Stand & Deliver

By Edward Humes

From Los Angeles Magazine
November 2000

When it comes to saving the lives of newborns, Dr. Guadalupe Padilla and her colleague at Long Beach Memorial’s neonatal intensive care unit are some of the best in the nation

“LUPE’S ON TONIGHT,” Denise Callahan, the nurse coordinator lets the nurses know. There are audible groans, “And you were wondering why we’ve been so busy. These kids know she’s comin’. That’s why they’re all turning blue.” Dr. Guadalupe Padilla, one of the four partners who run the neonatal intensive care unit at Long Beach Memorial Medical Center, is the attending physician on call tonight; she’ll work well into the morning then may or may not go home. Now she shrugs and smiles at the familiar remark. “What can I say?” There’s genuine mirth in her voice — she’s a woman who relishes banter. “It’s all true.”

There are stories about all the attending doctors — nurses cherish them, pass them on, maintaining an oral tradition for the neonatal intensive care unit. The Lupe stories are among the most gleefully retold. Legend has it that whenever the weekly schedule puts Lupe on call or in Room 288, which houses the NICU’s toughest cases, admissions go up, emergencies multiply and the babies get sicker — a pattern even she agrees has held true since her days as a chief resident, when she earned the nickname “Angel of Death.” The moniker, never spoken within earshot of parents or other outsiders, has nothing to do with her patients’ outcomes, which are as good as or better than any neonatologist’s in the business. She earned the nickname because the staff feels worked to death whenever she’s around.

Things just seem to happen more with Lupe around, this tall, imposing woman with flying dark hair and rumpled scrubs, who eschews makeup and nail polish and fashionable shoes as if they were infectious diseases, whose medical knowledge is encyclopedic but who never seems to know how to find her key ring or her beloved God-what-did-I-do-with-it-now Palm Pilot. If she’s monitoring the normal newborn nursery, more babies seem to need an NICU admission. If she’s on nights, the babies seem to need resuscitation more often. Outlying hospitals call for more transport teams. The unit fills up like Los Angeles International Airport the day before Thanksgiving. One night, the unit got so crowded that a closet had to be converted to an extra patient care area. No one had to ask who was on call.

Given her reputation, Lupe likes to proclaim herself the unit pessimist. Her glass-half-empty outlook, she says, is why she so readily admits a baby to the NICU with even the mildest of symptoms, whereas some of her colleagues might take a wait-and-see approach and let a child stay in the healthy newborn nursery for observation. Once an infant is admitted to the NICU, the minimum stay is usually three days, which is how long it takes to culture an infection — — or to prove no infection is present. This is an eternity for parents who just want their babies home, so some neonatologists bend over backward to avoid that delay unless there is strong evidence that a newborn is sick. Not Lupe: She assumes the worst will befall any baby in question, admits the kid for three days, then hopes she is proven wrong — believing that 72 extra hours in the hospital is a small price to pay for a lifetime of peace of mind, both hers and the parents’.

* * *

Colleagues who know her best argue that this amounts not so much to pessimism as to an abiding (even optimistic) belief that her NICU is the best place in the world to be if you’re a baby whose health is in question. If so, she has a point: The Miller Children’s Hospital NICU at Long Beach Memorial has long been at the forefront of neonatal care, a pioneer of new methods since the ’70s, a teaching hospital that provides the highest level of infant care available anywhere, treating from 60 to 70 seriously ill infants at a time, making it one of the biggest in the nation. It is a feeder hospital, where even large and respected medical centers in the region ship their toughest cases, from pound-size micropreemies born four months too soon to babies with birth defects and infant heart and lung disease in for long treatments and surgeries.

Yet in this era of medical bureaucracy and cost containment, the unit is a surprisingly human — and humane — place, where attending physicians staff the unit round the clock. Other parts of this hospital — and most other neonatal units — leave nights and holidays to the fellows and residents, the scut workers of medicine, making pennies on the dollar as they earn their licenses. But here, the desperate parents of desperately ill babies know that at least one of the attending neonatologists is always on duty. Not surprisingly, survival statistics at Long Beach are far higher than at the average NICU, which may be why Lupe feels justified in playing the unit pessimist, admitting babies whenever she is in doubt.

And so the Angel of Death legend has endured, the image of Lupe as a human tsunami spreading from the intimate confines of the unit to the hospital at large: When the latest crop of residents put on the annual roast of their mentors, the young doctor playing Lupe wore a hat with a giant black cloud attached. Whenever her character was about to speak, she would be paged to a medical emergency and would race offstage under her storm cloud, unable to complete even the briefest conversation. The skit was a showstopper, provoking laughs and hoots of recognition. Lupe’s reaction was typical: “I’ve got to get one of those hats,” she told her husband.

“What does she need the hat for?” Denise later quips. “She’s got a real storm cloud over her, everyone knows that.”

