FAMILY PLANNING EXCERPT Charlotte Hopper was good at keeping secrets. That's what she did all day—collect up women's secrets. She knew who got pregnant and who didn't. She knew who was cheating on whom, and sometimes why. But when she felt blood trickling down her leg as she stood in the exam room talking to Darla Beckwith, she knew she had kept one secret too many. It was one thing to hold on to her patient's secrets. Something entirely different to hold onto her own. Darla Beckwith was seated on the exam table, her blue eyes round with sincerity. She was wearing a too-big T-shirt with an arrow pointing down toward her abdomen that said "baby on board." "And I just know I'm pregnant," Darla said. "I feel sick all the time, I get dizzy, and my boobs hurt..." "Darla," Charlotte said, glancing down at the big red minus sign in the chart, "You said that you had a normal period two weeks ago." "Well, one of my girlfriends said she got her period every time. Right up to when the baby was due." Charlotte pulled her pen out of her lab coat pocket. In the slot labeled diagnosis she wrote pseudocyesis, imaginary pregnancy. She flipped back through the notes for the previous few visits. It was always the same story. "Darla. Your pregnancy test is negative. You are having normal menstrual cycles. I am certain you are not pregnant." Charlotte studied Darla's round face wondering if she was flat-out crazy or just above average dumb. Darla was twenty-five according to her chart, but she looked much younger, especially swimming in that huge maternity T-shirt. "But my girlfriend told me her pregnancy test came out negative until they did a blood test." It would be much easier just to order blood test than to sit here and argue with her. But the blood test cost money, and this patient had no insurance. She couldn't approve a blood test that the patient clearly didn't need just because the patient was nuts. Charlotte felt like sitting down. She was tired, and her back was starting to hurt. She looked at Darla Beckwith's chipmunk face. Suddenly, the exam room, the linoleum floor, the sink, the counter-top, the exam table, zoomed out of focus, then zoomed back in. Charlotte grabbed the edge of the counter-top to steady herself. What was with her? Well, she knew what it was actually. The same thing that was the matter with half of the girls she had seen that morning—just not with Darla Beckwith. She blinked twice, eased up her grip on the counter edge, and tried to imagine ahead of time the way her voice should sound—soft and supportive. "Darla, I know how much you must really want to be pregnant." "Oh, I do. I do. That's all I want in the world." "And you will be, Darla. You're young. You're healthy. How long have you been trying?" "Three months," Darla said earnestly. "And I'm starting to feel the baby move." But Charlotte grimaced. She felt a sharp pain in her abdomen. She gripped the counter edge again. She blinked. Could feel sweat beads popping out on her forehead. Darla saw the grimace. "You don't believe me, do you?" It was right about then that Charlotte felt the blood trickling down her leg. She wasn't sure it was blood, when she first felt it. "Thank you Darla," she said. "You can just head out to the window. They'll check you out." Charlotte could hear Darla protesting, "but I need a blood test. Everything makes me nauseous. My girlfriend says..." Charlotte pushed out of the exam room door, passed the new girl, whatshername in a hurry, and pushed her way into the bathroom. She stared at the thin red line rolling down her leg. She sat down on the toilet, wiped, looked at the tissue. Bright red blood. Her heart started beating fast...no not blood... Charlotte took a deep breath, tried to calm herself. Now think. It may be nothing. Maybe just a little spotting. Pain again. A thick band of pain, dull and sharp at the same time. Don't let there be more blood, then wiped again, but this time there were only a few pinkish strands mixed with mucous. She felt her heart rate slowing down a little. She was almost two months along, and somehow, the moment had never come to tell her husband Charlie that she was pregnant. Now, holding a bright red piece of toilet paper in her hand, she thought maybe she should have tried harder to find the right moment. She sat for a moment longer, slumped on the porcelain, pressing her forehead against the cool white surface of the sink. She should have told him, and Charlotte, who was prone to feeling guilty, thought that maybe keeping it from him was part of what was making this happen. She wiped one more time: this time, nothing. She stood up, washed her hands, splashed water on her face, and then ran her fingers through her faded brown pageboy. She took in the puffy skin around her eyes, the creases that were starting to appear between her brows, The Guatemalan beaded earrings from the fair trade store in Wayne. She picked up a little of Arecely's mango hand cream that was sitting on the bathroom sink, and she smoothed it on her hands breathing in the scent, then unlocked the door and went back out. The new girl, (what was her name? Right. Mary Louise) was standing in the hallway, waiting for her to emerge from the bathroom. "Do you need me?" She saw Mary Louise draw her head down between her shoulders. "Well, if you're busy I..." Mary Louise spoke so softly that Charlotte could barely hear what she said. She was an older woman, but she seemed completely new to medical office work. "Actually, I..." It was Mary Louise's second day on the job, and there was already an office pool about whether she would last through the day. They were all on eggshells hoping she wouldn't quit like the last two new girls had. "I'm sorry," she whispered. "Don't worry about it," Charlotte said, trying to keep the impatience out of her voice. "I just can't remember which papers go in the chart. Is it the white paper and the blue paper, or the yellow paper and