Small Great Things

by Jodi Picoult

Genres: Literary Fiction; Sagas; Women's Fiction

Synopsis

'I don't want that nurse touching my baby.' Those are the instructions from the newborn child's parents. However, when the baby goes into cardiac arrest, Ruth, a nurse of twenty years' experience, sees no option but to assist. But the baby dies. And Ruth is charged with negligent homicide. Ruth is shattered and bewildered as she tries to come to terms with her situation. She finds different kinds of support from her sister, a fiery radical, and her teenage son, but it is to Kennedy McQuarrie, a white middle-class lawyer, to whom she entrusts her case, and her future. As the two come to develop a truer understanding of each other's lives, they begin to doubt the beliefs they each hold most dear. For the privileged to prosper, they come to realise, others have to suffer. Racism takes many forms and is reinforced by the structures of our society. In gripping dramas like Nineteen Minutes, My Sister's Keeper and The Pact, Jodi Picoult has explored the big issues of our time through characters whose lives resonate with us. Here we see once again her unrivalled ability to immerse us in a story whose issues will linger with us long after the final page has been turned.

Release date: October 11, 2016

Publisher: Ballantine Books

Print pages: 528

Sample

***This excerpt is from an advance uncorrected copy proof***

Copyright © 2016 Jodi Picoult

Stage One: Early Labor

Justice will not be served until those who are unaffected are as outraged as those who are.

—Benjamin Franklin 

 

 

Ruth

The miracle happened on West Seventy-fourth Street, in the home where Mama worked. It was a big brownstone encircled by a wrought-iron fence, and overlooking either side of the ornate door were gargoyles, their granite faces carved from my nightmares. They terrified me, so I didn’t mind the fact that we always entered through the less impressive side door, whose keys Mama kept on a ribbon in her purse.

Mama had been working for Sam Hallowell and his family since before my sister and I were born. You may not have recognized his name, but you would have known him the minute he said hello. He had been the unmistakable voice in the mid-960s who announced before every show: The following program is brought to you in living color on NBC! In 1976, when the miracle happened, he was the network’s head of programming. The doorbell beneath those gargoyles was the famously pitched three-note chime everyone associates with NBC. Sometimes, when I came to work with my mother, I’d sneak outside and push the button and hum along.

The reason we were with Mama that day was because it was a snow day. School was canceled, but we were too little to stay alone in our apartment while Mama went to work—which she did, through snow and sleet and probably also earthquakes and Armageddon. She muttered, stuffing us into our snowsuits and boots, that it didn’t matter if she had to cross a blizzard to do it, but God forbid Ms. Mina had to spread the peanut butter on her own sandwich bread. In fact the only time I remember Mama taking time off work was twenty-five years later, when she had a double hip replacement, generously paid for by the Hallowells. She stayed home for a week, and even after that, when it didn’t quite heal right and she insisted on returning to work, Mina found her tasks to do that kept her off her feet. But when I was little, during school vacations and bouts of fever and snow days like this one, Mama would take us with her on the B train downtown.

Mr. Hallowell was away in California that week, which happened often, and which meant that Ms. Mina and Christina needed Mama even more. So did Rachel and I, but we were better at taking care of ourselves, I suppose, than Ms. Mina was.

When we finally emerged at Seventy-second Street, the world was white. It was not just that Central Park was caught in a snow globe. The faces of the men and women shuddering through the storm to get to work looked nothing like mine, or like my cousins’ or neighbors’.

I had not been into any Manhattan homes except for the Hallowells’, so I didn’t know how extraordinary it was for one family to live, alone, in this huge building. But I remember thinking it made no sense that Rachel and I had to put our snowsuits and boots into the tiny, cramped closet in the kitchen, when there were plenty of empty hooks and open spaces in the main entry, where Christina’s and Ms. Mina’s coats were hanging. Mama tucked away her coat, too, and her lucky scarf—the soft one that smelled like her, and that Rachel and I fought to wear around our house because it felt like petting a guinea pig or a bunny under your fingers. I waited for Mama to move through the dark rooms like Tinker Bell, alighting on a switch or a handle or a knob so that the sleeping beast of a house was gradually brought to life. “You two be quiet,” Mama told us, “and I’ll make you some of Ms. Mina’s hot chocolate.”

