THE sound of the beeper ripped through the darkness like a bomb going off next to my ear. I sat bolt upright in bed.
“Delivery room six STAT, Delivery room six STAT.” The automated voice cracked an unforgiving, authoritative command.
My feet hit the floor, and I was in motion before I gave it any conscious thought. A STAT call to the delivery room could only mean one thing: a baby was in trouble. Sometimes, even when the monitors attached to the expectant mother gave ominous warnings that something was wrong with the baby, when it was finally born, it could look fine. Other times, the baby’s condition at birth could be critical. In those situations, the decisions I made within the first few minutes could mean the difference between a bouncing, healthy newborn and a train wreck. A moment’s hesitation or a slight error in judgment and a baby could go from having a bright, promising future to being either dead or brain-damaged.
As I raced down the single flight of stairs, taking them two or three at a time, I acknowledged the knot growing in my stomach. I was in my last year of residency in a top-level pediatric training program, but despite all my experience and having intervened in numerous neonatal emergencies, I was still anxious. I never discounted the magnitude of my responsibility. I wasn’t sure I’d ever be able to forgive myself if I thought a mistake I had made resulted in a bad outcome.
I practically sprinted into the central back corridor that connected all the delivery rooms. This area was only accessible to physicians and staff. Each delivery room had two entrances. One entrance was on the outside wall of the delivery room and had a door at least six feet wide, intended for patient use. Hospital beds carrying pregnant women could be easily wheeled through these. On the inside wall of the delivery room was the staff door that opened into the central back corridor. Each of these doors was flanked by a metal sink and cabinets with supplies that had to be immediately accessible. In one sweeping motion, I pulled a scrub cap out of one of the cabinets, secured it over my head, and then tied a surgical mask in place over my nose and mouth.
There was already a flurry of activity when I burst into the delivery room. Several IV bags hung from poles around the head of a woman who lay on an operating table. A quick glance at her expression registered that she was confused and panicked. The anesthesiologist was feverishly drawing up medicines and infusing them into a small tube that disappeared into the middle of the woman’s lower back. Apparently, when the team had anticipated an uneventful, normal delivery, he had given her an epidural with the intent of allowing her to experience the birthing process free of pain. Now he was hoping to utilize the same line to administer higher doses of anesthesia and thus allow the obstetrician to safely perform an emergency caesarian. The IV bags had been primed in the event that this was unsuccessful and he was forced to resort to emergency general anesthesia.
I made my way over to the neonatal resuscitation station, knowing this was where my participation would be essential. The station was kind of a platform on wheels. It consisted of a cushioned pad with both a warmer and a bright halogen light overhead. Its back panel housed various switches and gauges. I connected an infant resuscitation mask to an adapter on the end of some sterile tubing and then attached the other end of the tubing to a valve that delivered oxygen. Knowing that getting oxygen to the baby was going to be my first objective, I turned on the valve and made sure there was a strong flow coming through the mask. As I worked, I caught Fern’s attention and asked her for a quick briefing. Fern was the charge nurse in obstetrics and pretty much ran the show.
She lifted her index finger in a “just a moment” gesture, then unwrapped a package of surgical instruments and, without touching them, dropped them onto a tray. With practiced precision, they landed next to an empty basin and a couple of sterile drapes. Within the next few seconds, one of the drapes would be used to cover the woman’s abdomen and the other hung to provide a barrier between her face and the surgical field. Fern expertly poured an antiseptic scrub into the basin, then stepped back to allow the nurse who was going to be assisting the obstetrician to step into position.
With impressive efficiency, Fern moved to the head of the operating table and leaned over the woman. “Becky,” she said. “Everything is going to be all right. I know this is a little disorienting, but we’re trying to move quickly so we can deliver your baby as fast as possible. We’re almost ready to begin, but before we do, I’ll get your husband. He’ll be by your side for the whole thing. For now, I just want you to take a few deep breaths and trust that you’re in good hands.” She ran her fingers softly across Becky’s forehead in an attempt to offer a little palpable assurance, then turned her attention to me to give me an abbreviated rundown. She spoke in hushed tones to try to minimize Becky’s alarm.
