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render the use of suction plates difficult or impossible ? " Under what. Walter Blundell and his patented apparatus for extracting teeth by. Adenosine is ambien cheaper than lunesta dipyridamole , and dobutamine are the most widely available pharmacologic agents for stress testing. Regadenoson, an adenosine analog, has a longer half-life than adenosine, and therefore a bolus versus continuous administration. Adenosine, dipyridamole, and regadenosine are cardiac vasodilators. They dilate coronary vessels, which causes increased blood velocity and flow rate in normal vessels and less of a response in stenotic vessels. This difference in response leads to a steal of flow, and perfusion defects appear in cardiac nuclear scans or as ST-segment changes. Dobutamine is a cardiac inotrope and chronotrope. The heart responds to dobutamine similarly to the way it responds to exercise. This direct coronary artery vasodilation induced by adenosine is attenuated in diseased coronary arteries, which have a reduced coronary flow reserve and cannot further dilate in response to adenosine. This is not the case in healthy or less-diseased coronary arteries in the same patient, which produces relative flow heterogeneity throughout the coronary arteries, resulting in relatively more coronary blood flow in the healthy or less-diseased coronary arteries compared with the more-diseased coronary artery. In most cases, coronary blood flow in the diseased coronary arteries does not decrease. In cases of severe vessel stenosis or total occlusions with compensatory collateral circulation, a decrease in coronary blood flow may occur in the diseased coronary artery, thus inducing ischemia via a coronary steal phenomenon. This regional flow abnormality also induces a perfusion defect during radionuclide imaging. Dipyridamole is an indirect coronary vasodilator that works by increasing intravascular adenosine levels. This occurs by the inhibition of intracellular reuptake and deamination of adenosine. However, the increase in coronary blood flow induced by dipyridamole is less predictable than that of adenosine. In one comparative study of dipyridamole and adenosine, 66% of patients except true coronary steal occurs more frequently. Dobutamine is a synthetic catecholamine, which directly stimulates both beta-1 and beta-2 receptors. A dose-related increase in heart rate, blood pressure, and myocardial contractility occurs. As with physical exertion, dobutamine increases regional myocardial blood flow based on physiological principles of coronary flow reserve. A similar dose-related increase in subepicardial and subendocardial blood flow occurs within vascular beds supplied by significantly stenosed arteries, with most of the increase occurring within the subepicardium rather than the subendocardium. Thus, perfusion abnormalities are induced by the development of regional myocardial ischemia. Regadenoson produces maximal hyperemia quickly and maintains it for an optimal duration that is practical for radionuclide myocardial perfusion imaging. Regadenoson's simple rapid bolus administration and short duration of hyperemic effect point to an advantage of enhanced control for the clinician. Another approach is the use of an imidazole phosphodiesterase inhibitor such as enoximone or milrinone, drugs that are relatively unaffected by concurrent use of a beta-blocker and are used for inotropic support in congestive heart failure. Enoximone stress echocardiography as an additional stress testing modality was evaluated in one study of 45 patients with chronic coronary artery disease and left ventricular dysfunction who underwent echocardiography with both dobutamine and enoximone. Both increased heart rate, but enoximone did not cause a significant change in systolic blood pressure. The positive predictive value and specificity were similar between enoximone and dobutamine. Concordant results were seen in 85% of affected segments, but enoximone had a higher sensitivity in predicting functional recovery after revascularization. Any physical limitation that prevents a patient from exercising maximally is an indication for vasodilator stress testing. Patients taking beta-blockers or other negative chronotropic agents that would inhibit the ability to achieve an adequate heart rate response to exercise are also appropriate candidates for vasodilator stress. Patients with left bundle branch block or ventricular pacemaker should undergo pharmacologic vasodilator stress because exercise stress often produces a false-positive perfusion defect in the interventricular septum. These defects are probably related to decreased septal contractility, which is accompanied by an autoregulated fall in coronary blood flow to the interventricular septum. Exercise stress or any other cause of tachycardia tends to enhance this heterogeneous perfusion by increasing the flow proportionately more in the normally contracting myocardium, resulting in a falsely underperfused interventricular septum on perfusion imaging. Vasodilator stress has been shown to overcome this coronary blood flow autoregulation, resulting in a more homogeneous perfusion pattern. Any physical limitation that prevents a patient from exercising maximally is an indication for vasodilator stress. Patients taking beta-blockers or other negative chronotropic agents that would inhibit the ability to achieve an adequate heart rate response to exercise are also appropriate candidates for vasodilator stress. Patients with left bundle branch block or a ventricular pacemaker should undergo vasodilator stress, because exercise stress often produces a false-positive perfusion defect in the interventricular septum. These defects are probably related to decreased septal contractility, which is accompanied by an autoregulated decrease in coronary blood flow to the interventricular septum. Exercise stress or any other cause of tachycardia tends to enhance this heterogeneous perfusion by increasing the flow proportionately more in the normally contracting myocardium, resulting in a falsely underperfused interventricular septum with perfusion imaging. Vasodilator stress has been shown to overcome this coronary blood flow