Small Great Things

by Jodi Picoult

  Sweeties are a little bit of sugar water, rubbed on the babies' gums to soothe and distract them from the discomfort. I would have given the baby sweeties before a circ, if I were his nurse.

  "I'm not taking care of this patient anymore," I say stiffly.

  Dr. Atkins raises a brow and opens the patient file. I see the Post-it note, and as she reads it, an uncomfortable silence swells, sucking up all the air in the room.

  Corinne clears her throat. "I gave him sweeties about five minutes ago."

  "Great," Dr. Atkins says. "Then let's get started."

  I stand for a moment, watching as Corinne unwraps the baby and prepares him for this routine procedure. Dr. Atkins turns to me. There's sympathy in her eyes, and that's the last thing I want to see. I don't need pity just because of a stupid decision Marie made. I don't need pity because of the color of my skin.

  So I make a joke of it. "Maybe while you're at it," I suggest, "you can sterilize him."

  --

  THERE ARE FEW things scarier than a stat C-section. The air becomes electric once the doctor makes that call, and conversation becomes parsed and vital: I've got the IV; can you get the bed? Someone grab the med box and book the case. You tell the patient that something is wrong, and that we have to move fast. A page gets sent from the hospital operator to anyone on the team who's outside the building, while you and the charge nurse take the patient to the OR. While the charge nurse rips the instruments from their sterilized paper bag and turns on the anesthesia equipment, you get the patient onto the table, prep the belly, get the drapes up and ready. The minute the doctor and the anesthesiologist run through the door, the cut is made, the baby's out. It takes less than twenty minutes. At big hospitals, like Yale-New Haven, they can do it in seven.

  Twenty minutes after Davis Bauer has his circumcision, another of Corinne's patients has her water break. A loop of umbilical cord spools out between her legs, and Corinne is paged from the nursery, an emergency. "Monitor the baby for me," she says, as she rushes into the woman's room. A moment later I see Marie at the head of the patient's bed, wheeling it with an orderly into the elevator. Corinne is crouched on the bed between the patient's legs, her gloved hand in the shadows, trying to keep the umbilical cord inside.

  Monitor the baby for me. She means that she wants me to watch over Davis Bauer. It is protocol that a circumcised baby has to be checked routinely to make sure that he's not bleeding. With both Marie and Corinne in the thick of a stat C-section, there is literally no one else to do it.

  I step into the nursery, where Davis is sleeping off the morning trauma.

  It will only be twenty minutes till Corinne comes back, I tell myself, or until Marie relieves me.

  I fold my arms and stare down at the newborn. Babies are such blank slates. They don't come into this world with the assumptions their parents have made, or the promises their church will give, or the ability to sort people into groups they like and don't like. They don't come into this world with anything, really, except a need for comfort. And they will take it from anyone, without judging the giver.

  I wonder how long it takes before the polish given by nature gets worn off by nurture.

  When I look down at the bassinet again, Davis Bauer has stopped breathing.

  I lean closer, certain that I'm just missing the rise and fall of his tiny chest. But from this angle, I can see how his skin is tinged blue.

  Immediately I reach for him, pressing my stethoscope against his heart, tapping his heels, unwrapping his swaddling blanket. Lots of babies have sleep apnea, but if you move them around a bit, change the position from the back to the belly or the side, respiration begins again automatically.

  Then my head catches up to my hands: No African American personnel to care for this patient.

  Glancing over my shoulder at the door of the nursery, I angle my body so that if someone were to come inside, they'd only see my back. They wouldn't see what I'm doing.

  Is stimulating the baby the same as resuscitating him? Is touching the baby technically caring for him?

  Could I lose my job over this?

  Does it matter if I'm splitting hairs?

  Does anything matter if this baby starts breathing again?

  My thoughts whip quickly into a hurricane: it has to be a respiratory arrest; newborns never have cardiac events. A baby might not breathe for three to four minutes, and still have a heart rate of 100, because its normal heart rate is 150...which means even if blood isn't reaching the brain, it's perfusing the rest of the body and as soon as you can get the baby oxygenated that heart rate will come up. For this reason, it's less important to do chest compressions on an infant than to breathe for them. In this, it's the opposite of the way you'd care for an adult patient.

  But even when I shove aside my doubts and try everything short of medical interaction, he doesn't resume breathing. Normally, I'd grab a pulse ox probe to get a monitor on his oxygenation and heart rate. I'd find an oxygen mask. I'd make calls.

  What am I supposed to do?

  What am I not supposed to do?

  Any moment now, Corinne or Marie might walk into the nursery. They'd see me interfering with this infant, and then what?

  Sweat runs down my spine as I hastily wrap the baby up in his swaddling blanket again. I stare at his tiny body. My pulse throbs in my eardrums, a metronome of failure.

  I'm not sure if three minutes have passed, or only thirty seconds, when I hear Marie's voice behind me. "Ruth," she says, "what are you doing?"