“She was having an uneventful labor when she must have abrupted. There’s a lot of vaginal bleeding and the scalp electrode on the baby shows significant bradycardia. The heart rate has already been down for four minutes.” Bradycardia was medical terminology for a slow heart rate, and the fact that it had already been down for four minutes wasn’t a good sign. Fern glanced over her shoulder at the progress being made in preparing Becky for the surgery.
Dr. Brian Torres, the obstetrician, stealthily pulled on a sterile gown, then pushed his hands into surgical gloves. He barked at the obstetrical resident who had just flown into the room that he would have no time to scrub. “Just throw a gown on and get ready. As soon as I get the go-ahead from Jack that she’s numb, I’m going to cut.”
The anesthesiologist, Dr. Devin Jack, said, “Give it another thirty seconds, and we should be good to go.” Almost without exception, the entire medical staff referred to him as just “Jack.”
I cringed. Dr. Torres wasn’t particularly known for his diplomacy, and I understood that in this situation brevity was key, but saying “I’m going to cut” within earshot of the patient seemed especially insensitive.
I watched the baby’s heart monitor dip even lower, and my anxiety went into overdrive. Fortunately, in the face of huge adrenaline surges, my tendency was to become laser focused. I shut out all the extraneous noise and began a mental run-through of what I anticipated I’d be up against.
A placental abruption meant the placenta tore away from the wall of the uterus before the baby was born. Its attachment to the uterine wall was essential in order for it to transfer oxygen from the mother into the umbilical cord and subsequently to the baby. If it tore away prematurely, the baby would be deprived of essential oxygen. If part of it tore away but some of it remained partially attached, the baby might get limited oxygen, but not in sufficient quantity to sustain life. As soon as an abruption occurred, you entered into a race for life.
I began to assemble all the equipment I anticipated needing so it would be within easy reach. I put the laryngoscope, a device that would allow me to look into the baby’s throat and see the vocal cords, on the side of the warming platform. Next to it, I placed what I guessed would be the appropriate-size endotracheal tube. I knew providing the baby with life-saving oxygen would be critical within the next few minutes, and the baby would have to be intubated immediately. I would extend the baby’s neck, put the laryngoscope into its mouth, visualize the vocal cords, then pass the endotracheal tube directly into its trachea. With some luck and a prayer, it would happen effortlessly. Was I feeling lucky?
As the frenzy began to reach a crescendo, I saw the big six-foot-wide door open, and a nurse escorted the woman’s husband into the room. “Mr. Carson, let me show you where you’re going to stand. You’re going to be right up here with your wife. We’re going to be able to proceed with the surgery using just the epidural for anesthesia. We didn’t need to put Becky to sleep. She’s awake and alert and will need your encouragement and comfort.” The nurse gave his hand a quick squeeze, mustered a smile of confidence, then guided him next to the side of the bed, where only his wife’s head emerged from under all the blue surgical drapes.
Mr. Carson had been hurriedly dressed in hospital scrubs identical to those worn by the operating room staff. The surgical cap had been hastily pulled over his head and came too far down his forehead. He repositioned it with a sweep of his hand, revealing more of his face. He was handsome, with strong features. Dark, curly hair stuck out from under the elastic band of the scrub cap. He had matching dark eyes, an olive complexion, and I could appreciate that the cotton scrub shirt covered a muscular torso. When he bent over to kiss his wife’s cheek, he disappeared behind the drape that had been hung to cordon off the surgical field.
Mr. Carson was trying to maintain a façade of calm in an attempt to reassure his wife, but when he spoke, his voice faltered a bit. “Honey, you’re doing great. The nurses said that it’ll be just a few more seconds. I’m right here. I’m sure our little girl will be fine. I love you, Becky. Hang in there, honey. We’re going to be fine. All of us, we’re going to be fine.”
