Thump-thump. Thump-thump.

The sound of Isabel’s heartbeat, pulsing through the arch of an ear smashed down against her pillow, woke her up. Eyes blinking away fading sleep, she stretched her arm out towards the cold, other half of her bed. Her fingers curled around her phone. She brought it up to her face.

9:24 AM.

She sighed. The girls were gone by now. Lizette and Jazmin, 13 and 8, would be at school. Her eldest, Sofia, would be serving up breakfast at the café during her free period in the morning. Sofia would have been in a rush to get to work on time, but Isabel was sure she had seen her sisters off to the school bus after making their breakfasts and packing their lunches before she’d left.

Isabel’s stomach gurgled at the thought of food. She wasn’t sure if she was hungry or nauseous. Dragging herself out of bed, she felt her stomach lurch.

Nauseous. Definitely nauseous.

In none of her past pregnancies had she experienced such morning sickness. Perhaps it was her age. Pushing 40, she felt she was past her time for bearing children. Her body seemed to be punishing her every morning for pulling it out of early retirement. Previously content to steadily tuck away fat in her hips and thighs without the aid of a pregnancy, her body had been slowing down its metabolic turbines for a gradual downward cruise into the valley of middle age.

Bleccchhhhhhh.

She emptied her guts into the toilet. Her knees, on the hard tiles, complained after supporting her weight for only five minutes. If they couldn’t take the pressure in the first few weeks of pregnancy, she couldn’t imagine how they would manage later on. Isabel rose slowly, the rusting hydraulics in her legs groaning. She rubbed the construction zone that was her belly. The baby was still buried deep within. She wouldn’t show for months, but the way this tiny thing was making its presence known was surely a sign it would be a big troublemaker.

Probably another girl then, she thought to herself as she tiptoed her way over Jazmin’s toys and Lizette’s sketchings scattered on the living room floor. Only Sofia’s presence in the home was conspicuous. It’s like she’s already gone, Isabel thought sadly. The house is going to feel empty without her.

Isabel looked at the clock over the stove. 9:33 AM. She still had an hour before she had to leave for her first prenatal appointment. As she wandered the kitchen searching for something that wouldn’t make her throw up, she called Sofia.

“What do you want Mamá?” Sofia asked as way of greeting.

“I just want to hear your voice baby,” Isabel answered. She yawned. “Thanks for getting the girls ready for school.”

“No problem,” her daughter said.

Isabel couldn’t hear the clinks and orders being yelled in the background that meant she was still at work. “Heading back to the high school now?”

“Yes,” Sofia said. Isabel heard the car door opening, Sofia sitting down and strapping in, and then the engine coming to life.

“Sorry. I hope you weren’t late for work. I was so exhausted.”

“It’s okay Mamá. I know the pregnancy has been tough. Everything with the familia isn’t helping either. You need your rest.”

At the mention of her family in Ecuador, Isabel felt the deadweight of grief that had settled in her chest over the past two weeks sink just a little deeper. But Sofia’s softened tones raised her spirits. “I don’t know what I’m going to do when you’re at college.”

Sofia snorted. “Maybe you can ask Nikesh to help out, since it’s his kid and everything.”

Isabel felt a cramp of discomfort, but not from the baby in her belly—rather, the one on the phone. “Nikesh does a lot for us Sofia,” Isabel said wearily. “I know it’s weird for you, but I don’t think I could have gone on caring for you three by myself for much longer. And…I needed someone for myself too.”

She listened to the sound of the road through the phone, cars rushing by and honking. At last, Sofia said, “I know Mamá. I’m sorry.”

“Don’t be,” Isabel said. “Just…think about going to college somewhere closer to home.”

Sofia sighed in exasperation. “Mamá! You’re the one who left Ecuador for college. At least I’ll still be in the same country.  Don’t guilt me like that. Don’t make me feel selfish. Going to Columbia would be good for all of us in the long run.” The sound of the car ceased suddenly. Isabel heard the click of the seatbelt and the smack of the door. Then Sofia said, “I gotta go to class Mamá.” She sighed. “I hope your appointment goes okay.”

