Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (9 page)

The answer is no; it's not going back in. The woman is bearing down like a mighty machine. You can actually see the misshapen egg, the baby's head, growing, pushing through the lips, a steadily enlarging globe. There is no going back.

You turn to Helen. “I need a bulb syringe,” you say and when she looks at you blankly, you demonstrate with your hand. “The little, squishy, rubber thing. To aspirate with.”

You are staring down at an eat now, the right ear of a baby that faces off to the left. You reposition your fingers past the vaginal lips and under the chin, which immediately pops out. The head rotates almost immediately and you stare down at the face of a very old man, eyes closed tight and lips pursed in suffering. Whatever it is looks very dead.

“Stop pushing,” you yell at the woman, and this time you can hear that note of authority, real authority, edge back into your voice. “Just give me a second.”

You take the bulb syringe and use it to suction the little nostrils and, very gently, the mouth. With your other hand you hold the body in the vagina.

“This is a tiny baby,” you tell the nurses. “Get ready,” although you have no idea for what.

You let go of the shoulder and wait a moment. The baby stays where it is—not moving at all. The mother goes through another set of contractions, another tidal wave, but the baby doesn't move, nothing.

You wait out the contraction, staring down at the baby. Shoulder dystocia, you think in awe, a phrase you never thought could someday terrify you. The baby has gotten hung up, shoulder trapped somehow within pelvis.

You wipe your forehead with what you can reach of your left shoulder and arm. You reposition your hands, poking an index and a middle finger of your left hand around the left side of the neck, sliding up under the shoulder. You sort of sweep your fingers inside the stretched lips of the vagina and the right shoulder pops out. But the other shoulder is still snagged somehow. You can't tell by what. You can't even get a finger over it—your hand keeps slipping and scooting around. That's when you look up at the nurses suddenly; you have forgotten they were there. There are three naked faces, mouths dangling open, staring down at you.

“Get me a sterile towel” is all you say, and you go back to trying to dig this baby out. You try with your fingers again, scooping up over the right shoulder. How long do you have? Not long. You try again. Nothing. Helen hands you a sterile towel by peeling open, banana-like, the paper edges of the sterile package. You shake it open and use it, first on your hands and then the head, neck and shoulder of the baby, so you can get a better grip. You try rotating the shoulders a little, twisting the body clockwise and then, in a rivulet of blood, the whole body slithers out so fast you almost lose your grip, and then you are sitting in a puddle of blood and amniotic fluid, the baby in your lap.

It is absolutely purple and it doesn't move, not a flicker. You hold it there gingerly for a moment, just staring at the thing on your lap, and then you reach up, fumbling around for the cord with your left hand.

“My baby,” the woman is shouting. “Is it all right? Is it all right?”

With the index finger of your right hand you begin tapping on the baby's leg.

“He's got a pulse,” you say. “Count my finger tapping.”

They do. After fifteen seconds Carol says, “One-ten.”

“My ba-aa-aa-bb-bb-y,” the woman is shouting.

One-ten. Time expands a little as you stare down at the blue, flaccid form in your lap. You start drying it like mad, trying to stimulate it. “Hello,” you say out loud. “Hel-lo, wake up, little guy.” You milk the cord for a moment and then turn to the nurses. “I need a clamp and scalpel,” you say. You go back to stimulating the baby, slapping it on the bottom of its feet, thumping it. Nothing. Helen hands you a scalpel and two plastic clamps—it takes you a moment to figure out how to work them. You clamp the umbilical cord and slice between the two clamps with the scalpel, producing even more blood. The baby is officially on its own now. Things don't look promising. You give it to the nurses to put it in the Isolette. Him in. It's a boy.

The APGAR score, you think ponderously as you rise and step through the primordial ooze on the floor. You need to get a one-minute APGAR. APGAR measures five things—or, in medicalese, “indicators.” Each indicator is given points: zero, one or two. Respiratory effort is one indicator. If the baby were breathing well he'd get a two. “Needs some stimulation to breathe but is doing so on his own,” nets a one. This kid is a big zero. Pulse is another indicator. A heart rate over a hundred gets this guy two big points. What else, you think, what else? Color. Pink is two points. This baby was blue from head to toe. Another zero. Reflex irritability, how much the baby was wiggling around—here is another zip.

