A matter of life in death

It begins with carnage and never really ends.

Published March 21, 2001 7:38PM (EST)

A piercing shriek cut suddenly short, a car flipping sidelong against its natural direction. For an odd, hanging moment, nothing else happened. The sky overhead buzzed as a helicopter changed directions. On the ground, asphalt sparked in an infinity of rising dust and fallen glass crystals around a dusty brown car; a palette of reds splattered and dotted the windshield, and then began to drip.

The car tumbled to a halt in a precarious stance on the passenger side, all four tires airborne, after one-and-a-half turns on the highway. The truck had recoiled back into the mouth of the crossing. The next 30 seconds or so following the helicopter's departure were still. Police records indicate several calls registered to 911 nearly simultaneously.

That's how it ends or that's how it begins.

The intersection, at Route 1 and Rippon Boulevard, was long familiar to 911 operators. Route 1, three lanes in each direction on a slight elevation, bends gently to the south and east. Rippon Boulevard enters blindly. Route 1 traffic is hidden by a 20- or 30-foot hill at the intersection, a mound of dirt and tall reedy grasses. A left turn is a grope until the middle of a lane in which cars stream by at 50 miles per hour. It's a setup. A meat grinder.

The nearest rescue squad, three blocks south, can get there in under a minute. The first vehicles arrived as the second round of calls lit up the 911 switchboard and they knew, before they even got there, that it was going to be a bad one.

The paramedics were ready for anywhere up to four or five occupants. The statistics of vehicle occupancy dictated that chances were good there would be a single victim, the odds on two a lot lower but possible. Three or more would have been a rare stroke of bad luck. As they shot out of their truck and scrambled over to the driver's side of the smashed car, a single occupant -- and a horrible surprise -- awaited them. It was instantly apparent. The lady's huge belly was moving.

First-responder protocols include perhaps one paragraph on the pregnant trauma victim: A) It is a rare situation, and B) get her the hell to the hospital as fast as humanly possible. The woman's body would take a minimum of five to 10 minutes to extricate from the wreckage. It was already so busted up they might only have attempted to find a pulse to confirm the fact of instant death, but with a living patient trapped inside their dead patient, they had to get her to the hospital no matter what.

A medic crawled in through the back seat to support the woman's head and stabilize her neck with a rigid-foam collar; a second medic broke through the windshield and produced a face mask and oxygen bag. Then, still at a crazy angle inside the vehicle, they attempted an awkward, ineffective CPR in earnest, one pushing in and falling back off her chest, the other blowing in oxygen from the bag and mask. The ambulance driver radioed for more help.

No one noticed that somewhere along the line the baby had stopped moving.

"Line one, Jul."

The call greeted me as I began my E.R. shift at 4 p.m. "They're working on what looks to be a near-term pregnant woman MVA out on Route 1. No vital signs, ground crew called for air backup. No ETA yet, they're still getting her out of the car."


I turned around to look at the patient board, scan the nursing station. A reflexive move, a dodge. Okaaay. "No vitals because they haven't gotten to her yet, or no vitals?"

"No vitals." As in dead.

"All right." I paused again, because this raised a million questions. "I'll get NICU (the Neonatal Intensive Care Unit) down here. Do they know?"

"Not yet."

I hung up. Lynn, the charge nurse, hovered over me with her hands on her hips. "What's coming in?" She skipped a grimace and went for a poker face when she heard the details. "Coming by air?"

"Called for 'em. Still getting her out of the car. We've got some time."

The message from Comm (communications) was clear: Mom was gone but if everything broke right there might be a chance to salvage the baby. Such rescues were rare, but not unheard of. They'd have to be here in 10 minutes max in order to give the baby a chance. Possibly the mother, too, if, for some reason, the pre-hospital info was wrong or overblown. So, in practical terms, the call meant we had to get the NICU, specialists in newborns and preemies, down to the E.R. in a hurry.

Activating a trauma team is as easy as pushing a button. The E.R. at Fairfax Hospital, in the suburbs of Northern Virginia, is a Level 1 trauma center, a place where miracles can -- and are expected to -- take place. But the rescue about to unfold was going to push our limits.

Comm called again almost immediately with an update. "Air crew's there. ETA 15," she said and disconnected. We had 15 minutes to get ready.

Kathy Kelly, the other E.R. doc who had been alerted to the coming trauma code, was on the phone when I found her. Her exasperated look, a too-calm "No, I need you now," signaled that the party on the other end wasn't cooperating. Her clipped tone, the "now" of her request, was the unique prerogative of the E.R. doc: When we call for help, we need help. Kathy set the receiver down and stared at it for a second before looking up at me. "That was OB. They'll try to make it."


