Disclaimer: The character names come from Stephanie Meyer's Twilight (not surprisingly)
Hopefully this will fix the disgraceful editing. I apologise sincerely. How embarassment!
"Thank you again for the referral, I will keep you informed of the outcome, yours sincerely etc". Dr Bella Swan put down the microrecorder and sighed, then glanced quickly at the clock on the wall. One more folder on her desk, one more patient to see, then hopefully she would make it to the hospital on time to keep her appointment with the Professor.
Bella's consulting rooms had the slightly barren, unlived-in appearance of a young professional just starting out in practice. The dark bookcase was relatively empty but the pale green walls were decorated with pleasant, abstract artworks. Her laptop was plugged into a nest of cables in the middle of the large wooden desk. Apart from the laptop and a spilling pile of patient files the desktop was empty.
Bella reached for the last file on the right of the unsteady pile. Attached to the front of the file was a printed result. Skimming the ultrasound result caused Bella to heave another long and heartfelt sigh. Then she glanced at the clock one more time and got up resolutely from her desk to open the door to the waiting room.
There was only one couple left in the room. They were seated together, holding hands and looking tense. When Bella called the woman's name they stood together and walked towards her still holding hands. The woman appeared apprehensive but the man's face was impassive. Smoothly Bella welcomed them, apologised for any waiting they may have done and directed them to take a seat next to her desk.
"I'm sure you would like to talk about your ultrasound result" she started and the woman nodded her head. Closer to her, Bella noticed that her eyes were darkly circled. In her gentlest voice she began to discuss the findings. The ultrasound specialist had noted an absent forearm on the left, an atrial septal defect, right talipes and choroid plexus cysts. Bella translated the medical details to the woman and her husband. The most serious defect was the lack of the lower part of the left arm. The specialist had thought that the hand appeared normal but it was most likely that it would actually possess some abnormalities or not function. The "hole in the heart" was probably minor and would possibly close by itself or might require surgery at one to two years of age. Talipes, a condition producing a misshapen foot, could be corrected by a number of techniques including some minor surgery. The choroid plexus cyst meant nothing by itself but together with the other abnormalities might suggest a chromosomal problem. The ultrasound specialist had performed an amniocentesis. It would take a further ten days to get the results of the genetic analysis but the early screening test was normal.
The woman digested most of this information in a frightened silence. When Bella paused, the husband cleared his throat. "The doctor who did the ultrasound called it a syndrome. He said it had reached epidemic proportions. What was he talking about?"
Bella nodded. The abnormalities fit the criteria for being called "Major multiple non-specific structural abnormality syndrome" or MSAS for short. It was true she admitted, that the diagnosis of abnormalities like those of the woman's fetus had become much more common quite suddenly over a period of a few years. The picture was always the same, normal early screening tests, then a finding of unrelated structural-type abnormalities at the midtrimester ultrasound. Sometimes there were genetic abnormalities, sometimes there weren't. There genetic abnormalities were apparently random and some experts argued that they were an unrelated finding, they were too disparate to be related, ranging from trisomies to minor deletions. All sorts of wild scare mongering was going around. People blamed everything including wireless internet, cosmic radiation and the use of certain types of plastics. The media had been particularly enthusiastic, suggesting new causes almost every week.
Bella was as reassuring as she could be. Yes, the defects fitted the description of MSAS but they needed to wait for the final genetic results which might yet reveal a chromosomal abnormality as the cause. They needed to have an appointment with a geneticist to discuss the possibility of an obscure syndrome, they needed to think about their options. They might want to talk to pediatric surgeons about the sort of surgery their child might need to have. They might want to consider the possibility of termination. They would need to make that choice.
Bella's flow of words halted and she caught the woman looking at her despairingly. As their eyes met, the woman asked "Was it something I did? Is it my mobile phone? I haven't used it since the ultrasound but they say the radiation is in the air. What causes it?"
Bella had seen this response too often. "No-one knows the cause" she said, shaking her head. "There has been a lot of speculation in the press but most of it is just wild rumours. We just don't know enough yet". "If it is the phones, I will sue them" said the Father vehemently. "They'll pay for it". Bella smiled as sympathetically as she could. She thought it was interesting how people had mostly latched on to the theory that it was caused by mobile phones. The other most popular theory was genetically modified food, the scapegoat for all sorts of medical problems. It crossed Bella's mind that these two might be most popular because they came with someone to blame, particularly multinational corporations potentially with large amounts for money for class-action payouts. For herself, she didn't see how that made it better but she knew that people's desire for some kind of vengeance was revealed in these circumstances. She doubted both theories but had nothing else to offer.
"No-one knows what has caused it" she began quietly but firmly. She had no desire to be writing statements for crackpot lawyers all day. "There are a number of theories apart from those two. I'm sure it was not your fault in any way. Just bad luck. As a matter of fact I am about to attend a conference in the US to address that very topic. That's why I asked you to come in so urgently. I'll be away for the next week. I'm presenting a study on the condition to a large international conference. There'll be some very important international speakers at the conference and I'm hoping that I might come back with some answers for you".
The couple were silent for a moment. Bella moved to close the session as she had an important appointment, but an obscure feeling of guilt prompted her to give them just a few extra minutes. "I'm so sorry to be going away at this time" she said almost beseechingly "But honestly I'm hoping that patients like yourselves will benefit from this overall. Dr Rosalie Hale is covering me, you can reach her through my secretary or through the same call service. I'll tell her all about you. She's lovely."
When the couple finally left the room, Bella realized that she had been holding her breath slightly. Consultations like that had become more and more common over the last few years. At first, her colleagues just started talking about it in the theatre tearooms. A coincidence, they all said, or jokingly, something in the water. Then the hospital ultrasound department held a grand round. A six month audit showed the numbers had increased by 20%. A year later the numbers of general structural abnormalities had increased by a further 10%. Another year later and they were still showing a further 5% increase.