autoregulation, resulting in a more homogeneous perfusion pattern. Consider dobutamine as a second-line pharmacologic stressor to be used in patients who cannot perform exercise stress and have a contraindication to vasodilator stress. Regadenoson injection is indicated for radionuclide myocardial perfusion imaging in patients unable to undergo adequate exercise stress testing due to body habitus or other comorbidities as outlined in contraindications for exercise stress testing in Medscape Reference article Treadmill Stress Testing. Regadenoson should not be administered to patients with second-degree atrioventricular block or sinus node dysfunction, unless these patients have a functioning artificial pacemaker. Review the patient's medication and caffeine intake. Theophylline can reduce ischemic changes on the ECG with vasodilator stress testing. Calcium channel blockers, beta-blockers, and nitrates can also alter perfusion defects on pharmacologic stress tests and therefore ideally should be withheld for 24 hours prior to pharmacologic stress testing. Instruct patients with diabetes regarding insulin requirements. Stress testing does not successfully identify all high-risk patients. The table below depicts findings and results for stress testing. Blankstein R, Cannon C, Udelson J. Update on pharmacological cardiac stress testing: efficacy, risk stratification and patient selection. Am J Med. 2014 Nov. 127. Patel JJ, Gupta A, Nanda NC. Comparison of hyperemic impedance echocardiography with dobutamine Stress Echocardiography to detect inducible myocardial ischemia: a pilot study. Echocardiography. 2016 Mar. 33 . Shah BR, Cowper PA, O'Brien SM, Jensen N, Patel MR, Douglas PS, et al. Association between physician billing and cardiac stress testing patterns following coronary revascularization. JAMA. 2011 Nov 9. 306. Pazhenkottil AP, Nkoulou RN, Ghadri JR, et al. Prognostic value of cardiac hybrid imaging integrating single-photon emission computed tomography with coronary computed tomography angiography. Eur Heart J. 2011 Jun. 32. Martin WH 3rd, Xian H, Wagner D, Chandiramani P, Bainter E, Ilias-Khan N. Arm exercise as an alternative to pharmacologic stress testing: arm exercise stress testing and outcome. Am Heart J. 2014 Feb. 167. Patel K, Alattar F, Koneru J, Shamoon F. ST-elevation myocardial infarction after pharmacologic persantine stress test in a patient with Wellens' syndrome. Case Rep Emerg Med. 2014. 2014:530451. . FDA Safety Annoucement. FDA warns of rare but serious risk of heart attack and death with cardiac nuclear stress test drugs Lexiscan . Zoghbi GJ, Htay T, Aqel R, Blackmon L, Heo J, Iskandrian AE. Effect of caffeine on ischemia detection by adenosine single-photon emission computed tomography perfusion imaging. J Am Coll Cardiol. 2006 Jun 6. 47. Korosoglou G, Gitsioudis G, Voss A, Lehrke S, Riedle N, Buss SJ, et al. Strain-encoded cardiac magnetic resonance during high-dose dobutamine stress testing for the estimation of cardiac outcomes comparison to clinical parameters and conventional wall motion readings. J Am Coll Cardiol. 2011 Sep 6. 58. Abe S, Takeishi Y, Chiba J, Ikeda K, Tomoike H. Comparison of adenosine and treadmill exercise thallium-201 stress tests for the detection of coronary artery disease. Jpn Circ J. 1993 Dec. 57. Beller GA. New directions in myocardial perfusion imaging. Clin Cardiol. 1993 Feb. 16. Beller GA. Radionuclide perfusion imaging techniques for evaluation of patients with known or suspected coronary artery disease. Adv Intern Med. 1997. 42:139-201. . Botvinick EH. Current methods of pharmacologic stress testing and the potential advantages of new agents. J Nucl Med Technol. 2009 Mar. 37. Cerqueira MD, Nguyen P, Staehr P, Underwood SR, Iskandrian AE. Effects of age, gender, obesity, and diabetes on the efficacy and safety of the selective A2A agonist regadenoson versus adenosine in myocardial perfusion imaging integrated ADVANCE-MPI trial results. JACC Cardiovasc Imaging. 2008 May. 1. Fletcher GF, Flipse TR, Kligfield P, Malouf JR. Current status of ECG stress testing. Curr Probl Cardiol. 1998 Jul. 23. Goraya TY, Jacobsen SJ, Pellikka PA, et al. Prognostic value of treadmill exercise testing in elderly persons. Ann Intern Med. 2000 Jun 6. 132. Guyton AC, Hall JE. Textbook of Medical Physiology. 9th ed. Philadelphia, Pa: 1995. Mansoor MR, Heller GV. Recent developments in the prognostic use of myocardial perfusion imaging. Curr Opin Cardiol. 1997 Nov. 12. Ruf J, Paganelli F, Bonello L, et al. Spare adenosine A2 receptors are associated with positive exercise stress test in coronary artery disease. Mol Med. 2016 Jul 19. 22:. Puente-Maestu L, Palange P, Casaburi R, et al. Use of exercise testing in the evaluation of interventional efficacy: an official ERS statement. Eur Respir J. 2016 Feb. 47 . Sampaio F, Lamata P, Bettencourt N, et al. Assessment of cardiovascular physiology using dobutamine stress cardiovascular magnetic resonance reveals impaired contractile reserve in patients with cirrhotic cardiomyopathy. J Cardiovasc Magn Reson. 2015 Jul 18. 17:61. . Hunter CR, Hill J, Ziadi MC, Beanlands RS, deKemp RA. Biodistribution and radiation dosimetry of . Normal radionuclide uptake . ECGs show a normal sinus rhythm and a sinus rhythm with a left bundle branch block. ECG depicts electrophysiologic events of left bundle branch block. Eric H Yang, MD Associate Professor of Medicine, Director of Cardiac Catherization Laboratory and Interventional Cardiology, Mayo Clinic Arizona Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha Disclosure: Nothing to disclose. Justin D Pearlman, MD, ME, PhD, FACC, MA Chief, Division of Cardiology, Director of Cardiology Consultative Service, Director of Cardiology Clinic Service, Director of Cardiology Non-Invasive Laboratory, Chair of Institutional Review Board, University of California, Los Angeles, David Geffen School of Medicine Justin D Pearlman, MD, ME, PhD, FACC, MA is a member of the following medical societies: American College of Cardiology, International Society for Magnetic Resonance in Medicine, American College of Physicians, American Federation for Medical Research, Radiological Society of North America Disclosure: Nothing to disclose. Disclosure: Nothing to disclose.. if

