Jake is ladling red sauce onto his noodles. His ladle stops in mid air. He blanches. White as a sheet, and locks onto Grandma Margaret. She looks to him. Then looks over the top of her glasses at Jake’s mother. As soon as Jake’s mother sees the over-the-glasses look she adds, “Oh, never mind, we can talk about it later.” 

     Ladle still suspended, eyes still on Grandma, Jake says, “I didn’t’ know you had another cardiologist appointment.” His voice is weaving between his boy and man vocal cords. He pushes his glasses back with his non-ladle hand. 

     “No, let’s not wait until later,” Grandma says. She nods toward Jake. “Now that we have brought up the subject, let’s just lay it flat out on the table. But first, because it’s more good news than not, let’s get served up and then I will tell what Dr. Kraus had to say.”

     It takes a moment for Jake to take his ladle hand off pause. The table is quiet, even the girls, as all in their turn, pass around noodles and sauce and grated cheese and garlic bread and milk. When they have finished Jake is the first to speak, “Okay Grandma, what did he say?”

     “First, it turns out that, at 76, I am now officially the oldest living person with a caged ball still clicking in my heart. This prosthesis has served me since I was 16 years old. Chloe, are you paying attention? Can you tell us how many years that is?”

     Both little girls’ eyes move as though they are reading calculations in the air. Chloe responds first, then a second later Zoe chimes in, ”Sixty years.” 

     “Yes, that’s right, sixty years. All the others have either died or switched out their old caged ball for the newer, quieter model.” Here she lays the flat of her hand over her chest, “I have the only one left clicking. It’s time for a change. Dr. Kraus recommends I switch to what he calls a biologic model.”

     Jake leans forward, “Is the one you have not working right?” 

     “Actually it is working just fine. The problem is that it has started to come loose.” 

     The family has stops eating and instead is focused on the conversation. 

     Jake’s voice slides into his higher register. “Coming loose? What do you mean coming loose?”

     “The bottom of the cage has a ring on it. That is the part that is sewn into the valve and it is coming loose and leaking.”

     “Ew,” Zoe whines, “It’s actually sewn into you, like with a needle and thread?”

     “Yes, I don’t feel it though. It’s not like it hurts.”

     “But I bet that’s why you’ve been too tired to climb the stairs sometimes,” Jake says. 

     “Yes, that could be. But I’m also as old as dirt.”  

     Jake’s mother says, “Seventy-six is not ‘as old as dirt.’ The president of The United States has ten years on you. Plus, your mother lived to be 100 and great-aunt Irma is 101.” 

     Jake’s father asks, “Margaret, I’m curious, how is it that your ball-and-cage has lasted so long?”

     “Like Janie said, I have genetics on my side. I have very little atherosclerosis. My blood vessels are pliant and strong. Plus I think the only time I have ever missed even one dose of my medication was on that blessed day that Janie was born.” She looks toward her daughter, Janie. And although Margaret is smiling, there are tears in her eyes. “And very good luck,” she adds. “It turns out I am the luckiest person in the world.”

     Jake’s father asks, “This won’t have to be open-heart surgery, right? I mean I’ve been reading that the new biologics can be placed without. . . .”

     Jake’s mother interrupts her husband with a loud throat clearing, “Ahem”

     “It’s alright,” Margaret says. “It will have to be open-heart because the caged ball needs to be removed. I have no problem with that. It is a small price to pay to avoid having a stroke. That’s the one thing I do not want, is a stroke. Plus, after it’s done, no more blood thinners for me. I can do this.” She looks around the table, “We can do this.”

     “Grandma,” Chloe asks. “What does biologic mean.”

     “It means, instead of metal I will have tissue.”

     “Tissue? You mean like toilet paper?” The family laughs. A little too loud. A little too long. All except for one. Jake is not laughing. 

     “No, not like toilet paper,” Grandma responds. This will be tissue from one of God’s creatures—probably either a pig or a cow.” 

     “But will it click?” Chloe asks?

     “Silly. Of course it will click.” Zoe says. “You don’t expect it to moo or oink, right?The family’s laugh is a little too quiet. A little too short. 

     The twins have heard the click of Grandma’s heart for all of their lives. When they were born, Grandma Margaret retired from her philosophy professorship at University of Wisconsin and moved her clicking heart up to Alaska to live with the family. She came, not so much to help with the twins, but to help with Jake. He was eight years old and afraid to sleep. 