As if in confirmation, the Stentofon barks to life. “We’ve got a crash C-section in OR-9,” the voice in the wall-mounted speaker informs the room. “We’ve got decels and mec. They’re cutting now.”

In the women’s hospital next door, Gillian Berger (not her real name) is already on the operating table, her abdomen about to be split wide open. It wasn’t supposed to happen this way. Gillian is 33, in perfect health. Until a few minutes ago, she and her husband, Harry, a food company executive, had enjoyed a textbook pregnancy. Every prenatal test had been normal, the ultrasound had looked great, the labor had progressed for hours without a hitch. They had every reason in the world to expect a textbook baby as well.

Then the numbers on the fetal heart monitor began to dip. The baby’s heart was struggling, not with the normal periodic slowdowns brought on by contractions but with an alarming condition called terminal bradycardia — prolonged drops below the newborn’s (and soon-to-be-born’s) normal minimum of 100 beats per minute. A depressed heartbeat can prevent the brain and other vital organs from getting sufficient oxygen, causing permanent damage, even death. Or the heart problem might be symptomatic of some other life-threatening condition. There is just no way to tell without examining and treating the baby outside the womb. Getting the baby out-and ending the source of the distress — had suddenly become a matter of life and death, with no time to spare. The Bergers listened to a hurried explanation, their terror mounting, with the nurses prepping Gillian for surgery before the doctor had finished speaking. Then she was raced to the OR for an emergency cesarean section, her husband stunned, a camera meant to capture the joyous moment dangling forgotten from his wrist. Inside the NICU, the speaker on the wall sounded its harsh bleat:

Decels. Mec. They’re cutting now.

Decels is an abbreviation for “decelerations,” a reference to the alarming drops in the baby’s heart rate. Mec is short for “meconium,” the hard fecal matter that forms inside babies’ intestines in utero, a substance stressed fetuses often pass into the amniotic fluid. It can then be inhaled, causing severe damage to the lungs. The neonatal team must use suction to remove the mec from the baby’s mouth and throat and treat the respiratory distress that inevitably results if some of the stuff finds its way into the lungs.

This must be the most horrible and momentous event in the Bergers’ lives, so it would no doubt bewilder them to learn that nothing about their personal nightmare seems particularly extraordinary or alarming to the NICU staff: Decels and mec are seen on a daily basis, and treating them is usually easy. The staff is concerned and ready but knows getting the baby out usually resolves the decels. The mec usually doesn’t make its way below the vocal cords. If there is such a thing as a routine emergency, this would seem a good candidate, which is why a first-year neonatal fellow, rather than an attending physician, goes over to handle the Berger delivery. It takes three years of training as a fellow for a pediatrician to become a neonatologist, but this first-year has done other deliveries that sounded a lot worse than the Bergers’. No one gives it a second thought.

It takes less than a minute for the team to realize there is nothing routine about this emergency. Before she was even handed over by the obstetrician and wrapped in a blue receiving blanket, Baby Girl Berger began coding — hospital-speak for dying, a variation of the venerable but descriptive medical euphemism “Code Blue.” Blood spews from the child’s lungs when the fellow inserts a breathing tube and suction is applied. She is not breathing on her own. Her heart barely registers. When the fellow pulls the breathing tube back out to look for the cause of the bleeding, the child’s heart thumps to a complete stop. While the nurse — the veteran night shift coordinator, Martha Rivera — begins chest compressions, she asks one of the labor/delivery nurses to call the NICU: “Ask for one of the attendings. Stat.”

TWO MINUTES LATER, LUPE PADILLA pushes into the room and takes in the scene: the baby in full code, the resuscitation under way, the respiratory therapist, a huge man named Greg Moses, moving gracefully in the tight quarters, “bagging” the child with his hand-pumped ventilator. The anesthesiologist who worked on the mother had to come over and help the neonatal fellow squeeze the breathing tube back into place, but he gives way when Lupe arrives. The sense of relief is palpable.

She says calmly, “Okay, whattawe got?”

“Pulmonary hemorrhage,” the first-year says gravely. Lupe nods, thinking, “Damn. Why did it have to be that?” Bleeding from the lungs, she knows, is one of the most devastating ailments the NICU faces, because there is no way to physically repair the bleeding vessels inside the lung, and because it can destroy a life more quickly than virtually any other trauma, as the baby literally drowns in her own blood. Something must have gone badly wrong during the last hours of Gillian Berger’s pregnancy — an infection, a blood pressure problem, something — and this is the result.

“They said it was mec, but there’s no mec,” Greg adds. “Just blood.” He pauses in his administration of pure oxygen and uses his suction hose. The clear plastic tubing turns bright red once again.

“There’s no heart rate, no respiration,” Martha says. “She’s been down for” — a glance to the clock — ”three minutes.”

