I'm half asleep in the Peds ED, the only thing that has stood between me and blissful sleep is a 12 y/o with abdominal pain. I was set to send her home until her WBC count clocked in over 15,000 and she bought herself a CT scan. One more rule out appy for my last shift before vacation.
"Do you guys have an attending in here yet" asks one of the residents from the adult ED. We do not in fact have an attending on, not until 8:00am. It is just me the intern and a second year pediatrics resident running a level 1 trauma center. "Call the NICU then, you have a premie comming in".
I start to wake the resident when the firemen walk through the safety doors carrying a towel. They are sweating profusely as they walk quietly to the rescusitation room. The women has her fingers delicatly positioned over the middle of the towel as her index finger softly pumps, one two, three, four.... Her partner is holding an oxygen mask over the towel completly obstructing my view. The nurses with vastly more knowledge and experience than me have already rolled over the warmer and turned it on. The fireman sets the towel down.
It's bright red, about the size of my hand. It eyelids are fused, and it's skin is so transparent I can see it's lung moving beneath impossibly small ribs. The frantic movement I see beneath the sternum I can only surmise is its heart. It is not even clearly human, it insteads looks like some shrunken alien crash landed on this planet. It's head is smaller than a lime, its mouth opens less than the width of a pea. It can't possibly be alive. And then it breathes. So hard that I can watch all the muscles between its ribs retract with every tiny breath. We all stop, the seasoned nurses, the naive intern. The ER is usually one big traffic accident and most of us have long since stopped rubbernecking but everyone comes to see this. And from each one you can here the same audible gasp.
Peter, the NICU resident arrives on the scene and states what I know we all understand in our hearts. "It's not viable, we don't have a tube that runs that small. We just have to get the weight and we can be done" The rule in neonatal recussitation is firmly drawn at 500 grams. Anything bigger we go all out, do everything, even though most will die or be permanently neurologically disabled. Anything less and we do nothing. Like it never even existed. Whether you live or dies depends on whether you can outweigh a Coke can.
It weighs in at 177 grams. According to the report from mom, she thinks she was 18 weeks pregnant. That's less than 5 months.
We rewrap it in the towel, turn off the warmer. Peter goes over to ask the mom if she wants to hold it, say goodbye. She does. I go back to my desk to see what the hold up is on my appy kid. The ED is eerily silent and I can here the nurses in the lounge talking about what has happened, decompressing, trying to forget. A half an hour passes and Peter returns to the Peds ED with the towel.
"OB is going to take Mom upstairs to check her out. I already talked to my fellow and she says that protocol is to put it in a specimen jar and send it to pathology." "Alright, " I say half paying attention, " thanks for all yor help". I hear him sigh and then slowly start to speak again. "the thing is, it's still breathing. " The world grinds to a halt as I turn to face him, to take in what he is trying to tell me. "I have all the paperwork for path, I even have the jar. But it's still breathing. I can't put it in the jar like this. We can't take it to the NICU if were not going to do anything. I didn't think it would still be alive." None of us did.
We agree to keep it downstairs with us. It doesn't have any where else to go. Technically it not alive, but it's still breathing so I can't really say it's dead either. We find an empty room, Peter and I are now co-conspirators of some horrific crime that up until tonight I had no idea existed. We lay it back down on the warmer but we don't turn the warmer on. " Don't wrap it up," he says as I begin to swaddle it. Looking at it breathing, I can't help but think of my daughter when she was a newborn. I want to hold it, to tell it that its okay, to comfort it. Does it feel pain? I don't know. But I do. It must feel something. To go from the comfort of being warm and snug suurounded by amniotic fluid with it's life finely tuned to the rhythmic beating of it's mother's heart. The world now cold and chaotic. We are as foriegn to it as it is foreign to us. " If you expose it then it will go faster."
And so we wait, while it continues to breathe and defy us. We wait as another intern on a different rotation stops by to see how my night went. I bring her in to see it. It is colder now, breathing more slowly. A bloom of bright red covers it's chest. Trauma from the fireman's CPR has ruptured its fragile blood vessels. And so we wait. My appy kid does not have an appy, just some kid with run of the mill abdominal pain. So we wait. Time has slowed to an unbelievable crawl as we wait for death to claim a life that never was. I come in to check on it. It is cold to the touch, it has stopped moving. I pick it up, ready to finally put it in the jar.
Then it breathes.
And so we wait. The nurses change shift and the waiting room fills with patients that have no idea what is happening in room 6. I wait for it to die, to be done. The attending comes in and I tell her about the cordened off room, the squiggly line on the board with no name and no chief complaint. We wait, in truth it is just me who is waiting. Everyone else seems content to forget about it but I keep returning to the room every half hour. To let it know that it has not been forgotten even though I will do nothing for it. I wait.
Four hours after it first appeared in the ED, one of the senior nurses comes in the doctor's area with a towel. There is no doubt what is inside. She gets the jar. I don't even know if it was actually dead when she put it in the jar. I didn't ask to see it, to see for myself that it was over. Who knows maybe she just has more nerve than me. All I know is that it is over. Or it least it should be.
But I am still waiting. Waiting for forgiveness though I my head knows I did nothing wrong. Waiting to stop seeing it breathe in my dreams. Waiting for it to give up on life even though it never knew what life was. Waiting to stop seeing it in my dreams. To stop seeing it in my daughter's eyes when she laughs. Waiting to stop being mad at myself for not holding it and giving it comfort while it died. To give it the gift of humanity that is all our birthrights, when it had, in fact, been born. It had lived though it will have no funeral, no name, no birthday. Just "it". I am waiting. I am still waiting. I wil always be waiting.