Jodi Picoult - Small Great Things

“Start compressions,” Marie tells me.

This time I don’t waver. With two fingers, I push down on the baby’s chest, two hundred compressions per minute. As the crash cart is jostled into the nursery, I reach with my spare hand for the leads and affix the electrodes to the baby so that we can see the results of my efforts on the cardiac monitor. Suddenly the tiny nursery is jammed with people, all jockeying for a spot in front of a patient who is only nineteen inches long. “I’m trying to intubate here,” the anesthesiologist yells at an ICU nurse who’s attempting to find a scalp vein.

“Well, I can’t get an antecubital line,” she argues.

“I’m in,” the anesthesiologist says, and he falls back to let the nurse have better access. She prods, and I push harder with my fingers, hoping to make a vein-any vein-stand out in stark relief.

The anesthesiologist stares at the monitor. “Stop compressions,” he calls, and I raise my hands like I’ve been caught in the middle of a crime.

We all look at the screen, but the baby’s rhythm is 80.

“Compressions aren’t effective,” he says, so I press down harder on the rib cage. It’s such a fine line. There are no abdominal muscles protecting the organs beneath that little pouch of belly; bear down a bit too much or a tad off center and I might rupture the infant’s liver.

“The baby isn’t pinking,” Marie says. “Is the oxygen even on?”

“Can someone get blood gases?” the anesthesiologist asks, his question tangling with hers over the baby’s body.

The ICU nurse reaches into baby’s groin for a pulse, trying to stick the femoral artery for a blood sample to see if the baby’s acidotic. A runner-another member of the code team-rushes the vial off to the lab. But by the time we get the results in a half hour, it won’t matter. By then, this baby will be breathing again.

Or he won’t.

“Dammit, why don’t we have a line yet?”

“You want to try?” the ICU nurse says. “Be my guest.”

“Stop compressions,” the anesthesiologist orders, and I do. The heart rate on the monitor reads 90.

“Get me some atropine.” A syringe is handed to the doctor, who pulls off the tip, removes the Ambu bag, and squirts the drug down the tube into the baby’s lungs. Then he continues to bag, pushing oxygen and atropine through the bronchi, the mucous membranes.

In the middle of a crisis, time is viscous. You swim through it so slowly you cannot tell if you’re living or reliving each awful moment. You can see your hands doing the work, ministering, as if they do not belong to you. You hear voices climbing a ladder of panic, and it all becomes one deafening, discordant note.

“What about cannulating the umbilicus?” the ICU nurse asks.

“It’s been too long since birth,” Marie replies.

This is going downhill fast. Instinctively, I press harder.

“You’re being too aggressive,” the anesthesiologist tells me. “Lighten up.”

But what breaks my rhythm is the scream. Brittany Bauer has entered the room and is wailing. She’s being held back by the recording nurse as she fights to get closer to the baby. Her husband-immobile, stunned-stares at my fingers pushing against his son’s chest.

“What’s happening to him?” Brittany cries.

I don’t know who let them in here. But then again, there was nobody available to keep them out. Labor & Delivery has been overworked and understaffed since last night. Corinne is still in the OR with her stat C-section, and Marie is here with me. The Bauers would have heard the emergency calls. They would have seen medical personnel rushing toward the nursery, where their newborn was supposed to be sleeping off the anesthesia from a routine procedure.

I would have run there, too.

The door flies open, and Dr. Atkins, the pediatrician, immediately shoves her way to the head of the bassinet. “What’s going on?”

There is no answer, and I realize I am the one who is supposed to reply.

“I was here with the baby,” I say, my syllables accented in rhythm to the compressions I am still doing. “His color was ashen and respirations had ceased. We stimulated him, but there was no gasping or spontaneous breath, so we began CPR.”

“How long have you been at it?” Dr. Atkins asks.

“Fifteen minutes.”

“Okay, Ruth, please stop for a sec…” Dr. Atkins looks at the cardiac monitor. The heart rate, now, is 40.

“Tombstones,” Marie murmurs.

It’s the term we use when we see wide QRS complexes on the cardiogram-the right side of the heart is responding too slowly to the left side of the heart; there’s no cardiac output.

There’s no hope.

A few seconds later, the heartbeat stops completely. “I’m calling it,” Dr. Atkins says. She takes a deep breath-this is never easy, but it’s even worse when it’s a newborn-then tugs the Ambu bag off the tube and tosses it into the trash. “Time?”

We all look up at the clock.

“No,” Brittany gasps, falling to her knees. “Please don’t stop. Please don’t give up.”

“I’m so sorry, Mrs. Bauer,” the pediatrician says. “But there’s nothing we can do for your son. He’s gone.”

Turk wrenches away from his wife and grabs the Ambu out of the trash. He shoves the anesthesiologist out of the way and tries to affix it again to Davis’s breathing tube. “Show me how,” he begs. “I’ll take over. You don’t have to quit.”

“Please-”

“I can get him to breathe. I know I can…”

Dr. Atkins puts her hand on his shoulder, and Turk collapses into himself, an implosion of grief. “There is no way you can bring Davis back,” she says, and he covers his face and starts to sob.

“Time?” Dr. Atkins repeats.

Part of the protocol of death is that everyone in the room consents to the moment it occurs. “Ten oh four,” Marie says, and we all murmur, a somber chorus: I agree .

I step back, staring at my hands. My fingers are cramped from performing the compressions. My own heart hurts.

Marie takes the baby’s temperature, a cool 95. By now Turk is anchored to his wife’s side, holding her upright. Their faces are blank, numb with disbelief. Dr. Atkins is talking softly to them, trying to explain the impossible.

Corinne walks into the nursery. “Ruth? What the hell happened?”

Marie tucks Davis’s blanket tight around him and slips the little stocking cap back on his head. The only evidence of the trauma he’s suffered is a small tube, like a little straw, coming out of his pursed mouth. She cradles the baby in her arms, as if tenderness still counts. She hands him to his mother.

“Excuse me,” I say to Corinne, when maybe what I really mean is Forgive me. I push past her and skirt the grieving parents and the dead baby and barely make it to the restroom before I am violently ill. I press my forehead to the cool porcelain lip of the toilet and close my eyes, and even then I can still feel it: the give of the rippled rib cage under my fingers, the whoosh of his blood in my own ears, the acid truth on my tongue: had I not hesitated, that baby might still be alive.

–

I HAD A patient once, a teenage girl, whose baby was born dead due to class 3 placental abruption. The placenta had peeled away from the uterine lining and the baby had no oxygen; the severity of the bleeding meant we almost lost the mother as well as the newborn. The baby was sent to our morgue pending autopsy-which is automatic in Connecticut for the death of a neonate. Twelve hours later, the girl’s grandmother arrived from Ohio. She wanted to hold her great-grandchild, just once.

I went down to the morgue, to where the dead babies are kept in an ordinary Amana refrigerator, stacked on the shelves in tiny body bags. I took the baby out and slipped him from the bag, stared for a minute at his perfect little features. He looked like a doll. He looked like he was sleeping.