"Do or do not," she said, in fair imitation of Yoda. "There is no try."

"So what's the scene here?" I asked.

In medical school, one of the fostering-nurturing things students are told ad nauseam is that there is no such thing as a stupid question. In the real world of medicine, 90 percent of questions are stupid, including the one I'd just asked. The "scene" was the New York subway, the F train at rush hour, and it was about to get substantially worse.

Lynn suddenly appeared from the mouth of the trauma room, dictating strategy and ready positions. With a double trauma on the way and every bed already occupied, her whip was already cracking. "Kathy. I'm moving the last two traumas out to the hall. Julian, the baby will go into Room 2 once he or she's out."

Because obstetric trauma occurs so rarely, neither obstetrics nor neonatology staff are used to the stop-drop-and-run drill that E.R. and trauma docs take for granted. A few obstetric and neonatal emergencies demand instantaneous care, but for the most part, their docs rarely need to go running to find them. When the neonatologist, Dr. Huntington, returned my page she, too, sounded busy, and her tone left me less than completely reassured that anyone would show up to help.

I had performed resuscitation on critically ill newborns and preemies during my pediatrics residency years before, but I had gotten a little rusty, and hoped the skills would come back to me. A lot of life hung on the results. I didn't need the NICU so much, but I prayed for them to arrive. I doubted any E.R. doc had ever done a crash cesarean section. A trauma surgeon, yes, probably, because trauma surgeons are accustomed to emergency surgery, but even then it might not be smooth.

An inescapable fact of medicine, unfailing as a law of nature, dictates that the more practiced a surgeon is at a procedure, the better the ultimate outcome. I had no idea at the time, really, how fast a crash C-section could be performed -- two minutes? three? -- but I knew that an obstetrics resident performed them far more often than a general surgeon.

Given the situation, doing it in two minutes was infinitely preferable to doing it in four minutes. And given, too, the grim fact that the mother, already dead in the field, had no realistic chance of resuscitation whatsoever, the only point of this whole exercise would be to immediately remove the baby in the remote to unlikely chance it had not already suffered irreversible brain damage.

All trauma patients, upon arrival in the E.R., are given a name, Alpha through Zulu. All receive the surname Doe. The woman headed our way was Sierra Doe; her baby, if she made it, Tango Doe. Once the helicopter bearing Sierra Doe landed on the roof of the E.R., it would take less than 60 seconds for the team to bring her down from the landing pad and into the trauma bay.

The only job I absolutely had to do was to check that we had a functioning warmer for the baby and a neonatal resuscitation kit ready. Residency training had ground into me that checking one's own resuscitation box was like packing your own parachute -- only the life at stake was not mine, but a newborn baby's. I had five or six whole minutes to get ready. An eternity.

Matt Minoli, the senior trauma surgery resident, had already been in the E.R. all day. He had just left to tend to a crashing patient in the Surgical ICU, leaving Prabhu, his junior resident, sewing up the head of the last trauma patient, who had arrived 20 or so minutes earlier.

Matt responded loudly to the page, "Fuckin' motherfucker. They're thinning the fucking herd out there today."

"OB's not here yet, and they sound busy," Lynn informed him on his return. "Ever done a stat section?" she asked.

"I've done C-sections once or twice," he said, folding his arms.

"Well, here's your chance to do another one," she said.

He rubbed his chin, eyes sliding to the trauma room, where his junior resident was still sewing the scalp laceration. He patted his pockets, found a surgical stapler. "Prabhu!" he called out. "Catch!" The silvery packet sailed across the E.R. Prabhu's puzzled look turned to a nod of understanding. The head wound was closed in an instant.

The Comm nurse had an update from the flight crew. Sierra still had no pulse, even with CPR. There was a "downtime" of 15-plus minutes, which meant she'd been pulseless -- dead -- at least that long. There was a lot of blood.

The only one listening besides the secretary, several patients and their families was Donna Rotondo, our social worker.

When a trauma patient arrives, one critical team member waits in the background, eyes and ears alert, arms folded, hands idle: the social worker. He or she watches from a corner, picking up bits and pieces of information, awaiting the family's arrival. Social workers routinely embrace the family's misery and loss, standing by through the ordeal and interpreting the goings on. Depending on the gravity of the situation, they offer condolences, tempered pessimism or reassurance, accompanied by advice on whom to call for emotional support.

