Informed Consent - chapter 6 (with images) (Patreon)

The cramp wakes me at four in the morning, a deep pull in the center of my pelvis. It feels like a fist closing slowly around a wet sponge. I lie flat on my back in the dark and breathe through it, waiting for it to pass, but it doesn't pass. It holds. The pressure radiates outward into my lower back, a heavy ache that settles right into the sacroiliac joint.

I put my hand flat against my lower stomach. The skin is warm.

Twenty-eight days, near enough two weeks since the ache on the right. I know what it is before I even sit up. The fever broke on a Saturday, and today is a Saturday. 

I swing my legs over the side of the bed. The hardwood is freezing. I walk to the bathroom, my hips rolling to compensate for the width, and I don't turn on the overhead light. I use the dimmer switch above the vanity, the one that hums when it's turned all the way down.

I pull down the gray cotton underwear and sit on the toilet.

There's a rusty smear on the fabric. Brown. Old blood, the kind the body flushes out first.

I sit there and look at it. I know what this is. I've worked in endocrinology for four years. I handed the pamphlet to fifteen-year-olds with PCOS and explained the endometrial lining and the drop in progesterone. I know the mechanism. I thought knowing the mechanism would make this feel like a routine lab result.

I wipe. The toilet paper comes away streaked with dark red. I drop it in the bowl and wipe again. More red. The cramp in my back tightens, a twisting sensation that makes me hiss through my teeth. I press my left hand hard into the hollow of my spine, right above the tailbone, and rub the muscle there.

I don't think I have anything for this.

I open the cabinet under the sink. Vicky's old tote bag is gone, but the plastic bag she left behind is still shoved in the back, behind the extra toilet paper and the rusted can of shaving cream. I pull it out. A half-empty box of super-absorbency tampons and a crumpled handful of individually wrapped pads.

I take a pad. I unwrap it. The plastic crinkles loud in the quiet bathroom. I peel the backing off the adhesive strip and press it into the crotch of my underwear. The padding is foreign, a solid ridge of cotton between my thighs. I stand up and pull my pants up. The pad bunches awkwardly. I reach down and adjust it, my fingers brushing against the damp heat of my own vulva. The sensitivity makes me jerk my hand back.

I go back to bed. The sheets are cold. I pull the duvet up to my chin and curl onto my side, pulling my knees up to my chest to take the tension off my abdominal wall.

It doesn't help. The cramping comes in waves.

I try to sleep. I watch the digital clock turn from 4:12 to 4:40. The blood feels heavy. I can feel the slow trickle of it leaving my body, saturating the cotton pad. It's a strange sensation, this passive leaking. I've spent my whole life holding everything in until I decide to let it out. This doesn't ask my permission.

At six, I get up and take three ibuprofen with a glass of tap water. I stand in the kitchen in the dark, leaning my hip against the counter, waiting for the medication to hit my stomach. The apartment is freezing. The furnace rattles in the closet.

I'm on the Saturday draw rotation and I have to be at the clinic in two hours.

I shower. The water is hot, almost scalding, and I aim the spray directly at my lower back. It dulls the ache. When I step out, the mirror is fogged. I wipe a streak clear with my hand. My face looks pale. My breasts are swollen, heavier than they were yesterday, the skin tight and shiny over the new tissue.

This isn't the ache I've been charting for a month. That one lives deep, a firm disc behind the nipple, a bruise-feeling I know by name now. This is everywhere at once, surface and depth, the skin itself so sensitized that the towel going over it registers as too much and I pat dry instead of rub. I know the words for it. Fluid retention. Cyclical mastalgia. The pamphlet lines them up in a row. None of them say that the tissue swelled ahead of the bleeding, like it knew first. The shape underneath is the same shape as last week. The volume isn't. It came on in a day.

They ache when I raise my arms to dry my hair.

I put on the sports bra. The compression feels like a relief. Then the scrubs. Then I change the pad. The old one is heavy, saturated with a dark flow that makes my stomach turn. I wrap it in toilet paper and bury it in the trash can under the wadded-up tissues from last week.

The drive to St. Luke's is a blur of gray morning traffic. I keep the heater blasting on my feet. The cramps get worse in the car, jolting me when I shift my weight to press the clutch. By the time I park in the staff lot, the ibuprofen is doing nothing.