You can't remember the last indicator.

Top APGAR score is ten. This baby: two.

The mother is struggling up off the gurney. Carol holds her back. “What's the matter? What's the matter?” the mother is calling out.

“He's not breathing,” you say, practically spitting the words.

“Oh God!” She flops back on the gurney and starts wailing. “Oh God, oh God.”

“Hook up the oxygen,” you tell the nurses. “And get me a face mask and an Ambu bag.”

“The first moments following delivery,” the textbook for your second-year pediatrics course counseled you, “is the crucial moment of life. The sudden inspiratory effort of the newborn opens the pulmonary tree and completely alters the circulatory system. The foramen…” The rest is lost in the dim reaches of your mind.

This baby wasn't doing any of this. Someone hands you a face mask that is too large. You throw it on the floor. “Smaller,” you say. You get handed another one that fits better. We were “bagging,” holding a face mask over the patient's nose and mouth, forcing air flow into the lungs by squeezing the attached oxygen-filled bag. Not the best way to breathe for someone—a lot of air goes into the gut—but for now it was the best we had.

You hold out a hand for the Ambu bag. What you know is this: the first breath is the hardest, the one that requires the most effort. If you can open up this baby's lungs, if you can help him take that first big breath, he might be able to go from there.

It's like resuscitating with toys; everything is so small. You fit the mask over the baby's face and squeeze the bag a little, then a little more. You lift the baby's chin with your little finger in order to get a better seal with the mask and then try again with more force. You lift the bag and check the baby. He hasn't moved.

“I'm going to have to intubate,” you say. That means putting the breathing tube down through the vocal cords in order to ventilate the lungs. “Somebody try for an IV.”

“Oh, sweet Lord,” Helen says and grabs up one of the baby's tiny fists. “I haven't done this in ten years.”

“What? What?” the mother shouts. “What are you doing?”

“I need an endotracheal tube,” you tell Carol. “A 3-0. What laryngoscopes?” You nudge her out of the way so you can get to the drawer in the crash cart with one hand while the other hand holds the bag in place. You sort through what you find and pluck out a handle and the smallest laryngoscope blade. You are surprised to see that your hands are steady. You've never intubated anything close to this small before.

It's simple, you tell yourself (and then answer immediately, “Hah!”). You just have to place this pencil-sized tube into the narrow breathing passage, the trachea, which is not much larger than the tube and has its opening tucked so out of the way it can sometimes be impossible to find. The easiest mistake to make is to put the breathing tube into the esophagus. This allows you to ventilate the stomach—no good for anyone.

You lean over the table with the tube and laryngoscope in hand. This baby is tiny, you think, as you look down. How small? Two kilos? Three? You look at the little hands, turning them over between your fingers. Doesn't look too premature though, you think. A very small, term baby.

Carol has her hand on the umbilical stump. “I've got a heart rate of eighty-two, I think.”

“Somebody get the kid on the monitor.” You flip open the laryngoscope. “What's going on about transport?”

Helen shouts to the unit clerk. “What's going on about the helicopter?”

The unit clerk shouts back. “They're saying they can't take any transports from us. The hospital hasn't paid transport bills for over a year.”

“So what the hell are we supposed to do?” you shout out.

“I'm trying to get somebody at Lying-in to do ground transport. They are checking with the neonatal critical team now.”

“Goddamn it,” you say out loud, but at least the clerk is trying. You return to the baby. With your left hand you slip the laryngoscope into the mouth, over the tongue, to the back of the throat and beyond. You can see the epiglottis, a flap of skin that seals off the trachea when food is passed through the mouth to the esophagus. You have to get the tip of the tube up under the epiglottis, then through the vocal cords. It's so hard with something this tiny. The anatomy doesn't seem right; nothing like in the textbook. You keep losing your grip. The doll's head rolls to the right, out of position. You lose where you are and have to reposition and start all over.