“Thanks baby,” Isabel said. “Have a good day.”

When Isabel set the phone on the counter, the echoes of their conversation continued reverberating. Don’t guilt me. Don’t make me feel selfish. How could Isabel subject her daughter to the same mental stresses she’d experienced herself?

Twenty years ago she’d left her home, Latacunga, to study civil engineering in the US. Her grandfather had always dreamed of sending his children to study abroad. When she won the scholarship, her Abuelo Victor ensured the entire town knew. From his pulpit at the cathedral, he asked everyone to pray for her success. The proud townspeople celebrated and wished her well.

However, not everyone was so ecstatic. Her older sister, Penelope, had congratulated her by saying, “Good for you. You always said you wanted to leave this place.” When Isabel had been hired at her firm, Penelope had said, “I guess you’ll move into a big house now. Remember how we shared a room with four other girls when we were growing up?” When Isabel had sent money home after the volcano next to Latacunga—Cotopaxi—caused another one of its earthquakes to destroy part of the town, Penelope had said, “You must feel like a saint for helping us out.”

When the COVID-19 pandemic descended and the world went into quarantine, she said, “Now you’ll visit us even less than you usually do. I hope this pandemic passes soon, otherwise your girls will be so American they won’t even remember how to speak Spanish.” When the vaccine was developed and Isabel urged everyone (Abuelo especially) to take the shot, Penelope asked, “How would you know what’s best for us when you’re not even here for us?”

And when Penelope called her two weeks ago to say that Abuelo Victor had passed away from COVID, she said flatly, “You didn’t come to say good-bye.”

Guilty. Selfish. Guilty. Selfish. Thump-thump. Thump-thump. Thump-thump.

Isabel’s heart could only handle so much. She felt like she’d betrayed her sister by following her dreams, like she’d betrayed her daughters by dating Nikesh, and like she’d betrayed her grandfather by not coming to see him in his final days. Isabel locked up all this pain inside her heart because she had to be strong. She had to maintain her composure for her daughters. Not a single tear would she allow to fall from her eyes. She had to keep pushing herself forward through work, through pregnancy, through life; all for them, even as her heart continued swelling with all the pain threatening to burst it apart.

“Isabel,” Abuelo Victor said to her, just before she was about to board the flight to America all those years ago. Her face was wet with tears, her breast brimming with the fear and doubt that accompanies the traveler leaving home. Not yet on the plane, she was already missing her familia, and wondered whether she should stay. But Abuelo Victor’s voice cut through her emotions. He cupped the sides of her face into his soft hands. When he spoke, it was with a gentle tone so different from his impassioned sermons. “You are about to face so many trials. God will test your faith and your patience. So, I want you to always remember: listen to your heart.”

Through the mess of tears, Isabel’s chuckle came out as a snort. “That’s so cliché of you Abuelo.”

His forehead furrowed, an expression the parishioners knew well to mean that fire and brimstone hotter than anything Cotopaxi could create were coming their way. “Let me finish Child!” he thundered. But then his face softened. He smiled and winked, getting her to laugh.

He placed a palm on her chest. “Listen. Listen. Literally listen to your heart. You hear that?” He puffed out his cheeks. “Thump-thump, thump- thump.”

He smiled. “God placed a miracle inside you. He wound it up and now it beats on its own. You don’t have to see it to make sure it’s working. So, whenever you wonder where God has gone, just stop and listen. You’ll hear the sound of His miracle singing inside you.”

Isabel wanted these loving words to be the last she remembered of his voice. But two weeks ago, all she had heard over the phone were his ragged gasps as he struggled to breathe in life. She didn’t have the courage to video call him. Seeing him sick would have shattered her composure. All the same, the echoes of those breaths had haunted her for nights.

