The Cole Trilogy: The Physician, Shaman, and Matters of Choice

  “This kid means a lot to me, Mona. A whole lot.”

  “Well, R.J., we’ll offer her every amenity,” Mona said, a little less warm than she had been.

  R.J. got the message that to Mona every patient was special, but she persisted doggedly. “Is Les Ustinovich still working there?”

  “Yes, he is.”

  “Could she have Les, please?”

  “Dr. Ustinovich for Sarah Markus. She’s got him.”

  * * *

  When R.J. picked her up at the log house, Sarah was too bright, too cheerful. She was wearing a loose two-piece outfit on the advice of R.J., who had explained that she would only have to disrobe the lower part of her body.

  It was a mild summer day, the air clear as glass, and R.J. drove slowly and carefully down the Mohawk Trail and Route 2, making Boston in less than three hours.

  Outside the clinic in Jamaica Plain there were two boredlooking policemen R.J. didn’t recognize, and no demonstrators. Inside, the receptionist, Charlotte Mannion, took one look at her and let out a whoop. “Well, hello, stranger!” she said, and hurried from behind her desk to kiss R.J.’s cheek.

  The turnover had been high; half the staff people R.J. saw that morning were unknown to her. The other half made a fuss over seeing her again, which she found especially gratifying because it visibly gave Sarah confidence. Even Mona had gotten over her snit and hugged her long and hard. Les Ustinovich, rumpled and grumpy as always, gave her the briefest of smiles, but it was warm. “How’s life on the frontier?”

  “Very good, Les.” She introduced Sarah to him and then took him aside and told him quietly how important his patient was to her. “I’m glad you were free to take care of her.”

  “Yeah?” He was studying Sarah’s forms, noting that Daniel Noyes had done the pre-clinic physical instead of R.J. He looked at her curiously. “She something to you? Your niece? Or a cousin?”

  “Her father is something to me.”

  “Oh-ho! Lucky father.” He started to turn away but came back. “You want to assist?”

  “No, thank you.” She knew Les was being gracious, a stretch for him.

  She stayed with Sarah through several hours of first-day preliminaries, taking her through admitting and medical screening. She waited outside, reading a two-month-old Time during the counseling session, most of which would be a repeat for Sarah because R.J. had gone over every detail with her as carefully as possible.

  The last stop of the day was in a procedure room for laminaria insertion.

  R.J. stared sightlessly at Vanity Fair, knowing that in the room next door Sarah would be on the examining table, her feet in the stirrups, while BethAnn DeMarco, a nurse, inserted a two-inch twist of seaweed, like a tiny stick, into her cervix. In first-trimester abortions, R.J. had dilated the cervix with stainless steel rods, each one larger than the last. A second-trimester procedure required a larger opening to enable the use of a larger cannula. The seaweed expanded as it absorbed moisture overnight, and by the next day the patient didn’t need further dilation.

  BethAnn DeMarco accompanied them to the front door, telling R.J. the whereabouts of several people with whom they had worked. “You might just feel a little pressure,” the nurse told Sarah casually, “or the laminaria might give you some cramps tonight.”

  From the clinic they went to a suite hotel overlooking the Charles River. After they registered and went up to the room, R.J. whisked Sarah off to Chef Chang’s for dinner, thinking to razzle-dazzle her with sizzling soup and Peking duck. But razzle-dazzle was difficult because of discomfort; halfway through dessert they abandoned the ginger ice cream because the “little pressure” DeMarco had mentioned was rapidly becoming cramps.

  By the time they got back to the hotel, Sarah was pale and racked. She took the crystal heartrock from her purse and placed it on the night table where she could see it, and then she curled up like a ball on one of the beds, trying not to weep.

  R.J. gave her codeine, and finally she kicked off her shoes and lay down next to the girl. She was painfully certain she would be rebuffed, but Sarah snuffled into her shoulder when R.J. put her arms around her.

  R.J. stroked her cheek, smoothed her hair. “You know, honey, in a way I wish you hadn’t been so healthy up to now. I wish you’d needed a few fillings at the dentist’s, maybe even had your tonsils and your appendix out, so you’d understand that Dr. Ustinovich is going to take care of you and that this will pass.