Appurva is already at the station when I walk in. She's labeling a row of purple-top tubes.

"You look like hell," she says. She doesn't look up from her label maker.

"Bad stomach," I say.

"Don't give it to me. I have a date tonight."

I log into the computer. The screen is too bright. I put on a pair of nitrile gloves and start pulling my morning trays. The physical act of setting up the needles, the alcohol wipes, the tourniquets, it's all muscle memory. I can do it with my eyes closed.

My first patient is a woman in her sixties. She smells like peppermint. I tie the tourniquet around her arm, feel for the median cubital vein, and slide the needle in. The flash of blood in the hub is bright red. I fill two tubes.

When I stand up to drop the tubes in the biohazard bin, a cramp hits me so hard I have to grip the edge of the counter. The blood in the plastic tubes seems to pulse. I look at the bright red liquid, and then I think about the clotted blood currently soaking into the pad between my legs. The connection makes me dizzy.

"Okay?" the patient asks.

"Fine," I say. "Just a cramp."

At ten-thirty, I go to the staff bathroom. I lock the door. The pad is ruined again. I change it, my hands shaking slightly. The blood is bright red now, thin and constant. I flush the toilet twice to make sure the water runs clear. I wash my hands with the harsh soap from the dispenser.

I check myself in the mirror. The fluorescent light is unforgiving. My jaw is soft. My eyebrows are arched. I'm wearing a bra under my scrub top. I look like a woman who's having her period.

I walk back out into the clinic. The waiting room is full. The overhead speaker crackles.

At one o'clock, I go to the break room. I buy a bag of pretzels from the vending machine and eat them standing up. The salt helps. My phone buzzes in my pocket.

Vicky: Found your camera's charging brick in the bathroom drawer. I'm dropping it in the mail.

I type back: Thanks.

I stand there for a minute, staring at the vending machine glass. I want to tell her. I want to text her, I got my period, and see what she says. I don't. I put the phone away.

I go back to the draw station. The afternoon drags. Every time I sit down on the rolling stool, the pressure in my pelvis shifts, and I have to fight the urge to double over. I smile at the patients. I ask them to make a fist. I tell them to apply pressure to the gauze. I'm a machine running on autopilot.

At three, Sonia Bhatt walks past my station.

She's carrying a clipboard. She doesn't stop, but she looks at me. Her eyes track from my face down to my chest, then to my hands.

"Marcus," she says.

"Sonia."

She keeps walking. The sound of her flats on the linoleum fades down the hall.

I look down at my hands. The knuckles are smaller. The skin is softer.

I finish my shift at five. I drive home with the heat on high, and stop at the grocery store on the way, the big one with the fluorescent lights that buzz, and I buy a box of tampons and a bottle of ibuprofen. The cashier is a teenage boy. He doesn't look at me. He scans the box and puts it in a plastic bag.

I get home. The apartment is dark. The couch is gone. I drop my keys in the bowl and walk straight to the bathroom.

I take my pants off and sit on the toilet. The pad is a mess. I throw it away and open the box of tampons. The cardboard applicator is smooth. I read the instructions on the back of the box, even though I know how they work. Insert at a forty-five-degree angle toward the small of your back.

I try. The angle is wrong. It hurts, a sharp friction against the vaginal wall. I pull it out and try again. I relax the pelvic floor. I push the applicator in, press the plunger, and pull the cardboard out. The tampon sits inside me, a cotton pressure, uncomfortable.

I stand up. I pull my pants up. I walk to the kitchen and make a cup of tea. The tampon shifts when I walk. It's a constant, low-grade reminder of the opening in my body, the space that's no longer closed.

I drink the tea. The cramps are still there, a throbbing baseline. I look at the box of tampons on the counter. Super absorbency. Twenty in a box.

I think about Caden Voss. I think about the vial I took, the blood that carried this into my veins. His results posted clean and he never knew a fourth tube existed.

I take another two ibuprofen. I go to bed at eight. I sleep for twelve hours.

The blood gets past the tampon sometime in the night.

I wake on my side with my knees drawn up and the sheet stuck to my thigh, and I know before I look. The pad I slept in is bunched sideways, useless, and there's a dark patch on the striped sheet the size of my palm, dried rust at the edges.