Her phone buzzed. 9:50 AM. She had ten minutes to make her appointment on time. If she felt her hasty attire of sweatshirt and joggers would be underdressing, she was promptly comforted when she was handed a gown to change into. And there was no need to worry about being late, as the resident himself entered the exam room at least forty-five minutes after her.

“I’m sorry, I’m sorry,” he said as a greeting. It struck Isabel as ironic that someone so late could look like they’d entered medical school too early. Probably only a few years older than Sofia, the resident sat down and started fumbling with the computer in the frantic manner of someone still learning what the hell they were doing. Yet, he introduced himself as “doctor” and smiled with enthusiasm and energy.

“Congratulations on your pregnancy!” he said, then winced and asked apologetically, “This is a desired pregnancy, right?”

Isabel shrugged her shoulders. “It was definitely unexpected, but yes, I’m choosing to continue.”

“Okay,” the young doctor replied. “Either way, I would respect your choice. I understand that circumstances aren’t always ideal for a child. I see my job as being a guide for you towards achieving your best quality of life.” He typed a sentence, then continued “Today is going to be about getting to know you. We’ll be seeing each other a lot throughout your pregnancy, so I want to make sure I have all the information I need to make sure both you and baby are healthy. That said, when was your last menstrual period?”

With a sheepish smile, Isabel said, “I don’t know.”

The resident waved his hand in the air. “No problem. We can do a bedside ultrasound today and get an estimate.” Isabel nodded, feeling a flutter of excitement. Maybe if she saw the face of her new loved one, she wouldn’t curse it every morning for all the nausea it caused.

“So, tell me about yourself. Where are you from, what do you do?”

“I’m from Ecuador originally,” Isabel replied. “I came to the States to study engineering, and then I moved here after my daughter Sofia was born…” As she answered all the resident’s questions about her medical history, she noticed that despite typing his notes, he continued to smile and nod throughout. At last, he asked if she was having any difficulties with the pregnancy. She replied with a melodramatic sigh, “Morning sickness!” He laughed sympathetically. “I can’t understand it Doctor! This never happened in any of my previous pregnancies.”

“Every pregnancy is different,” he said with an apologetic shrug. “Sounds like you have a troublemaker in there.”

She shook her finger in the air. “No, no! I don’t need any more trouble in my life.”

The resident stood up. “Let me go get the ultrasound. Afterwards we can talk about some things we can try to calm down that little hot head in there,” he said, pointing to her stomach. “He must have a lot of Ecuadorean blood in him. Didn’t you mention earlier you grew up by a volcano?” Isabel nodded and laughed. She was happy he had remembered. The resident excused himself from the room, then soon returned rolling in an ultrasound machine.

“I’ve always wondered why they call it an ultra-sound?” she asked, emphasizing the parts of the compound word.

As the resident helped her lay back on the exam table, he explained, “The ultrasound probe emits sound waves that bounce off of the objects they’re directed at. Whatever bounces back is interpreted as an image.” The resident cracked a wide grin. “Don’t ask me to explain anything more than that. I just know how to turn the thing on and off and point it in the right direction.”

Isabel winced as he squirted some cold gel onto her belly. He gently placed the probe down on her skin. The resident stared at the monitor intensely while he swept the probe across her belly, searching. “All I do know,” he said, “is that seeing what we can’t with only what we can hear has to be something of a miracle.”

“What?” Isabel asked softly, taken aback. She turned her attention from the screen to his face.

The resident hadn’t heard her. He continued sliding the probe across her belly. Then, his face relaxed and he smiled. “There’s the uterus. And there’s…” His voice cut off. He looked confused.

The weight of sadness that had been pulling down on her heart suddenly yanked on it again. Part of her had anticipated this. She knew the risks of someone her age having a baby. But it wasn’t until this moment, when the threat of losing it became real, that she realized she did want to have the baby. “Is there—is there no heartbeat?” she asked, her voice thin.

The resident turned to face her. Now he was the one smiling sheepishly. “Actually…there are two heartbeats.”