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Fiction by Scott Eubanks

AS DANNY USHERED HER through the narrow entryway, Helen considered how her life had always felt like a succession of giving up what she needed, and accepting what she had never wanted.  They entered a cluttered living room with a vaulted ceiling and mismatched furniture. 

            Danny was a short, broad man with a peninsula of curly hair on top of his head.  He wore a new polo shirt that still had the XL of plastic tape on the left sleeve.  She wondered if his wife, Mrs. Falkenstein had bought him the shirt specifically for this occasion.  Deciding not to point out the tape, she sat on a faded black pleather couch in the center of the room and smiled politely to the social worker, Ms. Allen.  On the far side of the coffee table, a moon-faced little girl with lime green barrettes in her hair sang in a low voice and played with a toy cuckoo bird. 

            “Marie will be back in a second,” he said.  “She just went to check on Willy.”

            “His name’s William,” Helen said.  Nervously smoothing the fabric of her slacks, she added, “He’s named after my father.”  Helen had never known a grown man who referred to himself as Danny.  It reminded her of an aging mouseketeer who could no longer act that happy without looking ridiculous, and had been relegated to taking care of other people’s children.   

            Pausing at the threshold of the kitchen, Danny managed a smile and said, “Would you like something to drink?”

            “No, thank you,” she said. “I really don’t anticipate staying very long.”  She looked over the assortment of magazines spread in an arc on the coffee table.  The new Time Magazine had a picture of the Shah of Iran on the cover and the caption read, Iran vs. the world.   

            Ms. Allen was arranging a stack of forms on her clipboard.     

            “That’s fine.  I hope you like cheese and crackers, mademoiselle.”  His attempt at a French accent sounded more like an Austrian one as he ducked into the kitchen, slamming doors and rattling silverware.

            “Actually, the adoptive parents can change the child’s name to whatever they want,” Ms. Allen said in a low voice.            