When the audit was presented at the local perinatal conference, the media picked up the story instantly. Branding it an epidemic, journalists managed to catch unwary notable obstetricians making references to a random selection of possible causes. The journalists picked the most sensational ones, usually also the ones with the least evidence. For a few weeks after the conference, almost every night the tabloids brought out a new story, another distraught woman and her desperate family. They interviewed obstetricians, geneticists, naturopaths, religious fundamentalists and psychics all with frightening and unjustified conclusions. Increasingly serious anchors stared directly into television cameras and asked the frightening question "What does this mean and will mankind survive?"
Bella had been looking for a new research topic. As a newly qualified obstetrician trying to establish herself, her private practice was not as busy as some of her colleagues and she also had closer links to the hospital. One of the ways to establish yourself was to take up some work at a public hospital. This served the dual purpose of increasing your referrals from midwives asked by patients to recommend someone and also supplying you with some regular income to pay for the expenses like setting up your own rooms. Bella was taken aback to find out how much it all cost, the rooms, the secretary, the software, the stationery, the cost of equipment and the use of a sterilization service had all been daunting without even considering her medical defense expenses. Older colleagues had been supportive and had offered everything from advice to cast-off examination couches. Someone she had long respected for his caring manner with patients told her that when he started in practice, his first booked patient had experienced an early miscarriage which had helped him to pay his first month of bills.
Part of her continuing association with the hospital included an honorary appointment with the University Department. Lecturing and teaching was another good source of definite income. During her specialty training Bella had been involved to varying degrees with a few research studies and although it was not her main focus, she had certainly found it interesting. There was no question however that as part of her role she was expected to produce some original research. A retrospective epidemiological study was relatively straightforward to perform, the difficult part was the analysis and justifying her conclusions. Bella had asked for help from her old biostatistics lecturer. He was a great guy who had become a friend over the two years of the epidemiology course. He was always there with offers of statistical help for his previous students. Unfortunately, this meant that although he was very helpful, he was always very busy. After her abstract had been accepted for a presentation at the conference, Bella had grown increasingly desperate in her pleas to him to complete the analysis, even at one time contemplating going to the University's expensive professional service. Luckily, her lecturer had come through a day or two ago. Early enough for her to be confident about having something to actually talk about at the conference but late enough that she knew she was still going to be working on her talk on the plane.
Bella hadn't discussed the project with her Head of Department in any detail, although, as always, she had checked for his general approval before starting anything. She saw him occasionally at meetings and in the antenatal clinic she attended once a week. He was a large man with a large personality and a fan in his office so that he could smoke secretly without setting off the fire alarms. He always had a number of international trials running. In the last few years he had been responsible for the trials demonstrating the benefits of the new hormone contraceptive formulations, fourth generation progestins and a new synthetic estrogen. He had presented the data at many prestigious conferences both at home and overseas. He was currently running a trial of a new fetal monitoring system. He was thought to be unusually entrepreneurial for a professor and was rumoured to have a stake in the company manufacturing the new system. He was well-connected in the international scientific community and generally well spoken of by his peers. If there was any conflict of interest in his running a trial of the equipment made by a company he was closely involved with, no-one would criticize him openly. He was bluff and personable and Bella had always got on well with him.
Last night she had checked her e-mails late at night to find a message. "Dear Bella" it began, "Please drop into office to discuss your conference presentation tomorrow before you leave. Most important. Do not leave the country without speaking to me first! I will be in during lunchtime. Can you be at my office at 1pm? Professor Aro Volturi". Bella had e-mailed back in the affirmative and then spent considerable time wondering what he could want to say to her. She couldn't help thinking that such a summons was untoward. He had never been that concerned about her presentations previously. She was even more distressed by the fact that she didn't have the presentation finished, than she would otherwise have been. Although she had no reason to think there might be anything wrong she was not exactly looking forward to the interview.
Having seen the last patient out, Bella closed down her computer and detached it from the surrounding spaghetti tangle of wires. Hastily she gathered up her coat, her computer satchel and her pen and raced out the door. At the desk she stopped to hand her mini tape record to Raymond the receptionist.
Bella had inherited Raymond from the previous obstetrician who had rented the rooms. Her name was Kristen Paterson. Amongst the rather conservative staff of her hospital, Dr Paterson had always stood out. She wore tight red or black dresses with high-heeled black boots and had flowing frizzy blond hair. She was never seen without a slash of bright red lipstick, even at 2 o'clock in the morning. She was enthusiastic about her work to an extent which could seem frenzied. Some of her colleagues muttered about her eccentricities but Bella rather liked her. She had covered her practice for her a few times as a senior registrar. One day shortly before Bella had received her fellowship Kristen had invited her to her house for drinks on a Friday night when she was not on-call. Over a couple of bottle of champagne she broke the news that she had decided to retire from practice to join an artists' colony in the country somewhere and offered Bella the lease of her rooms. Glowing with good-humour and alcohol Bella had agreed immediately. The evening had gone on with the arrival of some of Kristen's artistic friends bearing takeaway Vietnamese food and a detailed tour of some of her hostess' collection of artwork including some of her own which seemed to solely depictions of male nudes in various attitudes. More guests continued to arrive throughout the evening including a man who Bella thought the obstetrician had introduced as "the latest in my long line of lovers", a statement which, even very drunk had made Bella blush with embarrassment and hastily excuse herself on the grounds of a need for a glass of water. Somewhere during the evening, she was introduced to Raymond who was wearing a costume resembling a medieval jester suit. Shortly after that she managed to call a taxi and get herself home. She told her husband, not very coherently, about Kristen's offer before collapsing entirely into bed. The next day, with a terrible hangover, she went over to collect her car and it seemed impolite not to ring the doorbell. The door was answered in a dignified fashion by a grey haired man who she thought might have been introduced as the current lover the previous night but she couldn't be sure. Close behind him was Kristen, dressed in a voluminous red bathrobe and looking as if she had just got out of bed but still with her trademark slash of red lipstick. Bella was reluctant to mention the offer of the rooms but Kristen referred to the deal straight away, reminding Bella that she had agreed to continue to look after Kristen's special patients if they liked her. It appeared that the offer did not include much in the way of furniture or equipment most of which was leased, but it did include the receptionist.
