“I can’t clear her airway.” Sara flicked open the blade, telling Jeffrey, “Keep her head still.”

Jeffrey shook off the dizziness. He braced his hands on either side of the girl’s head. Her skin was no longer pasty white, but purple-ish blue. Her lips were turning the color of the ocean.

Sara found her mark, then opened a small, horizontal incision along the base of the girl’s neck. Blood seeped out. She was performing a field tracheostomy, bypassing the blockage in the throat.

Jeffrey took a ballpoint pen out of his pocket. He unscrewed the barrel and got rid of the ink cartridge. The hollow plastic bottom of the pen would act as a tube for the girl to breathe through.

“Shit,” Sara hissed. “There’s—I don’t know what this is.”

She used her thumbs to make the skin gape around the incision. The fresh blood gave way to a grainy mass packed inside her esophagus. Jeffrey could see streaks of blue among the red, almost like the girl had swallowed dye.

“I’ll have to bypass the blockage.” Sara ripped open the girl’s thin T-shirt. The sports bra was too thick to tear, so she sawed at it with the serrated blade until she could rip the material the rest of the way open.

Jeffrey watched Sara’s fingers press into the top of the sternum, just below the tracheotomy incision. She counted down the first few ribs the same way she had counted off compressions. The girl was so thin that Jeffrey could see the outline of the bones under her skin.

Sara pressed the thumb of her left hand just below the clavicle. She layered the heel of her right hand over it, then pushed down with all of her weight.

Her arms started to shake. Her knees came off the ground.

Jeffrey heard a sharp crack.

Then Sara did the same thing again, but lower.

Another sharp crack.

“That was the first and second rib,” Sara told him. “We have to work fast. I’m going to dislocate the manubriosternal joint with the knife. I’ll have to lift the manubrium and push down on the sternum. Then I need you to use the top part of the pen to carefully move the vein and artery out of the way. I can access the trachea between the cartilage rings.”

Jeffrey couldn’t follow the instructions. “Just tell me when to do it.”

Sara pushed back her shirtsleeves. She wiped the sweat out of her eyes. Her hands remained steady. She used the small, sharp blade on the knife to make a four-inch vertical incision down from the previous one.

Dark blood welled over the edges of the opening. His stomach recoiled at the bright white of bone inside the body. The sternum was flat and smooth, maybe half an inch thick, about the size and shape of an ice scraper. Jeffrey had a football player’s understanding of anatomy. He knew all the bad places to get hit. The breastbone had three sections, the stubby top, the long middle and a short tail-like bit that stuck out at the bottom. The bones were all joined together, but with enough force, they could be broken apart.

If Jeffrey was right, Sara was going to pry up the stubby top of the sternum like the lid on a soup can.

She flicked open the serrated blade. “Hold her down. I’m going to score along the joint to make it easier to dislocate.”

Jeffrey pressed his hands into the girl’s shoulders.

Sara was on her knees again. She sawed back and forth across the bone the same way you would carve at the joint of a turkey leg.

Jeffrey bit the inside of his cheek. The taste of blood made him feel dizzy again.

“Jeff?” Sara’s tone warned him to keep his shit together.

He gripped the girl’s shoulders as Sara hacked back and forth. The victim was so small. Everything about her seemed fragile. He could feel her body jerk with each rough cut of the blade.

“Tighter.”

That was all the warning Sara gave him.

She jammed the blade underneath the junction of the joint.

His teeth gave an involuntary chatter at the scraping sound.

Again, Sara used the weight of her body. The heel of her right hand pushed down against the body of the sternum. Her left hand fisted around the knife handle as she pulled up, trying to lift the bone with the serrated blade.

Sara’s shoulders started to shake again.

Nothing opened like the lid on a soup can. It was more like stabbing the knife into the lid and trying to break open the can by force.

Sara told him, “Pull up and press down on my hands.”

Jeffrey covered her hands with his own. He leaned forward, tentative, afraid he would crush the girl.

“Harder.”

He pressed and pulled harder, though every muscle in his body told him not to. The girl was so slight. She was barely more than a teenager. Breaking her open went against every part of Jeffrey that was a man.

“More,” Sara ordered. Sweat dripped down from the tip of her nose. He could feel her shoulders shaking into his hands. “Harder, Jeffrey. She’s going to die if we don’t get air into her lungs.”

He pushed his weight downward and pulled up as hard as he could. The blade started to bend, but Jeffrey realized that the blade wasn’t giving. The bone was.

The joint cracked like an oyster shell.

He tried not to vomit again. The splintering sensation had reverberated up his arms and into his teeth. Worse was the sucking sound of cartilage breaking, sinew tearing, tendons separating, as the bone was wrenched away from the joint.

“Here.” Sara pointed into the open incision. “This is the vein. This is the artery. You need to use the top of the pen so your hand isn’t in the way.”

He could see the vein and artery stringing in front of the ringed trachea like two pink straws. One of them had little red things attached to it. The other looked slick. He couldn’t get the tremble out of his fingers as he used the pen to gently press the vein and artery out of the way.

“Hold still.” Sara held the plastic barrel of the pen between her thumb and fingers. Her elbow was tight to her body. She moved downward, pushing the silver tip of the barrel into the trachea until the bottom third of the pen was inside.

“Move.”

He carefully lifted away his hand. The vein and artery slid back over.

Sara took a breath. She sealed her lips around the pen barrel and exhaled a stream of air directly into the trachea.

Nothing happened.

Sara took another breath. She exhaled through the pen.

They both strained forward to listen, hearing birds chirping and leaves rustling and then finally, after what felt like an eternity, the whistle of air pushing out of the barrel.

The girl’s chest shuddered as it rose to take in a breath. The resulting fall was slow, almost imperceptible. Jeffrey held his own breath, counting off the seconds until the chest rose again and she filled her own lungs with air.

He breathed with the girl, in and out, as the blue drained from her face and life came back into her body.

Sara peeled off the bloody exam gloves. She stroked back the girl’s hair, whispering, “You’re okay now, sweetheart. Just keep breathing. You’re okay.”

Jeffrey didn’t know if Sara was talking to the victim or to herself. Her hands had started to tremble. Tears welled into her eyes.

Jeffrey reached out to steady her.

Sara recoiled, and he had never felt so monstrous, so worthless, in his entire life.

His let his hands fall uselessly back to the ground.

All he could do was wait with her in silence until the ambulance arrived.

Atlanta

4

“Tessa,” Sara practically yelled into the phone. “Tessie, would you just—”

Her little sister wasn’t going to listen. She kept rambling, her voice taking on the cadence of the adults in Peanuts cartoons.

Wah-wah-wah-wah, wah-wah-wah-wah.

Sara tapped the phone on speaker and rested it on the shelf above the sink. She washed her face with the pink soap from the dispenser. The cheap paper towels disintegrated in her hands. If Sara did not get out of this prison soon, they were going to have to put her in a cell.

Tessa picked up on the noise. “What the hell are you doing?”

“I’m taking a whore’s bath in the visitor’s restroom at Phillips State Prison.” Sara peeled a piece of wet paper towel off her cheek. “I’ve been up to my eyeballs in blood, piss and shit for the last five hours.”

“It’s like college all over again.”

Sara laughed, but not so Tessa could hear. “Tessie, do what you want to do. If you want to train to be a midwife, train to be a midwife. You don’t need my approval.”

“Bull. Shit.”