Idiot, idiot, idiot, you whisper to yourself. In the distance, far, far away you hear the mother shouting again. Out of the corner of your eye you see her waving her hands. The kind nurse, the one whose name you still don't know, is standing over her, trying to calm her.

Placenta, you think, she's delivering the placenta. The rest is a blur. You hunker back down over the child and look again. You can't see well, you can't really see at all, so you poke and hope, guiding the tube in the general direction of the vocal cords, the voice box. The tube slides forward, then stops, hung up on something. You try again, passing again. Same thing. You straighten up and start to bag the infant again. This isn't working.

Think, think,
you tell yourself. If you were alone, you'd butt your head against the wall; that's how frustrated you are.

Helen is still working on the IV, and she is not having much luck. She has to pass a tiny needle into a vein not much larger than a hair. Right now she is down on her knees, her head bowed over the baby's blue fist, tapping, tapping at it, looking for another IV site. She blew the last one.

“Give me a smaller tube,” you tell Carol.

“What size?”

“Two point five.”

“We don't…No, wait.”

She hands you a package and you break it open. A size 2.5 endotracheal tube. You bow back over the baby, and once again you insert the laryngoscope and lift the jaw forward, looking for the larynx and the vocal cords, but you don't see much more than you did before.

Blind again. You slip the tube down toward where you had it before, and this time it slides easily forward.

You gasp and straighten up, struggling to fit the Ambu bag onto the tip of the ET tube. One breath, two, another, and you watch as the stomach rises and falls.

“Somebody check for lung sounds,” you hiss.

Carol does. “No. I think it's in the stomach.”

You pull the tube out and lean again, taking the laryngoscope back up.
Think,
you tell yourself,
think.

Carol stands looking up at the monitor. “We've got a heart rate of about forty here.”

You kneel again and slip the laryngoscope over the tongue and down beyond. This time you lift the tongue at a different angle, rocking the laryngoscope handle a little bit.

“Somebody give me some cricoid pressure,” you say—pressure on the neck to help bring the vocal cords into view.

You think you can see better now; there is, perhaps, the treasure at the end of the rainbow. You slip the tube forward and in it goes, unhindered. You straighten up, give the Ambu bag a few squeezes and watch the chest rise and fall. The chest—not the belly.

“Listen for me,” you tell Carol.

She does. “Sounds good,” she says.

You look up at the kind nurse and say, “We need blood from the umbilical cord. Just put it in a red-top tube. We can run it as a blood gas.” You turn back to Helen, who has abandoned her second catheter and is working on a third. “I'll try a scalp vein,” you say.

You look up at the monitor. The heart rate has already jumped from 40 to 64.

You need access. IV access. Scalp veins are often the biggest, most accessible veins neonates have. You get at them by putting a tourniquet around the top of the baby's head, usually a rubber band, and using a type of needle with two plastic wings, called a butterfly. You are working, brushing the slick seal-like hair out of the way, searching for a vein, when Helen says, “Look.”

You look up at the baby. There is a flush, barely pink across the chest and the abdomen. Wait, no. It's just your wishful thinking.

But no. It's really there. A near-rose color that is not your imagination. You look up at the monitor, heart rate 105, and you stand there, flatfooted for a moment, gazing at the monitor in wonder, until from the corner of your eye you see something shifting, moving. You look back down at the baby and you see it again. The hand is twitching and grasping a little on its own. The fingers of the left hand are curling, twitching, and now you see that the flush across the chest, a color, once barely vermilion, is now almost rose. A radiant rose. The kid is oxygenating. The carotid pulse is easily palpable. The kid is coming around, you think, and as he turns pinker and pinker you stand waiting for more movements of the hands. You find yourself praying, waiting, hoping for another twitch, but there is nothing.

You turn back to the scalp vein and begin fussily pawing through the IV cart, looking for a 23-gauge butterfly. “Do you have anything small enough to take a blood pressure?” you ask as you paw. “Have we got the cord blood back? And I need a fluid setup; we've got to get this baby's volume up.”

You are working under the infrared light of the Isolette. It's there to keep the baby warm, but instead it heats you. Now you've gotten to the point where you are dripping sweat on the baby. You wipe your forehead with your arm again, but it really doesn't seem to do any good.