Twelve hours in a tampon. I've given the toxic shock talk to patients. I say the words eight hours, sudden fever, rash on the palms to a stranger twice a month, and then I go home and do this.

In the bathroom I pull the tampon and it comes out dry on one side, a white streak down the cotton where it never even reached. The drag of it makes me wince. I drop it in the trash and stand there bleeding slowly onto the bath mat, one dark drop at a time, and then I get in the shower.

The water at the drain runs pink, then clear, then pink again when I move. The pamphlets we hand out at the clinic say the whole cycle is a few tablespoons. Standing in the water watching it, the pamphlets feel like they were written by someone who measured somebody else.

I'm understocked. The leftover pads from under the sink got me through yesterday. What's left is a box of super tampons that hurt going in and come out half dry, and I'm not walking three blocks to the store like this. I stand in the kitchen in a towel with my phone and type four versions of the text.

The one I send is: I got my period.

Then, because the first one sounds like an announcement and it isn't, it's a distress call: I need supplies. There's blood on the sheets and I don't know what I'm doing.

The reply comes in under a minute.

How bad.

Bad.

Don't go anywhere. Don't put on white pants. On my way.

I take two ibuprofen and sit on the edge of the bed on the gray towel, and the apartment is very quiet, and the cramps come up through my back in slow waves that have nothing to do with my spine.

I hear the key before the knock. She still has it. We never traded back, never stood in a doorway and done that part, and the sound of it turning in the deadbolt is so familiar that for a second none of the last month happened. Then she's in the doorway with a CVS bag and she stops.

The living room is empty. The lamp with the paper shade, the bare floor, the pale wall.

"You sold the couch."

"You told me to."

"I didn't think you'd actually do it." She comes in and puts the bag on the counter. "I loved that couch."

"I know."

She opens my fridge like she still lives here, looks in without taking anything, closes it. Her hand goes to the cactus magnet and straightens it without her looking at it. Some part of her body still works here.

"Okay," she says, and unpacks the bag. "Overnight pads, the purple pack. Wings, obviously wings. Regular tampons. The supers are for people with experience and no cervix pain, which isn't you this week. Heat wraps, the stick-on kind. Midol is Tylenol and a cup of coffee in a fancy box, so here's real ibuprofen and a Coke, you need the caffeine. Chips." She sets a chocolate bar on the counter. "Seventy percent. Milk chocolate is for amateurs."

The receipt comes out of the bag in a long ribbon and touches the floor. She balls it up.

"Show me the damage," she says.

She strips the bed while I stand in the doorway. She's fast at it, corners popping, the whole thing wadded into a bundle in under a minute, and she carries it to the small bathroom and runs cold water in the sink.

"Cold. Never hot. Hot cooks it in." She takes the hydrogen peroxide from under the sink, finds it faster than I would have, and pours it on the wet stain. It foams up white and loud. "You drew blood for four years and you don't know the peroxide trick."

"I never bled on anything I had to keep."

She scrubs the fabric against itself, knuckles in the cold water. I sit down on the closed toilet lid and watch her do it. Her hair falls forward and she hooks it behind her ear.

"You don't have to do that," I say.

"Shut up."

She keeps scrubbing. The peroxide stops fizzing. The stain is gone, or gone enough, and she wrings the sheet out and drops it in the tub and runs the showerhead over it.

"On a scale," she says, "one to ten, ten is your appendix."

"Four. Five when it waves."

"Day two is the worst. It slopes off." She looks at me for the first time since the sink, really looks, up and down, the towel, how I'm sitting, hips tilted forward to take the pressure off my back. "Mine always went to my back. Yours set up in the front, huh."

"Both."

"Greedy." She turns the water off. "Get in the bath. I'll run it."

She runs it too hot and then fixes it, and she hands me a folded towel and a pad through the door cracked exactly the width of her hand, her face turned away toward the hall.

"I'm not looking," she says.

"You've seen it."

"That was different."

The door closes. I get in the water and the heat hits my back and the cramps loosen for the first time since four in the morning, not gone, just wider apart. My breasts ache in the hot water, heavy and tight at the sides. A thin thread of blood curls off me into the bath and I watch it drift and the water goes faintly cloudy and I let it, because it's my tub and she told me to get in it.

When I come out, the bed is made. White sheets, tucked tight, hospital corners, her habit, the one she could never break at home. Across the middle of the bed, stretched flat, is the gray towel.

