By Conrad Murphy

Somewhere between the second and third year of medical school, you start to grow tired of the phrase “You can’t just know the information — you have to apply it.” They keep telling us that, but they don’t exactly tell you how to do that. Medical school is a game of memorization in large part. How many tidbits of information can you squeeze in your brain? Not only that, but can you dig it back out after months of putting it in? 

“Mr. Murphy, what are the hard signs of an arterial bleed?” Well, let me go excavating the deepest caverns of my mind where my mother-in-law’s birthday resides along with the name of that Scandinavian group that had a killer song come out during high school (sorry mom-in-law, I am trying my best!). Sometimes I was able to dig out the information in time to answer the attending, sometimes I couldn’t dig it out, and sometimes I just never put it in.

A popular analogy compared the volume of medical school knowledge to drinking out of a fire hydrant. My favorite, however, was imagining that you had to eat 12 pancakes every day as a student. If you only ate eight of your pancakes today, tomorrow you’d have 16. One of the many tools that medical students have at their disposal to eat their fictional flapjacks is a computer program. It’s essentially just a fancy system of flashcards. It gives you a prompt and you fill in the blank by thinking of the answer (hopefully we all know what flash cards are). A pleasant day of studying for me is going to Round Mountain Coffee, grabbing an aromatic pour-over from some incredible Rwandan coffee beans, and dredging through a few hundred flashcards that morning. Usually, I have headphones listening to some music. Swedish House Mafia, haven’t heard them in a while. 

How does cardiac output change in hypovolemic shock? 

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Decreased

Only 387 more cards to go. A few months earlier, I was on a trauma surgery rotation. I enjoyed the pace of it while slowly embarrassed my way around being in the emergency department. Seeing how the interprofessional team operated when traumas came through the door was the most rewarding part. I signed up to receive the trauma pages on my phone, so I knew when to head down to the trauma bay no matter where I was in the hospital. The first one came through on that particular day:

Level 1 MOI: mcc trauma code 

It was a level 1 trauma –, the mechanism of injury was a motorcycle crash. Typically, they included heart rate, blood pressure, and the Glasgow Coma Scale number. They also usually gave the estimated time for arrival, but as we soon found out, there wasn’t time for any of that to be included in this case. I took my spot at the whiteboard where I was the one writing down all the physical exam findings, given timekeeping medications, and completed procedures. Once the cart rolled through the main doors of the department, I could only see one of the nurses turn to give us a grim look. Our patient came through the doors, and I immediately noticed the LUCAS device automatically giving compressions onto his chest. It was a violent machine. The thrusts shook the rest of our patient’s body, sacrificing all manner of gentleness for efficiency. 

All at once, the team coordinated decisive actions and employed closed loop communication to establish intravenous access, place an airway for ventilation, and continue resuscitation to bring him back to a stable rhythm. At some point the device was removed and although he was grossly unresponsive, a flicker of cardiac activity came across on the EKG monitor. The decision was made to pursue an emergency thoracotomy in the ED to attempt cardiac massage. This was an effort to provide direct compression with hands directly to heart. The resident made an incision on the left chest wall, applied rib spacers, and mobilized the heart in what seemed like five seconds. Through the organized chaos I saw her hands rhythmically squeezing the ventricles with her palms, one hand above and below. After some time, the trauma team leader called a time of death. We debriefed before cleaning up the room, taking used needles into safe containers, picking up wrappers from all the equipment that was used, and cleaning the floor as best we could. Most importantly, we sought to retain the dignity of our patient for his family that was waiting a couple doors down for news. I wiped down the whiteboard to get ready for the next trauma to come through. 

I thought about that trauma page for a while. I knew that thoracotomy procedures in the emergency department were rare for students to witness. Although I was extremely sad for the patient and the family, I felt somewhat privileged to see one. I had only heard about the procedure in textbooks and watched healthcare documentaries that mentioned them. My mind tracked back to the resident’s hands holding the heart, beating for it. 

What is the next step in management for a patient with penetrating abdominal trauma without peritonitis, evisceration, or hemodynamic instability?

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FAST scan → if negative → CT

A few days later I had my only trauma call shift for my surgery rotation. Every student was required to do 24 hours of trauma call, either all at once, or split into two days. Fortunately, I had already been on a trauma rotation for a couple weeks and knew what to expect. I showed up for my regular day on the trauma service and stayed behind afterward to carry my shift through the night. I had almost no trauma pages come through for the first several hours of that evening. I was studying and eating pizza in the team room by myself for a while. 