  “Just tomorrow, and then it will be over,” R.J. said, patting Sarah’s back gently and even rocking her a bit. It felt right, and they lay like that for a long time.

  Next morning they arrived at the clinic early. Les Ustinovich hadn’t had his morning coffee yet and gave them a nod and a grunt. By the time he’d had his caffeine fix, DeMarco had ushered them into the treatment room, and Sarah was positioned on the table.

  She was pale, rigid with tension. R.J. held her hand as DeMarco administered the paracervical block, an injection of 20 cc of Lidocaine, and then started the IV. As luck would have it, DeMarco made a couple of false tries with the IV needle before she found the vein, and Sarah was gripping R.J.’s hand so tight it hurt. “This will make you feel better,” R.J. said as DeMarco started conscious IV sedation, 10 mcg of Fentanyl.

  Les Ustinovich came in and looked at their welded hands. “I think you’d better go to the waiting room now, Dr. Cole.”

  R.J. knew he was right. She reclaimed her hand and kissed Sarah on the cheek. “I’ll see you in just a little while.”

  In the waiting room she settled onto a hard chair between a skinny young man who was concentrating on biting off a cuticle and a middle-aged woman who was pretending to read a tattered issue of Redbook. R.J. had brought the New England Journal of Medicine but she had a hard time concentrating. She was thoroughly familiar with the timetable and knew exactly what probably was happening to Sarah. The curettage was done in two stages of suctioning. The first was called “the long session” and took about a minute and a half. Then, after a pause, the second, touch-up suctioning was briefer. She hadn’t had time to make her way through an entire article before Les Ustinovich came to the door and beckoned to her.

  He had only one clinical manner, bluntness.

  “She’s aborted, but I perforated her.”

  “Jesus Christ, Les!”

  He froze her with a glance that brought her to her senses. He undoubtedly felt bad enough without salt in the wound.

  “She jerked her body at just the wrong moment. God knows she wasn’t feeling any pain, but she was a nervous wreck. The perforation of the uterus took place where she has a fibroid tumor, so there’s some ripping and tearing. She’s bleeding a lot, but she’ll be all right. We’ve got her packed, and the ambulance is on its way.”

  From then on, everything went into very slow motion for R.J., as if suddenly she existed under deep water.

  She never had perforated a uterus during her time at the clinic, but she always had worked on women in the first trimester. Perforations happened very rarely, and they required surgical repair. Luckily, Lemuel Grace Hospital was only minutes away, and the ambulance was there almost before she had finished reassuring Sarah.

  She made the short ride with Sarah, who was taken to the operating room on arrival.

  She didn’t have to request a surgeon. Sarah was assigned a gynecologist whom R.J. knew by reputation. Sumner Harrison. He was supposed to be very good, the luck of the draw.

  The place that once had been so familiar to her was slightly out of focus. A lot of strange faces. Two familiar people smiled and said hello as they passed her in the corridor, hurrying from someplace to someplace.

  But she remembered where the telephones were located. She picked up a phone, ran her credit card through the slot, and dialed the number.

  He picked it up after two rings.

  “Hello, David? This is R.J.”

  31

  A RIDE DOWN THE MOUNTAIN

  By the time David got to Boston, S
arah was out of surgery and doing nicely. He sat by her bed and held her hand as she emerged from anesthesia. At first Sarah wept to see him and watched him warily, but R.J. thought he handled her in exactly the right way; he was tender and supportive and gave no indication he wasn’t completely in control of his thirst.

  R.J. thought it best to give them some time alone. She wanted to know details of what had happened, and she telephoned BethAnn DeMarco and asked her if they might meet for dinner. BethAnn was free, and they met in a small Mexican restaurant in Brookline, near where BethAnn lived.

  “This morning was something, wasn’t it?” DeMarco said.

  “Some morning.”

  “I can recommend the arroz con polio, very good,” BethAnn said. “Les feels bad. He doesn’t talk about it, but I know him. I’ve worked at the clinic four years, R.J., and this is only the second perforation I’ve seen.”