Raymond was dedicated, hard-working and very obviously gay. Her colleague had given him a glowing character and promised that all the women loved him; he kept them happy when she was running late by buying them jelly beans and he could be relied upon to chat knowledgably on any subject from home renovation to urinary incontinence. Raymond had held an extraordinary variety of jobs in the past including professional juggler. He started working for her colleague during a period where even his varied skills couldn't find him work and after a while, found that the role of receptionist suited him. He was neat and organized and genuinely interested in people. Now, a year later, Bella didn't know what she would do without him.
"So you're off tomorrow then?" he said as soon as she appeared in front of her desk. "Jetsetting off around the world, and leaving me here. Seriously, did you say you were going to San Francisco? Without moi?" He produced an affected pout and threw his hands in the air. Bella smiled and replied that he knew perfectly well she was going to San Francisco because he booked the tickets for her and that if he wanted to come too he should have said so and found himself a replacement to cover the office while he was away. Raymond grinned and dropped his exaggerated gay act. He loved San Francisco he said but going with her would be too restrictive. "Are you saying I'm not good enough to introduce to your friends?" she teased. "Of course not!" he replied. "They're not good enough for you. I mean it. Seriously. You haven't seen them," he added, pulling a face. Bella gave him her dictation cassette and reminded him of her cover arrangements while she was away. She started to go through the list of things he had to do and check although she had already gone through it about four times. "And I've just seen that couple with the diagnosis of multiple fetal abnormalities" she added. "They might want to see someone while I'm away. Get them in to see Shane if they need to. And Mrs Cope…" "Yes, yes we've been through it and I have it all in hand" he interrupted. "Now off you go to chat to your nice Professor. And for God sakes, while you're doing all this terribly important conference stuff try to enjoy yourself just a little bit!'
Bella laughed. She was aware that Raymond thought her life was too one-sided, consisting of too much work. "You know how to get me if you need me" she persisted. "Don't ring me because I won't answer the phone but you can always SMS me or we can skype if we need to".
"Get out of here!" the receptionist said playfully. Bella said a quick thanks and ran out the door. When she looked back through the glass door of the office, Raymond playfully blew her a kiss and waved goodbye.
Bella dashed up the stairs to the sixth floor, bolted past the reception desk with a weak grin and pulled up in a rush outside Professor Volturi' door. There she paused and tried to get her breathing under control while she checked the clock on her phone against the one on the wall over the door and listened to see if he were with anyone. Not hearing anything from within, she knocked politely and waited to hear a response from inside. There was an appreciable pause and then a voice called "Come in".
Bella came into the room and took the chair indicated at a table set up in front of the desk. The fan in the wall behind the desk was working which was a telltale sign that Professor Volturi had been smoking furtively up until a few moments earlier. The rumour around the hospital was that he had an enclosed ashtray in the bottom drawer of his desk but no-one had ever seen it. It was also rumoured that he wore nicotine patches to last him through clinic. No-one had ever documented him smoking outside the front entrance but then Bella considered that she could understand his desire to avoid that. Most of the inpatients could be seen down there in dressing gowns on cold mornings or sleeveless t-shirts in the heat, some of them dragging along their IVs on poles or sitting in wheelchairs. Staff hurrying to work in the morning generally tried to avoid meeting their eyes so that they could continue to pretend to believe them when the patients tried to claim that they had totally given up. When she was a registrar Bella used to greet her own unit patients at the door and tell them that she would see them up on the ward in half an hour for the round. It would not be seemly for a professor. On the other hand, if that wasn't enough motivation to give the wretched things up, she didn't know what would be.
Professor Volturi came forward and took a chair. He had longish hair going gray in the front and a Machiavellian beard which, according to various photographs around the department, he had been sporting for years, or at least long before small chin decoration beards were fashionable.
"Hello" he said "Dead on time as ever! How are you?"
"Well, thanks" she replied. "And you?"
"Not too bad" he said. There was a slight pause. Bella plunged on ahead. "In your e-mail you said you wanted to see me?" she asked.
"Ah yes". The professor appeared slightly amused at Bella's directness. "Now tell me all about this conference of yours" he said.
"It's an international scientific meeting" Bella started immediately. "It's been organized by the American Society for materno-fetal medicine in association with the European perinatal society. There's a three-day program. Henry Dubrovnic is the keynote speaker. You know he's based in Chelsea and he's done lots of work on fetal malformations in the past. He described the short q syndrome. He's giving his talk on the last day and he's rumoured to have some exciting results."
"And your work?" asked the Professor.
"Well I sent in the abstract of that epidemiological survey I did using the database and the CIS data" Bella explained. "I told you about it at the time. You were concerned that there wouldn't be enough numbers to make a significant study but I got a really positive response from the abstract committee. In fact," she added, blushing slightly "I got a half hour oral presentation on the last day".
The professor's expression did not change but to Bella's mind he exuded a faint air of disapproval. Bella told herself that she was being ridiculous. Why would he disapprove?
"So, show me your presentation" was all he said. "Were you going to show it to me, by the way? You know I like to be kept informed about research projects".
Bella squirmed slightly in her seat. "Of course I was going to show it to you, but I only just got the results of the analysis back myself. Steve Parris helped me with it which was terribly nice of him but he's so busy…" Bella got out her laptop and set it up. There was the usual wait while the computer booted up and she found her file and opened it.