"Trust the towel," she says. "The towel has saved more bedding than any product ever made."

I put on the pad and clean underwear and a t-shirt soft enough to sleep in, and when I come out of the bathroom she's sitting on the bed with the chips open, and she's on her side. The left side. The side that was hers for two years. I can see her realize it. She doesn't move. I don't say anything, and I get in on the right, and the chips sit between us on the gray towel like a border we both agreed to.

"How are the cramps now?" she says.

"Better in the heat."

"Stick one of these on." She pulls a heat wrap from the box, peels the backing, and reaches behind herself and presses it to the back of her own jeans to show me the placement, low, over the sacrum. "On the underwear, not the skin. It says skin-safe. It's not skin-safe. Twenty minutes on, then give it a rest." She hands me one. It warms against my palm like something coming alive.

"You get them in your back," I say.

"Every time. Three days, one bad one, and I'm mean for a day before. You didn't notice because you were busy being scared of me." She eats a chip. "You might be a heavy one. Some people are. You'll know by tonight."

"Thrilling."

"Welcome to the worst club," she says. "Dues are monthly."

Around three I go to the bathroom and something comes out of me that isn't liquid, a dark mass the size of a grape, and I stand there with my heart going hard and the toilet paper in my hand.

"Vicky."

She opens the door a crack. "What."

"Something came out. Like. Tissue."

"Bigger than a quarter?"

"I didn't measure it."

"Then it's lining. It's supposed to do that. Flush it and wash your hands." She pauses. "You okay."

"I know what it is," I say. "I know it's lining."

"Okay," she says, and her voice goes a half step softer. "Then you know."

She closes the door. I flush it and wash my hands and stand there a second longer than I need to, because knowing it and having it turn out to live in two different rooms, and she knew that, and she let me say it myself.

Back on the bed she says, "Did you tell Nico?"

I texted him at seven that morning, before she got here. "I canceled the dinner. I said I was sick."

"You are sick. Technically."

"He texted you," I say, because I can see it on her, the held thing.

She eats a chip with unusual focus. "He asked if you were actually sick or avoiding him. I said actually sick. I didn't say how." She brushes salt off her hands onto the towel. "Reschedule. He likes you. Don't be weird about it."

"What do I tell him? If he asks."

"You say you had a stomach thing. Men don't ask. They don't want to know. That's the one good thing about them." She looks at me. "Say next Tuesday. Tuesdays are non-threatening."

I send the text from the bed with her watching. Feeling human. Next Tuesday?

The reply comes while the phone is still in my hand. Next Tuesday. I'll cook you dinner. Glad you're better.

"See," Vicky says. "He used an exclamation point in his head. You can tell."

She stays until the light goes long through the blinds. We finish the chips and half the chocolate and she tells me about her sister's fiancé, Derek or Eric, who put up a shelf crooked and then drilled a second hole to fix the first, and it's an easy hour, the easiest since the Crock-Pot, and neither of us mentions the lasagna night at all. When the light fades she gets up to leave.

At the door she gives me the discharge version.

"Change every four hours. Heat twenty on, twenty off. Overnight pad tonight, don't be a hero with the tampons, they hurt because it's new, not because you're doing it wrong. If you soak through an overnight in an hour, you call me, not WebMD." She picks up her keys. "And drink water. You look like a raisin."

"Vicky."

"What."

"Thank you."

"Yeah." She says it fast, to the door, and then she turns and hugs me, brief, both arms. Our chests meet and it's a new negotiation, soft where it used to be flat, and I feel her register it and the hug ends a beat early, and she opens the door.

"Text me tomorrow," she says. "I want the flow report. Full charting, nurse to nurse."

She goes. The deadbolt turns from the outside with her key, a small click, and my phone rings while her footsteps disappear down the hall. First Sunday, my mother checking in. I let it ring out.

I tear the hospital corners out getting into bed, on purpose, and then feel bad about it. The heat wrap is warm against my back. My phone lights up one more time, Giorgio in the group chat about Friday, and under it the thread with Nico, Next Tuesday. I'll cook you dinner.

The towel under my hips is the gray one. She folded it in thirds, the way she taught me.