"You knew this was coming in, didn't you?" the Comm nurse asked.

Donna shook her head no, her face registering alarm.

Donna's task was to find the husband and arrange for him to get over here if the 911 rescuers had not dispatched police to do that already. Maybe the woman's wallet would help someone from the ambulance crew find the guy. If not, Donna would make first contact. This delicate art requires her to prepare him for a brutal shock without telling him the worst of it. After all, none of us knew yet what was coming our way.

Donna is the person you want in the room at the moment your life is shattered. The daily, close contact with vulnerable and confused people facing their most primal fears is not for the faint of heart. The trauma code could last a matter of minutes at most. Intense, hairy as it might be, it would blow over quickly enough. Everything afterward, preparing the father to cope with the hours, days, months, years ahead, fell on her shoulders.

With Donna dispatched, the Comm nurse repeated her update. Sierra Doe had taken the full impact of the oncoming car. There was a subtext: In the science of crashes -- and car wrecks are meticulously referred to as crashes, not accidents -- somebody is always at fault. When a car runs a light, the driver of that car risks being crunched under the force of an accelerating vehicle, the caving door just inches away from his or her body. The innocent driver is at least a hood's length way from impact. By the harsh logic of vehicular crash statistics, our girl may have run the red.

We didn't want to believe it. Pre-hospital information is sometimes sketchy, inaccurate or just plain wrong. (Subsequent accident reconstruction investigators later did, in fact, find otherwise.) But news distracted us.

That's when we heard it. The helicopter carrying Sierra Doe chopped into our thoughts and at that moment, despite all the commotion, not one true specialist who could help her in a meaningful way was present.

The baby box was under the warmer and everything seemed to be ready: tubes for the airway, I.V. catheters, pre-filled medication syringes. My thoughts were racing so fast at that moment I was only half-aware of what I was checking. I didn't want to miss the action in the next room. At first, I nervously registered a couple of syringes, a bunch of tubes. I forced a deep breath, then focused on each item one by one. Each medication syringe appeared to be properly labeled, none expired or outdated, all the correct tube sizes. Very few items are needed to rescue even the most gravely ill newborn.

Kathy, Matt, Prabhu and select nurses began to rip open sterile packs containing turquoise blue surgical gowns, matching booties, masks and caps. An obstetrics cart had been wheeled in and Matt headed there first. He was soon joined by two women I did not recognize, both skinny and blond, neither one in trauma garb, who had followed us in without our being aware of their arrival.

The obstetrics team -- finally.

Their belated arrival added to the crackling air of anticipation. Our patient was being unloaded from the helicopter, rolled into the elevator. In another moment, she would emerge into the corridor a few yards away. NICU was still AWOL.

Matt and the obstetrician reviewed their strategy. The trauma surgeons were to be at Sierra's head and chest as the OB team, at the belly, sliced and grabbed. "Who's going to take the baby?"


The surgeons whirled around and seemed to see me for the first time.

Prabhu, lacing and unlacing his fingers, looked across an empty stretcher to Matt. "She won't make it," he said. "Right?"

"Bet she will," Matt said.

"A beer," the junior rejoined.

"You're on."

"Prabhu," Kathy said softly from immediately behind his shoulder, "don't bet on patients. Don't bet on death."

A few students and residents had been trying to squeeze into the room so as not to miss out on the rare experience. Lynn, assuming the role of recording nurse, shooed them out one by one, from a podium at the back of the room. Each time a swish of a body came through the door, all eyes turned in anticipation, followed by grumbling at the inconsiderate idiots breaking their attention, stretching their nerves.

Lynn, getting exasperated, yelled out into the E.R. for someone to keep everyone else out of the room and then pulled the door closed. The trauma record, a massive, three-page document, unscrolled in front of her.

The door opened again, and Lynn countered with a lunge of her own. "I told you to keep out!" she snapped.

A dark-blue-sleeved arm, bearing the insignia of the AirCare rescue team, forced her arm backward. Sierra Doe, the guest of honor, had arrived.

The 15 or so sea blue bodies packing the room -- doctors, nurses, techs -- distinguishable only by their eyes, parted for the stretcher and paramedics. As if choreographed, a gap opened around the trauma bed, and the phalanx of dark blue rescuers marched in with Sierra Doe.