            “I haven’t changed my mind about this,” Helen said.  She remembered the cast of nannies, au pares, and other professional help who had raised her in her parents absence.  In high school, she had promised herself that she would never let that happen to her own children. 

            “I was just hoping that you’d put some thought into it,” Ms. Allen said.  They both watched the little girl on the floor play with her doll.  “Is your father, by any chance, Judge Marr?”  

            Helen nodded.  She winced as she rearranged the thin strap of her purse that had slid across her chest.  Her breasts were still swollen.  When they weren’t leaking, they vacillated between just being tender and aching like abscessed teeth.  

            “After we spoke in the hospital, your name sounded so familiar to me,” she said.  “It’s kind of funny because I just voted for your dad, and well, here we are.”

            “I didn’t vote for him.”

            There was a long and awkward pause before Ms. Allen perked up and said, “Did you have any trouble finding the place?”

            “No,” she said.  She glanced around the room, noting the tragedy of the suburbs, of money surpassing taste.  The walls were covered with tacky photographs in mismatched frames, and she thought of her own living room where an entire wall was arranged with a pristine collection of rare mounted insects that ranged from a protracted morpho Adonis butterfly to a golden silk orb-weaver spider with its legs held to the cloth with droplets of glue.

            She was familiar with Lancaster.  Even though she lived in L.A., Helen had driven right by the Falkenstein’s neighborhood once a week for the last three years to play alone at the golf course.  She looked forward to the long drive and didn’t know anyone in the area, which guaranteed nearly six hours of silence.  There was a man about her age with horn-rimmed glasses and spiked hair who brought his son every Sunday afternoon.  The boy would never be any good, but his father was patient with him and ruffled his hair playfully when he smacked the ball into the bushes.  She often delayed her tee time so that she could watch the two of them.  Her father taught her how to golf.

            “Do you have any questions about this?” Ms. Allen said.

            Taking a ballpoint pen out of her purse, Helen shook her head and said flatly, “You can give me what I need to sign to take my son home.”  She was used to saying what people didn’t like to hear.  She was a financial advisor for one of the largest pharmaceutical firms in Los Angeles.  The rhythmic sounds of Danny closing the cupboards and drawers in the kitchen had stopped.

            Ms. Allen nodded and looked down at the little girl playing on the floor with her cuckoo doll. 

            Helen hadn’t noticed it before, but the little girl was oddly proportioned with stubby arms and legs and mottled flesh.  The epicanthic folds of skin on her inner eyelids were thickly formed and her ears were too low on her head.

            “Does she have Down’s?” she asked.

            Ms. Allen nodded.  The little girl on the floor began to sing Jingle Bells as she played with her doll but substituted all of the original lyrics with the word “birds” with a heavy lisp. 

            Helen didn’t really see what all the fuss was about.  The little girl playing at her feet was adorable.  She wasn’t anything like what the doctor had described.  She imagined Down’s would turn her son into a drooling monster that would ultimately force her to quit her job so that she could wipe his ass until he was old enough to be shipped off to an institution.  As he spoke to her, all she could see in her mind was herself holding a handful of crap in her cupped hand—the inevitable conclusion to her life.  She had nine months of baby books, doctor’s visits, and cappuccino cravings to dream up who her son would be only to have it all discarded on the whim of a chromosome.

BY THE OBSTETRICIAN’S EXPRESSION in the delivery room, Helen knew something was wrong.  Shaking his head, he whispered something to the nurse.  Taking the baby from the doctor, the nurse glanced at her on the way out of the room, the same look that passing motorists had when they cruised by fatal car accidents with the windows rolled up, suddenly thankful for their own lives. 

            Helen was delirious with a mixture of agony and drugs from forty hours of labor.  Still smeared with blood and iodine, she felt as hollow as a punctured balloon and didn’t remember falling asleep. 

            When she woke up, she was in a hospital room with a muted TV mounted on a steel frame above her.  Her mother sat next to the adjustable bed clutching her purse in her lap, wearing two-carat diamond earrings, and high heels.  She could hear the vent by the window humming as it exhaled dry air that stunk like an autoclave.  Everything was pale blue, the curtains, sheets, her gown, even the doctor’s smock.  The doctor stood next to the bed and managed a smile.  Next to him, a short, middle-aged woman with blunt features and a box of tissues in her lap patted Helen’s hand above her IV and said, “How are you feeling?” 

            Before she could ask what the tissues were for, the doctor said, “I’m sorry to be the one to tell you this, Ms. Marr, but your son has Down’s syndrome.” 