The power of the emotion in these situations always impressed me. The couple obviously loved each other. I was sure their past nine months had been spent in eager anticipation, looking forward to this eventful day, when the culmination of their love and their very seed would come into the world—healthy, pink, perfect. I looked up at the clock. Up until six minutes ago, every indication had been that their dream would come true. Now, their very future was teetering on the edge. The promise of a beautiful baby girl could be supplanted by the tragedy of a fetal demise. Even for me, the gravity of that prospect raised an uncomfortable lump in my throat.
Jack’s voice alerting Dr. Torres brought me immediately back into the moment. “Okay, Brian, Becky’s anesthesia is adequate to begin. She’s ready when you are.” Though he continued to prepare drugs to go through Becky’s IV, he smiled down at her and winked. “Piece of cake.”
Dr. Torres already had his scalpel in hand and had identified the landmarks on the woman’s abdomen where he was going to make the incision. Typically, a cesarean was performed under very controlled conditions and the incisions were made delicately, leaving time to carefully control any minor bleeding as it occurred and going through each muscle layer very methodically. This time I knew that Dr. Torres would have his hand into Becky’s uterus trying to extract the baby within about ten seconds of making the initial cut.
I held my breath.
Rather than just making a skin incision, Dr. Torres pushed the scalpel blade deep. He quickly tossed it back onto the surgical tray and then thrust both his hands into the cavity he had created. He begin to push the layers of muscle aside, and when he had opened what he hoped would be a hole of adequate size, he gave curt instructions to the resident. “Get a couple retractors in here and hold back the uterine wall.” When that had been accomplished, Dr. Torres dove his left hand deeply into the womb. He diverted his eyes to the ceiling, his features fixed with an expression of deep concentration. At this point, trying to see what he was doing would be pointless; his hand had disappeared into a pool of blood and tissue. Instead, he had to rely on feel. His practiced fingers begin to identify landmarks and wrapped them around the baby’s leg. He quickly put his other hand into the cavity. He brought the baby’s legs together and began to pull. Apparently, he had determined the baby’s head was already so far down into the birth canal that trying to turn her would have been a waste of time. Dead or alive, this baby was coming into the world feetfirst.
The next few seconds were a bit of a blur. Dr. Torres pulled what looked like a lifeless, limp, blue body out of the bloody quagmire, clamped the umbilical cord with two forceps an inch apart, then used a pair of surgical scissors to cut between them. In one quick motion, he handed the baby to the resident, who until that moment had had his back to me. The resident pivoted awkwardly on his heel and almost tossed the baby like a hot potato into my waiting arms.
The room then fell immediately silent. All conversation ceased, the rattle of metal equipment being jostled around stopped, and I felt everyone’s stare fall directly onto me. It was so quiet I thought I actually heard a little voice in the back of my head whisper, “Do or die.” I flew into action.
My stethoscope was already in my ears. I placed it briefly on the baby’s chest to confirm there was a heartbeat. The sound I heard was slow and weak, but present. I thrust a suction catheter into the baby’s mouth to try to evacuate some of the obvious blood and secretions, then grabbed the neonatal resuscitation mask and placed it over the baby’s nose and mouth. I was thankful I had already checked the oxygen flow. By squeezing the little bag, I delivered a series of rapid, oxygen-rich breaths to the baby and was encouraged when I saw her chest rise and fall in response. In one fluid motion, I picked up the laryngoscope in one hand and the endotracheal tube in the other. There was still a lot of crap in the back of the baby’s throat, but I could see the vocal cords. The hole between them represented a tiny target, but under the nimble guidance of my fingers, I watched the tube pass smoothly through them.
By this time, Fern was by my side. Without me having to direct her, she was ready with an adapter to put on the end of the endotracheal tube. She connected the adapter to the oxygen line and then began gently squeezing the bag. Relief! At least the baby was now getting oxygen. Whether it made any difference or not was yet to be seen. She was still blue and lifeless.