"It's not quite finished," she said nervously. The professor only nodded politely and murmured, "Of course, you'll have time to polish it up on the plane, I'm sure. I just want a preview". With no further excuse to delay, Bella opened the slides and started her presentation.
"This is the hospital for women where I work" she began. "It has 350 beds and does about 7000 deliveries a year. Obstetricians at my hospital were first alerted to the rise in MSAS about 5 years ago when the ultrasound department presented an audit demonstrating a 10% increase in unrelated fetal structural abnormalities".
Bella tapped the mouse pad and the slide show advanced. "These figures show that the rate of these diagnoses has continued to increase every year since that time. The rate of the increase appears to be slowing but the trend has not yet reached a steady state".
"Where did you get those figures from?" interrupted professor Volturi.
"From the ultrasound database directly" Bella replied. "Although I also confirmed them with the head of ultrasound. They've continued to keep up-to-date audit figures themselves. And they've started a weekly meeting about newly diagnosed cases" she added. "Some of them are external referrals of course", she went on "But there's no reason for that to be a confounder because our referral sources are the same as ever. It's not as if we have added a new region or had a major ultrasound service close down or something". The professor did not reply but merely nodded and motioned for her to continue.
"OK, well I have a few slides showing examples of cases. Not too many because everyone will have heard it thousands of times by the last day but I thought I'd just show them some of our pictures so they can get an idea of the quality of our service". She flicked through a few slides, all quite similar, with an ultrasound picture on one side and a baby on the other. "I thought it was important to show that we confirmed the abnormalities as much as possible, either with the baby or at autopsy". Again the professor nodded.
"Then I start with the demographic data. No relation to maternal age, no relation to smoking (how unusual is that!) There are a few positive associations, like previous miscarriages but they're fairly weak, no relation to BMI, folate supplements, vitamin D, thalassaemia.." Bella went on through her lecture, discussing the various factors which had been investigated.
"So in conclusion, the strongest associations were noted for oral contraceptive use, number of previous sexual partners, age at first pregnancy and also a history of chlamydia." Bella paused and frowned slightly. "That chlamydia one might be confounded because it's also associated with age at first pregnancy so the real association might be that one…"
Bella's explanation trailed away and she looked at Professor Volturi expectantly. His expression was guarded and he had his hands steepled together with fingers touching point for point; in Bella's experience this was a sign that he was choosing his words with care.
"These correlations are very rough," he said "And I'm sure you haven't had a great deal of time to review and verify the data. Are you sure you want to present this in such a public open forum? You might be obliged to retract it. Research fraud is a serious issue, you know. People have been forced to resign their positions".
Bella was shocked. "But it's not fraud! I've done this research in good faith using recognized techniques. I freely admit that it's using retrospective data and so I'm relying on whatever was entered into the history. I agree that many records are incomplete but I've kept statistics on those. I know that a research project designed to record the factors of interest would be so much more effective but you'd have to wait years for the outcome!" Bella paused and tried to continue more calmly. "When I first discussed it with you, you didn't raise any objections…"
The professor put his hands in his lap. "Yes, but I didn't know that you would be planning to present your rather wild conclusions in such a public forum. You do tend to be a bit impulsive you know. This conclusion you've drawn about the oral contraceptive pill now, it's hard to justify on a biological basis isn't it? The pill's been around for 50 years at least and yet we've only seen this new syndrome in the last five years or so".
"But what about the new pills" countered Bella quickly. "Two new estrogens and a fourth generation progestin all came out in the last, well, eight years or so. And there was considerable uptake of those pills because they were supposed to have less side effects".
"But these are women having babies so they would be unlikely to use those pills" the Professor protested. "Look I can't stop you, but I'd like to give you some friendly advice. I strongly suggest that you remove the part related to the oral contraceptive pill. Trust me. I'm honestly trying to help".
Bella stared at her Professor in consternation. She was very surprised at his request. He had never spoken to her in this way before.
There was a short silence, which was broken by Professor Volturi with an air of dismissal. "When are you leaving? Tomorrow is it? And I assume you'll be contactable? You'll have your phone with you? Well, I'll be here as usual this week. You know you can always e-mail me or SMS me. I'd be happy to advise you any time you needed it".
Bella got up slowly as it was evident that the interview was over. "Well, thanks" she said. "I appreciate your interest and advice". "I wouldn't want anything to happen to you," said the Professor lightly. He smiled in a saturnine fashion into his beard.
Bella smiled in return, slightly reassured by his manner. She gathered up her things and turned to go. "Thanks again" she said "I'll keep in touch". "Have a safe trip," replied the Professor. As she went out the door she saw that he had gone back to his computer and was already typing busily.
"Raymond knows to call you if he has any problems. Oh and there's one more thing" Bella said. She was speaking on the carphone to another obstetrician who had agreed to cover her practice while she was away. Bella had given her a summary of her current inpatients (there were only two and they were both due to go home the next day following successful normal deliveries) and also any possible problems amongst her other patients. "There's a Mrs Cope who I just saw this afternoon. The fetus has probably got MSAS, it's talipes, ASD and absent left forearm so it seems very likely but it also has some choroid plexus cysts so Louise did an amnio and we'll wait for the result before counseling them. I spoke to them today and they seem to be coping very well but they might want to come and see you to discuss it again". "Poor thing" the other end of the phone replied. "Don't worry, I'm happy to see them. Have you organized a geneticist?" "Yes, they're booked to see Fred after we get the amnio result. Just in case he can come up with some strange syndrome." "Well they're going to the right person aren't they? After you present at this conference you'll be the local expert won't you?" Bella found herself blushing. Her colleague often said flattering things like this and Bella was never sure what she meant by them. "Not really" she said with a slight blush, "It's only a simple epidemiological study". "That's not what I heard" her friend replied. "I heard you've got some astounding new findings. Anyway have a great time and don't worry about your patients, they'll be fine." "Thanks Rosalie" Bella said sincerely, "I really appreciate it".