            The social worker, Ms. Allen, explained that her son would never be normal and that there was no cure for Down’s syndrome.  He would never go to college, get married, or live anything that even approached a full life.  There was a test they could do to know for sure, but the doctor was positive that her son, William, had it.  Her mother stood up, and without a word left the room.

            Helen felt light and numb like she had been stuffed full of cotton.  She couldn’t really pick out the context of what the social worker said.  She wanted to scream that they had the wrong room.  As Ms. Allan struggled to maintain a soft, even tone in her voice, Helen looked up at the television.  A nature program was on.  One of the larger eggs in a birds nest had hatched and the first thing the fledgling did was push out the other eggs.  They shattered at the base of the tree, exposing the translucent skeletons of unborn birds with dark smudges for eyes and squared heads that reminded her of her first ultrasound.  All that the technician said was that she had a boy and that he had a healthy heartbeat. 

            She told them both to get out.

            The doctor looked relieved and apologized again as he hurried out of the room.

            Ms. Allen said, “I know you’ve been through a lot, but you suffered a serious hemorrhage during the delivery and the doctor’s worried about infection.  He’s recommended that you stay here for at least the rest of the week.”

            “I said get out,” she said.

            “You’re lucky to be alive.  I don’t mean to rush you, but what are your long term plans for your son?” she said, setting the box of tissues on the bed.

            Helen hadn’t realized she was crying.  “I was going to take some time off work, but there’s an au pair that I can call,” she said.

            “Your son may need more care than that,” she said, “With Down’s, there’s a higher incidence of everything like leukemia, heart deformities, epilepsy…”

            “…I didn’t plan on this, okay.  I did everything I was supposed to do,” she said.  She felt like she was cleaving apart like an iceberg, dissolving into an indiscriminate sea.  

            “This was out of your hands.  Women like you in their mid-thirties are ten times more likely to have a child with Down’s,” she said.  Clicking her pen and scribbling something on her clipboard, she added, “Do you think your family would take him for a while?  Maybe give you some time to get better?”

            “My mother didn’t just leave to get us some drinks.  She’s probably left the hospital, and my father didn’t even bother showing up because ‘he didn’t raise an unwed mother,’” she said.  She winced and held her stomach as she leaned forward to sit up straight in the bed. 

            Picking up her clipboard, Ms. Allen let out a sterile sigh and said, “You do have options, you know.”  Looking up from her forms, she added, “Have you considered placing your son with a foster family?”


            “While you recover, and get the rest of your life back on track, we can place your son with a family who specializes in taking care of children with disabilities,” she said. “Just until things become manageable.  It would only be temporary.”       

            She listened to Ms. Allen rattle off her proposal.  The way she talked seemed almost electronic, as she’d done it a thousand times that week. Helen was exhausted.  Not remembering much else, she signed the packet of forms that agreed to a temporary placement. 

THE MOON-FACED LITTLE GIRL set her cuckoo doll down and crawled around the coffee table.  Stopping at Helen’s feet, she looked up at her.  When she smiled, her puffy eyes nearly closed and she held out both of her arms for Helen to pick her up.    

            Helen wasn’t sure how she should act, and smiled.  She thought of how her secretary, Jenni, played with her son when she brought him to work, causing him to squeal every time she lifted him off his feet.  Helen put her index fingers in the little girl’s hands.  Her tiny fingers curled tightly around Helen’s fingers, and as she lifted her off her feet, Ms. Allen said, “You really shouldn’t do that.”

            Quickly setting her back down, Helen said, “I’m sorry.  I just thought…”

            “It’s okay.  You didn’t know.  Children with Down’s have low muscle tone.  It makes their muscles so loose that picking them up like that can cause their shoulders to dislocate,” she said.   

            It occurred to her how little experience she had had with children, even normal children.  Growing up, she never had to baby-sit like the teenagers she’d seen on sitcoms because she didn’t need the money, and her parent’s friends all had nannies.

            “It sounds like you’ve already made up your mind about this,” she said.  The little girl let go of the coffee table and stumbled to Ms. Allen, holding her arms out.   

            Helen felt like she had a knot of wood in her throat when she said, “What kind of person gives up their child?”

            “You’d be surprised.  They’re people who realize that their child has special needs that they might not be equipped to handle,” she said.  When Ms. Allen picked the little girl up, she looked surprised and hung limp like a chubby cat between her hands.    

            Helen asked, “Is she their daughter?”

            “No.  The Falkensteins’ adopted Sarah when she was only ten days old,” she said. “She might as well be, though.”