“What?!” Isabel exclaimed. She almost leapt out of bed to look at the screen, but then of course the image disappeared. Laying back down, she herself grabbed the resident’s hand to jam the probe back to the place it had been before. The resident used his other hand to show Isabel two distinct bubbles on the screen. Sure enough, there were two hearts  beating away on their own inside her.

The images on the screen started to blur. Isabel didn’t understand. Was something wrong with the machine? The probe hadn’t moved position.

A second later, Isabel felt something hot and wet streaking down her cheek, and she realized that tears in her eyes were blurring her sight. And once the tears broke through the barriers she’d built, they started flooding out of her. All the feelings she had been stuffing inside her now burst to the surface. She cried like the volcano Cotopaxi; not when it threw one of its tantrums and shook the townspeople at night, but like the volcano when it oozed out hot magma in silence.

The resident tapped a button on the machine to freeze the image, another to print it for her. He wiped the gel from her stomach and helped her slowly sit up. Handing her a box of tissues from the cabinet, he leaned against a wall and waited.

After what felt like fifteen minutes, Isabel felt her tears subsiding. She wiped away the last few and said, “I’m sorry. I found out recently that my grandfather in Ecuador passed away from COVID. I never got to see him before he died.” The resident nodded his head and only went hmmm as a way of expressing his empathy. Isabel continued, “I wasn’t expecting to get pregnant. I definitely wasn’t expecting to have twins. Seeing their hearts…”

Her voice faded away. The resident looked into her eyes and said, “It’s a lot to process.” She nodded.

“I know he would have been happy to hear about them. I know he is happy for me,” Isabel said, rubbing her belly. “My grandfather used to say that we need death for life to grow. He was a pastor in our town and when Cotopaxi would erupt, the townspeople would ask him for guidance. He would always remind them that the mudflows from the volcano destroying our homes were making fertile fields to feed us for generations.”

The resident smiled and said, “I don’t know if this is part of my job as a doctor, but can I share something from my own spiritual background?” Isabel nodded. The resident continued, “What your grandfather used to say reminded me of something my community says in times of hardship: ‘God does not test us with more than what we can bear. Surely in difficulty there is ease.’” He handed her the printed images of her new babies.

For the first time in weeks, Isabel felt her heart relax. The pain was still there of course. After years of building up, it would take more than a few tears to heal. But like the fields tilled by Cotopaxi, she now felt some peace and some hope for the future to come. She touched her fingers to the pictures of her twins.

“Well, now we know the reason for the bad morning sickness!” the resident said. He gave her a reassuring look. “Ms. Vincente Alarcón, before we talk about bloodwork and treatments for your nausea, I want to thank you for sharing about yourself and how you’ve been feeling. I can’t care for you if I don’t know you. And what I know now is that you a very resilient person who has already raised three healthy girls. You’re going to get through this too.”

By the time Isabel stepped out of the clinic, it was well past noon. The brightness of the day caused her to close her eyes and suddenly the sound of the full world filled her ears. She listened to the rustling of leaves drying in the trees, the intermittent shyoo of cars on the road, and the incomprehensible conversations of people in the distance.

Closer now, Isabel listened to only herself. Thump-thump. Thump-thump. Her abuelo had called it a miracle, the heart giving her life and the will to go on. Now there were two more miracles for her to listen to.

Go on, go on, they all seemed to say. Thump-thump, thump-thump.

“Good-bye Abuelo,” she whispered to the sky, knowing full well in her heart he would always be close by.

Tajwar Taher is a Family Medicine Resident at Rutgers-RWJ University Hospital Somerset. After frightening his family by studying English Literature at the University of Washington, he completed medical school at Oregon Health and Science University. He hopes to integrate lifestyle and behavioral health into his medical practice, with an attention to structural determinants of health. In his spare time he enjoys volunteering at local masjids, scrutinizing both blockbuster and arthouse films, and cooking up puns for his food blog on Instagram @drs_without_horsdoeuvres.