Tense and Release
My pager goes off. OR 10 it reads in fluorescent green letters.
When I arrive at the operating room, the OB is poised with a scalpel, ready to cut.
“Pediatrics is here,” says the scrub nurse in charge of the operating table.
“Pedi is here,” the OB echoes, “Time to go.” He makes the first cut. In just a few minutes, a baby will be born. I turn to my station, a baby-sized hospital bed with a warming light that is already turned on and drawers holding everything I might need in case the baby requires resuscitation.
Standing by the baby warmer is Denise, the nurse from the neonatal intensive care unit, or NICU. She’s an experienced hand whom I’ve worked with before. “Full term, repeat section, normal labs,” she says, shorthanding to me that this pregnancy has been unremarkable and the C-section is routine.
This should be an easy one.
I pick up the bag and mask used to pump air into a baby’s lungs if he is not breathing, and press the mask against the heel of my hand, testing the pressure. I check the tube I use to suction blood, meconium, and amniotic fluid from a baby’s mouth, watching the pressure gauge on that as well. I open and close the laryngoscope, the instrument I use to place a breathing tube, and check that we have the correct size tube in the drawer.
“Everything’s good,” Denise says impatiently.
“I need to check it all myself,” I say, garnering a haughty look from a nurse who has thirty years’ experience on me. “It’s a good habit,” I insist, and her face softens. She has worked with enough residents – trainees – in pediatrics to know that even two years in, we are still working to develop our good habits.
I stand on my tiptoes and try to see what’s going on in the surgery.
“Uterus,” the scrub nurse says as the womb is opened, and a few seconds later I see a baby’s head emerge from the woman’s big belly. This part always startles me. The baby isn’t born yet, so he’s still blue, eyes closed, not making any sound, until the OB tugs him free and he takes his first breath. For a second or two in every C-section delivery the androgynous baby head just hovers over the mother’s abdomen, flopping from side to side as the OB reaches in to free the shoulders.
Finally the OB wiggles the baby free, and I see the tiny feet emerge.
No crying. Not good.
Denise starts the timer that tracks the seconds since birth. If this baby doesn’t start breathing on his own in thirty seconds, we’ll start delivering breaths through the bag and mask. We’ll check his breathing every thirty to sixty seconds, escalating care if he doesn’t perk up. A breathing tube. CPR. IV lines, labs, medications.
I run through the algorithm in my head. My shoulders tense.
After the sharp click of the umbilical clamps, the baby is unceremoniously dropped onto the warmer. He is a she, and she is still blue. Blue as a squid, as the nurses say.
The baby nurse and I start rubbing Baby Girl’s back and feet vigorously, trying to wake her up. I use a suction bulb to get a scant amount of fluid out of her mouth and nose.
“Come on, sweet pea,” I murmur under my breath tensely. “You’re in the world now.”
She’s breathing, but shallowly and infrequently; this won’t be enough.
“Heart rate is seventy,” Denise says, her fingers on the baby’s umbilical cord. Normal is over one hundred.
Thirty seconds flash by on the timer, and I suction her mouth again. I pick up the bag, fitting the tiny mask over her mouth and nose. Carefully, I puff a breath into her lungs, and her chest rises. Forty-five seconds.
I give a few more breaths, and we pass the one-minute mark.
“Wake up, baby,” I continue muttering, my level of anxiety rising a little. She’s still blue, her heart rate is still too slow, her arms and legs are akimbo and unmoving. I can’t see anything except the baby, her blue chest rising, her bald head sticky with blood and amniotic fluid. Eyes closed. Come on, baby. Come on.
I breathe for her, attempt to keep my own breaths slow and steady. I adjust the mask. I ask if someone can listen for breath sounds; they do, and confirm that I’m moving air into the baby’s lungs with each gentle squeeze of the bag.
And then through the mask I see her tiny face crunch into an angry look and she emits a weak, muffled cry. I lift the mask slightly, and she cries in earnest. More seconds pass; we rub her back and flick her feet. Her chest and belly start to pink up; the beeping of the heart rate monitor that Denise has attached to her foot increases in speed to a normal range.
I sigh, “All right, baby, good job.”
The father has appeared over my shoulder, looking anxious. “She didn’t cry right away, that’s bad right?” he says, peering at his new baby girl, who is now screaming her head off, arms and legs curled up and flailing, lips pink.
I move out of the way and put on my happy congratulatory pediatrician face, letting him get a full view of his daughter. “It just took her a minute to figure out that she was born, and we had to give her a little bit of help to breathe at first, but she’s doing great now. Does she have a name yet?”
He doesn’t seem to hear me as he touches his finger to his new daughter’s hand, and she curls her five fingers around its tip. This is only a reflex, but for him, she’s holding his hand for the first time.
