. “Do you remember the rest of it? Massage the uterus now. This is the part I always liked, reconstruction, restoring order to the chaos.” Dr. Swenson leaned forward for a better look. “The baby is gone, he’s someone else’s problem, and you can pay more attention to the details. There isn’t the same sense of urgency.”
From the other side of the room the baby was crying now and the husband, still fixed to his wife’s hand, craned his head towards the sound. “Tap the Ketamine,” Dr. Swenson said. “There’s no point in her waking up now.” Marina suctioned out the belly again and set to work on the heavy stitches, a procedure as delicate as closing a Thanksgiving turkey with kitchen twine. The nurse, so much braver than one would have imagined, moved her shoehorns back knowledgeably while Marina reassembled everything she had taken apart: the uterus sewn, the bladder placed back on top.
“This is a good man,” Dr. Swenson said, nodding to the husband. “He stayed right with her. You don’t see that. They like to go fishing. Sometimes when they hear it was a son they’ll come in for a look, but that’s about it.”
“Maybe it’s their first,” Marina said.
Dr. Swenson shook her head. “I should know that. I can’t remember.”
Marina was making her last knot when the baby was returned. She slid the Ketamine out of the woman’s arm and lay the baby there in its place, though the mother, who was just barely flicking her eyelids, did nothing to hold it. It was a good looking baby, two furry eyebrows and a rounded mouth, swaddled in striped yellow cloth. He gave half a cry and half a yawn and everyone seemed to find this charming.
Marina was stiff
coming up off her knees. “See?” Dr. Swenson said, pointing. “It’s hard enough for you.”
Marina nodded, taking off her gloves, and looked at the blood on her arms, the blood on her dress, the tidal pool of blood in which she had been sitting. “Good Lord,” she said. She looked in the bag for a blood-pressure cuff.
Dr. Swenson shook her head. “You don’t realize how much blood there is when you have all those other people waiting there to sop it up for you. This is a perfectly reasonable amount. You wait and see, she’ll be fine. They’ll both be fine.”
The nurse came over and covered the woman with another blanket. “It would be good if we could just move her to someplace that was dry,” Marina said. “I can’t leave her lying in all of that.”
“There are certain things we cannot expect the Lakashi to do,” Dr. Swenson said. “They cannot perform cesarean sections. That is a matter of training and equipment. They do know that a sick woman should not be left to lie on a sodden blanket, and they know perfectly well how to clean up. You will come back tonight and check on your patients, Dr. Singh, and come back again to check on them tomorrow. You’ll see how well they manage without you.”
The woman who had been nursing a baby when they arrived had handed that one off and was now nursing the new one while his mother slept on the floor. The father came to Marina, who was putting the contents of the used surgical kit back in her bag, and very lightly slapped her back and arms with his open hands. Then the others came over, all except the woman nursing and the woman sleeping, and did the same. The two children hit her legs and the old man reached to slap her ears. Marina in turn pounded the back of her nurse who had never flinched or turned her head during the surgery and in return the woman gently slapped Marina’s face with the back of her hand.