The first page came through sometime around 11 p.m. It was a transfer from another hospital unable to appropriately care for the patient due to limited resources. The trauma was some sort of accident with a piece of yard work equipment. It was a straightforward assessment — not much to write on the whiteboard since our patient had already been sedated throughout travel and she was stable before she even left the previous hospital. Our attending physician already spoke with the patient’s previous surgeon about plans for a surgical repair the next morning. Our job tonight was to make sure they were stable when they arrived and start making progress on the repair if we could. I didn’t realize it at the time, but another page had come through while we were already in the emergency department. 

Level 1 MOI: GSW R flank, MTP activated HR/SBP/GCS:100/80/14 ETA: 20 min.

It was a level 1 trauma. The mechanism of injury was a gunshot wound to the right side of the lower back. There was a significant concern for blood loss, so they activated Mass Transfusion Protocol, a method used to preserve and replace blood loss to patients quickly. The patient’s heart rate was at the upper limit of normal, not uncommon for trauma patients. The blood pressure was significantly lower than the normal range, a sign that somewhere the patient may not have the blood volume to adequately support oxygen delivery to his tissues. Finally, the patient was supposed to arrive in 20 minutes, but those minutes had come and gone while I was with the first patient. My attending had already left after our patient was stable and he went to meet the ambulance when it arrived.

I walked right over to the next trauma bay and heard the usual callouts and scattered noise from the physical exam and various procedures. I saw the patient on the table — a man writhing in pain and discomfort. His GCS score was 14, a good number, meaning that he was responding appropriately to the paramedics during the ride to the hospital. The nurses in the trauma bay were asking him his name and about his life to keep him engaged and to assess his mental status. 

What is the management for a penetrating wound below the T4 intercostal space in hemodynamically unstable patients?

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Exploratory Laparotomy

At some point it was decided that they needed to take back our patient for emergency surgery to try and stop some sort of bleed that the bullet may have caused when it entered the patient’s back. In a matter of a few minutes, he was intubated and sedated; he moved to the elevators that would bring him to the operating room. I left the trauma bay to join our attending and resident in the case. I hadn’t yet seen an exploratory laparotomy and needed to see one prior to finishing my clerkship. I didn’t quite know my role in emergency surgery as a medical student. I stood in the OR while the attending, the resident, the anesthesiologists, and the other operating room staff prepared our patient for surgery. 

“Conrad, scrub in, we’re going to need your help.” My attending had started painting our patient with an antiseptic solution. I went outside the room and scrubbed in, thankful to have the opportunity to help and see where the case was going to go. I walked back in and gowned up with the help of the nurses and surgical technologists there. The room felt very much alive, everyone was alert, active, and ready to go despite the hour going past midnight. As the gloves slipped across my hands, the surgeon made an incision from the bottom of the patient’s sternum all the way to several inches below the navel. 

I was helping to retract the abdominal wall while the attending and resident started the laparotomy procedure, packing all four quadrants of the peritoneal cavity to stop any bleeding and to look for any sources. To me, it was a very important and personal thing to see our attending carefully searching every surface of our patient’s abdomen to look for any lacerations or abnormalities. Immediately he noticed some portions of the patient’s bowel that needed a resection. He asked for a unique sort of stapler, one that I hadn’t seen before. He quickly moved a slide across two surfaces of bowel, taking out the damaged portion while sealing off the healthy ones. We’d come back later to anastomose the portions, since it wasn’t the most pressing issue at the moment. As he moved to the left lower quadrant of the abdomen, I heard him say, “Here we go.” He pulled out what looked like a metallic piece of popcorn, the warped bullet that had somehow found its way to the patient’s lower left side coming from the right side of his back when it entered. 

He dropped the fragment into a container and continued to work. We kept looking for a source of his bleeding, scouring every surface. We mobilized the kidneys and saw that his right kidney had been lacerated by the gunshot, but there was no active bleeding coming from the site. 

“Guys, his pressure is in the tank.” The anesthesiologist shouted as he leaned over the drape at the head of the table. We all looked up to the large monitor and saw the change. He was previously around 80mmHg of his systolic pressure while being transfused with blood, but now was fluctuating between 30-40. We turned back to the patient and worked faster, knowing that we needed to find the source of bleeding fast. The anesthesiologists continued to transfuse blood as fast as possible and the bags of blood products stacked up on the table beside them, ready to be emptied. 