The overnight pad is nearly clean when I wake up. Day three. I stand in the bathroom looking at it and feel nothing one way or the other. The trash can by the toilet is full of the week's wrapped evidence. I tie the bag off and carry it down to the dumpster before my coffee, in my sweatpants, in the cold.

The dumpster lid is the kind with the stiff spring hinge. I've flipped it one-handed for two years. This morning it gets halfway and stalls, and I have to set the bag down and put both arms and a shoulder into it. It bangs open. I throw the bag in and the lid bangs shut behind it, and I stand there a second with my hands buzzing from the metal.

The bra from the store, the one Bryn sold me a cup up, is loose in the cup again. Friday it was full. The swelling went out with the rest of it, and what's underneath is mine on the ordinary days. In the notebook I write the tape numbers and add a note in the margin: swelling, day one through day three. The first entry on the page with a rhythm instead of a direction.

I call my mother back from the parking lot. She talks eleven minutes about a neighbor's fence. I say uh huh and mm and that's crazy and nothing longer than three words.

"It sounds like you're getting over something," she says. "Are you okay?"

"I'm fine, Mom." My father is in the room. I can hear the television.

"Be sure to drink fluids."

"Will do." And I hang up.

At work the schedule is a wall of blue. First draw is a woman in her forties who apologizes for her veins before I've even tied the tourniquet, and I tell her the veins are fine, they always say that, and I get her on the first stick. Routine. I need routine.

The phone rings at nine. Courier dispatch, confirming tomorrow's pickup, the same woman who's called every week for a year. I give her the confirmation number and she says, "Thanks, ma'am, you're set," and hangs up. She has never called me ma'am. I put the receiver down. I didn't do anything. Didn't pitch it low, didn't shorten the sentences. It came out as whatever it is now, and the word on her end matched it. I try to find the day the cracking stopped and I can't. There wasn't a day.

Appurva passes with a rack of tubes. "Was that Denise?"

"Yeah."

"You sound like my sister on the phone." She shifts the rack. "Huh." She keeps walking.

There's a mirror in the staff bathroom and a mirror in the hall by the elevators and I've been managing both of them for a month, and this morning I stop managing.

A resident I've never met comes through the double doors at nine looking for the lab and says excuse me, do you know where I'd find, and then stops and looks at my badge, and I watch it happen. The badge says a name he can read from four feet away. His eyes go to the badge and then to my face and then to the badge, and then he decides I'm somebody's daughter or somebody's clerk and asks me the question again with different words.

Down the corridor. Past the centrifuge room.

And I could have fixed it. A month ago I could have dropped my voice and squared up and given him the flat institutional yes-what-do-you-need and he'd have filed me correctly and gone away. I run the inventory standing there after he's gone: the voice is gone, the jaw is gone, the shoulders are gone, the hands are gone. There's no lever left in this body to pull.

A month I've been holding a door shut. This morning I find out the door came off the hinges some time ago and I've been standing in the frame holding nothing.

The glove thing happens at ten.

I reach into the box of mediums the way I have every morning for four years and pull one on and the fingertips bag out half an inch past my own. The nitrile is loose around my palm. You can't feel a vein through a glove that doesn't fit. The finger pads slide around on the skin. Appurva stops with the label maker and looks.

"Since when do you wear smalls?"

"Since today."

I strip the gloves off and pull a pair from the box of smalls.

The glove sits snug, the blue nitrile smooth across knuckles that used to strain a medium. Appurva looks a moment longer than the question needed and then goes back to her label maker. The sound of it spitting out a strip fills the gap she left.

"Your loss," she says. "Mediums never run out. Smalls are a blood feud by March."

The email is on the screen when I get back to my desk. Mandatory in-service, bloodborne pathogens, annual requirement, Conference Room B, one o'clock. Attendance will be taken. Sonia's name is at the bottom, sent on behalf of.

Appurva reads over my shoulder. "Ugh. She does the whole deck. There's a quiz that's not a quiz."

Conference Room B is in the basement, down the hall from the centrifuge room. Somebody's half-erased diagram of an insulin sliding scale is still ghosted across the whiteboard, the numbers faint under the wipe marks. The sign-in sheet goes around on a clipboard. The projector remote only works if you hold it up high and aimed at the corner of the ceiling, which Sonia does without looking, an old habit, like starting a car you know.

There's a donut box. Green cardboard, the place on Colfax. Appurva takes a glazed and eats it over a napkin with the concentration of a woman who skipped lunch.