Delivered at Midnight
The room is dungeon-like, and the bed is hard. I shut off the lights, and it’s pitch black — perfect for short bursts of unsettled sleep, which are all I’m allowed while I’m at work.
I’m on my delivery room rotation, a core part of my training in pediatrics. I’ve advanced to the point where I’m the first responder to middle-of-the-night deliveries, backed up by more experienced physicians if necessary. This is one of my favorite roles in the hospital, though it does make for sleepless nights.
It seems like it’s only moments after I shut my eyes when my pager sounds. The clock reads 12:04 a.m.
OR 10, unscheduled C-section.
Well duh it’s unscheduled, I think as I rub the sleep from my eyes.
When I arrive at the OR four or five minutes later, the room is strangely quiet. The surgeons are poised to cut, scalpel literally positioned above the mother’s swollen belly. My nurse isn’t here yet.
“Pedi is here,” the scrub nurse announces, and everyone is suddenly moving very fast.
It dawns on me then that an inexperienced nurse has paged me with unscheduled to mean emergency, which is why everyone looked so grave when I arrived. They think the baby is dying inside his mother for some reason I don’t know yet, and I was the holdup to get him out. My NICU nurse doubtlessly got the same page, which is why she isn’t here yet.
I notice a young woman in scrubs who is sitting out of the way — the nurse from obstetrics. I can only see her eyes through her OR garb; I don’t think I know her.
“Call for backup, now,” I say, pointing at her, and she pages the cadre of people — a neonatal specialist, a respiratory therapist, and my nurse, again — who are activated when I say those words.
But I need help here too. I look over the warmer; nothing is checked, nothing is set up. The blanket the baby should lie on is still neatly folded. Plastic encases all of my equipment, equipment that I will very shortly need. I feel panic rising in my throat, and my hands start to shake as I flip on the warmer with one hand and hastily open the blanket with the other.
I find the long cord that should attach to the oxygen apparatus on the wall. I’m struggling to untangle it when suddenly the baby is on the warmer, which is not yet warm.
It’s a boy, and he’s blue as a squid. He is also covered in meconium, the sticky tar-like substance babies pass when they stool in the first days of life. If a baby breathes it in before or during birth, it can damage his lungs and cause problems for his heart.
My hands are shaking in earnest now. I am fixated on the tiny human in front of me, unmoving, arms and legs splayed. My ears roar; everything looks too bright, the harsh OR lights failing to bring color to the baby’s gray skin, to the black meconium coating his body.
As quickly as I can, I suction some of the meconium out of the baby’s mouth using the suction bulb; I don’t get a lot, so hopefully there’s not a lot in there, but I can’t be sure.
I do my best to open the baby’s mouth and take a look with the laryngoscope before inserting the breathing tube. Once the tube is in place, I hold my left hand out toward the nurse. After two or three seconds, my hand is still empty, and I look up.
The nurse is looking at me blankly and I realize that she doesn’t know what I’m asking for; she’s never been in this kind of delivery before.
“The meconium aspirator,” I prompt her, turning my attention back to the baby. She snaps into action, unwrapping the aspirator and attaching it to the suction hose, handing it to me. I occlude the end with my thumb. Nothing.
“Turn on the suction. To eighty,” I say, struggling to keep the exasperation out of my voice.
My thumb, still over the opening on the suction device, feels pressure build behind it, and I attach the device to the breathing tube, drawing the tube slowly out of the baby’s mouth, watching it catch thick brown-black meconium on the way out. The baby remains limp, unmoving.
I glance up at the timer and realize no one has started it. I have no idea how long it has been. I also don’t know what the baby’s heart rate is, my primary way of assessing whether he’s getting better or worse.
I ask the nurse to turn the timer on and give me the ventilation bag and mask. She finally checks the heart rate; fifty beats per minute. Far too slow. The heart and lungs are linked; when a baby isn’t breathing, the heart slows down and will eventually stop. We must get him breathing.
I go through the familiar motions of fitting the tiny mask over the tiny face, hands still tremulous. I puff a little air into his lungs; there’s some resistance, but I think it goes in. I continue my puffs as the timer ticks the seconds by. I’ll do this for thirty seconds, and then recheck a heart rate.
The door to the OR opens, and finally my nurse arrives, quickly assesses the situation and takes up her position at the bedside. She checks the heart rate herself: 58. Rising, I think, but still too low.
Next, I do something I’ve never done before. “The heart rate is still below sixty,” I say, signaling to all the next step in the resuscitation algorithm. “We need to start chest compressions.” We’re doing full-on CPR now.
The NICU nurse wraps her hands around the baby’s chest and uses the strength of her thumbs to compress the delicate sternum twice for every one breath I administer. Pump-pump-breathe. Pump-pump-breathe.
