Melanie was one of Renee’s first new patients, a twenty-seven-year-old woman with cystic fibrosis, already on the lung-transplant list. A sprite of a thing, barely five feet tall, married to a longshoreman named Carl who towered over his wife. Shoulders nearly as wide as Melanie was tall. Dark hair receding in a sharp widow’s peak. A kind, gentle smile.
As they entered Renee’s office, Carl held the door for Melanie and pulled the portable oxygen tank behind them. Clear tubes ran from the tank over Melanie’s ears and into her nostrils. Melanie held out a hand to Renee, the long fingernails painted a brilliant aqua blue. “Matches the hospital gowns,” she said. “I’ve got mascara the same color, too.”
Renee laughed.
Since Melanie’s diagnosis, her doctors had managed the disease, but her condition had worsened in the past year, and she came to Renee for a new evaluation to move her position up the transplant waitlist. Because of Melanie’s small size—105 pounds at the height of good health—her potential donors were limited: a man’s lungs, for example, would not fit inside her chest.
“My heart is so full!” Melanie told Renee. “My rib cage just doesn’t know it.”
Renee advised her to keep exercising, to be ready to come to the hospital at any moment, to travel no more than an hour from the city, to stay healthy, to eat well. They’d shaken hands again at the door, and Renee felt vitality in the warmth and press of Melanie’s palm.
Over the course of the next six months, Melanie Jacobs grew sicker and sicker. After she was admitted full-time to the hospital, Renee would find herself lingering in Melanie’s room, talking and laughing with her. On paper the two could not have been more different. While Renee was graduating magna cum laude from college and pursuing her medical degree, Melanie worked as a receptionist at a Toyota dealership, as a packer at a vegetable-canning facility, and as a waitress. She met Carl when she served him a piece of chocolate cream pie and he offered her a bite. But like Renee, Melanie had been raised by a single mother. Like Renee, she’d worked her way through college, though Melanie had stopped one semester shy of graduation after another hospital stay.
Month by month Melanie’s name rose higher and higher on the national transplant list until finally Melanie Jacobs was the sickest lung-transplant patient in the country.
“A dubious honor,” she croaked to Renee, who had seen her diminish from the bright, blond smart aleck to this, a frail shell beneath a sheet. Carl would arrive every day straight from work with Thai food and DVDs or a People magazine or a thriller that he would read aloud to her. After Melanie fell asleep, he would leave and then return the next day to do the same thing all over again. His union provided excellent benefits, Carl told Renee. The work was punishing, the shifts long, but he couldn’t quit now. Not until Melanie was better.
“We’re having a kid when this is all over,” Carl told Renee one afternoon as she conducted a routine exam. By now Melanie had been waiting ten months for a lung donor.
“I just want one,” whispered Melanie through the oxygen mask. “Boy or girl, doesn’t matter. I’m going to spoil that kid rotten. Carl’s not a carrier, so we won’t pass on the CF, thank God.” Here she crossed herself over the sheets. “I’ve got good eggs in a freezer. We were getting ready for liftoff before things turned bad.”
Later Renee couldn’t remember how she had responded to this information. Good luck, she had probably said. My mom had four, and let me tell you, we were a handful.
The call came at 2:00 a.m. Renee immediately jolted awake; Jonathan, accustomed to her call buzzer, slept soundly beside her.
Car accident, the nurse said. A twenty-two-year-old Caucasian woman, five foot five, slight, small-boned, blood type O. A fit.
Slipping into her clogs and coat in the kitchen, Renee called Carl’s cell.
“It’s time,” she told him.
At first the surgery appeared successful. It had taken nine hours, and Renee felt the exhaustion in her bones and core as though wet, heavy clay had been pumped inside her. She’d briefed Carl, telling him that Melanie was already out of the recovery room and in the ICU, that he should go home and get some sleep. Renee herself had gone home, remembering only from Jonathan’s note on the kitchen table—See you tomorrow, love you—that he had meetings in L.A., and fallen into bed.
Five hours later she woke to the buzzing of her phone. Ten missed calls flashed on the screen. Never before had Renee slept through a call buzzer. She cursed herself as she stumbled through her apartment, trying to reach the on-call attending, pulling on jeans and shoes. A thickness rose in her throat. A dread.
Heart failure was the official cause of death. Melanie had lasted three hours in the ICU and then unexpectedly crashed.
Renee found Carl alone in the hospital’s small chapel room. He’d already been told, but Renee wanted to see him, ask if he needed anything, if there was anyone she could call. If there was anything she could do, anything at all.
“Melanie was simply too weak to recover from a surgery of this magnitude,” Renee explained. These were words she had said before, but for the first time she felt the true weight of their delivery. “The team did everything they could to save her, but her heart wasn’t strong enough.”
Carl did not meet Renee’s gaze. “Her heart was strong,” he said. “It was her body. And the fucking transplant list. Why did she wait so long?”
It was a question that Renee had been asked before. The lung-transplant list operated on a system of need and perceived chance of recovery and pure dumb luck, she explained now to Carl. It was a complicated calculus, imperfect and unjust, but it was the system they had. Some people were saved. Some had to wait too long. Some died waiting. There weren’t enough donors, it was that simple.
Carl listened. He nodded, dry-eyed. He’d already done his crying, he said. “Thanks for everything, Dr. Renee.” Into his pocket he stuffed the thriller he’d been reading to Melanie before the surgery, and then he left the hospital.
* * *
Renee didn’t hear from Carl for seven months. Every so often she thought of him, but she had new patients, all with their own families and stories, and the memory of Melanie Jacobs faded. A smart aleck. Brightly painted fingernails. The only child whom one day she’d spoil rotten.
And then Carl knocked on Renee’s door at New York-Presbyterian. It was an unseasonably warm day in April, and Renee had her lab coat off, her shoes off beneath her desk. It was near the end of her workday, but the door was open, and she waved him in.
“Carl,” she said, surprised at how glad she was to see him and also how the sight of him alone, no oxygen tank, no Melanie, shifted a weight in her chest. Rising from her desk, Renee hugged him.
Renee took Carl down to the hospital cafeteria, where he insisted on paying for their coffees. They sat at a small table overlooking a paved courtyard where fat pigeons fluttered and clucked. It was 4:00 p.m. The cafeteria was empty and overheated, smelling of pasta water and Windex. Across the room one lone window was open, and brief, tantalizing bursts of fresh air washed over them. With each one Renee breathed more deeply.
“Dr. Renee, you ever want kids?” Carl asked her.
Melanie would often ask Renee personal questions—What’s your favorite movie, Dr. Renee? Do you ever smoke pot?—but Carl never had, and for a moment Renee was taken aback. She sipped her coffee and considered Carl’s question. Had she ever wanted kids? She remembered a discussion with Jonathan not long after they’d met. This was shortly after Joe’s engagement party, still almost two years before the accident. Jonathan’s no to kids was as emphatic as Renee’s own, though she admitted to him one point of ambivalence. On a practical level, she liked the idea of creating newer, fresher, better Skinners. Our mortality weighed on Renee. Given our father’s example, it seemed any of us might disappear at a moment’s notice. With our bad luck and genetics, how would the Skinners continue? The pressure had lifted a bit with Caroline’s three, but those children were Duffys, not Skinners. It was clear even then that I was unlikely to become a mother, so it had to be Joe or herself, Renee, keeping her maiden name, procreating with a certain degree of independence or an extremely understanding partner. When she explained this to Jonathan, he had smiled and said, “Joe is a born father. Look at him. I bet he’ll have three wives with two kids each. At least. Don’t worry. We’re off the hook.”