Sonia stands at the front with the printed deck in her hand. She doesn't use the projector for most of it. She knows the material from the underside.

"Hand hygiene you know," she says. "PPE you know. We're going to spend the time on sharps, because that's where it happens."

She passes out the safety needles, capped, one per chair, and talks us through the mechanism. One hand. Activate the sheath. The click means it's locked. Around the room there's a ragged chorus of clicks, thirty of them, and I click mine and feel the small give of it under my thumb.

I used a needle without a safety sheath. The supply closet stock, the old box at the back of the shelf. The thought arrives fully formed and I let it pass through and keep my face where it was.

"If you have an exposure," Sonia says, "you wash, you report, you go to occupational health. If the source is high risk there are prophylaxis options, and the window is short. Seventy-two hours for some pathogens, and shorter is better. Time is the whole thing." She looks around the room without hurrying. "The exposure we can treat is the one you tell us about. The one we can't do anything for is the one you sit on."

Seventy-two hours. I had the better part of four days. I sat in mine and counted the days like a dose schedule and told Vicky it was the flu. The room is warm and the donut sugar is on Appurva's fingers and nothing about my face changes. I've gotten good at that this spring.

And there's the other side of it. Four weeks of draws with a viral load in my own arms. Eleven, twelve patients a day, a needle in each of them, my hands an inch from the puncture. I never had a stick and I never had a splash and I wore gloves for every one of them. I could sit here and build the exposure risk for a colleague in ninety seconds. For myself I've been letting it stay a shape at the edge of the room.

"Every stick in this building goes into a log," Sonia says. "I keep the log myself. Eleven sticks last year, all reported, all followed up." She closes the deck. "First quarter of this year, zero. Cleanest quarter in three years. Let's keep it that way."

Appurva leans over. "She says zero sticks like we did it for her birthday," she murmurs.

I smile at that. It's a real smile.

The quiz that's not a quiz takes ten minutes. People sign the attendance sheet on the way out, the clipboard going hand to hand. Appurva has a two o'clock and goes up with the crowd. I'm gathering my pen and my paper when Sonia says, without looking up from stacking her deck, "Marcus. Stay a minute."

The room empties. The projector fan runs. Sonia straightens the deck against the table twice, aligning the corners, and then sets it down and takes her glasses off and lets them hang on the beads.

"The Voss line," she says. "The quarter review closed last week. I ran it. You're not in it."

The fan hums. I wait.

"There was no harm anywhere in it," she says. "The assay ran on the three tubes that arrived. Results posted. Dr. Yuen has her numbers. The patient was never even inconvenienced. So there was nothing to report, and I reported nothing." She folds the glasses into her pocket. "But I went through the order and the protocol and the add-on rules twice. There is no clinical reason that fourth tube existed. Nobody needed it. Nobody asked for it. Somebody drew it anyway, and wrote it off after hours." She says it without self-pity. A fact she's reporting, same register as the stick count. "Errors happen to you. This wasn't an error. Somebody drew extra blood from that patient on purpose. I don't know why. I don't like the sound of it."

"Maybe the count was wrong," I say. "Somebody miskeyed the draw record."

"The count wasn't wrong." She picks up the donut box and folds the flaps in, one, two, and then stops with her hands on the cardboard. "I pulled the original order. I wanted to know what kind of blood it was."

Something in my chest goes very still.

"It wasn't routine chemistries," she says. "The draw was a viral panel. Expression assay. Viral load." She looks up at me. "That tube was the most infectious material in the building that week. And nobody needed it. The assay never touched it."

"I didn't know what the order was," I say, which is a lie, and it comes out smooth, and I hear how smooth it is.

"Whoever took it was handling that blood," she says. "If it broke. If it splashed. If there was a stick nobody reported." She lets that sit for a second, and then she picks up the deck again. "There was no stick. I keep the log. Zero sticks, first quarter. I said it in there and I'll say it to you. Nobody had an accident in March. So whatever happened to that tube, nobody got hurt."

The fan pushes warm air across the table. The ghost of the insulin diagram floats on the whiteboard behind her.

"You were out that whole following week," she says. "I checked the schedule when I was doing the reconciliation. Called in Monday, out the week. Flu, wasn't it."