  “Who did the other one?”

  BethAnn looked uncomfortable. “It happened to be Les. But it was so innocuous it didn’t require surgery. All we had to do was pack her and send her home for bed rest. That wasn’t Les’s fault this morning. The girl just gave an involuntary lurch, like a big twist, and the curette penetrated. That doctor who examined her out where you live …”

  “Daniel Noyes.”

  “Well, Dr. Noyes can’t be faulted either. For missing the fibroid, I mean. It wasn’t large, and it was in a little fold of tissue, impossible to see. If it had been just the perforation, or just dealing with the fibroid, it would have been easier to handle. How’s she doing?”

  “She seems to be fine.”

  “Well, all’s well that ends well. Me for the arroz con pollo. How about you?”

  R.J. didn’t care; she had the arroz con pollo too.

  It wasn’t until later that evening, when she and David were alone, that he began to formulate the hard questions that she found difficult to answer.

  “What in hell were you thinking of, R.J.? Don’t you know you should have consulted me?”

  “I wanted to, but Sarah wouldn’t hear of it. It was her decision, David.”

  “She’s a child!”

  “Sometimes pregnancy makes women out of children. She’s a seventeen-year-old woman, and she insisted on dealing with her own pregnancy. She went before a judge, who decided she was mature enough to end the pregnancy without bringing you into it.”

  “I suppose you arranged for her to see the judge?”

  “At her request. Yes.”

  “God damn you, R.J. You acted as if her father were a stranger to you.”

  “That isn’t fair.”

  When he didn’t answer, she asked if he intended to stay in Boston until Sarah was released from the hospital.

  “Of course.”

  “I have patients waiting to see me. So I’ll go back.”

  “Yes, you do that,” he said.

  It rained hard for three days in the hills, but the day Sarah came home the sun was warm, and the spicy smell of the summer woods was in the soft breeze. “What a day for riding Chaim!” Sarah said. It was good for R.J. to see her smile, but she was pale and tired-looking.

  “Don’t you dare. You stay in and rest for a few days. That’s important. Do you understand?”

  Sarah smiled. “Yes.”

  “This is a chance for you to listen to some ba-ad music.” She had bought the newest Pearl Jam CD, and Sarah’s eyes filled when R.J. gave it to her.

  “R.J., I’ll never forget …”

  “Never mind that. Now, you take care of yourself, sweetheart, and get on with your life. Is he still angry?”

  “He’ll get over it. He will. We’ll honey-hug and sweet-talk him.”

  “You’re a great girl.” R.J. kissed her on the cheek. She decided she had to talk to David without delay. She walked out to the barnyard, where he was unloading bales of hay from his pickup truck. “Will you please come to dinner tomorrow night? Alone?”

  He looked at her and then nodded his head. “All right.”

  The next morning shortly after eleven she was preparing to drive down into Greenfield to visit two hospitalized patients when her telephone rang.

  “R.J., it’s Sarah. I’m bleeding.”

  “A lot or a little?”

  “A lot. A whole lot.”

  “I’ll be right there.” She called the ambulance first.

  Sarah had been content to sit for hours like an invalid on the old stuffed rocking chair next to the jars of honey and watch what she could see, squirrels chasing pigeons on the barn roof, two rabbits chasing one another, their neighbor Mr. Riley driving by in his rusted blue pickup truck, a large and obscenely fat woodchuck browsing on the clover in the northwestern corner of the pasture.

  Presently she watched the woodchuck scamper clumsily to pop into its burrow under the stone wall, and a few seconds later she saw why, because a black bear ambled out of the woods.

  It was a small bear, probably born only last season, but its scent carried to the horse. Chaim’s tail came up, and he began to prance in terror and to whinny loudly. At the sound the bear hightailed it back into the woods, and Sarah laughed.

  But then Chaim’s shoulder hit the one bad post in the barbedwire fence. Most of the posts were newly split black locust and would fight moisture for years. This one was pine, and it had rotted nearly in two at the place where earth met air, so that when the horse went into it with his shoulder it had fallen with only the slightest sound, allowing him to leap at once over the suddenly lowered strands.

