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  Ryan said, "If she's in trouble, I'm calling. I don't care what she's saying." His finger punched the numbers 9-1.

  The tough part about being a doctor is making the decision. Call for help too often, and you're a dumbmuffin crying wolf and wasting everyone else's time. Call for help too late, and the patient dies.

  Thump.

  From inside the bathroom.

  Ryan and I jerked around to stare at the closed door.

  It sounded like she'd fallen against a wall with her entire body weight. Never a good idea in anyone, let alone a sick, pregnant woman.

  Ryan pressed the final 1 of 911, his lips tight.

  We both saw the doorknob turn and the door drift a few crucial millimetres inward.

  "She wants me there," I said to him. He grabbed my shoulder.

  I knew what he was thinking: 14/11. It never left my mind, either. "I'll come with you," he said, but Joan shrieked, a noise terrible enough to make my heart stop beating for a second.

  I could see the whites all the way around Ryan's eyes now, which struck me as distantly funny, even as I said, "No. I'm pretty sure that's not okay in her culture. I'll leave the door unlocked. And you talk to the paramedics. Okay, Joan?" I raised my voice, but she was sobbing now, and praying for sure, because I heard words like "Jesus, help me" and "in this hour of need."

  I can't tell you how many bad memories reared up and smashed me in the brain.

  I wanted to pray, too.

  I'd been running away from patients. I'd run away from Montreal. Hell, you could say I'd run away from Tucker, albeit with his permission.

  But God damn it all, I was going in there. I reached for the doorknob.

  Chapter 26

  She was sitting on the toilet, naked from the waist down, her panties ringed around her ankles.

  I stopped. Even for a doctor, this is not a common sight.

  My first instinct was to sprint out of the room, howling, "Excuse me!"

  Instead, I pressed my back against the fragile wooden door, sealing Ryan out, and tried to figure out what was going on.

  She'd been crying. Her face was still contorted, but most of the tears were silent and somehow all the more terrible, like she couldn't permit herself to cry.

  She stared at me, the sternocleidomastoid muscles in her neck tenting the skin as she gulped for air. Her eyes didn't look 100 percent "there," if you know what I mean.

  "Joan, it's me, Hope," I said, partly so Ryan could hear me talking. "Are you having contractions?"

  Her hands drew into fists.

  Her dress was Michelin-manned around her waist, exposing her powerful brown thighs and bush and—what was wrong with her skin? I tried not to look, but my eyes were inexorably drawn toward the thing I shouldn't stare at.

  Her skin wasn't smooth. It was marked with dark brown spots on her upper thighs.

  I've had those dark spots myself, in other places. After a rash, or a burn, the skin turns darker as it heals. It's one of the side effects of having melanin. Not a big deal, but a recognizable difference from our whiter companions.

  For some reason—maybe because her ABC's were clearly okay—I couldn't stop staring at that post-inflammatory pigmentation which, at closer glance, was concentrated around her vulva and upper thighs.

  I was pretty sure I knew what had attacked her in the past. Herpes.

  This poor, poor woman had been infected by not one but two infectious diseases.

  When you have herpes, you shouldn't deliver vaginally if you have any active lesions.

  These were old scars, not new ones, but we now think that having two viruses instead of one makes you more likely to have congenital Zisa syndrome. At least in mice, Type 2 Herpes Simplex Virus amplifies production of the Zisa virus.

  "Let's get you to the hospital. Ryan—"

  "I'm already on it," he said, and I could hear him talking through the door.

  Joan shook her head, but she was in no shape to argue. She bent forward and grunted.

  What bothered me the most was her thousand-yard stare. I usually see it on people with congestive heart failure who are struggling/bubbling to breathe. All they can do, the only thing they can focus on, is getting enough air into their lungs.

  I lunged forward. "Let me get you—"

  Too late. Her legs flashed open, and even as I dove between them, something splashed into the toilet.

  She screamed.

  I screamed too. "Get. Off. Get off the toilet!"

  She hunkered down instead.

  I shoved her arm. I wouldn't slap her across the face, but I needed her to get the message. Now.