Having Fern manage the airway freed my hands to continue the resuscitation. The clock was ticking, and the baby was still shocky and had only a weak heartbeat. I knew I would have to be aggressive to optimize her chances. I turned to the nurse standing next to the crash cart. “Pull me up point three milligrams of epinephrine.”
She opened the medicine drawer designated for neonates, grabbed a vial, and then filled one of the smallest syringes with a clear liquid. As she did so, she repeated my order to verify accuracy. “Epinephrine, point three milligrams.”
I removed the clamp that had been secured to the end of the umbilical cord. The cord had been cut about an inch above the skin of the baby’s abdomen. I needed to be able to administer medicine and fluids to the baby quickly. The best way was to utilize one of the vessels from the umbilical cord. They were relatively big, easily accessible, and carried a good blood supply. With a small pair of tweezers, I teased the three vessels contained within the cord apart, identified an artery, then carefully threaded a tube less than half a millimeter in diameter through it. After advancing the tube about two inches, I injected thirty cc’s of saline into it, then pushed the epinephrine into it as well.
While Fern continued softly squeezing the bag in rhythmic four-second intervals, another nurse placed tiny little electrodes onto the baby’s chest. The monitor indicated that her heart rate was slowly picking up. I again placed my stethoscope on her chest to confirm what I hoped was a sign of improvement. Her heartbeat was indeed a little stronger.
“Now give me thirty cc’s of albumin.” A syringe appeared in my hand almost before the request escaped my mouth. I slowly pushed it into the tube going into the baby’s umbilical cord. Her skin, ever so slowly, started getting pink. The beeps coming from the monitor also sprang to life, orchestrating what sounded like a symphony to announce that the baby’s condition was improving.
“Let’s follow that with three milliliters of bicarb,” I said, apprehensive that the baby had not yet completely turned the corner.
Then, miraculously, the baby started to move. Her movements were tentative at first but soon became more purposeful. Her heart rate climbed to one fifty, and she appeared to be trying to cry around the tube down her throat.
The relief experienced by everyone in attendance was palpable. For the first time since starting the resuscitation, I glanced over my shoulder to look at the parents. Neither of them could see their baby on the warming platform. They were both still locked in a catatonic state. Becky was on her back with her head turned toward me. Her pleading eyes peeked out from under the surgical cap that covered her hair. Her position on the operating table prevented her from moving more than her head and shoulders. One of her arms was secured onto an IV board extending from the side of the gurney. Antibiotics slowly dripped into it.
Her husband, whose name I later learned was Greg, was holding on to her other hand where it appeared from under the surgical drapes. His knuckles were white, and I couldn’t help but thinking that if Becky hadn’t been so worried about her baby, she would have realized that her hand was uncomfortable in his tight grasp.
Suddenly, all the anticipation and anxiety came to a climax, and Becky emitted a mournful sob. “Why can’t I hear my baby crying? Is she dead?” The desperation of her question was heartwrenching. Tears began to cascade down her cheeks, and her chin quivered as she wept. Greg, on the other hand, stood stoically, his expression unwavering. He was obviously trying to prepare himself to hear horrible news and seemed determined to remain strong.
I calibrated my response to make my voice sound intentionally optimistic. “You know, right now I’d have to say this little girl looks pretty darn good. She got off to kind of a rough start, but it appears she’s a real fighter and refuses to be kept down. For the time being, I have a tube in her windpipe that’s helping her to breathe. It prevents her from being able to cry, but don’t worry, she’s moving her fists enough to let me know she’s not too happy about it. Being angry is a good sign. It means she wants the tube out and intends to breathe on her own.”
Both parents froze in suspended animation while they registered what I had just said. Then tears began pouring even more heavily down Becky’s face. “Oh thank you, thank you, thank you,” she sobbed in a hoarse whisper.
The tension in Greg’s face fell as well. The magnitude of the anxiety he’d been suppressing had been so great that, when relief came, it almost overwhelmed him. Its surge must have made him feel as if he’d been struck by a bus. He began sobbing as well. “Are you sure she’s going to be okay?” he pleaded; he seemed almost afraid to let himself believe he was really awakening from his nightmare.