By the time she had finished the conversation, Bella had pulled into her garage. She sat in the car for a moment thinking about her colleague's comments. How had she heard anything about her results? The only person who had seen them apart from Bella was Steve, her biostatistics lecturer and Prof Volturi. Then again Rosalie was the sort of person who knew everybody and heard everything. As ever, Bella didn't know what to make of her flattering attention but she did know that she was an excellent obstetrician and that patients liked her a lot. Bella got out of the car and resolved not to worry about it any further.
Bella's husband Jacob wasn't home, but that wasn't unusual. Jacob was an orthopaedic surgeon. Just like Bella he had recently completed his training and was starting out in private practice. In order to increase his sources of referrals and supplement their income, Jacob had joined the staff of two public hospitals and was struggling to keep up with the oncall after hours. There were always lots of urgent broken bones to be repaired and they all had to be done after hours so Jacob was usually in all night operating when he was on call. Having only just completed his specialist training, Jacob was very much the junior on the staff. He was usually rostered on with the more inexperienced registrar and in addition to his own on-call, some of his older colleagues would ask him to cover bits of theirs. As well as the public work, Jacob was also keen to make himself available to the private emergency departments so that he could build up his private practice. As a result, since the start of the year, about half the time Jacob didn't get home until Bella was in bed asleep and left just as she was waking up in the morning. It had been a bit of an adjustment at first, but as her husband pointed out, it was just a sacrifice that would have to be made for a few years. Once his reputation was established and the private practice was running more smoothly, he could cut back on the public work.
In one way, Bella didn't mind, as she quite enjoyed her own company and liked the peace and quiet of being on her own in the house. Before they got married she though Jacob had spent so much time in her flat that they practically lived together, but afterwards, she realised that perhaps he hadn't been around as much as she thought. Certainly, after they got married she noticed that Jacob was noisier than she remembered and also alarmingly there all the time. Their three bedroom terrace house was comfortable but not exactly spacious and she found herself retiring to the front room to escape regular bursts of loud sport and terrible music. There had been a few fights while they got used to each other. Bella had found so many unexpected things about getting married became an issue, including stupid things like whether to keep the glad wrap in the drawer or in the cupboard. Now, having got used to him around all the time, and after settling most of their differences, she found herself spending much of her time on her own again. The worst thing about being on her own was how restful she found it and how difficult it was to adjust back to Jacob being around again when she saw him.
She agreed with him that it was a necessary sacrifice but she was also aware that the time was coming when they would have to put in some effort to stay together or they would drift apart. She had been planning to bring up the subject when they next had some time together, but the right occasion had stubbornly refused to present itself.
Bella rang Jacob but received no answer, which probably meant he was scrubbed in theatre. She discovered a neglected text message on her own phone that read "2 NOFS & a washout to do, ETA about 9 if all goes well". Bella knew that meant more like half-past nine and only then if things went well. She made some pumpkin risotto happily enough, thinking about her presentation, her wardrobe and what the weather would be like in San Francisco. She watched the news while she ate her solitary dinner and then got down her suitcase and started packing for the trip.
Bella usually tried to pack far too many things when she went anywhere. She made piles of things on the bed, clothes she'd like to take, clothes she knew she had to take and a pile of somewhere in between. It helped a little that she was packing for the reverse season, so as the weather was becoming colder at home, where she was going it would be getting into Spring and getting warmer. As a result, she could hopefully pack the clothes she was currently wearing. This was always easier she found, than packing for the complete opposite season; trying to remember what she wore last winter when it was a sweltering forty degrees outside was always a struggle. Bella was a complete sucker for those trashy magazine articles which always began "The perfect essential travel wardrobe". Over the years she had tried to assemble such a thing but somehow it never worked out. Her husband always teased her about the amount of clothes she packed for holidays and particularly about the number of items which she packed, but never found occasion to wear. He always boasted of travelling around Europe for three months with only a small shoulder bag which Bella found very annoying, especially when she discovered from their other friends that he had only succeeded in this by wearing the same pair of underwear three days running and by turning his socks inside out and wearing them again. This was, needless to say, before they were going out together.
After a difficult hour well distracted by the problem of whether she could bear to wear her low shoes with her formal suit for the presentation or whether the occasion really demanded formidable heels, Bella finally sat down at her computer. Firstly, out of habit she checked her e-mails. There was one from her ex-biostatistics lecturer discussing some of the finer details of the analysis and apologizing again that it had taken him so long. "There are a number of uncertainties affecting the logistic regression analysis" he wrote "Certainly Prof seemed to think so." That reminded Bella of her own interview with Professor Volturi earlier that day. Again, she brooded about his attitude. Why was he so concerned about her presentation?
Clearing her mind, Bella put in an hour's work on her talk, in particular adding some of Steve's corrections. Jacob rang in between cases, things were going slowly and the Emergency department had added a compound fracture to the list. She should just go to bed and not wait up for him and he would say goodbye in the morning. They gossiped inconsequentially for a little while, filling in the time between cases but then the anaesthetist called him away and she said goodnight. Finally, she e-mailed her presentation to herself as a backup, and rounded up her passport and her ipod as the two essential things to take when travelling.
The next morning, Bella was awakened by Jacob leaning over her and giving her a kiss. It was not quite light and he was fully dressed in his suit. "I have to go" he said quietly. "I'm sorry, I've got a case on early this morning. It was the only time theatre could give me". Bella sighed and struggled to rouse herself. "Whassatime?" she asked, trying to unstick her eyes. "Just after seven. Have a great trip. Be careful. Give me a call from the lounge. I'll try to find a time to skype when you get there". He kissed her again, gently and then left. She lay back on the bed listening to his footsteps retreating and the back door closing. Then she went back to sleep for a while.