  "Nothing," I respond, paralyzed. "I'm doing nothing."

  She looks over my shoulder, sees the blue skin of the baby's cheek, and for a hot beat meets my gaze. "Get me an Ambu bag," Marie orders. She unwraps the baby, taps his little feet, turns him over.

  Does exactly what I did.

  Marie fits the pediatric face mask over Davis's nose and mouth and starts to squeeze the bag, inflating his lungs. "Call the code..."

  I follow her order; dial 1500 into the nursery phone. "Code blue in the neonatal nursery," I say, and I imagine the team being pulled from their regular jobs in the hospital--an anesthesiologist, an intensive care nurse, a recording nurse, a nursing assistant from a different floor. And Dr. Atkins, the pediatrician who saw this baby only minutes ago.

  "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 h
our, 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.

  I just couldn't find it in myself to hand this woman an ice-cold baby, so I wrapped him up again and went to the emergency room for some heated blankets. In the morgue, I swaddled the baby in them, one after another, trying to take the chill from his skin. I took one of the knit caps we usually put on newborns to cover the peak of his head, mottled purple with settled blood.

  We have a policy, if a newborn dies: we never take him away from the mother. If that grieving woman wants to hold her baby for twenty-four hours, to sleep with him tucked against her heart, to brush his hair and bathe him and have all the moments with her child she will never get to have, we make it happen. We wait until the mother is ready to let go.

  That grandmother, she held her great-grandson for the entire afternoon. Then she put the infant back into my arms. I put a towel over my shoulder, as if I were nursing him, and got into the elevator, taking him down to the basement level of the hospital, where our morgue is located.

  You'd think that the hardest part of an experience like this is the moment the mother gives you her child, but it's not. Because at that moment, it's still a child, to her. The hardest part is taking off the little knit hat, the swaddling blanket, the diaper. Zipping him into the body bag. Closing the refrigerator door.

  --

  AN HOUR LATER I am in the staff room, taking my coat from the locker, when Marie pokes her head inside. "You're still here? Good. Got a minute?"

  I nod, sitting down across from her at the table. Someone has tossed a handful of hard candy on it. I take a piece and unwrap it, let the butterscotch bleed onto my tongue. I hope it will keep me from saying what I shouldn't say.

  "What a morning," Marie sighs.

  "What a night," I answer.

  "That's right, you pulled a double." She shakes her head. "That poor family."

  "It's horrible." I may not agree with their beliefs, but that doesn't mean I think they deserve to lose a baby.

  "We had to sedate the mom," Marie tells me. "The baby's gone downstairs."

  Wisely, she does not mention the father to me.

&nbs
p; Marie flattens a form on the table. "This is obviously just protocol. I need to write up what officially happened when Davis Bauer went into respiratory arrest. You were in the nursery?"

  "I was covering for Corinne," I reply. My voice is steady, soft, even though every syllable feels as dangerous as a blade at my throat. "She got called to the OR unexpectedly. The Bauer baby had his circ at nine, and couldn't be left unattended. Since you were at the stat C, too, I was the only body even available to stand in for observation."

  Marie's pen scratches across the form; none of this is anything she doesn't know or expect. "When did you notice that the infant had stopped breathing?"

  I curl my tongue around the candy. Tuck it high in my cheek. "A moment before you arrived," I say.

  Marie starts to speak, and then bites her lip. She taps the pen twice, then puts it down with a definitive click. "A moment," she repeats, as if she is weighing the scope and size of that word. "Ruth...when I came in, you were just standing there."

  "I was doing what I was supposed to do," I correct. "I wasn't touching that baby." I get up from the table, buttoning my coat, hoping she cannot see that my hands are shaking. "Is there anything else?"

  "It's been a tough day," Marie says. "Get some rest."

  I nod and leave the break room. Instead of taking the elevator to street level, though, I plunge to the bowels of the hospital. In the overexposed fluorescent fixtures of the morgue, I blink, letting my eyes adjust. I wonder why clarity is always so damn white.

  He's the only dead baby there. His limbs are still pliable, his skin hasn't taken on a chill. There's mottling in his cheeks and feet, but that is the only clue that he is anything other than what he seems to be at first glance: someone's beloved.

  I lean against a steel gurney, cradling him in my arms. I hold him the way I would have, if I'd been allowed to. I whisper his name and pray for his soul. I welcome him into this broken world and, in the same breath, say goodbye.

  IT'S BEEN QUITE THE MORNING.

  First, we all overslept because I thought Micah had set his alarm and he thought I had set my alarm. Then our four-year-old, Violet, refused to eat a bowl of Cheerios and sobbed until Micah agreed to fry an egg for her, at which point she was so far gone down the path of nuclear meltdown that she burst into tears again when the plate was set down. "I want a fuckin' knife!" she screamed, and it was quite possibly the only thing that could have stopped both Micah and me in our frenetic tracks.