February 28, 2025

It's the shoulder pain that finally forces Susan to call.

The bleeding back on February 22—three weeks after New Year's Eve—had seemed like an answer to prayer. Her period, finally. Three weeks late—but that happened with stress. She and Jake had talked that afternoon, both flooded with relief. They'd dodged it. New Year's Eve was just a scare, a wake-up call. They promised each other to be more careful, to wait until marriage like they'd always planned.

Except the bleeding had been lighter than normal. And it stopped after a day.

Then the nausea started. Different from regular period cramps—sharper, concentrated on one side. Susan told herself it was stress. Community college finals. Extra shifts at the diner. The same reasons her period had been late in the first place.

But last night, she'd found herself searching "sharp pain in shoulder during pregnancy" at 3 AM. The results made her blood run cold: "ectopic pregnancy symptoms," "medical emergency," "maternal death in first trimester."

The February bleeding wasn't her period. It was the ectopic pregnancy implanting wrong, her body trying to warn her.

Jake's phone buzzed at 7:43 AM on March 1st. He was already up, about to head to the dining hall for his weekend breakfast shift.

"Jake." She breaks off, breathing shallow. "Something's really wrong."

Twenty minutes later he's in his truck, speeding down the interstate toward Millerton. His MAGA hat sits on the passenger seat where Susan usually sits. His ROTC command already emailed–emergency family leave approved. The radio's off. The only sound is the engine and his own breathing, too fast, too shallow.

Susan's parents meet him at Millerton General—except it's not Millerton General anymore. The building's dark, chain-link fence around the parking lot. A sign reads "PROPERTY FOR SALE - CONTACT REGIONAL HEALTHCARE PARTNERS."

The closest emergency room is sixty miles away.

"We have to take her to City Memorial," her father says. His jaw tightens. "She… thinks it might be an emergency. A pregnancy…"

Jake's breath stops. Pregnancy. But they'd been so relieved a week ago when the bleeding started. They'd thought it was over.

"She's in the car," Mrs. Fletcher says. Her voice is clipped, angry. Not at Jake–at least, not only at Jake. At everything. "We need to go. Now."

The drive to City Memorial takes fifty minutes. Jake knows because he watches every minute tick by on his truck's dashboard clock, following the Fletchers' minivan through pre-dawn darkness. Susan's curled in the back seat with her mother.

The OB-GYN, Dr. Blaine, studies the ultrasound screen with practiced eyes. Her expression shifts from professional concern to something more urgent.

"I need to explain what we're seeing," she says, turning to face them all. "The pregnancy has implanted in the fallopian tube instead of the uterus. This is called an ectopic pregnancy, affecting about one to two percent of all pregnancies." She pauses, choosing her words carefully. "I need you to understand–this is not a viable pregnancy. There is no possibility of the baby surviving to term."

Susan stares at the screen, trying to make sense of the grainy image. "But you said it's not viable. If it's not a real pregnancy, how come my test was positive? I took three tests–they all said pregnant."

Dr. Blaine's expression softens. "It is a real pregnancy, Susan. The embryo is real, the cardiac activity is real, your body's hormonal response is real–that's why the tests were positive. HCG hormone doesn't distinguish between a normal pregnancy and an ectopic one." She pauses. "What I mean by 'not viable' is that it cannot develop into a baby. The fallopian tube can't expand like a uterus. As the embryo grows, the tube will rupture. There's no medical intervention that can move it to your uterus or allow it to continue safely."

Susan's hand finds her mother's. "But… but there's a heartbeat?" Her voice cracks on the word.

"Yes," Dr. Blaine says gently. "At six weeks, four days, we can detect cardiac activity. Some ectopic pregnancies do resolve naturally through miscarriage." She sees hope flash in Mrs. Fletcher's eyes and continues carefully. "But waiting carries significant risks. The fallopian tube can rupture as the embryo grows, causing severe internal bleeding. This is a leading cause of maternal death in the first trimester."

Mrs. Fletcher's grip on her Bible tightens. "So we should wait? Pray for natural resolution?"

"The shoulder pain Susan's experiencing concerns me deeply," Dr. Blaine explains. "It means blood is already irritating her diaphragm. The tube could rupture at any time, causing catastrophic internal bleeding."