Bella arrived at the airport with plenty of time to check-in, look at the duty free and settle comfortably in to a couch in the airline lounge. She set up her laptop using the free wireless and sent Jacob an e-mail. She got a cappuccino and a biscuit, just for the pleasure of using the coffee machine and opened her presentation to go over it once more. On impulse, she sent it to Professor Volturi with a covering note stating that she hoped he approved of her final version.
She had reverted to browsing the local newspaper when she heard her name and looked up. Approaching her was another obstetrician, someone from another hospital and indeed, the rival university. His name was Mike, but for some reason at Uni he had been known as "Froony". Bella found that she still thought of him this way and every time they met she was briefly reminded of the infamous time when he had broken a toilet with a beer bottle at a party.
Despite the fact that they graduated in the same year, Mike had managed to get a place on the training program the year before her. This had given him a slightly condescending air that continued to annoy her in a small way. After completing his fellowship he had taken a job across the other side of town at a rival university hospital and their paths seldom crossed, for which Bella found herself profoundly grateful.
Now she groaned inwardly at the thought of sharing her pleasant travelling solitude. Mike greeted her cheerfully and without particularly asking, put his carry-on luggage down on the armchair opposite hers. "You're presenting at the big international meeting in San Francisco," he announced. Typical, Bella thought and found herself slightly irritated on one minute into the conversation. "You're going too?" she asked, determined to be pleasant. "Yes" he replied with a pleased grin. "Actually I've been asked to give a talk. I'm on the morning of the last day, in the same session as Henry Dubrovnic. He's head of the Research Institute at Chelsea and he's rumoured to have some new results that he's bringing to the meeting…" "Yes" she said through gritted teeth "I know who he is". Trying to change the subject, she asked, "Do you know of anyone else who's coming?" Mike looked taken aback at the sudden change of topic. "Well, Professor Hancock told me she was coming" he began and Bella tried to ignore her annoyance at his obvious name-dropping. After all, she had asked the question. "Oh, good" she replied coolly "She's very good. I'll enjoy hearing her views on the presentations. Anyone else?" Mike launched on a list of all the notable obstetric researchers around Australia and his speculations on whether they might be attending or not based apparently upon his intimate knowledge of their lives. Bella soon found her attention drifting but fortunately Mike only needed the occasional "Oh, yes" to continue.
When their flight was called, Bella was relieved to discover that they were not seated particularly close. It did cross her mind that it was useful to know that there was definitely another medical practitioner on the plane just in case there was one of those announcements "If there is a medical doctor on the plane could they make themselves known to the crew?"
On the plane, Bella settled into her routine for long-haul flights. She was pleased to find that she had her requested seat on the aisle but not quite so pleased when an elderly lady moved into the window seat next to her. The plane was held up taking off, apparently waiting for a late passenger, according to the announcements. A nondescript man in a dark grey suit was ushered through the cabin to a place a few rows behind her and immediately afterward the doors were closed and the plane began to taxi down the runway.
For the first couple of hours, Bella attempted to do some work on her talk, however she found it difficult to concentrate. She realised the cabin crew were starting the meal service when she heard the voice of the attendant repeatedly asking someone to move out of her way. Looking around, she thought she saw the man who had arrived late, standing in the aisleway apparently looking intently up the plane but he sat down immediately. She couldn't be sure it was the same person.
The fourteen-hour flight to Los Angeles passed slowly as usual. Bella watched a number of indifferent movies. After about eight hours she felt a desperate longing to lie down but the seat would only recline a short way. In a series of contortions she managed to doze fitfully for a couple of hours. At one point, Bella was awakened from a light sleep by the passenger to her right who turned his light on for a few minutes in order to find something. Feeling thoroughly awake and very irritable, Bella checked the flight path and discovered that there were only two and a half hours to go. She knew that the cabin crew started waking people at 2 hours. Instead of trying to go back to sleep, she thought she might go to the toilets and try to make herself presentable for the day before everybody had the same idea. She got up and collected her bag from the overhead locker and made her way to the toilets at the front of the cabin. She got herself into the compartment then discovered that her hairbrush was actually in her handbag and still back at her seat. Fortunately there was no-one else around, so she took the risk of leaving her carry-on outside the toilet and went quickly back to her seat to pick up her handbag. When she got to her seat she was startled to see a man crouching on the floor looking under the seat in front of him. Standing in the aisle, she placed her hands on her hips and hissed "Excuse me, that's my seat, what are you doing?"
The man looked up at once, clearly startled. Seeing her, however he appeared to relax. "I dropped my pen around here somewhere as I was walking past" he explained easily. Bella picked up her handbag and after a moment's hesitation also took her laptop for good measure. The man continued to hunt around on the floor. She walked back to the front of the cabin. When she got to the toilets, she half turned back to see that the man had stood up and appeared to be dusting off his hands. She told herself that no-one steals things on aeroplanes because they would be caught too easily but she still checked that her computer seemed intact. Mechanically she went through her routine bag check; wallet with credit cards, passport, ipod, memory stick.
When she got back to her seat, the flight crew had switched on the lights and were handing out hot towels. In the general slow, overheated bustle, she took the opportunity to ask the elderly lady next to her if she had noticed the man crawling around her seat during the night. However when the woman replied, "What was that dear?" and held her hand behind her ear, Bella thought the better of it and shook her head "Nothing" she said "Don't worry" but she had to repeat it twice more before she was understood.