  She sobbed, "It's too much. Lord, it's too much. I can't take—"

  "Joan. Move!" I darted to her side, planted one foot, and lunged forward with the other. Using my entire body weight, I was able to dislodge her a few inches.

  That surprised her enough that she started to rise, leaning her weight into her feet to stand up.

  Once she did, her legs shaking, I belatedly realized that she was still attached to her baby by the umbilical cord.

  I couldn't worry about the cord though, because even with the blood and urine in the water, I could see the baby floating, curled face down, in the toilet bowl, its tiny sides working as it struggled to breathe underwater.

  Chapter 27

  I dove forward, thanking God for my gloved hands, wishing for a full gown and a mask with an eye shield, but you can't have everything.

  I scooped up the baby, sluicing dirty water down on either side of it, like a fish rising out of the water, except bigger and slippery-er, and oh God, it had the bulging eyes and the small forehead of microcephaly, but I couldn't think about that now, either.

  "Is she alive?" Joan screamed, and Ryan banged on the door, and I said, "Yes. Your baby is alive." I hadn't checked the sex as I concentrated on A and B.

  The little mite was breathing. Or at least heaving.

  I called through the door, "Ryan, tell them we've got a 28-week-old microcephalic baby, born in a toilet, who aspirated the water and is now breathing fast and getting tired."

  Baby was doing that bellows breathing that means trouble. At 28 weeks, everything looks like a colossal effort, but I didn't like the look of her.

  I needed her warm and dry and breathing properly after swimming in a toilet bowl. Little ones tire quickly. They may manage for a few minutes and then wear out suddenly and catastrophically, even without bacteria water having a party in their lungs.

  Ryan almost never swears, but he said a few choice things about Jesus that made Joan cry out, appalled, before he told the 911 operator, "I'm sorry, ma'am. No, not you, ma'am, the mother is upset … "

  My biggest problem was that I'd shoved away Joan's bum and dived between her legs, so now I held the baby between her legs and her butt, and the cord was pulled to its extreme limit.

  I couldn't yank too hard on the umbilical cord because you can actually invert the uterus, as in flip it inside out. A fellow medical student did that the month before I rotated through obstetrics.

  At least the ABC's were intact. I could see and feel baby's heartbeat pulsing in her chest at over 100 beats per minute. I told Joan, "Let me get her warm. I'm not going to cut the cord right away, because she needs a little more blood, but I need a towel." I pointed at the yellow hand towel on the wall-mounted bar facing the toilet.

  Joan's legs trembled. Actually, her whole body was shaking. Maybe stress, maybe maternal sepsis, maybe normal variant. In any case, she was not about to grab me the towel.

  I considered swaddling the baby in my shirt, but the towel was almost within my reach. I shifted the baby to my left hand and stretched out my right. One advantage of a miniature space: I managed to snag the fabric between two of my fingers.

  I swaddled the baby as best I could in the cheap terry cloth. It was big enough. She was less than a double-handful, such a tiny mite.

  That's what I would call her, mite. No, Might. Because she Might live. And she could end up
Mighty powerful. How many babies could survive potential Zisa, herpes, and a toilet birth?

  "Do you have any other towels?" I asked, nodding at the damp cloth.

  Joan's legs wavered. She made as if to fall back on the toilet, which would potentially drop Might back into the water.

  "No! Stand up!" I pushed her in the back and kneed the toilet handle to make it flush, so at least we wouldn't be dealing with urine water anymore.

  "What's going on?" Ryan yelled.

  "We're okay. Baby's still breathing. ABC's intact but laboured," I said. I tried to switch to soothing. "Joan, I know you're tired and in shock. I'll get you sitting in a minute, but I need to get your baby away from the toilet. Spread your legs, Joan."

  She stepped her feet eight inches apart. Good enough.

  I threaded her baby's body through her legs, bringing Might toward Joan's belly, so she could see her clearly for the first time.

  After a long moment, long enough for her to recognize the microcephaly, Joan cried out, a sharp sound that could have been pleasure or grief or both.