            A woman with wide set hips came down the stairs holding a tiny baby wrapped in blue cloth against her shoulder.  She gave her a placid smile and whispered, “You must be Helen.  I’m Marie.”  She sat down on the couch next to her.  Everything about her radiated with maternal warmth.  She even seemed to glow like a new mother, and suddenly thinking of her own sore tits and flabby stomach, Helen wanted to hate her, but it was the first time that she had seen her son.  She realized she was holding her breath and it seemed like every cell in her body was polarized towards the edge of the baby’s face that poked out of the flannel blanket.  Her son’s eyes were closed and his tiny features looked as fragile and smooth as marzipan.    

            “He isn’t exactly awake yet, but would you like to hold him?” Marie said.

            Helen unwound her purse from her shoulder and gently set it on the coffee table.  She held out her hands and gingerly took him in her arms.  After some direction from Marie, she cradled his head in her palm.  He was surprisingly warm.  She held him in front of her face and pored over his features, searching for the telltale imperfections that had already doomed him.  Aside from a dark wisp of hair on top of his head, he looked nothing like her. 

            Balancing a ceramic sombrero platter covered with slices of cheese, salami, and crackers, Danny set it on the coffee table and said, “I hope you guys are hungry because I think I got a little carried away.”  When Helen looked up at him, he didn’t meet her eyes.  Instead, looking more than a little uncomfortable, he thrust his hands into his pockets and smiled at Ms. Allen.

            “Danny is a biology teacher at the high school, you know,” Ms. Allen said. 

            “Is that where the cuckoo came from?” Helen said, pointing at the doll.

            “I thought it was more than a little ironic,” he said.  When nobody said anything, he laughed nervously and added, “I thought it was funny that Sarah liked it because cuckoos lay their eggs in other bird’s nests, and well…”  He looked at Marie and shrugged helplessly.

            “Willy’s a very good baby, you know,” Marie said.  “He sleeps through most of the night.”    

            “His name is William,” she said.  She thought the name, Willy, sounded like some pothead carpet installer from the Valley.  It had been a tradition in her family to name all of the firstborn son’s after her great grandfather, William.  She hadn’t spoken to her father since she told him that she was pregnant and hoped he would appreciate the gesture.  A part of her also secretly enjoyed the irony of it.  After she was released from the hospital, her mother had called to smooth things over and asked to meet for lunch.   

HELEN SPOTTED HER MOTHER from across the crowded restaurant, sitting in the corner by the window, watching the swallows pluck dead stems out of the hanging flowerpots that overflowed with corn marigolds and California poppies. 

            Slinging her purse across the back of her chair, Helen said, “Is dad in the bathroom?”

            “Your father’s not coming,” her mother said, taking her eyes off the swallows long enough to finish her wine.

            “Why?” Helen didn’t sit down.  She pushed her chair back in and picked up her purse.

            Standing up, her mother said, “Please.”

           The people at the adjacent tables had stopped talking and turned and see what was going on.  

           “Then why did you call me?” she said as she sat down.  

           “Just so that we can talk.”  Her mother gave the other diners a reassuring smile as she rearranged the starched napkin in her lap.

           “About what?  Having a baby?” she said.  “Let’s talk about when you left me and my son at the hospital.” 

           “I’m sorry,” her mother said.  “I didn’t know what to do.  I couldn’t think of anything to say to the doctor, so I went outside to get some fresh air.  After I calmed down, I was so ashamed that I’d left you alone.”  With a plaintive look, she placed the tips of her fingers against her sternum and took a series of deep breaths.

            Helen waited until she was finished.  “This isn’t about you, mom,” she said.  In a tone she usually reserved for overwrought clients, she added, “It’s about William.” 

            “I really wish you wouldn’t call him that,” her mother said.    

           “You can’t make me do anything,” Helen said.  She was suddenly aware that they had dredged up a variation of the same argument that they’d had since she was thirteen.  She was tempted to say something hurtful, a combination of words that would impale her mother on her own hypocrisy, but reminded herself that she had outgrown this. 

           Up until a few months ago, they had lunch every other Saturday.  It had always been awkward, and Helen spent the majority of their time together jabbing croutons in half with a fork, trying to remember all the subjects that weren’t appropriate to discuss.  Her mother had stopped asking about men after she got out of college and one time even alluded to her acceptance of her being gay.  She always reminded her to use the correct fork, and cross her legs, despite the fact that she wore slacks, a trend her mother vehemently opposed. 