As usual, Bella staggered off the plane feeling dry, greasy and faintly nauseated. She stumbled through passport control, had trouble producing a decent fingerprint and answered the rather surly questions about the purpose of her trip and whether she would be leaving again, put to her by the laconic LA customs official. She caught glimpses of Mike in the customs queue but managed to get away with giving him only a brief smile and a "Good morning". Nobody really feels like talking at this point in the trip she told herself. With a faint lurch of anxiety and a mental prayer that her suitcase really had been checked through to San Francisco and was not even now either languishing on a baggage collection belt or on its way to Alaska, she found the correct bus to take her to the American airlines terminal. The sun was coming up quite strongly and she was aware of the LA haze beginning to spread across the sky. The LA airport streetscape was very familiar from lots of previous trips, the 70's brown of the airport, the peculiar pale American roads and the large slightly dilapidated taxis. The airport was even noisier than most in Bella's opinion, not just plane noises but loud traffic noises and often even louder people noises. It was the first thing you always noticed about Americans she mused, their loudness. Bella's thoughts went on a path down a well-travelled track about how Americans looked different to Australians. Casual dress, she thought was the key. Lots of track suits and t-shirts, all in bright colours, lots of sneakers. Looking at the people coming off her plane you could tell the Australians immediately. Paler faces in general, less strong makeup on the women, less formal hairdos, less hairspray. Grey and yellow crooked teeth, very different to the shiny straight white American ones. A sort of formality to their dress, even if they were wearing jeans, they were likely to be wearing leather shoes and as the plane was from Melbourne, most people were wearing black. Black was the safe choice at home if you didn't want to stand out in the crowd but it didn't work nearly as well in the US, as she had found in the past.
Americans were also generally very loud in Bella's opinion. Even just walking down the street by themselves, they thought nothing apparently odd in singing aloud. Bella had spent quite some time in the US over the years and she still found Americans a bit puzzling. She often said that it was disorienting being in the States for any length of time. At first the people seem normal, a little loud perhaps, but generally nice and friendly and then suddenly they do something that would make her feel very alien indeed, like the time she was in a bar in Philadelphia and the whole bar spontaneously started singing the "Stars and Stripes" at the announcement of a minor military victory on the television news. Bella had spent enough time in the US to know that she was never really at ease there. She never really trusted the apparent friendliness of the people; how many times had she been warned by close American acquaintances of the various scams and tricksters waiting to pounce on the unwary, not to mention the violence, gangs, organized crime or police, it was all the same she had been told. Keep your hand on your wallet and your eye on their gun and trust nobody. Even the beggars were louder in the US than elsewhere coming up to her to inform her that God loved her, leaving her bewildered as to why that was supposed to make her part with some hard-earned coins. The beggars were a painful sight in what was reputed to be the most affluent country in the world, in Bella's opinion. Especially when they were likely to be plying their trade metres from limousines containing the fabulously wealthy.
The other thing Bella found odd about Americans was the zeal with which they pursued even the most menial of tasks. The person parking the car, or serving the water all genuinely seemed to care about whether they had done a good job of it. At home, people doing more menial jobs seemed all too aware of the nature of their work. I'm doing this rubbish job, they seemed to say ,but don't expect me to enjoy it. People in the US though, genuinely seemed to enjoy their incredibly low-paid wage slavery, something which puzzled Bella exceedingly.
Standing in the airport security line, Bella was engrossed in her usual thoughts about Americans when suddenly someone gripped her by the shoulders from behind and an American voice said "Don't move!" loudly in her ear.
Tired as she was, Bella felt the sickening sensation of startling and her heart pounded in her chest. "Bells!" the unknown party called out and the hands that had been gripping her arms momentarily released their hold as the man moved around into her swimming field of vision. "It's great to see you! What are you doing here?"
As soon as she heard the pet name Bella recognized her attacker at once. "Edward" she said, "You scared the hell out of me. I'm just off the plane from Melbourne, I've had no sleep. Don't ever do that again." Her initial relief now had a noticeable edge of irritation to it.
The cause of her fright was 6 foot 2 inches tall with glasses and mass of artfully untidy bronze hair. He had a spare sort of figure and was slightly stooped, not a surprising consequence of being taller than 90% of the population. He towered over the relatively petite Bella by about 25 centimetres. His skin was very fair giving his cheeks and forehead a bluish tinge. He was dressed in a casual but preppy way in a nondescript navy blue shirt and dark jeans. "Nice to see you too" he said, smiling. She noticed that he continued to hold her lightly around the tops her arms. "Is that any way to be? We've hardly seen each other since you dumped me years ago!"
Edward Masen was Bella's ex-boyfriend, who she sometimes referred to as her ex-fiancé. When she thought about it, she couldn't remember him actually asking her to marry him, but she certainly remembered him suggesting reception places, honeymoon ideas and even window shopping for wedding rings. Given all of this, she had to assume that they had been engaged at the time. They met when they were both at University. Edward was doing Science rather than medicine. She suspected that he had actually started with the idea of being pre-med as they call it in the US but he vehemently denied that he had any intention of doing so. Edward had spent a few years in Melbourne as a child when his father was transferred as part of his job working for some giant American multinational. He had made some friends from school who he still kept up with. By the time his parents decided to move back to Australia some years later, Edward was already at college. He came out to spend what he called his 'vacations' with his family. It was during one of these holidays that they met.
As a boyfriend, Bella found Edward a refreshing change from the local examples. Edward was an early prototype of the sensitive new age guy. He loved going shopping with her, including standing around for hours while she tried things on and giving detailed but adoring critiques of various outfits ("You still look gorgeous in that one, but I like the other one better"). He was both sentimental and affectionate. He loved dancing. He made dozens of mixes for her. Bella had never been out with anyone like him.
Unlike her other boyfriends, he made no attempt to compete with her. He was proud of her academic achievements and he freely admitted that he couldn't match them. He was very easy company. He used to joke about her having to be the breadwinner and how much he would enjoy being a kept man. He sang her the XTC song "Mayor of Simpleton".
They had occasional fights over stupid things like matters of taste. Bella was constantly making scathing comments about his Americanisms all of which he took in good part, merely remarking that "You say tomayto and I say tomahto" with a grin. His sunny good nature made it impossible for her to stay upset with him for long.