  In the ensuing silence, I paused to see if she would scoop Might up in her hands, freeing me to cut the cord. Delayed cord clamping usually doesn't mean waiting more than 180 seconds, or until the cord quits pulsating.

  I pinched the cord between the fingers of my left hand. It was still pulsing faintly, so I relaxed my fingers and let the blood flow, for now.

  Joan began to sob.

  I flinched. Bawling sounded even worse in a teeny, enclosed space that smelled like blood and amniotic fluid and old urine. And I was sweating.

  Joan's lips trembled. She looked greyish. Her forehead gleamed with perspiration. I had to get her and the baby in a safe position, fast, before she fainted or the baby stopped breathing.

  The cord would have to wait. "Sit down, Joan. Please."

  She plunked down on the toilet seat, hard enough that I could feel the vibration in my feet.

  I brushed aside the towel folds with my left hand.

  Might was gasping away. Her chest reminded me of a bullfrog inflating his throat. The most disturbing thing was that her sternum was starting to suck inward with each inhalation because her ribs were more cartilage than bone.

  She was tiring out.

  "Joan, it's hard for her to breathe."

  Joan closed her eyes. Her torso swayed in a semicircle before pitching forward.

  I shrieked and propped her up with my left hand, holding Might with the other. "Ryan, Mom's going to faint on me! Do we have an ETA?"

  I heard him shouting into the phone on the other side of the door.

  Joan opened her eyes and righted herself on the toilet. She said, with dignity, "I am not fainting."

  "You're weak. You just had a baby. Lie down."

  "I am not—uhhhh."

  She slumped over Might for a second. My heart stopped, but she caught herself again. I could feel Might panting away in my hand. Not great, but not in respiratory arrest. Yet.

  Joan was bleeding into the toilet. I couldn't monitor a post-partum hemorrhage when it was all going into the plumbing. It's hard to tell the difference between bloody and bloodier water, but she sure wasn't acting like someone who had all her faculties.

  I glanced around the bathroom for hemorrhage supplies. I finally noticed some spare towels folded on a mini-shelf above the toilet. A cabinet under the sink might prove useful. The rest of the room was barely big enough for the toilet, a plunger, and a shower stall against the far wall.

  I rubbed Joan's shoulder in circles, trying to bring her back into her body instead of spiralling away in a mental fog. My therapist had me do jumping jacks, which I wouldn't recommend in this situation.

  "I want you to lie down," I said. "It's better for the baby too. She can lie on top of you. You'll be like a big, warm Mommy mattress for her."

  She seemed more stable. I risked grabbing a towel off the mini-shelf to my left. "Let's keep your baby warm and dry. I don't want her to shiver." The last thing I needed was Might's glucose and maybe calcium dropping when I couldn't monitor it.

  I unfolded another towel on to the cold, wet tile floor. Lying down on it wouldn't feel good for Joan, but neither would cracking her neck and squashing Might.

  "It'll be like a bed. Please, Joan."

  She sighed, but she began to lever herself on her back.

  "They're coming. ETA 10 to 15 minutes," Ryan told us through the door.

  A septic premie can die in 10 minutes. Easily. "That's the fastest they can do it?" I hollered.

  "They said it might be closer to ten, but they couldn't promise it. It's snowing, maybe freezing rain."

  No. The only thing worse than a premature herpes/Zisa baby was having to keep one alive, solo, in a bathroom, with no equipment.

  Chapter 28

  "They're asking—is baby still breathing?" Ryan yelled through the door. "Yes! But she's tachypneic. That means she's breathing fast." I stopped to count her breaths. "Like, 75 or 80. She's going to tire out."

  Joan made a noise. She shifted on the ground, propping her head up on her elbows as she avoided putting her feet in the shower stall. Then she held out her hands for Might, and I cautiously handed her to her mother, adding, "But she's tough. She's done really well so far."

  I had limited options on how to help the baby breathe.

  1) Warm the baby up and stimulate her. Done.

  2) Give mouth to mouth. But I didn't want to suck Zisa +/-herpes into my lungs, as long as she was holding her own.

  3) Call for help, which Ryan had already done.