It was imported from Paris, and it tasted like heaven. So as Mama tied on her white apron, I took a piece of paper from a kitchen drawer and a packet of crayons I’d brought from home and silently started to sketch. I made a house as big as this one. I put a family inside: me, Mama, Rachel. I tried to draw snow, but I couldn’t. The flakes I’d made with the white crayon were invisible on the paper. The only way to see them was to tilt the paper sideways toward the chandelier light, so I could make out the shimmer where the crayon had been.

“Can we play with Christina?” Rachel asked. Christina was six, falling neatly between the ages of Rachel and me. Christina had the biggest bedroom I had ever seen and more toys than anyone I knew. When she was home and we came to work with our mother, we played school with her and her teddy bears, drank water out of real miniature china teacups, and braided the corn-silk hair of her dolls. Unless she had a friend over, in which case we stayed in the kitchen and colored.

But before Mama could answer, there was a scream so piercing and so ragged that it stabbed me in the chest. I knew it did the same to Mama, because she nearly dropped the pot of water she was carrying to the sink. “Stay here,” she said, her voice already trailing behind her as she ran upstairs.

Rachel was the first one out of her chair; she wasn’t one to follow instructions. I was drawn in her wake, a balloon tied to her wrist. My hand skimmed over the banister of the curved staircase, not touching.

Ms. Mina’s bedroom door was wide open, and she was twisting on the bed in a sinkhole of satin sheets. The round of her belly rose like a moon; the shining whites of her eyes made me think of merry-go-round horses, frozen in flight. “It’s too early, Lou,” she gasped.

“Tell that to this baby,” Mama replied. She was holding the telephone receiver. Ms. Mina held her other hand in a death grip. “You stop pushing, now,” she said. “The ambulance’ll be here any minute.” I wondered how fast an ambulance could get here in all that snow.

“Mommy?”

It wasn’t until I heard Christina’s voice that I realized the noise had woken her up. She stood between Rachel and me. “You three, go to Miss Christina’s room,” Mama ordered, with steel in her voice. “Now.” But we remained rooted to the spot as Mama quickly forgot about us, lost in a world made of Ms. Mina’s pain and fear, trying to be the map that she could follow out of it. I watched the cords stand out on Ms. Mina’s neck as she groaned; I saw Mama kneel on the bed between her legs and push her gown over her knees. I watched the pink lips between Ms. Mina’s legs purse and swell and part. There was the round knob of a head, a knot of shoulder, a gush of blood and fluid, and suddenly, a baby was cradled in Mama’s palms.

“Look at you,” she said, with love written over her face. “Weren’t you in a hurry to get into this world?”

Two things happened at once: the doorbell rang, and Christina started to cry. “Oh, honey,” Ms. Mina crooned, not scary anymore but still sweaty and red-faced. She held out her hand, but Christina was too terrified by what she had seen, and instead she burrowed closer to me. Rachel, ever practical, went to answer the front door. She returned with two paramedics, who swooped in and took over, so that what Mama had done for Ms. Mina became like everything else she did for the Hallowells: seamless and invisible.

The Hallowells named the baby Louis, after Mama. He was fine, even though he was almost a full month early, a casualty of the barometric pressure dropping with the storm, which caused a PROM—a premature rupture of membranes. Of course, I didn’t know that back then. I only knew that on a snowy day in Manhattan I had seen the very start of someone. I’d been with that baby before anyone or anything in this world had a chance to disappoint him.

The experience of watching Louis being born affected us all differently. Christina had her baby via surrogate. Rachel had five. Me, I became a labor and delivery nurse.

When I tell people this story, they assume the miracle I am referring to during that long-ago blizzard was the birth of a baby. True, that was astonishing. But that day I witnessed a greater wonder. As Christina held my hand and Ms. Mina held Mama’s, there was a moment— one heartbeat, one breath—where all the differences in schooling and money and skin color evaporated like mirages in a desert. Where everyone was equal, and it was just one woman, helping another.