           She ordered them both tiny dishes that were rich in fiber and ate practically nothing on her plate.  Helen was forced to listen to her mother’s stories of running into one of Helen’s old classmates at the market.  She laughed when she was supposed to, when she heard how much weight they had gained since high school.  She thought of what her old friends must have said about her mother behind her back. 

           Her mother had attended an all girls’ school until she got pregnant in her first year of college and married her father in a quiet ceremony.  She had majored in art and could talk about renaissance sculpture for hours, but she had never driven a car and over drafted her checking account once a month, despite their substantial savings.  She had lived a harmless and decorative existence that was consumed with a fifty-year-old concept of etiquette.      

           “I’m sorry,” her mother said again.  She nodded to the waiter and raised her wine glass.  “What are your plans?  Are you still taking him home?”  

           “Of course,” she said.

           “What could I possibly say that would convince you that this is a bad idea,” her mother said with a smile.  “Your father and I at least had each other to raise a family you know.”  She set her wineglass on the napkin in front of her so that the waiter could refill it.

           “I never wanted your life,” she said. 

           “I’m not saying you should be anything like me, Helen.  I gave up everything for you and your brother,” she said.  “What about your life?  Your job?”

           “I don’t know.  Maybe I’ll quit,” she said.

           Her mother laughed and put her hand against the waiters sleeve as she nodded politely.  “How would you make your house payment, or your credit card payments for that matter?  I couldn’t possibly imagine you living anywhere else than that beautiful house of yours.”

           Standing up, Helen put her hand on her mother’s and said, “I got to go, mom.”

           Her mother nodded and stepped around the table and gave her a hug.  “You don’t have to call him William you know.  My father’s name was Charles, and you could always call him Chuck,” she whispered.

           Helen rolled her lower lip into her mouth as she bit back the urge to cry, and said, “I got to go, mom.”

           Stepping back, her mother grabbed both of her hands and squeezed them.  They felt as smooth and soft as cabbage leaves.  “Your father and I are not going to help you,” she said.  “I’ll see you next Saturday.”   

           As Helen left the restaurant, her mother looked back at the birds out the window as they disappeared over the rooftops across the street.

WILLIAM OPENED HIS EYES and struggled, letting out a high-pitched groan before he settled back against Helen’s shoulder.  She knew that she was supposed to feel something as she looked into the face of her son, but instead she felt like she could have been holding anyone’s baby. 

           “He looks hungry,” Danny whispered. 

           “I’ll get it,” Marie said, going into the kitchen.  After a few moments, she walked into the living room with a bottle of formula, pinching the nipple, and shaking it until the cloudy contents resembled milk.

           “I think it’s time for us to discuss William’s future,” Ms. Allen said.  “From speaking with Ms. Marr on the phone…”

           “…We don’t have to do that now,” said Marie.  Crouching down in front of Helen, she said, “Would you like to see his bedroom and feed him?” 

           “Sure,” she said, feeling foolish for being so grateful.  She followed Marie upstairs and into a modest bedroom with a faded blue recliner positioned next to a white crib and changing table.  The walls had balloons stenciled on them, and a large bay window with a bench looked out on mountains that were covered with dusty chaparral and boulders that had been polished in the sea.  Helen thought of how much nicer the baby room in her condominium was, with handmade mahogany furniture and toys she had ordered from Paris.     

           Marie patted the arm of the recliner and handed her the bottle.  “When he’s done, you’ll know,” she said, “And take your time.”  Holding the door handle to close it behind her, she paused and said, “We’ll keep Ms. Allen entertained.”

           She wanted to thank her as she sat down in the chair.  “Do you have any children of your own?”  She felt her face flush as she realized how insulting the question was.

           “No,” she said.   “Danny and I can’t have children.”  She looked past Helen out the window at the blue jays nesting in an oak tree in the backyard.  Her face looked much older in the harsh light when she wasn’t smiling. 

           “I’m sorry.  I didn’t mean for it to sound so bitchy,” she said.     

           “It’s fine,” she said, stepping back into the room.  She lingered over them for a moment, and ran her fingers through William’s hair.  “I love those birds.  Sometimes I just sit in the window and watch them,” she said.  “You know, Danny thought that it was kind of crazy when I brought up the idea of adopting a child for the first time.  I just thought that we were wasting this big house in a good neighborhood.  I’m home all day anyway, so why not?”  She crouched down in front of Helen and almost whispered, “If I were you, I’d take my son home too.”  She stood up and left the bedroom, closing the door behind her.   