The attending went back to the patient’s right upper quadrant and after dissecting further, a pool of old blood began to rise and flood his abdomen. We suctioned as much as possible to help him see where it was coming from. He found the source, but the blood resurfaced so quickly that he only had milliseconds at a time to visualize the patient’s anatomy. We switched to a stronger suction device and pulled out most of the fluid. 

“Sponge sticks, now!” The surgical technologist handed him two large forceps with packed gauze on the end of them and he pressed them down deep, looking to stop blood flowing from both the proximal and distal end of a possibly transected vessel. 

“It’s probably the IVC.” The inferior vena cava was the largest vessel that brought blood back from the lower extremities into the heart. A transection of that vessel would certainly cause the immediate blood loss we were seeing. If this was directly caused by the bullet, I couldn’t grasp why we were just now seeing hemodynamic collapse. At that point, it didn’t matter why. 

Unfortunately, we had a very difficult time keeping up. It felt like every drop of blood being transfused was just being lost through the suction. Our patient’s heart couldn’t survive with such low volume. The anesthesiologists told us that his pressure was so low that his heart was beating erratically and skipping beats altogether.

We started chest compressions to help push blood to our patient’s brain, beating for the heart through his chest wall. I pressed deep with each compression, trying to keep the pace that I was taught. We had intermittent moments where the heart found its rhythm again. We had moments where it seemed like the bleeding was controlled. But again and again, it came back.

“We’re doing a thoracotomy.” The attending physician showed me where to press on the sponge sticks to keep the IVC occluded so he could help the resident to mobilize the heart from the thoracic cavity. “Do not move, whatsoever!” He said as he left my side of the table and walked around. I pressed hard with intention, looking for any kind of loss. Our suction was still taking up some blood, but it wasn’t as substantial as when we first found the source. 

The resident made an incision on the left side of the patient’s ribcage, just like I’d seen another do in the emergency department a couple weeks prior. They took out separators to move the ribs so they could mobilize the heart for cardiac massage. After a couple short minutes, I saw the resident wrap her hands around our patient’s heart and rhythmically squeeze out the blood after it began to fill. We continued like this for a minute to monitor his circulation. I could feel my entire back and brow filled with sweat from pressing hard and leaning under the lights for so long. After about 30 seconds, we started to notice that the bleeding started welling not from the right side as much where I was holding the sponge sticks, but from the left. Another red flood began to fill the patient’s abdomen. 

“Conrad, I need you to take the heart now, let me take those.” He grabbed the sponge sticks from my hand. He needed the resident’s help to control the other side of bleeding and to stop it where we could. I quickly walked to the other side of the table and placed my hands under the resident’s while she gently slipped hers out. The heartbeat was strong in my hands — a perfect push and pull of cardiac muscle. I felt the rush of fluid come and go out of the chambers. “Now you see it’s beating well, you don’t need to squeeze much if you see it beating well, but if it fades, you need to squeeze the blood from the ventricles up to the vessels.” They continued to work away while I watched the heart in my hands beat, occasionally giving support with my palms. 

In our medicine courses, our instructors emphasized “treating the whole patient.” Don’t just treat the lab value, the abnormality, or even the disease. Treat the patient. In those moments with our patient’s heart between my palms, that instruction didn’t apply. It felt like the heart was the patient. It was the only thing that I could tangibly see alive. I was struck by how well it was working despite the complications we’d encountered so far. By this time, another trauma surgeon had rushed in, just finishing up another trauma evaluation in the emergency department below. She filed in with us, looking to help control the bleeding. It was just too deep. One step forward, two steps back. 

We weren’t keeping up. I felt the walls of the heart start to slowly give way beneath my hands and I found myself squeezing for almost every beat. For those unfelt beats, they were erratic, unorganized, panicked. Before long, I could tell that my hands were providing all of the effort. Several anesthesiologists on the other side of the drape were looking down at my hands, looking for any signs of activity aside from my own. 