     Since he’d been a baby, Jake had had problems with sleep—restless and awake, then unpredictably falling asleep. He had begun talking in his sleep by age two, then walking in his sleep by age three. At five he had gone outdoors at 2:am and 3 below. Jake’s father had freaked out. ”Thank God for the Peterson’s fucking yapping dog,” he had yelled. There had been neurology visits ending in Jake’s dad setting up motion sensors so he could be alerted to Jake’s sleep walking. The next few years Jake had improved and episodes became rare. Then all of a sudden, out of the blue, at eight, when his mother was pregnant with twins, Jake had started having sleep paralysis. He’d awaken, and already afraid, be unable to move. Although panicked he could not call for help. Afraid to sleep, Jake had tried to keep himself awake. His health had deteriorated. 

     Back to the neurologist. Before trying meds, Jake’s parents decided to take the pediatrician’s advice and see a psychiatrist. That led to the decision that Margaret retire early and come to help. The clicking of Grandma’s caged ball was a lucky accident. First, Dr. Waldt helped Jake learn how slow his breathing, relax, then focus on moving one body part at a time, beginning with his index fingers. Waldt used the clicking of Margaret’s heart as cue control. Jake’s bed was changed to a queen size and Grandma slept with him. When he awoke, in a panic and paralyzed, he could hear the slide-click of her heart. This was his cue to slow his breathing, relax, and begin progressive, micro movements until the paralysis passed. It took only a month for Jake to lose his fear of sleeping. Another month and Grandma moved to a cot beside his bed, then across the room, then to the hallway, and finally to her own bedroom across the hall. Until now, these events, so long in the past, were all but forgotten by the family. Except, of course for Jake, who had begun having nightmares. Jake had not told anyone, not even Grandma, about the nightmares.

     He thought he could handle them on his own. He remembered the skills Dr. Waldt had taught him. More importantly, he remembered Dr Waldt’s prediction. Jake knew that Grandma remembered it too, because for the last year or two she would ask after his sleep and even asked his father to reinstall the motion sensors. Just to make sure. Just to make sure. All those years ago Dr. Waldt had explained that the parasomnias had nothing to do with the twins, or anything that Jake thought or did. These sleep disturbances have to do with normal changes in the brain. The brain does not grow evenly over time. It has bursts of growth, just like the body does. Waldt predicted the next brain growth spurt would be in Jake’s early adolescence. Hormonal changes might well wake up Jake’s sleep problems. The paralysis might even return. But, no worries, because the same techniques would work again. 

     One part of Jake has been assuming that the nightmares are part of the many changes he is experiencing— his changing voice, this summer’s growth spurt and even his sexual fantasies. Just last week his dad had coached him in shaving. That’s one part of him. Another part of him lives in low level dread and on the edge of panic. 

     Jake places his hands flat on the table and leans forward. “Yeah, but the new valve won’t click, right? Will it click, Grandma?” 

    “No, it will not click,” Grandma says. “No mooing, oinking or clicking.”

     “How will you know your heart is working?” Zoe asks. 

     “Same as yours. When you hold your ear against someone’s chest you can hear a quiet ‘lub dub’. My heart will sound just like yours.” 

     Jake slides his hands toward him until his fingers are on the edge of the table. He pushes down with the palms of his hands. Leaning in, he pushing hard enough that his fingers to turn white. It’s as though he holds on and dangles from the edge of a cliff. “But Grandma, how will I sleep?” 

     She throws him a lifeline. “We have some time. By the time I have my surgery you will be ready. We will all be ready.”

     Jake leans back away from the table and removes his hands from the edge. “Okay,” he draws out the word, changing intonations, and blurring the distinction between statement and question. 

     She goes on, “You remember Dr Waldt, right?”

     “Oh, yeah.” Jake says.

     “Right, well he is still practicing. I talked with him. He is going to help. He has a plan. First we meet with him together and then you will meet with him by yourself for a few times.”

     “How will that help?”

     “I don’t know exactly. But Dr Kraus gave him a recording of my clicking heart. He’s going to use that somehow to get us ready.”     

     “When?” Jake asks pushing back his glasses. “When?”

   “Three weeks. Surgery will be in three weeks.”