           Helen wanted to thank her, but instead she stared at the door.  William started fussing again.  She balanced his head on the crook of her elbow and he willingly took the nipple into his mouth and drank the formula.  His body felt so fragile against hers.  She reminded herself that this was the most natural thing she could do.  She shifted her body in the overstuffed armchair because it was already hurting her back and she wished she was home in William’s room. 

           She had purchased a specially made ergonomic chair and ottoman that rocked gently with the slightest movement.  The sales clerk said it was perfect for breastfeeding.  At the beginning of her third trimester, Helen found herself unable to sleep for more than a few minutes at a time.  At first, she just attributed it to stress.  Three days later without sleep, the doctor refused to prescribe any sleeping pills because they would harm the baby.  By the end of the week, she couldn’t go to work anymore and took to drifting through her condo like a ghost late at night.  She tried sleeping everywhere; the couch, the spare bedroom, the bathtub, even the living room floor, but she was still too uncomfortable to stay asleep for more than a few moments.  She ordered takeout and sobbed helplessly as she ate, watching inane programs on TV.  She didn’t want the baby anymore.  It had become appallingly clear to her that it was ruining every aspect of her life.  On the same night she purchased a box of sleeping pills from the pharmacy, she discovered the power of the rocker.  She had wandered into the baby’s room to take another inventory of what she might need.  Sitting down for only a moment and setting the pills on the changing table, she woke up to the sound of birds chirping in the predawn sky, having slept nearly six hours.  For the rest of her pregnancy, she slept in the chair every night, dreaming about what it would be like to breastfeed her baby as she listened to the Santa Anas carry the sound of the shushing waves from Santa Monica.

           Turning pink and grimacing, William spat out the bottle and sucked in a shuddering breath before he began to wail.  It sounded thin and metallic like an old tin noisemaker.  Setting the bottle on the floor, she laid him against her chest and rubbed his back to burp him.  As if in pain, William’s cries rose into jagged shrieks that hurt her head.  His tiny, fat limbs strained against the flannel blanket he was wrapped in, and from the weight of his body on her chest, Helen’s breasts began to throb. 

           Holding him in front of her, she tried quieting him, but he continued to scream.  She started thinking about how long it would take before Ms. Allen came through the door to declare her an unfit mother.  He spit the bottle out a second time and screamed louder when she tried rocking him in her arms.  A terrible thought occurred to her as she paced around the room. What if it was her?  She set him in his crib and watched his knotted up face continue to bellow.  It would be worse if Marie came to the door.  They were both shaking uncontrollably, and tears were already dripping off her chin.  The front of her blouse was wet with what she thought to be pee, but she realized that her breasts had leaked through her bra. 

           It was a sense of inevitability that guided her movements as she stood over the crib, unbuttoning her blouse.  It was the only thing that she could do that Marie couldn’t.  She undid her bra, and slid the strap off one of her shoulders and picked him back up.  Sitting in the recliner, she cupped her swollen breast in her hand and used her other hand to hold the baby’s head against her engorged nipple.  Leaning back in the chair and looking at the ceiling, she took a deep breath as she waited for the feeling of his little mouth to tug at her breast hungrily. 

           He gagged and struggled, spitting up formula on her, howling angrily.

           Setting him in his crib, Helen understood that he was only partially her son.  As she wiped herself off with some baby wipes, she looked out the window at the thick-limbed oak tree that shaded the yard.  She buttoned up her blouse and carried William over to the window.  In the light, she could see the strange shape of his eyes.  He squinted in the sunlight and quieted down a bit. 

           She thought about the sacrifices she had made for her parents and her job as she watched the blue jays flit among the shaded boughs of the tree, under leaves that hooked like talons.  They carried bits of string and dried stems for their nests.  She knew why cuckoos left their young behind.  Like her, they had been doomed by heredity to a self-imposed loneliness, a necessary act that was in itself the only grace she was ever permitted.  Looking over the sleepy, pastel neighborhood, Helen considered, for only a moment, what it would have been like to have kept her son.  She would ask them to keep his name though, her family’s name.

Scott Eubanks lives in Spokane, Washington, with his girlfriend, four-month-old daughter and 200 lbs. of dogs. He grew up in a foster home for children with developmental disabilities and his family ended up adopting five kids with Down’s syndrome. Until he was about five, he thought he was a genius because he could walk and dress himself. He received his MFA in nonfiction from Eastern Washington University where he was the nonfiction editor for Willow Springs Literary Magazine. His work has appeared in Memoir(and), the Yellow Medicine Review and the Whitefish Review.

Read Jessica Powers’s interview with Scott, buy ambien generic.

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