“Everyone, please stop, stop transfusing guys.” There was no more progress to be made. Our patient passed. The room was silent aside from a couple sounds here and there from the monitor. We shared a couple seconds of silence together and our attending debriefed the team. We each went around the room sharing any thoughts. One thought that struck me came from a nurse that said he was able to tell her his name. It was true that it felt different to lose a patient when they came in and able to speak. A couple weeks earlier, the patient who came in was completely unresponsive. We were inclined to expect a poor outcome. The situations were each very dire, this one more insidious. 

“If this happened to me, I would want each one of you here,” another nurse said. I wholeheartedly agreed. Heroic actions aren’t always met with similar results. The attending surgeon nodded with his eyes at the ground as each person spoke. He thanked everyone in the room afterwards and left to go speak with our patient’s family.

The SPIKES protocol can be used to deliver bad news:

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S- Setting

P- Perception

I- Invitation

K- Knowledge

E- Emotions

S- Summary

The rest of the night passed as a blur. As the sun rose over the hospital buildings, I drove home, the adrenaline from the night gone, the images of that case creeping back to my mind. I remember losing tears on the way home, some from exhaustion, most from sadness. When I arrived home, I fell asleep after a while. I found it somewhat cruel that I was finishing my surgery rotation next week and would be moving on to something else while the same attending and the resident stayed on call throughout the month. 

Going through my flashcards, I came back to myself in the coffee shop. I didn’t have any that gave insight on that case — no cards on how to handle the drive home, fall asleep easier, or get up and go the next day. From that point I started to see the hospital differently, my kids differently, even myself. What is there to do in those circumstances? At least there’s one thing: We can do our best to remember the suffering we see and the bravery of those doing everything they can to help.

Conrad Murphy is a third year medical student at UAMS. He lives with his wife and two daughters in Conway, Arkansas. 

By Michael Ward

It was just after midnight on the Ides of March when I first held my daughter—merely an hour old—and watched the nurses try to save her mother’s life. Still dazed from the cesarean section, J. lay shaking on the hospital bed. Her fever had spiked to nearly 104 degrees, and significant blood loss during the surgery had cut her red blood cell numbers by half. Between trying to decipher the medical jargon that bounced around us and glimpses of the pained, wide eyes the nurses often presented when they looked at her, I kept thinking back to Macbeth.

One day some nine months before, as I hunkered down in the icy air conditioning of a Dallas summer day spent indoors, J. walked down our stairs with a smile. In her hand was a pregnancy test. Though it was a surprise that it actually happened, it was no less a welcome one; we had been trying for several months by that point. But just as you can feel a room change when the air conditioning clicks off and the oppressive Lone Star heat laps at the windows, so too does the room change when you learn, for the first time, you will be a parent.

It is then that you enter the liminal space of becoming a parent. Some people don’t want kids or can’t have them; some people already have them. But for another group, there are 40 weeks spent fretting over what’s about to happen. It’s sort of like being told there will be a party for you, but nothing more. Not quite a surprise, not quite known. This period of months is soon lost once the actual parenting begins. With time, memories morph, dissolve, or lie but they rarely sharpen.

A full-term pregnancy takes one through three seasons of life, three-quarters of a revolution around our nearest star. It is one of the longest gestational periods among mammals, any animal really. Physically and emotionally taxing, just a few hundred years ago it killed up to one out of every 20 women who tried it. Those numbers have, thankfully, dropped through the intervening centuries, but not to zero. In 2021, more than 1,200 mothers in the United States alone died as a consequence of pregnancy. It’s a mortality rate two to three times higher than most other developed countries. The rate is even worse for women of color and, like J., older moms.

We drove to the hospital for the pre-induction appointment in my two-door, standard-transmission small car. Anyone could tell, theoretically, that such a vehicle wasn’t ideal for carting around a new family. But I proved the point empirically by adding a car seat in the backseat, which in turn launched my driver’s seat forward and encouraged my knees to flirt awkwardly with the dash. A little closer to the windshield, I kept my eyes on the sky.

March weather in Dallas is, at best, capricious. The city sits near the foot of “tornado alley,” an unofficial meteorological designation spun up by Air Force officers during the Eisenhower-era study of severe weather on the Great Plains. When viewed from a distance, tornadoes are spectacular demonstrations of nature. From within, they are monstrous nightmares. As I shifted into first gear on March 13, the air was chilly and leaden with humidity. In the distance, silver clouds gathered.