She doesn't say it like a question. My pulse is up and I can feel it in my throat and I answer the way I'd answer a chart query, flat and cooperative.

"Knocked me flat. You saw me when I came back. I looked like hell."

"You did," she says. "You look better now." She pauses. "Different, though."

I don't say anything. There's nothing to say that isn't a direction.

Her eyes drop. Not to my face. To my chest. For one cold second I think she's looking at the shape under the scrub top, the size-up top I hide in, and then I understand it's the badge. It's clipped at my sternum, the lanyard, the photo from when I was hired.

"HR's reissuing badges," she says. "Photos. Yours is due."

She looks at it a moment longer. I don't look down. I know what the photo is. Four years old. The jaw I used to have. A shadow of stubble. A man's face under clinic lighting, expressionless. I haven't shaved in three weeks. There's nothing left to shave.

"You don't look much like your picture anymore, Marcus," she says.

The name is wrong in her mouth now. She's saying it out of habit, out of the badge, out of the chart. The woman standing in front of her in a scrub top that can't quite hide what's underneath doesn't answer to it anymore. The badge photo is the only place that man still exists.

"I lost weight," I say. "I should get it retaken."

"You should." She tucks the deck under her arm and picks up the folded donut box. "Take care of yourself. You look pale."

She goes. Her flats make no sound on the carpet. The door swings shut behind her and the projector fan keeps on, and I stand there in the empty room with my pen and my quiz that's not a quiz, and I breathe.

Take care of yourself. You look pale. I can't read it. It's the thing a manager says to a nurse who looks tired. It's also the thing a woman says when she's decided something and is watching to see what you do next. Both of those fit in the same sentence and she knows it.

The staff bathroom is single occupancy with a lock, down the hall from the break room. I go in and lock it and stand at the mirror.

The face looking back has no stubble. The jaw is soft, the skin clear, the cheekbones higher than they were. The eyebrows have shaped themselves into something I didn't choose. My hair is past my ears now, thick and dark, and I tuck it behind one ear and it stays. The collarbones show through the scrub neckline. Under the top, the bra straps are visible to a careful observer.

I unclip the badge and hold it up next to my face, the photo and the mirror side by side.

Four years. Same eyes, same nose. Everything under the chin has been revised. The woman in the mirror isn't the man in the photo. There's no ambiguity left. A patient this morning called me miss and I answered to it without thinking.

She has the lot number. She has the schedule, the sick week aligned against the Thursday like two columns balancing. She has the log with its clean zero, the absence that closes off the only innocent story there is. And she has the badge photo, four years old, clipped to the chest of a body that contradicts it a little more every week. Anyone holding those papers would only have to look at me once to figure it.

I clip the badge back on and it turns photo-side against my chest, flipped inward. I leave it. I wash my hands because I always wash my hands. The soap is the harsh stuff from the wall dispenser and I dry on a paper towel and drop it in the can.

Four draws left on the afternoon schedule. I go back to my station and pull on a pair of smalls and the nitrile sits snug across my knuckles. I take the first patient's arm and tie the tourniquet and find the vein with two fingertips and do the draw.

The badge flips itself photo-out again during the next draw, riding against my sternum when I lean over the tray. I catch it and turn it back. By the end of the shift it has flipped three more times, and the last time I let it stay, the old face looking out at the waiting room, the old name under it in block letters, and I walk past Sonia's corridor on the way to the elevators with it showing, and I don't look down her hallway to see if her light is on. 

After my shift I stop at the Target on Colorado and buy a lipstick.

I don't need a lipstick. Nothing in my life requires one. I stand in front of the wall of them for a long time with the sample marks all over the back of my left hand, six of them, in a row, like a patch test, and I pick one because I like the name on the bottom of the tube and not for any other reason.

In the car I put it on in the visor mirror, badly, and I don't blot it because I don't know that you're supposed to. It's darker than I meant. I look at myself for a while.

Then I take a picture. And I don't delete it.

I sit in the Target parking lot at six in the evening with a lipstick on and my phone in my hand, and the last picture I took of myself I deleted twice because I know how phones work, and this one stays, and I don't have anybody to send it to and I don't need one. It's just on the phone now. It's a picture of me.

I wipe most of it off on a napkin before I drive home, and it stays in the creases of my lips all evening, and every time I catch it in a window I'm glad.