That miracle, I’ve spent thirty-nine years waiting to see again.

 

 

 

 

Stage One: Active Labor

Not everything that is faced can be changed. But nothing can be changed until it is faced.

—James Baldwin

 

 

 

 

Ruth

The most beautiful baby I ever saw was born without a face.

From the neck down, he was perfect: ten fingers, ten toes, chubby belly. But where his ear should have been, there was a twist of lips and a single tooth. Instead of a face there was a swirling eddy of skin with no features.

His mother—my patient—was a thirty-year-old gravida 1 para 1 who had received prenatal care including an ultrasound, but the baby had been positioned in a way that the facial deformity hadn’t been visible. The spine, the heart, the organs had all looked fine, so no one was expecting this. Maybe for that very reason, she chose to deliver at Mercy–West Haven, our little cottage hospital, and not Yale–New Haven, which is better equipped for emergencies. She came in full term, and labored for sixteen hours before she delivered. The doctor lifted the baby, and there was nothing but silence. Buzzy, white silence. “Is he all right?” the mother asked, panicking. “Why isn’t he crying?”

I had a student nurse shadowing me, and she screamed.

“Get out,” I said tightly, shoving her from the room. Then I took the newborn from the obstetrician and placed him on the warmer, wiping the vernix from his limbs. The OB did a quick exam, silently met my gaze, and turned back to the parents, who by now knew something was terribly wrong. In soft words, the doctor said their child had profound birth defects that were incompatible with life.

On a birth pavilion, Death is a more common patient than you’d think. When we have anencephalies or fetal deaths, we know that the parents still have to bond with and mourn for that baby. This infant— alive, for however long that might be—was still this couple’s son.

So I cleaned him and swaddled him, the way I would any other newborn, while the conversation behind me between the parents and the doctor stopped and started like a car choking through the winter. Why? How? What if you . . .? How long until . . .? Questions no one ever wants to ask, and no one ever wants to answer.

The mother was still crying when I settled the baby in the crook of her elbow. His tiny hands windmilled. She smiled down at him, her heart in her eyes. “Ian,” she whispered. “Ian Michael Barnes.”

She wore an expression I’ve only seen in paintings in museums, of a love and a grief so fierce that they forged together to create some new, raw emotion.

I turned to the father. “Would you like to hold your son?”

He looked like he was about to be sick. “I can’t,” he muttered and bolted from the room.

I followed him, but was intercepted by the nurse in training, who was apologetic and upset. “I’m sorry,” she said. “It’s just . . . it was a monster.”

“It is a baby,” I corrected, and I pushed past her.

I cornered the father in the parents’ lounge. “Your wife and your son need you.”

“That’s not my son,” he said. “That . . . thing . . .”

“Is not going to be on this earth for very long. Which means you’d better give him all the love you had stored up for his lifetime right now.” I waited until he looked me in the eye, and then I turned on my heel. I did not have to glance back to know he was following me.

When we entered the hospital room, his wife was still nuzzling the infant, her lips pressed to the smooth canvas of his brow. I took the tiny bundle from her arms, and handed the baby to her husband. He sucked in his breath and then drew back the blanket from the spot where the baby’s face should have been.

I’ve thought about my actions, you know. If I did the right thing by forcing the father to confront his dying baby, if it was my place as a nurse. Had my supervisor asked me at the time, I would have said that I’d been trained to provide closure for grieving parents. If this man didn’t acknowledge that something truly horrible had happened—or worse, if he kept pretending for the rest of his life that it never had—a hole would open up inside him. Tiny at first, that pit would wear away, bigger and bigger, until one day when he wasn’t expecting it he would realize he was completely hollow.

When the father started to cry, the sobs shook his body, like a hurricane bends a tree. He sank down beside his wife on the hospital bed, and she put one hand on her husband’s back and one on the crown of the baby’s head.

They took turns holding their son for ten hours. That mother, she even tried to let him nurse. I could not stop staring—not because it was ugly or wrong, but because it was the most remarkable thing I’d ever seen. It felt like looking into the face of the sun: once I turned away, I was blind to everything else.

