Jodi Picoult - Handle with Care

I folded my hands over my stomach, as if you were still inside.

“If Mrs. O’Keefe had been your patient, Doctor, what would you have done?”

“I would have taken more images of the chest-looking for rib fractures. I would have measured all the other long bones to confirm that this was a generalized short-bone condition. And at the very least I’d have referred the case to a center with more experience.”

Marin nodded. “What if I told you that Mrs. O’Keefe’s obstetrician did none of those things?”

“Then,” Dr. Thurber said, “I’d say that physician made a very big mistake.”

“Nothing further,” Marin said, and she slipped into the seat beside me. She immediately let out a heavy sigh.

“What’s the matter?” I whispered. “He’s very good.”

“Did it ever occur to you that you’re not the only one with problems?” Marin snapped.

Guy Booker got up to cross-examine the radiologist. “They say hindsight is twenty-twenty, don’t they, Dr. Thurber?”

“So I’ve heard.”

“How long have you testified as an expert witness?”

“For ten years,” the doctor said.

“I’m guessing you don’t do this for free?”

“No, I’m paid, like all expert witnesses,” Thurber replied.

Booker looked at the jury. “Right. There sure seems to be a lot of money flying around these days, isn’t there?”

“Objection,” Marin said. “Does he really expect the witness to answer his rhetorical questions?”

“Withdrawn. Doctor, isn’t it true that osteogenesis imperfecta is very rare?”

“Yes.”

“So a small-town OB, for example, might go through her entire professional life without ever seeing a case?”

“That’s true,” Thurber answered.

“Isn’t it fair to say that only a specialist would have been looking for OI on an ultrasound?”

“There is the old medical saying about hearing hoofbeats and assum ing it’s a horse instead of a zebra,” Thurber agreed, “but any trained obstetrician should be able to look at an ultrasound and spot red flags. She might not be able to identify what they signify, but she would know them for their abnormality, and would recognize that the patient’s care needs to be taken to the next level.”

“Is there any condition other than osteogenesis imperfecta that can give you such a clear image of the near field of the brain during an ultrasound?”

“The lethal form of congenital hypophosphatasia, but it’s extremely rare and it still wouldn’t have changed the need for the patient to be referred to a tertiary-care center.”

“Dr. Thurber,” Booker said, “do you ever get a particularly clear image of intracranial contents of the skull…on a healthy baby?”

“Occasionally. If the plane of the ultrasound on a particular image happens by chance to go through one of the normal cranial sutures, instead of bone, the interior of the brain will be shown clearly. However, we take multiple pictures of the brain looking at different intracranial structures, and the sutures are very thin. It would be virtually impossible to see multiple pictures of the brain for multiple projections where the transducer manages to hit a suture every single time. If I saw one image that showed the near field of brain very clearly but the other images did not, I would assume that single image had been taken through a cranial suture. In this case, however, all of the images of the brain show the intracranial contents unusually well.”

“How about that femur length? Have you ever measured a short femur during an eighteen-week ultrasound and then seen a perfectly healthy baby delivered?”

“Yes. Sometimes the technologists’ measurement can be off by a hair because the fetus is moving around or in an odd position. They measure two or three times and take the longest axis, but even being a whisker off at eighteen weeks-we’re talking millimeters-can drop the percentile significantly. Many times when we see a borderline-short femur length, it’s just undermeasured.”

Booker walked toward him. “As useful as ultrasound technology is, it’s not an exact science, is it? Certain images might be clearer than others?”

“The clarity with which we see all structures in the fetus is variable, yes. It depends on many things-the size of the mother, the position of the fetus. There’s a continuum, really. On any given day we might not be able to see them well, or conversely we might be able to see everything clearly.”

“At an eighteen-week ultrasound, Doctor, can you definitively say that a child is going to have Type III OI?”

“You can tell that there’s something wrong skeletally. You can see indicators-like the ones that were in Charlotte O’Keefe’s file. As the gestational age increases, if you see broken bones, you can generally guess that the fetus has Type III OI.”

“Doctor, if Charlotte O’Keefe had been your patient, and you’d seen the results of her eighteen-week ultrasound, and there were no broken bones, you would have recommended she have follow-up care?”

“Based on the short femur length and demineralized calvarium? Absolutely.”

“And once you saw broken bones on a subsequent ultrasound, would you have done what Piper Reece did: immediately refer Mrs. O’Keefe to a maternal-fetal-medicine practitioner at a tertiary-care center?”

“Yes.”

“But would you have conclusively diagnosed Mrs. O’Keefe’s fetus with OI at eighteen weeks, based solely on that first ultrasound?”

He hesitated. “Well,” Thurber said. “No.”

Sometimes I wonder what really constitutes an “emergency.” I mean, every teacher in my school knew about the trial and the fact that both of my parents were not only in it but squaring off against each other. The whole state knew, and maybe even the whole country, thanks to the newspaper and television coverage. Surely even if they thought my mother was insane or moneygrubbing, they felt a smidgen of sympathy for me, being trapped in the middle? And yet, I still got yelled at in math for not paying attention. I had a huge English test tomorrow, vocabulary, on ninety words that I was most likely never going to use in my life.

To that end, I was making flash cards for myself. Hypersensitive, I wrote. Too too too sensitive. But wasn’t that the point? If you were sensitive, weren’t you bound to take things too seriously in the first place?

Trepidation: fear. Use it in a sentence: I have trepidations about taking this stupid test.

“Amelia!”

I heard you calling, but I also knew I didn’t have to answer. After all, my mother-or maybe Marin-was paying that nurse who smelled like mothballs to watch over you. This was the second day she’d been here when I got off the bus, and to tell you the truth, I wasn’t impressed. She was watching General Hospital when she should have been playing with you.

“Amelia!” you yelled, louder this time.

I screeched the chair back from my desk and thundered downstairs. “What?” I demanded. “I’m trying to study.”

Then I saw it: Nurse Ratched had barfed all over the floor.

She was leaning against the wall, her face the color of Silly Putty. “I think I ought to go home…,” she wheezed.

Well, duh. I didn’t want to catch the bubonic plague.

“Do you think you can watch Willow till your mother gets back?” she asked.

As if I hadn’t been doing just that my whole life. “Sure.” I hesitated. “You are going to clean it up, first, right?”

“Amelia!” Willow hissed. “She’s sick !”

“Well, I’m not going to do it,” I whispered, but the nurse was already heading to the kitchen to mop up her mess.