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Hospital administration called me a “support person” for J. I took that to mean I could stay close but out of the way, lest I cause more trouble than my presence was worth. Within minutes of arriving at the hospital, four or five nurses—actual support persons with education and real experience—swarmed J., who sat up in the bed in the middle of the room. They hooked her up to a handful of devices that charted vitals like her pulse and blood oxygen levels. Here’s where I made a mistake.

A nurse appraised J.’s left arm, tracing a finger down her veins, inspecting them as a grocer might inspect a bundle of asparagus or rhubarb. Satisfied, she inserted an intravenous cannula into J.’s median cubital vein. Now, I’ve had blood drawn from my veins dozens of times in my life, and, while not particularly pleasant, I’ve always been able to watch with a certain curiosity. That evening, however, blood unexpectedly spurted out of her vein, dribbled down her forearm, and stained her floury white bedsheet. I looked away, but it was too late. My head began to feel lighter; the activity in the room began to slow down; my blood pressure dropped. I wasn’t nauseous, but I knew that if I stood up, I’d risk collapsing into the medical equipment. So I did the only thing I knew I could do: I sat still and avoided becoming the undo center of attention and listened to the voices in the room fade away.

Music from an old, scratchy radio began to fill my ears. Strange, ethereal, and hypnotic, it was nothing like I had ever heard before. I listened and wondered why I was hearing music at all. The next thing I knew, the brown eyes of the nurse who had administered J.’s IV were looking right at me. From behind her mask, she cried out, “Are you ok?” 

For a moment, I didn’t know where I was. I looked over to the right to find J. with the shimmery, salty remnants of tears trailing from the corners of her eyes. I had been unconscious for mere seconds—apparently stuck in some position with my legs stretched outward and my face contorted, like a Zoom call with a cursed WiFi connection—but it might as well have been an hour for all J.’s concern. The fainting experience I had is known as vasovagal syncope, which the Mayo Clinic notes can be triggered by the sight of blood. What the clinic is silent on is how fainting, when your only real job is showing up, comes with soul-crushing side effects.

An exam that followed revealed J.’s cervix had dilated only about two centimeters. Underwhelmed by such progress, her gynecologist inserted a Cook’s balloon, a device with two bulbs inflated with saline, to “encourage” the cervix to open. Invented by Israeli gynecologist Jack Atad in the 1990s, it’s similar to how one might use an air wedge to force open a locked door. If that analogy sounds distressing, it only gets worse. 

Francis Bacon wrote in 1605 that a doctor’s job is “not only [to restore] health, but [to mitigate] pain and dolors; and not only when such mitigation may conduce to recovery, but when it may serve to make a fair and easy passage.” If you’re in pain, you go to a doctor. If it’s not pain, exactly, which brings one to a physician then maybe it’s what Dr. Oliver Sacks once termed “a general feeling of disorder,” an awareness that something is wrong, a lack of internal homeostasis. That’s at least psychological pain. However measured and in whatever capacity, pain had punctuated J.’s anxieties leading up to the birth. Mine, too, if I’m to be honest. But what if the doctor is the cause of the pain? Pain and medicine often find themselves locked in a feedback loop.

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If the pain of the Cook’s balloon was intense for J., so were the contractions. That first evening in the hospital, an anesthesiologist came into the room with a roll cart. After barely a word to J., he began opening drawers and unfolding the tools of his trade. He inspected J.’s back much like the nurse had inspected her arm. Satisfied, he began to insert an epidural into her spine. (Given my recent medical history, I was not allowed to watch this.) Within minutes, fentanyl coursed through J.’s veins. Effectively today’s ether, the notorious drug is a synthetic opioid that was isolated in 1959 by Belgian doctor Paul Janssen and given a brand name as lofty as its nineteenth-century counterpart: Sublimaze. The drug successfully alleviated pain for tens of thousands of patients—mostly those with cancer—before it was used on women in labor.

Just before 8 a.m. the next day J.’s amniotic sack ruptured. Throughout the day, as I scrawled notes from the couch next to her bed, she was placed in various positions—left side, right side, peanut pillow wedged over here, elbow over there. These bed-ridden gymnastics were all in service of encouraging our unborn daughter to shift to a better delivery position while J.’s labor progressed. But the labor didn’t, in fact, progress. By 9 p.m., more than twelve hours later, J. was encouraged to go forward with a cesarean section.