the green paper?" "Don't worry Mary Louise, these papers confuse everyone at first. You're doing fine." Finally, after a few moments, she managed to break away. That was the thing about Charlotte. She had a hard time saying no to anyone. Some people thought that was one of her strengths, but she knew that it was more of a weakness. She punched the numbers of Dr. Goodman's number into her keypad, trying to steady her trembling hand, which she could feel was trembling. * * * There was a fluttering heartbeat on the ultrasound. Charlotte could see it, and for just a brief moment, she felt an surge of joy, but then the joy started to seep back out of her as Dr. Goodman pointed to the screen and in a matter-of-fact voice told her the problems: an irregular shaped sac, a slower than average heartbeat. For now, the pregnancy was still viable, but the outcome was far from clear. "I'm going to run serial betas," Dr. Goodman said. Two blood tests two days apart. The HCG hormone should double every day. If it didn't then she might be losing the pregnancy. She didn't want to cry in front of Dr. Goodman. She sucked in her breath and looked out the window, afraid if she spoke that her voice might crack. "So... what should I do?" "You can go home and rest if it makes you feel better," Dr. Goodman said, "But it isn't going to change the outcome one way or another.". Charlotte could feel a single tear escape from her eye. She wiped it away, hoping she wasn't going to start sobbing full out, there in the office. That was the kind of thing that happened to Charlotte. One minute she was calm, and the next minute, she was a sobbing mass of wet Kleenex and runny nose. Dr. Goodman laid a hand on her arm. "I know this is hard, but at this point, all you can do is wait and see." Of course, as a women's health nurse practitioner, Charlotte already knew all this, but when she was the one sitting on the exam table her knowledge and training didn't seem to help. * * * It was always hard not to be struck by the difference between Dr. Goodman's office and the place where Charlotte worked. Dr. Goodman's office was in a new office complex in Westville. Inside the waiting room there were pleasant upholstered sofas, a fish tank, and an air of calm. El Centro, where she worked, was just two miles away, but the distance from Westville to Londondale seemed longer. After she drove past the new shopping center with the Starbucks in it, the businesses along the highway started to change. Now ramshackle homes, tractor sales, and little Spanish markets lined the highway. El Centro de la Mujer/The Women's Center of the Greater Londondale Area (everyone called it El Centro) was a dilapidated old farmhouse that had been converted into medical offices back in the seventies. It sat in the middle of a parking lot, across the street from a trailer park, and behind it stretched fields that led out toward the Smithbridge mushroom farms. As she walked up the steps, Charlotte peeked through the waiting room window. Inside the waiting room, on faded sofas with broken springs, every seat in the house was taken. * * * Later that afternoon, after the last patient had been seen, Charlotte was sitting at her desk, a pile of lab results to review and slips for phone calls to be returned stacked in front of her when LeAnn popped her head in the door, her jacket on. "See ya, Charlotte," "'Night, LeAnn." Charlotte barely looked up, but then as LeAnn started to disappear down the hall, she called out behind her. "Hey, LeAnn..." She stopped. "Yeah?" "Did I get any phone calls." "Phone calls...phone calls...Oh, yeah. Dr. Goodman's office called. They said to call back before 4:30." Charlotte looked at her watch. It was five minutes to five. "LeAnn, it's five minutes to five. Why didn't you tell me?" "You were with a patient," she said. "Sorry..." Charlotte felt like standing up and hollering at her, but what good would that do? LeAnn was as scatter-brained as they come. Scolding her wasn't going to change that. She punched the numbers of Dr. Goodman's office into the phone, but, as expected, the answering machine picked up. She would have to wait until tomorrow. No more bleeding, no more cramping either. She had been allowing herself to feel temporarily hopeful. But without the lab results, it was still hard to know. Charlotte thought about the tiny life inside her—she had already fallen into dreaming about names and imagining baby clothes, she tried to rehearse what she was going to say to Charlie, "I know the timing isn't great, but, still, it's what we've been hoping for..." They had been trying for, how long? Three years? Four...? Five...? Until they had forgotten they were trying, until Charlotte wasn't sure if Charlie even wanted it anymore... While Charlotte was sitting there, staring into space, Arecely came to Charlotte's office door, her movements so quiet that Charlotte didn't even notice she was there. Arecely's hair was long and styled in ringlets that were carefully held in place by a copious amount of hair gel. Even at the end of the day her pink scrubs looked freshly ironed, her, sneakers were snow white, and her make-up looked fresh. "Charlotte?" Arecely spoke softly. "Yes?" "There's a patient just walked in. Says she needs to be seen right away." "What's the problem?" "She wouldn't say." Arecely said. Charlotte glanced at her watch. "Does she have an appointment?" "No." Charlotte looked at the stack of charts on her desk. Clinic policy was not to take walk-ins. Especially not five minutes before closing time. "She... she looked upset." Charlotte frowned, looked at her watch again, the stack of charts. It was hard for her to turn people away. "I'm sorry Arecely, but it's too late for a walk-in." "But I thought you said..." "Tell her that if she wants to be seen she needs an appointment. Tomorrow." Arecely spoke softly but there was quiet determination in her voice. "But she's upset." "Tomorrow." "But you