At one point, I took that stupid nursing student into the room with me, ostensibly to check the mother’s vitals, but really to make her see with her own eyes how love has nothing to do with what you’re looking at, and everything to do with who’s looking.

When the infant died, it was peaceful. We made casts of the newborn’s hand and foot for the parents to keep. I heard that this same couple came back two years later and delivered a healthy daughter, though I wasn’t on duty when it happened.

It just goes to show you: every baby is born beautiful. It’s what we project on them that makes them ugly.

Right after I gave birth to Edison, seventeen years ago at this very hospital, I wasn’t worried about the health of my baby, or how I was going to juggle being a single parent while my husband was overseas, or how my life was going to change now that I was a mother.

I was worried about my hair.

The last thing you’re thinking about when you’re in labor is what you look like, but if you’re like me, it’s the first thing that crosses your mind once that baby’s come. The sweat that mats the hair of all my white patients to their foreheads instead made my roots curl up and pull away from the scalp. Brushing my hair around my head in a swirl like an ice cream cone and wrapping it in a scarf each night was what kept it straight the next day when I took it down. But what white nurse knew that, or understood that the little complimentary bottle of sham- poo provided by the hospital auxiliary league was only going to make my hair even frizzier? I was sure that when my well-meaning colleagues came in to meet Edison, they would be shocked into stupor at the sight of the mess going on atop my head.

In the end, I wound up wrapping it in a towel, and told visitors I’d just had a shower.

I know nurses who work on surgical floors who tell me about men wheeled out of surgery who insist on taping their toupees into place in the recovery room before their spouses join them. And I can’t tell you the number of times a patient who has spent the night grunting and screaming and pushing out a baby with her husband at her side will kick her spouse out of the room post delivery so I can help her put on a pretty nightgown and robe.

I understand the need people have to put a certain face on for the rest of the world. Which is why—when I first arrive for my shift at 6:40 a.m.—I don’t even go into the staff room, where we will shortly receive the night’s update from the charge nurse. Instead I slip down the hall to the patient I’d been with yesterday, before my shift ended. Her name was Jessie; she was a tiny little thing who had come into the pavilion looking more like a campaigning First Lady than a woman in active labor: her hair was perfectly coiffed, her face airbrushed with makeup, even her maternity clothes were fitted and stylish. That’s a dead giveaway, since by forty weeks of pregnancy most mothers-to-be would be happy to wear a pup tent. I scanned her chart—G1, now P1—and grinned. The last thing I’d said to Jessie before I turned her care over to a colleague and went home for the night was that the next time I saw her, she’d have a baby, and sure enough, I have a new patient. While I’ve been sleeping, Jessie’s delivered a healthy seven- pound, six-ounce girl.

I open the door to find Jessie dozing. The baby lies swaddled in the bassinet beside the bed; Jessie’s husband is sprawled in a chair, snoring. Jessie stirs when I walk in, and I immediately put a finger to my lips. Quiet.

From my purse, I pull a compact mirror and a red lipstick.

Part of labor is conversation; it’s the distraction that makes the pain ebb and it’s the glue that bonds a nurse to her patient. What other situation can you think of where one medical professional spends up to twelve hours consulting with a single person? As a result, the connection we build with these women is fierce and fast. I know things about them, in a mere matter of hours, that their own closest friends don’t always know: how she met her partner at a bar when she’d had too much to drink; how her father didn’t live long enough to see this grandchild; how she worries about being a mom because she hated babysitting as a teenager. Last night, in the dragon hours of Jessie’s labor, when she was teary and exhausted and snapping at her husband, I’d suggested that he go to the cafeteria to get a cup of coffee. As soon as he left, the air in the room was easier to breathe, and she fell back against those awful plastic pillows we have in the birthing pavilion. “What if this baby changes everything?” she sobbed. She confessed that she never went anywhere without her “game face” on, that her husband had never even seen her without mascara; and now here he was watching her body contort itself inside out, and how would he ever look at her the same way again?

Listen, I had told her. You let me worry about that.

I’d like to think my taking that one straw off her back was what gave her the strength to make it to transition.