As I am about to ask for another check of the heart rate, the OR door swings open again, and I see the neonatologist walk in and absorb the energy around the warming table. She takes the bag and mask out of my hands and pushes me aside; this is her patient now.
She reorganizes the table, stopping the chest compressions. Expertly, she re-suctions the mouth with aggressive, confident motions I have not yet developed, but will remember forever, and she gets more of the sticky black substance out. She does it once more, and then fits the mask back over the baby’s face. She begins again.
The heart rate rises over the magical sixty, and continues to rise. I stand, hands limp at my sides, as the nurses on either side of the baby rub his back and flick his feet.
I look at the timer. Six minutes. Seven.
He begins to curl up his arms and legs, his face scrunches into a cry. His skin turns pink.
We’ve been hearing about these twins for days, as their mother has been observed in the hospital by her obstetrician, threatening to go into labor at any moment. Finally tonight we got a call from the OB saying that delivery is impending.
The warning gives us a chance to assemble our team. After separating ourselves into two resuscitation teams, with a doctor, a NICU nurse and a respiratory therapist on each, we troop down to the room where the mother is laboring.
I set up my station, preparing to receive Twin A and vaguely listening to what’s going on behind me. I can’t see the mother’s face, but I hear her wailing through contractions, and the encouraging words of the people holding her hands and surrounding her.
I feel my attending neonatologist, ultimately responsible for the outcome of this delivery, hovering over my shoulder.
“So this is a thirty-three weeker, so the baby should be ok,” he says as I turn to face him. He means that the baby probably will need only minimal intervention to support his breathing, which is the primary concern for infants born at this age. “But twins can be a little less mature than their gestational age, so he might need some help.”
“So just dry and stimulate him like normal, and see what he can do.” He gives me a jovial smile and walks away. I turn back to checking the warmer just as there’s an announcement over the hubbub behind me that, “Head of Baby A is out!”
We’re on. A few more seconds and suddenly a tiny human practically bounces onto the warmer in front of me as the OB drops her off and rushes back to attend to Baby B, whom it seems will be arriving imminently.
I pick up a suction bulb and poise it over Baby Girl’s face, but she is squalling like a banshee already, tiny translucent hands waving in protest at being forced out of her cozy cocoon, into the bright, bad world. I put it down again and check the timer — not even a minute has passed. All is well. We rub her dry. I check her reflexes and examine her tiny body. She has the fine, soft hair that covers babies born this early. She has next to no fat and can’t suck on my finger yet, so she’ll need to live in a temperature-controlled plastic box called an isolette, and likely feed through a tube for a while. Once she gets over the shock of being born she may have trouble sustaining her breathing and need a little help, but for now she’s breathing great. She’s doing fine.
I idly glance over my shoulder to see if Baby B has arrived yet. It seems he has, and people seem stressed in that corner of the room. The physician’s back is to me, but she is leaning forward with her shoulders hunched and elbows close to her sides, peering into the baby’s face. I recognize her stance as the one adopted when placing a very small breathing tube in a very tiny airway.
A nurse speaks quietly to the father, who hovers behind the medical team for Baby B, explaining what the breathing tube is for. I hope that someone has also explained this to the mother, still lying in the bed, delivering the placenta.
“Ready to go?” someone asks behind me. While I’ve been distracted, the baby on my warming table has been wrapped, weighed and measured. She’s ready to be placed in an isolette, taken to see her mother briefly and then brought upstairs to her temporary home in the NICU.
We wheel the baby, in her box, past her father.
“You can come with us to the NICU, or stay here, whichever you like,” one of the nurses offers. The furrow in his brow deepens as his gaze bounces between the hubbub around his suffering new son and the face of his exhausted wife. She is peering back at him with a distressed look on her face, as the OB continues to work over her.
“I’ll stay here,” he says, and after glancing down for a moment at his thriving baby daughter, turns his attention back to Baby B.
We bring Baby A to meet her mother, and then whisk her out of the room. As the OR door swings shut behind us, I avoid looking back at her dad.
No Breakfast in Bed
A nurse hands me a list and I scan down it. Epinephrine, for increasing the heart rate and blood pressure when the heart isn’t pumping. Midazolam, for agitation. Vecuronium, for paralyzing the patient so he doesn’t struggle against the breathing tube. Dopamine, to help his heart pump. Dobutamine, same. Cryoprecipitate, to keep him from bleeding. Sodium. Calcium. Potassium.
I enter the medications, one by one, that we have administered in the last several hours, so that the hospital will have a record, for billing and posterity, of what we had to do to keep this baby alive.