“Well, I can’t give you a 100 percent guarantee that we’re completely out of the woods. I’m still worried that her heart rate was dangerously low for quite a while, but I take a lot of consolation in seeing a baby turn around quickly, and this girl just set a record. She’s already looking better. We’re going to take her up to the neonatal intensive care unit to monitor her, and we’re going to have to run some tests, but I’d put my money on this girl still being Harvard bound.”
Dr. Torres, Dr. Jack, the resident, and the entire nursing staff looked as if they wanted to leap into the air and high-five each other. Instead, Dr. Torres peeked over the drape to look at Becky. “You did really well, Becky. This girl’s going to make it only because her mother’s so strong. Thanks for sticking with me. Now, don’t you think that it would be a good idea for me to see about putting you back together? That daughter of yours insisted on making her appearance through a big stage door.”
He looked up at the scrub nurse, who I could see smiling under her mask. “You have some suture ready? I have some sewing to do.”
I smiled at Becky. “Mrs. Carson, I’ll understand if you don’t want to get up, but, Mr. Carson, you might want to consider coming over to meet your daughter.” Her little fist was now really flailing around. “It would appear she’s eager to say hello.”
Greg slowing pulled his fingers from his wife’s hand. He hesitantly took a step forward, looking like he still didn’t trust his legs to support his weight. He stood over the warmer that held his daughter and seemed mesmerized by seeing her. Just moments before, Dr. Torres had pulled a blue, lifeless rag from out of his wife’s womb. Now, though, the baby had a tube in her windpipe, a line coming out of her belly button, and electrodes attached to her chest, he looked enchanted by the vibrant, little pink life before him, who was seemingly trying to wrestle herself free from all the restraints.
Not wanting to break the spell that he was enraptured in, I spoke in a hushed whisper. “I’m going to take her upstairs. We’ll want to get a chest X-ray and run some other tests. Your wife is going to be, shall we say, tied up for a little while, so if you’d like, you can come upstairs with us. The nurses won’t let you stay too long, as they will have a lot to do to get your daughter tucked in, but you can at least see where she’s going to be. Then you can come back down to report to Becky.”
His tears had begun to subside and he looked jubilant. “I think I’d like that.” He turned to his wife. “I’ll only be gone a sec, honey.” Then, concerned about Becky’s own delicate condition, he quickly retracted his intentions. “Or, do you want me to stay here with you?”
She too was jubilant, but exhaustion was catching up with her. Prior to things heading south, she had already been in labor for more than ten hours. The combination of pushing for so long, the stress, and an emergency surgery was rapidly taking its toll. “No, you go up,” she encouraged him. “I need to close my eyes for a minute. Just hurry back down to tell me how she’s doing. And, honey,” she said as she smiled weakly, “be sure to bring me good news.”
Encouraged that the baby was doing well and certain she could tolerate it, I disconnected her briefly from the oxygen, picked her up, and carried her quickly over to where Becky could see her. I held the baby to within inches of her mother’s cheek. “Let’s get a kiss for luck and we’re on our way!” Damn! How gay did I sound unintentionally quoting from a Carpenters song?
No matter; no one seemed to notice. Another surge of tears poured from Becky’s eyes as she placed a quick, loving kiss on the baby’s cheek. She gave me a relieved, appreciative smile. “Thank you, not just for the kiss, but for everything. Thank you.”
By this time, Fern had wheeled the transport incubator into the delivery room. I put the baby into it, then attached the endotracheal tube to the portable oxygen canister. Fern resumed squeezing the bag rhythmically. One of the other nurses attached the electrodes to a monitor that was built into the side of the incubator, and another attached an IV line to the tube coming from the baby’s umbilical cord. She confirmed that it was infusing at a rate of twenty cc’s per hour, then announced that the entire caravan was ready to roll.