It’s funny. When I tell people I’ve been a labor and delivery nurse for more than twenty years, they’re impressed by the fact that I have assisted in cesareans, that I can start an IV in my sleep, that I can tell the difference between a decel in the fetal heart rate that is normal and one that requires intervention. But for me, being an L & D nurse is all about knowing your patient, and what she needs. A back rub. An epidural. A little Maybelline.

Jessie glances at her husband, still dead to the world. Then she takes the lipstick from my hand. “Thank you,” she whispers, and our eyes connect. I hold the mirror as she once again reinvents herself.

On Thursdays, my shift goes from 7:00 a.m. till 7:00 p.m. At Mercy– West Haven, during the day, we usually have two nurses on the birthing pavilion—three if we’re swimming in human resources that day. As I walk through the pavilion, I note idly how many of our delivery suites are occupied—it’s three, right now, a nice slow start to the day. Marie, the charge nurse, is already in the room where we have our morning meeting when I come inside, but Corinne—the second nurse on shift with me—is missing. “What’s it going to be today?” Marie asks, as she flips through the morning paper.

“Flat tire,” I reply. This guessing game is a routine: What excuse will Corinne use today for being late? It’s a beautiful fall day in October, so she can’t blame the weather.

“That was last week. I’m going with the flu.”

“Speaking of which,” I say. “How’s Ella?” Marie’s eight-year-old had caught the stomach bug that’s been going around.

“Back in school today, thank God,” Marie replies. “Now Dave’s got it. I figure I have twenty-four hours before I’m down for the count.” She looks up from the Regional section of the paper. “I saw Edison’s name in here again,” she says.

My son has made the Highest Honors list for every semester of his high school career. But just like I tell him, that’s no reason to boast. “There are a lot of bright kids in this town,” I demur.

“Still,” Marie says. “For a boy like Edison to be so successful . . . well. You should be proud, is all. I can only hope Ella turns out to be that good a student.”

A boy like Edison. I know what she is saying, even if she’s careful not to spell it out. There are not many Black kids in the high school, and as far as I know, Edison is the only one on the Highest Honors list. Comments like this feel like paper cuts, but I’ve worked with Marie for over ten years now, so I try to ignore the sting. I know she doesn’t really mean anything by it. She’s a friend, after all—she came to my house with her family for Easter supper last year, along with some of the other nurses, and we’ve gone out for cocktails or movie nights and once a girls’ weekend at a spa. Still, Marie has no idea how often I have to just take a deep breath, and move on. White people don’t mean half the offensive things that come out of their mouths, and so I try not to let myself get rubbed the wrong way.

“Maybe you should hope that Ella makes it through the school day without going to the nurse’s office again,” I reply, and Marie laughs.

“You’re right. First things first.”

Corinne explodes into the room. “Sorry I’m late,” she says, and Marie and I exchange a look. Corinne’s fifteen years younger than I am, and there’s always some emergency—a carburetor that’s dead, a fight with her boyfriend, a crash on 95N. Corinne is one of those people for whom life is just the space between crises. She takes off her coat and manages to knock over a potted plant that died months ago, which no one has bothered to replace. “Dammit,” she mutters, righting the pot and sweeping the soil back inside. She dusts off her palms on her scrubs, and then sits down with her hands folded. “I’m really sorry, Marie. The stupid tire I replaced last week has a leak or something; I had to drive here the whole way going thirty.”

Marie reaches into her pocket and pulls out a dollar, which she flicks across the table at me. I laugh.

“All right,” Marie says. “Floor report. Room two is a couplet. Jessica Myers, G one P one at forty weeks and two days. She had a vaginal delivery this morning at three a.m., uncomplicated, without pain meds. Baby girl is breast-feeding well; she’s peed but hasn’t pooped yet.”

“I’ll take her,” Corinne and I say in unison.

Everyone wants the patient who’s already delivered; it’s the easier job. “I had her during active labor,” I point out.