After the nurses had wheeled J. out of the room and began prepping her for surgery, I was left alone to don a set of scrubs and booties. Not since my time in Medical Explorers, back in high school, had I worn scrubs. I looked into the bathroom mirror and saw a man dressed as the doctor he once thought he would become. Now I was moments away from becoming something else: a father. Those next moments, however, would prove devastating.

The nurses wheeled J. into the operating room, which looked so like every such room I’d seen on television or in movies it was surreal. The circular, overhead lights as large as gladiators’ shields. The cool mint green coverings draped over stainless steel tables. The way the light reflected lifelessly off the metal. The faceless doctors and nurses behind masks. The morbid chill of the air. The feeling that I was the only one in the room who didn’t absolutely have to be there. J. didn’t need me by her side; the surgery could’ve happened without my presence.

The surgical team then erected a three-foot vertical curtain starting near the top of her chest. Neither she nor I could see around it, but it wasn’t draped to the ground. There, directly next to my feet, were the light blue booties of the gynecologist. For the next half hour, I witnessed grasping and pulling and tugging. J. flinched and shook. The air in the room felt like that spilling from an open refrigerator, and I felt guilty thinking it was cold when next to me J. was splayed open. As the procedure continued, my gaze occasionally fell to the floor where the formerly blue booties of the surgeon had turned red with blood.

Suddenly, our daughter cried out.

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A birth is an act of violence. One being is expelled from another through one of two methods: painful muscle contractions or a knife. For me, I was transported 35 years into the past. There, in my seat on the far side of Ann Gorman’s middle school English class, I tried to make sense of Macbeth. As a young student, I had only a vague understanding of a cesarean section and certainly no idea of its traumatic impact on a woman’s body.

Written about the same time that Francis Bacon was writing about physicians and pain, it’s a famously bloody production: bloody clothes, bloody faces, bloody hands, bloody daggers. It is all a vasovagal syncope trigger if ever there was one. In Act IV Scene 1, the infamous witches even conjure a “bloody child” to the stage. “Be bloody, bold, and resolute,” the boy says. “Laugh to scorn / The power of man, for none of woman born / Shall harm Macbeth.” We’re told in the stage directions that the boy then simply “descends.”

This enigmatic message is, of course, lost on Macbeth. In the final scene of the play, as he and his archenemy Macduff battle to the death, Macbeth reiterates his prophesied invincibility. Macduff parries with one of the greatest plot twists in English drama. “Despair thy charm, / And let the angel whom thou still hast served / Tell thee Macduff was from his mother’s womb / Untimely ripped.”

Ripped is right. The cesarean section to which Macduff alludes—and answer to the riddle “not of woman born”—was likely performed on Macduff’s mother because she was dying and could not complete the labor. A knife was plunged into her body with little regard for her life and in a concerted effort to save that of the unborn child. Given maternal mortality rates at this time, many of the people in Shakespeare’s audience would’ve known of a mother who had died during pregnancy or labor. Though rare, they may have even known a child born like Macduff. Such a child may have been considered a peculiar sort of miracle. 

Though not through the birth canal, my daughter was no less “of woman born.” I was there when it happened. The woman was J., and as she was brought to the recovery room, she was shaking, visibly distraught, and had lost more than a third of her blood. As the nurses looked at her vitals, their eyes grew wider. What led to J.’s shaking and her pallid presentation was not the waning effects of fentanyl, as might’ve been expected. Rather, they were the symptoms of something potentially more dangerous than the very surgery she had just undergone.

To give a clear understanding of what was involved with this surgery, J.’s doctor described the “ripping” this way. 

A low transverse incision was made sharply. This was carried down to the underlying fascia with Bovie cautery. The fascia was incised in the midline and extended laterally sharply. The underlying rectus muscles were dissected off bluntly and sharply. The peritoneum was entered sharply and this incision was extended superiorly and inferiorly…. The incision was extended laterally manually… Brisk bleeding was noted from the right uterine vessels.

After four years of medical school, four years of a gynecological residency, and years of private practice, such a description sings with the tenor and dispassion of a beat cop’s report of a crime scene. The “brisk bleeding” noted during the procedure was itself unrevivable without modern medicine. This all was carried out not in a dank, eleventh-century Scottish castle but in a state-of-the-art medical facility in Dallas.