My first glimpse was of a small mass -- a swath of skin, a tangle of hair and a plastic tube. The head and face. Next came a huge mass, a thunderhead -- her gravid belly. Dried and not yet dried blood covered her face, her hair, every inch of her flesh, the middle part of the dark blue flight suits surrounding her. It permeated the fabric of her dress. The torso of one of the paramedics rhythmically pumped up and down on her chest as the effort at cardiopulmonary resuscitation continued.

Fifteen bodies closed in on Sierra Doe as swiftly as they parted. Exhale, inhale. A pair of heavy-duty scissors hacked through the remains of her blue jeans up to her blood-soaked maternity top. The bloody rags were pulled aside.

Simultaneously, the chief flight paramedic stepped back and gave his report, his the only voice in the room for the moment. Standing just beyond the patient's head, he described the scene we all knew by heart: T-bone collision, high speed in an intersection. Driver-side car door into her side.

Matt and Prabhu were on opposite sides of her chest, talking in voices loud enough to be heard over the paramedic. Matt apparently didn't like what he saw and called, "Thoracotomy tray!" The paramedic performing CPR was waved off by Matt, who intended to slice open her chest and explore for heart wounds -- the first swirl of chaos in the otherwise orderly proceedings.

The obstetrics surgeon had not said a word. Standing immediately in front of me, next to the enormous belly, she started her procedure. My eyes snapped from Sierra Doe's chest to her belly; the mental sequence of neonatal resuscitation stopped running abruptly. In another two minutes, maybe three, I would have the baby.

"Probably 25 minutes realistically," blared the voice of the flight medic over the din. Dead for 25 minutes. An eternity. What are we all doing here? In just that flick of an eye upward, I missed half of the cesarean.



Subcutaneous fat.

Linea alba.

A scalpel raced through them, a single horizontal slice. A brown-black mass appeared through the incision; the obstetric resident's assistant's hands shoved back the ecchymotic flesh, further exposing the darkened uterus.

Lynn barked irritably from her podium: "Tell me what you're doing, people." A nurse holding a bag of blood spiked it with an infusion set, called out to the nurse closest to the body to open up. At the nod, she squeezed the bag with all her might, and a cord of red -- transfusion No. 1 -- began snaking its way into Sierra Doe's broken body.

Fascia sheath.



The OB resident deftly flicked the scalpel handle around in her hand and passed it off to her assistant. Then, equally swiftly, she produced a fine pair of scissors, poked the point of the blade through the uterine fundus and guided the scissors down vertically from umbilicus to pubis. A slice first this way, then that. Thirty seconds, tops. She reached into the black waters and brought out a baby.

It's a girl.

No wail, no cry, just a purple slippery form.

"Time of delivery 4:13," she called loudly, and the room froze momentarily.

In a final display of dexterity, the OB resident's hands again appeared, this time at the improbable reed dangling beneath the baby. She clamped the umbilical cord once, moved up an inch and flicked the second clamp down, closing it on the cord. She cut the cord a moment after the second clamp was on, and Tango Doe was free.

I had been standing just behind the OB doc, stepping in closer as the startlingly brief cesarean unfolded. As she wheeled around, holding aloft the newborn girl, I raised my arms to receive her. Before I could lay gloved hands on her, Dr. Huntington, the NICU herself, darted in, grabbed the baby and fled.

A single, graceful arc traced her journey from mother's dark womb to isolette landing pad. I saw the baby's assessment had already started: A pair of the NICU doc's fingers fixed at the base of the umbilicus, feeling for a pulse.

The infant flopped down limply, and it was clear, without a nod or grunt from Huntington, there could be no pulse, no heart rate, as -- at the tender age of 15 seconds old, 20 -- no cry, no respiration. Same deeply saturated grape hue as mom. Lifeless, stillborn. Dr. Huntington had brought along just one nurse and they began their work: an endotracheal tube down the throat to breathe, a long I.V. catheter placed through the umbilical cord. Reflexively, my fingers were on the baby's chest, performing rapid compressions.

The nurse applied monitor pads, connected I.V. fluids, accepted medications from me. The quiet of Trauma Bay 2, punctuated by brief, staccato comments and replies, was a stark contrast to the rising din in the next room. They must have found something.

Sierra Doe, epicenter of the frenzy, lay paralytically still. Her color was an ashy purple, ashy from the rivers of blood drained through her many injuries, purple because the little blood left in her body had been depleted of all its oxygen. Her short brunet hair was matted in blood. The thin rim of her dilated pupils was too small to register a color.