“Right,” Marie says. “Ruth, she’s yours.” She pushes her reading glasses up on her nose. “Room three is Thea McVaughn, G one P zero at forty-one weeks and three days, she’s in active labor at four centimeters dilated, membranes intact. Fetal heart rate tracing looks good on the monitor, the baby’s active. She’s requested an epidural and her IV fluid bolus is infusing.”

“Has Anesthesia been paged?” Corinne asks. “Yes.”

“I’ve got her.”

We only take one active labor patient at a time, if we can help it, which means that the third patient—the last one this morning—will be mine. “Room five is a recovery. Brittany Bauer is a G one P one at thirty-nine weeks and one day; had an epidural and a vaginal delivery at five-thirty a.m. Baby’s a boy; they want a circ. Mom was a GDM A one; the baby is on Q three hour blood sugars for twenty-four hours. The mom really wants to breast-feed. They’re still skin to skin.”

A recovery is still a lot of work—a one-to-one nurse-patient relationship. True, the labor’s finished, but there is still tidying up to be done, a physical assessment of the newborn, and a stack of paperwork. “Got it,” I say, and I push away from the table to go find Lucille, the night nurse, who was with Brittany during the delivery.

She finds me first, in the staff restroom, washing my hands. “Tag, you’re it,” she says, handing me Brittany Bauer’s file. “Twenty-six-year- old G one, now P one, delivered vaginally this morning at five-thirty over an intact perineum. She’s O positive, rubella immune, Hep B and HIV negative, GBS negative. Gestational diabetic, diet controlled, otherwise uncomplicated. She still has an IV in her left forearm. I DC’d the epidural, but she hasn’t been out of bed yet, so ask her if she has to get up and pee. Her bleeding’s been good, her fundus is firm at U.”

I open the file and scan the notes, committing the details to memory. “Davis,” I read. “That’s the baby?”

“Yeah. His vital signs have been normal, but his one-hour blood sugar was forty, so we’ve got him trying to nurse. He’s done a little bit on each side, but he’s kind of spitty and sleepy and he hasn’t done a whole lot of eating.”

“Did he get his eyes and thighs?”

“Yeah, and he’s peed, but hasn’t pooped. I haven’t done the bath or the newborn assessment yet.”

“No problem,” I say. “Is that it?”

“The dad’s name is Turk,” Lucille replies, hesitating. “There’s something just a little . . . off about him.”

“Like Creeper Dad?” I ask. Last year, we had a father who was flirting with the nursing student in the room during his wife’s delivery. When she wound up having a C-section, instead of standing behind the drape near his wife’s head, he strolled across the OR and said to the nursing student, Is it hot in here, or is it just you?

“Not like that,” Lucille says. “He’s appropriate with the mom. He’s just . . . sketchy. I can’t put my finger on it.”

I’ve always thought that if I wasn’t an L & D nurse, I’d make a great fake psychic. We are skilled at reading our patients so that we know what they need moments before they realize it. And we are also gifted when it comes to sensing strange vibes. Just last month my radar went off when a mentally challenged patient came in with an older Ukrainian woman who had befriended her at the grocery store where she worked. There was something weird about the dynamic between them, and I followed my hunch and called the police. Turned out the Ukrainian woman had served time in Kentucky for stealing the baby of a woman with Down syndrome.

So as I walk into Brittany Bauer’s room for the first time, I am not worried. I’m thinking: I’ve got this.

I knock softly and push open the door. “I’m Ruth,” I say. “I’m going to be your nurse today.” I walk right up to Brittany, and smile down at the baby cradled in her arms. “Isn’t he a sweetie! What’s his name?” I ask, although I already know. It’s a means to start a conversation, to connect with the patient.

Brittany doesn’t answer. She looks at her husband, a hulking guy who’s sitting on the edge of his chair. He’s got military-short hair and he’s bouncing the heel of one boot like he can’t quite stay still. I get what Lucille saw in him. Turk Bauer makes me think of a power line that’s snapped during a storm, and lies across the road just waiting for something to brush against it so it can shoot sparks.

It doesn’t matter if you’re shy or modest—nobody who’s just had a baby stays quiet for long. They want to share this life-changing moment. They want to relive the labor, the birth, the beauty of their baby. But Brittany