“You ready, Dad?” I smiled at Greg. “Your daughter’s impatient. Better get used to it!”
He kissed his wife and then followed us out of the room. We took an elevator up one floor then wheeled the incubator into the neonatal intensive care unit. Margo, the charge nurse there, waved us over to a waiting warmer. Fern had called ahead, so the nurses were expecting us. At this point, I was able to step back and enjoy the impressive spectacle as the nurses got to work. They were the epitome of professionalism and efficiency. They had that baby on the warmer and attached to a ventilator before I was able to offer a single directive. Oh well, I thought, this baby is in great hands.
Meanwhile, Greg wasn’t missing a beat. He kept a vigilant eye on everything happening to his daughter. In an attempt to break the tension a little, I asked him, “So, does she have a name?”
He tore his gaze away from the activity occurring on the warmer and appeared to have to think about my question for a minute. “Oh yeah, yeah. Her name is Sophie. We named her after Becky’s grandmother. She’s eighty-four but in great health. She’s a spunky thing too. Guess we chose the right name. That must be where Sophie gets it from. Her spunk, I mean.” The realization seemed to console him. “My daughter’s got her great-grandmother’s spunk.”
He smiled pensively, still reeling from the drama of the delivery. He’d reached up to wipe some of the sweat that had collected on his forehead off when he seemed to realize he was still wearing his scrub cap. “May I take this thing off now?”
“Sure,” I said. “You wouldn’t want to be confused for anyone other than a new dad. As for me?” I adjusted mine thoughtfully and smiled. “I think I’ll keep mine on. Given the number of names on the board downstairs, it looks like I’ll probably be making another few trips down to the delivery room before morning.”
Greg peeled his scrub cap off and shoved it into the back pocket of the surgical pants he was wearing. In their haste to get him dressed, the nurses had apparently grabbed him a pair of pants that were obviously too big. He’d had to really cinch the drawstring to keep them from falling down.
With the cap off, I was better able to observe his appearance. He was handsome. Kind of rugged-looking. He had a nice smile and a cleft that dimpled the middle of his chin. He wasn’t model material but was certainly way above average.
One of the monitors that Sophie was connected to began to sound an alarm. I aborted my review of the guy’s features and directed my attention immediately back to his baby. Fortunately, however, the alarm had been triggered as the result of a lead coming loose. Sophie was still rock stable. She didn’t appear to have even registered the sudden, shrill beeping.
“Well,” I said, “as I told you, we’re going to have to run a few more tests. Sophie continues to look great. Why don’t you go back down and check on your wife. If you’re still awake, you can come back up in a few hours to see how Sophie’s progressing. By that time, Dr. Schmidt will have taken over for me. She’ll be able to give you a full update and will be the one taking care of Sophie for the next few days.”
He looked a little startled. “Why won’t you be taking care of her? We really trust you.”
I smiled. “I’m working in the cancer wing this month. I was just on call here tonight to help cover. Don’t worry, though. Sophie will be in good hands.”
His eyes started to well up a little again. “I can’t thank you enough. You saved our little angel. We’ll be indebted to you forever. Listen!” he said, looking at my name tag. “Dr. Sheldon, I run an automotive shop. I’m gonna leave my card with the nurses. If you need anything, and I mean anything, you just give me a call. I know it will be impossible, but I just have to try and find a way to thank you.”
I was both humbled and flattered. “Just be a good dad. That will be thanks enough. Now go see how your wife is doing.”
He held my gaze for a second, broke it off as he turned for the door, then reconsidered. He spun back around, grabbed me in a tight bear hug, and pounded me gently on my back.
“Thank you, Doc. Really, thank you. You’re the best. You’ll never know how much this has meant to us.”
He relinquished his embrace, gave me another slap on the shoulder for good measure, and then, perhaps fearing that he might once again become emotional, he almost sprinted out of the room.
I turned my attention back to Sophie and began a more thorough exam. A feeling of warmth spread through me. Sometimes being a doctor was a good thing.