After her amniotic sack ruptured earlier that morning and while she labored in various positions throughout the day (and I—woefully unencumbered—wrote notes), bacteria multiplied in her uterus, infecting the tissues surrounding our daughter. The result was that not only did J. suffer significant blood loss during the operation, but she was fighting an infection known as chorioamnionitis. Without antibiotics, which didn’t exist until 1928, J. would’ve been treated with little more than cold compresses and prayers that her fever might break and the baby would be delivered normally. The infection would likely have overtaken her by midnight. Doctors, with their own pained eyes, would have had little choice but to remove our daughter, “untimely ripped,” at the expense of her mother. With antibiotics, her fever dropped and the shaking subsided. J. was alive. And several hours after the surgery, she first held her daughter.

The last evening that we were in the hospital, I watched the sky grow from an anemic yellow to anthracite black. Rain began to smash against the window. From seven floors up, the rest of the world looked remarkably far away. Our phones pinged and alerted us that we were under a tornado warning. Within minutes, a handful of nurses entered our room to usher J. and her massive hospital bed into the hallway. I pushed our daughter in the hospital carrier right behind them. The corridor, which had remained quiet for days, was filled with a dozen moms, fellow support persons, and babies. There, in that hallway, we waited for the storm to pass.

Michael Ward, M.S., is an essayist and fiction writer. His work was most recently featured in The Pinch (University of Memphis), The Twin Bill, and Diagram. He has forthcoming essays in X-R-A-Y and The Museum of Americana. Michael lives in Dallas with his wife and daughter.

By Rachel Weaver

In the way of five-year-olds, my kindergartener is convinced he knows sign language. He moves his hands and arms around in elaborate gestures that sometimes involve his hips, and then quizzes me on what he just said. 

Usually it’s “Can I have some milk?” or “I love Mama.” 

Today he gets that specific look on his face that means here comes some sign language. So I take a deep breath and try to focus on him through a fog of dizziness, my constant companion of 12 years. A specific version of migraine. Some days are worse than others, some aren’t too bad, but I feel seasick always. At least once a day, the room loosens, threatens to spin, sometimes does spin. My head has hurt for so long it has moved into my teeth. There is the simple exhaustion of no way out. But my five-year-old does not know any of this. 

Most days I can act normal enough that no one knows how much it aches to move my eyes or the way my head is too clouded to think, or the way walls shimmer like curtains in a slight breeze. But sometimes I have to lie down to play Candyland or I need to go to bed at 6:30 in the evening. Because I don’t want him to grow up around someone who complains, I don’t complain. Because I don’t want him to believe that life is mostly hard and unforgiving, I don’t act like my life is mostly hard and unforgiving. And most days, convincing him, convinces me. 

I want more than anything to protect him from the way life can rob you of yourself with no forewarning, I want more than anything to be a mom who jumps on swings, goes down the swirly slides, takes her kid skiing. I do not want to be defined by my illness and so I tuck it away deep within me and we do what I can do. 

He stands in front me on our back deck, preparing, jostling from foot to foot. He rubs away his wild-eyed smile with his little hands and settles into a serious face. Apparently, sign language today is a serious matter.

He is so far away, the vast darkness of this illness stretching between us. I will not lose him to this, I think. I begin the process of clawing my way toward him. Some days, the dizziness sits in the corner of my mind, hands folded, with me, but not in my way. Today it is raging through my head, my heart, my mind. My son knows none of this, of course. I am sitting in a chair, two feet in front of him on a bright blue spring day, hiding my dizziness from him.

He starts with a palms up, wide-armed gesture, his chin jutted out, that in the adult world usually means What the hell?        

But he’s decided it means Mama. 

“Mama,” I say, decoding.       

“Yes!” he screeches, and dances around. He races back to his position in front of me, drops his face back into the serious look. Next, he holds out one hand, palm down, puts all the fingers of his other hand underneath and turns them in a slow circle. This is a new one. 

“What’s that the sign for?” I ask.       

He drops his hands as his face pulls into a slow smile. The deck moves like the surface of a lake underneath him. I wonder how much longer I can stand it, what will happen when I can no longer maintain the distance between how I feel and how I act. 

He peers into my eyes and says, “That means I will love you when you’re all twisted up.” 

Rachel Weaver is the author of the novel Point of Direction, which Oprah Magazine named a Top Ten Book to Pick Up Now. Point of Direction was chosen by the American Booksellers Association as a Top Ten Debut for Spring 2014 and won the 2015 Willa Cather Award for Fiction. Rachel is on the faculty in the MFA Program at Regis University in Denver, Colorado.