Her arms were extended at both sides, the better to receive blood and fluids, the better to expose her flanks for various and sundry crash surgical procedures. The rest of her features were vague and distorted by the circumstances of her death: her face swollen and cut up, her body similarly disfigured and opened in unnatural ways.

But she inched closer back to life each moment. Matt found several fractured ribs and a gaping chest wound, perhaps sheared by glass, perhaps from the door itself crunching under the impact. Like the OB doc a few moments ago, he made a hasty slashing incision to explore. If the worst of her injuries was only a lacerated heart muscle, he would know the moment he held it in his hands. Fixable. The brain and its starvation for oxygen -- screw it. Never believe the worst until you see it for yourself.

With one hand inside her chest, Matt used the other to shove away the medic doing CPR. Sierra Doe's chest relaxed, allowing Matt's fingers to crawl deeper into her thorax. Maybe there was a chance for a good resuscitation after all.

The second unit of blood arrived, then almost as quickly began to leak through the sieve of her wounds. Prabhu spiked a needle into the right side of her chest and was greeted immediately by a rush of air and a stream of blood, and the right lung reexpanded. A step closer.

It was with the third unit of blood, the third of eight eventually muscled in, that the miracle occurred. Matt's fingers, caressing the woman's heart, failed to identify a tear, and for a moment his spirits fell. The woman would not be tricked from death by something as easy as a lacerated heart.

As his fingers withdrew, he perhaps tickled a fiber, a sensitive spot. Something. Kathy's eyes, still darting briskly, flicked up to the monitor above.

A beat. A pause. Another. Another.

"Is there a pulse with that?" Kathy asked, her voice rising through the din.

And there was. As the heart resumed its ceaseless motion -- contract, relax, contract, relax -- the pallor of Sierra's face transformed from purple to pink, from ghostly death to flickering life, from a gargoyle into a pretty, young mommy.

"God must not have wanted her," Lynn said, tears pouring forth from her eyes.

Everyone in the room froze as Richard stepped in. The only movement was the flare of a white bedsheet as it was hastily thrown over Sierra Doe's gutted abdomen and thorax. The nurses, docs and techs met his eyes with a blank stare. We had assembled for the sole purpose of giving this man a chance to be with his wife and baby, but no one seemed to know what to do with him once he got there.

Kathy sensed her cue and approached him, softly, telling him about the broken ribs, the internal bleeding. She pointed to chest tubes. He nodded, possibly understanding, possibly following what she was saying. The sheet covering his wife's belly was turning red as Kathy pointed to it; the surgeons needed to get her to the O.R. right away to explore for other injuries, like a lacerated liver or spleen. Again a nod. He looked around nervously. A rainbow of reds splashed seemingly everywhere, on towels thrown to the floor, smearing the sea blue surgical gowns and hanging from the last two transfusion bags into the body of his wife. Too much blood. No baby.

We don't know yet if any head injuries have been sustained, Kathy continued. There's no obvious sign of head injury, and the tube coming from her mouth is for breathing. Once more, a nod.

Then she handed him off to me.

He engaged my eyes first. He was so young.

"Here. Come with me," I said, guiding him by his shoulders through the cubicle between the two trauma rooms.

The view in Trauma Bay 2 presented a far more antiseptic picture: Here was a small baby, swaddled in blankets, in the arms of a nurse. We arrived just as Dr. Huntington and her nurse were preparing to take the baby to their unit. They didn't know the father had shown up.

I told him, "It's a girl" as the nurse handed her over, placed her in his arms. "Oh ... a girl ..." he cried. "A girl ..."

He carried her stiffly, like any new father, afraid he might break her. It all looked so normal.

The long-dormant memory reawakened, the reflex of how to talk a new dad through a disastrous delivery that may -- will -- have lifelong consequences. I told him that his baby had revived as soon as we started to work on her, that her ultimate prognosis would be known better once some testing could be done in the NICU. "Prognosis" is a portentous, scary enough word, and I left it at that. He hadn't heard me, wasn't even listening.

"Her name is Elizabeth," he whispered, his eyes brimming. My eyes welled, too. "That's a beautiful name," I said. "She's a beautiful baby girl."

"Liebchen and I picked the name just a week ago."

Dr. Huntington explained that she was there to take the baby to the NICU in the mobile warmer just behind him. As he gave away his baby, he lapsed once again into a series of nods and "uh-huhs." The nurse placed Elizabeth in the isolette. I took the father by the shoulder and guided him back to his wife.