When he returned to the US to go back to college at the end of his holiday, they fell into a long distance relationship without thinking much about the consequences. Over the next two years, they saw each other during the holidays. He came to Melbourne for the three months of his summer holidays and two weeks at Christmas and she went to the US for at least six weeks of her summer break. In that way they managed to see each other for five months out of the year. She wasn't unhappy with the situation. They had spectacularly romantic reunions and tearful tragic partings, drippingly sentimental phone conversations and they sent each other cards and letters, or at least she sent him letters and he made her long rambling recordings because he said he found writing difficult. Occasionally they saved enough for a phone call. It all kept the romance going and she found that she liked it.
At the end of his Bachelor degree he organized to spend an honours year in Melbourne although he didn't think it would do much for his career. They spent many happy hours talking and planning for it and for the first six months they were blissful but then she found out that he was applying for Doctor of Philosophy opportunities in the US. He started talking about the opportunities for her career in the US. He bought her a directory of all the different medical schools. He wrote to various places asking about their policies on transfers. It was the beginning of a paralyzing slow end for the relationship. Neither one wished to admit that they had reached a point about which they couldn't compromise but it was becoming increasingly obvious that he wanted to live in the US and she didn't. At the end of the year he moved to Texas to start on his doctoral studies. The night before he left, they stayed up all night trying to reach a conclusion. Bella found it hard to remember the details of the discussion later, she was horribly tired, she'd been crying for hours and she thinks they left it at saying that they still loved each other and if they were ever living in the same continent again they would get back together. Even after her marriage, they still kept in contact although by now, she hadn't had an e-mail from him for months. She had congratulated him on his PhD, commiserated with him on the difficulties of finding a post-doctoral position when he was out of work for a few months, then congratulated him again on starting work in the prestigious Daresby laboratory. She hadn't actually seen him since that last night before he went back to the US.
Now she regarded him with a mixture of affection and exasperation. A few years ago he had taken to referring to their break up as her "dumping" him and she wondered why he made the opportunity to throw it in her face like that. Was he trying to be hurtful? They both knew that the comment was far from the truth. "We haven't seen each other since you decided you'd rather live on the other side of the world from me" she countered. "But of course it's nice to see you. I just wish it had been a bit less of a shock".
It was awkward; he still had his hands lightly on her arms and she wasn't sure what he wanted her to do. The easiest thing was to stand on tiptoe and give him a hug, but after a brief second she reflected that she had been travelling for about eighteen hours, she felt filthy and exhausted and she dropped her arms a little abruptly, before he could kiss her. She stood back and slid into conversation a little too desperately. "So of all the security lines in all the airports in the world, what brings you to mine?" she asked not even attempting a real Humphrey Bogart impersonation.
"I'm going through to San Francisco" he replied promptly "I've got a poster to present at a scientific meeting". "Not the conference on the MSAS crisis" she exclaimed. His smile widened a little and he nodded and said "Yep, you too?" "Yes!" she said, pleased. "Are you on the same flight? What a coincidence! Where are you staying?"
They swapped travel details. He was staying at a recommended conference hotel but a different one to hers, somewhat less expensive and a few blocks away. He had also arranged to share a room with another scientist he knew from his old university. His poster session was on the first day. He hadn't seen the latest version of the scientific program and hadn't realised that she was speaking. "What's your poster about?" she asked, frowning. "I thought you were working in immunology?" He appeared gratified that she remembered his area of scientific interest, but clearly felt he needed to set her straight. "I started in immunology but that was ages ago. I've moved into different areas. I've done some work on cytokines and on nuclear receptors. I was part of the group that first described the bell-like receptors," he added with a virtuous air of resisting the temptation to boast. "We reckon that the BLR pathway is the explanation for nearly everything, so we did some BLR work on cultured placentas from MSAS affected pregnancies. It's not really my work but I was next up for a sponsored trip and I really like San Francisco, so here I am. Which is pretty lucky for you" he added teasingly.
They finally made it through the security process which was one of the more involved ones including removing their shoes and checking their bags for traces of explosive material. By the end, Bella was feeling completely wrung out so she suggested a rest and a coffee. She looked for an ATM but Edward insisted on buying, so she gratefully sank into a chair at the Starbucks on the other side of the security area. She sat at the table and wondered at the coincidence that had brought Edward to this same conference. She also wondered if he was going out with anyone. The thought brought a guilty "So what if he is?" reflex response. Adding to her confusion, her phone made the whizzing noise that accompanied the arrival of a text message from her husband. She busied herself with answering that all had gone well through immigration and that she was now getting coffee. It was four o'clock in the morning but he couldn't sleep and had seen her message from when she arrived. He was glad that she had got there safely. Bella texted him that she was fine, having a cup of coffee and waiting for the next flight and that he was to go back to sleep all in less than 30 characters. She hesitated briefly over whether to mention Edward but immediately decided that it was unnecessary. Jacob had never met Edward. He wouldn't be interested, she told herself.
They spent the wait for the flight catching up. She asked where he was living in Texas, about work, work colleagues, family and holidays. She asked about everything except relationships and as time went on she began to be conscious of avoiding the topic. She wondered if he noticed. Edward answered her questions easily but didn't ask so many about her. He did ask briefly after her husband but then quickly let the subject drop. She was happy not to talk about anything too seriously as the coffee was definitely starting to wear off and she began to get that feeling of vague unreality that accompanies the combination of lack of sleep and disturbance of the circadian rhythm known as jet lag.
They were seated separately on the plane, however Edward asked politely for the man next to her to swap seats. She wasn't sure if this was a good idea as she had really looked forward to a rest on the flight but she didn't have the heart to say so. To her surprise however, he didn't ask her any more questions or make any efforts at conversation. Instead he told her to lean back and have a rest because she was looking tired. Gratefully, she did as he suggested, lolling her head against the seat back and staring out onto the tarmac at the blue sky tinged with the grey of LA haze. The last thing she was conscious of was the motion of the plane taking off.