As I punch them in, ticking them off the list, I review the events of the day in my head. Gave epi. Gave vec. Started a dopa drip. Epi again. Started a continuous epi drip. Started dobuta. Went down on the epi.
Why did they wait so long to come in? Who was with them, who was telling them to wait? That waiting was the best thing for their baby?
I continue down the list. More epi. Labs came back — needed sodium, calcium and potassium. I entered those already, so I can skip them.
He was born through thick meconium after more than a day of labor at home, stressing both mom and baby. When they finally arrived he was an emergency C-section. He emerged blue and stayed that way. He had sucked the meconium down into his lungs, damaging them, and he might have had an infection to boot. He was taken directly to the NICU, and then when he grew too sick for even the NICU to handle, they transferred him to the medical ICU, where we can give a higher level of life support if needed.
Even with all our medicines we couldn’t get the baby’s heart to pump well enough, so we decided to hook him up to a machine that would filter and oxygenate his blood until his body could do it for him. It’s the highest form of support that we have.
The surgeons came, and we needed a lot more epi then, as they carefully cut into the largest veins and arteries in his body.
His blood started flowing through the machine. His labs improved.
His mother will be arriving at the ICU soon, allowed to leave her hospital bed temporarily to visit her new baby boy, whom she had hoped to have at home. They were supposed to be cuddling this morning over breakfast in bed.
For a moment I allow myself to imagine this scene, and wonder what they would be doing now, if different choices had been made. If they had come sooner, or been nearer. If they had had a doctor with them, or a nurse midwife, to say that things had gone on too long, that they were getting more dangerous and the baby needed to come out.
My chest and throat tighten. I look down, and stop typing.
Over the computer, my attention snaps up as someone calls my name. I need to change the dose on the epi.
Cause for Joy
Initially, I breeze by the security desk in front of the elevators, but then reconsider. I should do this officially.
“I’m here to visit a patient. Ellen Chung,” I say, leaning my crossed arms on the desk.
I unclip my hospital ID from my waistband and hand it over. She copies my name onto a visitor badge, which I stick on, and the guard smiles and waves me through merrily.
“Go on up!”
Ellen texted me that Maura had been born while I was on an overnight shift last night, so I’ve decided to visit on my way home from work. I’ve scrubbed my hands and changed my clothes, so as not to expose their brand new baby to all the germs I picked up last night in the emergency room.
I hear a tiny newborn cry from outside the door, and knock.
As I walk in, Ellen is holding her new daughter to her breast, where Maura hasn’t quite figured out where the nipple is. Ellen is trying to show her, squashing her tiny face into her chest and stroking her cheek.
“Hi!” I lean over the bed to give Ellen a hug, and then walk over to the other side of the room to hug her husband, Kevin. As Kevin sits back down in the recliner by the bed and turns his attention back to his wife and new infant daughter, a grin settles across his face, and stays.
“So how was the delivery?” I ask, sitting down at the foot of the bed. “Did they call pedi?” There’s a chance that someone we know was at the delivery, as we’re all in training together in this hospital. Ellen will be a pediatric endocrinologist, and Kevin will be a pediatric neurologist.
“No… She cried,” Kevin says. “It was fine.”
I hold my arms out for the baby, whom Ellen hands over carefully and I lay on my lap, my cupped hands supporting her head, her tiny feet kicking against my abdomen.
Her complexion is rosy and translucent, a combination of her mother’s smooth olive and her father’s mildly ruddy Irish. She has none of the usual baby rashes that we get called to diagnose in the nursery, nor any of the filmy white vernix you see on babies born slightly early. She opens her eyes, which are large and deep blue; they won’t develop their true color for weeks. Her features are delicate, and her hair is thick and dark, like her mother’s, sticking out every which way. She is striking. She is totally, utterly healthy.
She looks at me, and I move my face closer so that she can make out my features; babies at this age can only see about eight inches, just the distance from the crook of their mother’s arm to her face when they’re feeding. She opens her mouth and squawks, and I squawk back at her.
After a couple minutes of this primordial back-and-forth, I turn my attention back to her parents, who have been taking pictures of us. “So…what have you guys been up to?” I ask, bouncing Maura gently on my lap.
“Not much,” Ellen replies. She juts her chin toward Kevin. “He’s been testing her reflexes.”
“They’re all intact!” Kevin remarks jovially, and we laugh. Neurology joke, and a lame one.
We fall silent for a moment. Ellen sits in her hospital bed, tired but calm, watching me play with her new baby. Kevin still has that wide smile on, leaning back in his chair, gaze moving from wife to daughter. Maura’s hand is poking out of her blanket, and, absently, I place my index finger on her palm, testing her grasp reflex myself. Her five fingers curl around mine.
* * *
Names of patients, doctors and nurses have been changed to protect confidentiality.