The collected surgeons, nurses and techs were chafing to get to the O.R., to get out of that room, finally. It seemed like an eternity since Sierra Doe had first rolled in, and the minute it took Richard to meet his daughter had been an excruciating pause. Matt and Prabhu were busting to get to the O.R., a home turf of sorts, and be done with the ghastly nightmare. But they would be forced to endure it for another moment, as Richard took a step to his wife, and bent down to her ear.

"I've just been in to see our daughter," he said, choking on the word "daughter." "Elizabeth. She's beautiful. Just like you."

Then he kissed her, lingering for a long moment, tears working their way down his face. "She loves her mommy. She told me to tell you."

And then it happened. Her eyelids twitched. Blinked. It was the last movement Liebchen ever made, and even now I think it was because she had heard him. In the darkening, closing paths and circuits of her brain, I am convinced she knew, just before she died, that she had given birth, was a mommy, and that her daughter was making her father so damn proud that she could finally let go.

No one else saw it besides Richard and me. I asked, and no one believes me. It hardly matters. She blinked. She acknowledged her husband's love and the birth of their daughter.

Richard stood up, ready to go, helpless and malleable once more. But halfway out of the room, he turned back to face us: a vast crowd, anonymous behind identical gowns, masks and caps. He stopped and addressed the sea of eyes. "Thank you. All." He stuttered, trying to think of something else to add. "I mean, just thank you. All of you."

The door shut softly behind him. Sierra Doe's blink, her baby's flickering survival, the stunning synchronicity of these unexpected events for the benefit of a husband and father -- it felt like perfection, like the apex of lifesaving, even with death, two deaths, around the corner. We had resuscitated battered humans before, but never with such graceful timing, never for such brief and rich reward.

As if a switch had been thrown, the team revived and broke into action, this time to disband. Someone kicked the brake from under the stretcher, releasing the wheels, and in another second the sea blue and blood-spattered phalanx escorted Sierra Doe to the O.R. A half-minute later, Dr. Huntington and her nurse rolled the isolette bearing Tango Doe silently away to the NICU. Both trauma rooms stood empty except for one or two housekeeping crew cleaning up.

Kathy and I exchanged glances, a few words, and we started to part company, too. The X-ray tech was hustling back toward us with a film's ugly truths and a confused, wondering look on her face. Everyone's gone, and she had something vital to share. "O.R.," I said.

"Look, though."

I held the black-gray film up to the light. "Yeah, OK." The head was attached only by skin and muscle, above a severed spine. Depending on where you stand, that's how it ends or that's how it begins all over again.

Liebchen, once known as Sierra Doe, died at 9:46 p.m. She was taken to the operating room from the trauma bay, where a quick exploration of her abdomen turned up surprisingly little damage. The X-ray tech jogged in with the film revealing the fatal separation between head and neck. Matt studied it as he worked his fingers on her intestine. He sighed, shrugged and instructed Prabhu and another junior resident to begin closing.

"See that?" he said. "Atlanto-occipital distraction."

The existing records fail to document how many times Richard held Elizabeth in his arms before she died the day after the accident. They are maddeningly dry with regard to her final moments: "The infant was removed from the ventilator and within six minutes there was no heart rate. The infant made no respiratory efforts off the ventilator. Thus the heart stopped."

But I know what goes on.

The nurse takes the baby's isolette to a quiet room, picks a fresh blanket from the warmer and sits the father in a comfortable rocker. She disconnects the monitors first -- the alarms going off would be a cruel distraction -- and then she caps off whatever I.V.s are running. This makes it a simpler matter to wrap the baby to make her look pretty and normal, and only then does she hand the baby over to the dad.

In a minute the nurse stops the ventilator. She breaks the connection between breathing tube and machine, and the baby's color fades, pink to ashy to deeply cyanotic, and the mingled sounds of crying and grief might fill the room. And then sometime later they will fade, too.

Almost to the day, four years later, Richard remarried. And almost to the day, two years after that, he held a baby girl in his arms once again, healthy, pink, kicking and crying. Which was the greatest act of faith? Getting married again? Crying for joy upon learning his wife was pregnant? Or something as subtle as watching her drive off to work one more time?

If asked, I'll tell you the most beautiful thing I can think of is this: At night, Richard puts his baby, Serena, to bed in the crib Liebchen's father made for another baby in another house in another life. Richard sings his daughter to sleep and sometime later on he'll check on her once more.

By J.B. Orenstein

J.B. Orenstein is a physician practicing pediatric emergency medicine in Fairfax, Va. His writings have appeared in the Washington Post, Annals of Emergency Medicine and Pediatrics.

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