She meets their eyes in turn. "There are two active treatment options. First, medication called methotrexate. It's actually a cancer drug that stops rapidly dividing cells. When caught early enough, it allows the body to reabsorb the pregnancy tissue naturally while preserving the fallopian tube." She leans forward. "This is critical for future fertility–Susan could still have children later. But…" She glances at the hospital's Catholic cross on the wall. "City Memorial follows Catholic medical directives. Catholic hospitals consider methotrexate an abortion drug, even though it's standard care for ectopic pregnancy. We'd need special approval."

"The other option?" Jake asks, his hand finding Susan's.

"Surgery to remove the affected section of tube containing the pregnancy," Dr. Blaine explains. She glances at the crucifix on the wall, choosing her words carefully. "Catholic hospitals universally accept this procedure under the principle of double effect–the primary action is removing the damaged tube to save the mother's life, with the death of the embryo being an unintended consequence. It's more invasive and would halve Susan's future fertility chances, but it aligns with Catholic medical ethics in a way that methotrexate doesn't, since methotrexate directly stops the embryo's growth."

She lets that sink in, then continues. "In most other states, this would be straightforward emergency care–we'd use the least invasive option, typically methotrexate. But here, I have to navigate Catholic hospital directives and state restrictions."
She doesn't add the rest: the possibility of criminal investigation, colleagues already facing prosecution for treating ectopic pregnancies despite standard protocols.

Susan doubles over with another wave of pain. "But I could die? If we wait?"

"Yes," Dr. Blaine says simply. "You could bleed to death in hours if the tube ruptures. That's not meant to frighten you–it's medical reality. And it's why I need to be absolutely clear about the stakes here, even though discussing this before getting legal clearance could put my license at risk."

There's a moment of silence. Mrs. Fletcher's grip tightens on her rosary. Mr. Fletcher's face is stone.

"There's a heartbeat," Mrs. Fletcher says finally. Her voice is steady, certain. "You said there's a heartbeat."

"Yes," Dr. Blaine says. "But—"

"Then it's a life. God's creation." Mr. Fletcher looks at his daughter. "We have to wait. Have faith."

Susan's hand finds Jake's, squeezing hard. Another wave of pain ripples through her. She closes her eyes.

Jake's mouth opens. Closes. Everything he's stood for in Dr. Brenner's class, every argument he's made about life beginning at conception, the March for Life he and Susan attended together just over a year ago–all of it feels like it's happening in a different world, one where Susan isn't gray-faced and terrified.

Dr. Blaine glances at her watch. Two more doctors had refused positions at City Memorial last month. One moved to California. The other quit practicing entirely. Even with the state's "exemption" for ectopic pregnancies, it wasn't really an exemption—it was an affirmative defense. Meaning she could still be arrested, still face prosecution, still have to prove in court that her medical judgment was correct. Up to 99 years in prison if the local prosecutor disagreed.

She thinks about the woman last month who nearly bled to death after three days of waiting. The one who lost 75% of her ovary. The Republican congresswoman from the Pro-Life Caucus who'd had to fight her own hospital's lawyers while experiencing an ectopic pregnancy.

She meets each of their eyes in turn. "I need to be very clear. This pregnancy cannot result in a live birth. The fallopian tube will rupture. When it does, Susan will bleed internally. I've already seen three women this year nearly die from delayed treatment. One lost her tube entirely." She pauses. "I could lose my license for saying this before getting legal clearance, but I cannot in good conscience stay silent…"

Mrs. Fletcher and Mr. Fletcher join her, their deep voice harmonizing with hers in ancient rhythms. Susan squeezes Jake's hand, her nails digging in as another pain hits.

Dr. Blaine steps away to make calls. Not just to legal. To colleagues in California, New York, anywhere that might take her after this. How many more cases before she quits too? Before another rural hospital closes, another doctor leaves, another patient faces this impossible choice alone…?

Jake sits in silence, watching Susan's face contort with pain. The Fletchers' prayers rise and fall in ancient rhythms. The crucifix on Susan's necklace catches the fluorescent light.

He thinks of Washington. Last January. Snow biting their cheeks. Fifty thousand people marching. A speaker saying "We will march until abortion is unthinkable." He'd believed it. Susan had squeezed his hand hard enough to bruise.

He's never thought about what comes after "unthinkable." What you do when the thing you wanted to prevent is the only thing that saves her life.

"Jake? Mom? Dad?" Susan's voice is small, scared. "What do we do?"