said..." "I said what? That we see walk-ins now? At closing time?" "You said we should never turn a patient away if they really have a problem, and this girl, she seems really upset, and she didn't want to give her last name. She's crying, and she says it's really important." Arecely looked at Charlotte steadily, waiting for her answer. Arecely was twenty, and had a four-year-old son who was waiting for her at her next door neighbors, and yet, she was willing to stay. "Ok, bring her in," Charlotte said, then added, "and you get out of here. I don't want you staying late." "She doesn't speak English," Arecely said. Charlotte felt a stab of defeat. "All right, well let's get her in and out as quick as we can." * * * The name on the chart, Maria Lopez, was probably not her real name. She was a slight, very young-looking girl who sat shivering on the exam table covered by a paper drape. Her hair was twined into a thick braid, and her cheeks were covered by a fine layer of coarse dark hair. Her legs, solid tree trunks with thick ankles, which hung down below the paper drape, were also covered in thick dark hair. Around her neck, she wore a gold chain, with a pendant that had a shimmering image of a female face, maybe the Madonna, suspended on it. She wasn't crying, but her face was puffy and her eyes were red. Arecely stood next to Charlotte, translating. It bothered Charlotte that she couldn't talk directly to her patients. It left her with the constant feeling that she was going to miss that one crucial and important thing. She had tried to learn, listening to Spanish tapes in her car, but she didn't seem to have any talent for it. The language barrier felt like a brick wall that obstructed the light. "Ask her what she is here for today?" Arecely asked her, and then a torrent of words came out, punctuated by a fresh stream of tears, then a hand on her belly, then more words and tears. Charlotte picked out, sangre, bleeding, and el parto, birth, but not much else. Charlotte had a feeling, a premonition that something wasn't quite right. Arecely turned to Charlotte. "She says she had a baby about a month ago. In Mexico. She didn't get the postpartum check. Now she's says there is something wrong with her boob." Charlotte noticed that on the front of the girl's tee-shirt there was a small damp spot—leaking milk. "Where's the baby?" Charlotte asked. Arecely turned to the woman and asked her. Charlotte stared at the woman, trying to read clues to her anguish there. She strained to understand what the patient was saying—to no avail. "She says she left it with her sister." "In the mushroom camps?" Arecely said something else. "In Mexico." "She left the baby in Mexico?" There was another long exchange in Spanish, it sounded heated, to Charlotte's ears. The girl was still crying, and her hands, which gripped the paper drape, were twisting it into shreds. "Arecely, what is she saying?" "She says her boobs hurt, from when she stopped giving the baby the milk." Charlotte looked at the milk spots on the girl's shirt. How long did it take to get from Mexico to Pennsylvania anyway? In spite of her constant contact with women like this one—intimate contact as she examined their bodies using her own two hands, she really didn't understand anything about them. How exactly a young woman without papers got from Mexico to Pennsylvania, or what the mushroom camps where they lived looked like. Charlotte's brief exam was quick and business-like, the diagnosis evident as soon as she did a breast exam— it was a severe case of mastitis, a highly painful infection of the breast that needs immediate treatment. Just a few more hours without treatment and she would have gotten sicker. Charlotte wrote out a prescription and handed it to the patient. "Tell her that the medicine might be expensive. Ask her if she has the money to pay for it. Tell her that it's really important," Charlotte said. Arecely said something that sounded reassuring, but Charlotte didn't recognize the word dinero. "Arecely, does she have a way to pay for the medicine?" Arecely shrugged. "She's going to ask her brother-in-law." "Does she understand how important this is?" Arecely didn't answer, and Charlotte left the question hanging there. She was doing what she could do, and she tried to repeat that to herself, but it had a hollow feel. Back at her desk, Charlotte tried to hurry as she finished the rest of her paperwork. From outside her cubicle, she could hear the girls getting ready for closing, and she wanted to be ready so that she didn't hold them up. Those small successes, agreeing to see a patient five minutes before closing, and then finding out that she was able to do some good, those used to be the things that kept her going. She worked long hours and was underpaid, but at least, she always told herself, she was part of the solution, not part of the problem. But somehow, lately, it was getting harder and harder for Charlotte—she referred people to specialists they couldn't afford to see, prescribed medicines they couldn't afford to buy, and still the line outside the clinic never diminished. She thought of the young woman (she very much doubted that her name was really Maria Lopez; the undocumented workers were often afraid to give their real names). Four weeks ago she delivered a baby in Mexico. Four weeks later, she was here, in a trailer outside a mushroom camp in Pennsylvania? Charlotte couldn't quite grasp how that could happen. It was hard enough to imagine losing a baby when she was only two months along. What circumstances would drive a woman to leave her baby behind when the milk was still hot in her breasts? Well, that wasn't entirely true...but Charlotte shoved that thought aside. As she zipped up her jacket, she whispered to the fragile spark of life growing within her: stay alive. © Elizabeth Letts BUY THE BOOK online from your local independent bookstore via BookSense, Amazon or Barnes & Noble.