  After Joan delivered the placenta, we could get her covered up and let Ryan in.

  If either of their lives were in danger, I'd throw open the door, but right now, since we couldn't offer the baby much and the EMS were on their way, Ryan could stay on the phone.

  Joan bent her knees, planted her feet on the ground, and groaned. Not a short grunt, but a prolonged sound.

  "Are you delivering the placenta?" My sense of time was off-kilter (complètement foqué, as we say in Montreal), but the placenta can take 20 minutes to disengage on its own. Normally, we apply traction to encourage it to come off, but I'd been focused on Might's breathing— and not looking forward to more blood on the floor.

  Joan rolled on to her right arm, toward the wall. She struggled to sit upright, heaving her hips off the tile and pressing into her feet, like a bridge pose on her side.

  "Hang on. Joan?" Her bum was pumping up and down in a way that seemed all-too-familiar. "Are you—"

  She twisted on to her front, still cradling Might. "Give me the baby!"

  She ignored me, crawling back toward the shower stall on to one hand and both knees. She reached for the edge of the shower door with her Might-free hand.

  "Joan, wait!" I crouched over her and scooped Might into my hands. Joan didn't resist, although Might crunched up her face like she wanted to cry.

  Joan sank into a squat, still holding on the shower stall door. She was taking up all the room between the toilet and the wall and the shower stall, so I backed up toward the wooden door.

  "Hang on, Joan." Might was so small that I thought I could hold on to her and catch the placenta one-handed, like the "football hold" in breastfeeding. The towel made Might a bit bulkier and easier to hold on to.

  Joan ignored me, sinking down so low that her buttocks nearly touched her heels.

  The ululation that ripped from her throat almost made me scream back.

  And then a small, smooth, glistening bit of flesh protruded between her legs.

  It didn't look like placenta.

  Placentas are dark. Really red-brown, kind of like liver, only round and smelly.

  This one was … holy shit. Holy SHIT.

  I dove on to the ground, one hand extended underneath her vagina. "Push," I babbled. "That's right, Manouchka, good job."

  "Manouchka?" said Ryan, from outside the door, but he had to remind me of the wrong name later, because I was so busy using
one hand to catch Might II.

  The surprise twin.

  Chapter 29

  "Ryan, we've got a twin here. Repeat, we have a twin," I shouted, even as my eyes locked on the miniature, red body lying so still in my hand.

  Might II wasn't breathing.

  I couldn't see her heart beating, either.

  "I'm starting CPR."

  I needed to resuscitate. I needed both hands.

  I placed Might I on the ground. "Joan, don't move!"

  Then I tried to set Might II on the floor beside her sister, to free up my hands. Only Might II didn't reach the ground. She was still attached to Joan through her shorter umbilical cord. And for whatever reason, Joan was struggling to stand, using the shower door as a wobbly ladder.

  "Joan, stop!"

  I'd have to cut Might II's cord.

  She needed CPR. And I couldn't do CPR in mid-air. I couldn't do both delayed cord clamping and CPR. Unless …

  I got down on my left knee, like I was doing the classic wedding proposal, and balanced Might II on my right thigh. She was so weensy that she fit lengthwise with inches to spare. I could easily interlace my fingers around her torso and overlap my thumbs on her sternum, above her xiphoid process, to start compressions.

  And 1 and 2 and 3 …

  Joan swayed. I shouted, "Joan, can you squat for 30 more seconds? I need your placenta higher than your twins, but I can't have you pulling Might I off the ground!"

  I had to compress fast and strong, over a hundred beats a minute, while I roared, "Ryan, I need help! I need mouth-to-mouth on this twin! And I need you to check the other one!"

  The position was so awkward, I was afraid I'd drop Might II, or at least get the seal wrong, if I tried to do mouth to mouth on my own thigh. Yet she needed oxygen.

  I could switch to the one-handed technique CPR to milk the umbilical cord, which held oxygenated blood, but I was already afraid Might II might topple off my thigh or that Joan would fall backwards and crush us all. I needed Ryan.

  He rattled the door knob.