  On the porch, Sarah had set down her cup of hot coffee and risen. “Damn. You! You bad Chaim, you!” she had called. “You wait right there, you bad thing.”

  On her way across the porch to the stairs she picked up a piece of old rope and a feed bucket that still contained a little grain. It was a good distance to go, and she forced herself to walk slowly.

  “C’mere, Chaim,” she called. “Come and get it, boy.”

  She struck the feed pail with her fingers. Ordinarily that was enough to bring him to her, but he was still spooked by the bear scent, and he moved a little way up the road.

  “Damn.”

  This time he waited for her, turned so he could watch the edge of the woods. He never had kicked her, but she gave him no chance, approaching him carefully from the side and holding out the bucket.

  “Eat, you dumb old thing.”

  When he buried his nose in the pail, she let him get a mouthful and then slipped the rope around his neck. She didn’t tie it, afraid he would spook again and get it caught on something that could choke him. She wished she could have swung up onto him and ridden him bareback. Instead she slipped the rope over his ears and past his eyes and held the two ends together with her hands, talking to him softly and tenderly.

  She had to lead him past the break in the fence, all the way to the rude gate, and then lift the heavy poles out of their slots until the way was open for him to reenter the field. She was putting the poles back and worrying about how she could close up the fence until her father came home when she became conscious of the wetness, of the shining-leather redness of her legs, of the shocking trail she had been leaving behind her, and the strength went out of all of her and she began to cry.

  By the time R.J. reached the log house, the towels Sarah had fashioned into packs had proven woefully inadequate. There was more blood on the floor than R.J. would have imagined possible. She guessed that Sarah had stood there and bled, not wanting to ruin the bedclothes, but then had flopped back onto the bed, perhaps in a faint. Now her legs dangled beyond the crimsoned bed, her feet on the floor.

  R.J. lifted her legs to the bed, removed the soaked towels and put in fresh pressure packs. “Sarah, you have to keep your legs together hard.”

  “R.J.,” Sarah said faintly. From very far away.

  She was already semicomatose, and R.J. saw that she wouldn’t be able to control her muscles. R.J. took strips of cling bandage and tied the girl’s legs together at the ankles, and the knees,
and then made a little pile of blankets and lifted Sarah’s feet onto it.

  The ambulance was there very soon. The EMTs wasted no time loading Sarah, and R.J. got into the back with Steve Ripley and Will Pauli and started oxygen therapy at once. Ripley did the workup and assessment en route, while the wailing ambulance rocked and swayed.

  He grunted when the vital signs matched the numbers R.J. had recorded in the house before the ambulance came.

  R.J. nodded. “She’s in shock.”

  They covered Sarah with several blankets, kept her feet raised. Behind the gray oxygen mask covering her mouth and nose, Sarah’s face was the color of parchment.

  For the first time in a very long time, R.J. tried to will every cell of her being into direct contact with God.

  Please, she said. Please, I want this kid.

  Please. Please, please, please. I need this clean, long-legged girl, this funny, beautiful girl, this possible daughter. I need her.

  She forced herself to take the girl’s hands in her own, and then she couldn’t let them go, feeling the trickling of the sand out of the hourglass.

  There was nothing she could do to stop it, to reverse what was happening. She could only fuss with the oxygen to make certain it was pouring out its richest mixture and ask Will to radio the hospital so that a supply of matched blood would be available and ready.

  When the Woodfield ambulance reached the emergency room, the waiting nurses opened the door of the rig and stood abashed and uncertain at the sight of R.J. unable to stop clutching Sarah’s hands. They had never before seen an ambulance arrive containing a broken doctor.

  32

  THE ICE CUBE

  Steve Ripley telephoned Mack McCourtney and asked him to get David Markus and bring him to the hospital.

  Paula Simms, the emergency room doctor, insisted on giving R.J. a tranquilizer. It made her very quiet and withdrawn but otherwise had no discernible effect on her horror. She was sitting frozen next to Sarah, holding her hand, when David arrived, his eyes wild.