“Okay, let’s see what we have here,” Lupe says, her gloved hands a blur over the child as she goes to work, her normally expressive voice now a careful monotone. As she speaks, she removes the breathing tube, then peers inside with her laryngoscope, a metal-handled, hammer-size tool capped by a light and a dull, flat blade that can be thrust down a baby’s throat. Lupe must push aside the tongue with the blade, finding a pathway for placing a breathing tube down the throat, past the larynx and into the trachea, so that oxygen can be pumped at high pressure directly into the lungs. Intubating a child — maneuvering the thin plastic endotracheal tube into a windpipe the diameter of a number-two pencil — at high speed, in a crisis, requires the finesse of a brain surgeon, particularly when copious amounts of blood are flowing, blocking the view. The residents watch in awe when their mentors do this without breaking a sweat.

“Okay, I’m in,” she says after a few seconds. “Let’s have a dose of epi, please.”

A small amount of epinephrine is poured from a vial into the baby’s breathing tube and blown into her lungs. Epi is one of the standard “code drugs” the team always brings to a transport or delivery — just in case. It is primarily a heart stimulant, but it also constricts blood vessels, a quality Lupe hopes will stanch the flow of blood from the baby’s lungs as well as jolt her heart. At the same time, she quickly threads an IV line into the stump of the umbilical cord still attached to the baby, the quickest way to administer more code drugs. All the while, Martha keeps performing compressions, using a delicate touch and two fingers of one hand, while Greg continues to “bag” the baby, trying to substitute external force for what the baby’s internal organs are supposed to be doing. Squeeze a chest and heart that are not moving, fill and empty lungs that are not breathing — and maybe there is still a chance.

“Another dose of epi, please.” This one goes into the umbilical line, straight to the heart. The baby still isn’t responding; the sense of urgency mounts with every passing second as the odds of saving her slip away with each tick of the clock.

BABY GIRL BERGER IS A PRETTY baby, Lupe can see. Looks perfect, chubby and bald. Lupe likes the bald babies. By all rights, this kid should be crying a hearty cry and lying on top of Mom’s belly right now. She’s a sucker-punch kid — the sort of baby everyone expected to be fine, who should be fine, but who crashes for no good reason. Beneath the streaks of amniotic fluid, blood and vernix — a thick, white, pasty substance that protects a fetus’s skin; nature’s cold cream, the nurses call it — the infant’s flesh looks gray instead of healthy pink. Her limbs lie flaccid, splayed out like a carelessly positioned doll’s. “This is an ugly one,” Lupe thinks. “This is not good.” Years ago, she backed out of a fellowship in pediatric intensive care because she could not bear the emotional toll of having to deal with older children dying, of seeing a five-year-old who had a wonderful life one day but was brain-dead the next because no one had seen him at the bottom of the swimming pool until it was too late. She had resigned from her fellowship after five months, telling her mentors she could not deal with it, and she had turned to neonatology, where a world of preemies and other babies who had no prior lives or bonds or expectations or crayoned pictures of Mom and Dad was somehow easier to take. Except there were these sucker-punch cases, the full-term babies who look perfect, and their parents, who had expected to take them home in a matter of hours.

But Lupe’s voice betrays no emotion and grows calmer with every order. “Thank you very much,” she says after each urgent order is met. Later she explains this method of dealing with emergencies: “It’s a way of exerting control over an out-of-control situation, a certain tone of voice. You get super, super polite. Sometimes it’s all we have.”

At the root of Lupe’s medical philosophy is an almost primal fear of making a mistake, a fear she embraces and makes use of every day. Fear is your friend, her mentor in the neonatal unit told her 16 years ago during her residency, before she realized what she was getting into — before she knew enough to be afraid. Fear keeps you honest, keeps you checking yourself. When you walk in this unit and feel no fear, irk time to go find a new job.

These words have stuck with Lupe: In every emergency, admission and delivery, each time she reviews a chart, peers over a resident’s shoulder or dictates a history and physical report, she remembers her mentor’s warning. She tries to remember her fear rather than her confidence in herself, her experience and all those machines, imagers and other devices that have made the hands-on physical exam a dying art. Echocardiograms are wonderful tools, Lupe says, but I want to listen to every heartbeat with my own ears. She memorizes the most distinctive heart murmurs like ditties, then hums them back at the residents, asking them what some rasp or whisper or minuscule skip in an infant heart might mean. She questions herself even more rigorously, mostly in her head but sometimes out loud: Did I prescribe the right dose? Did I choose the right med? Was my diagnosis correct? Shouldn’t I order another ultrasound or X-ray just to be sure?

Not that any patient or colleague can sense that fear. Whatever might be going on inside her head, few figures in the NICU inspire more hope in parents and confidence in staff than Guadalupe Padilla. Families find comfort in her easy, relaxed manner, the way she seems to relate with anyone who walks into the room. Is the father of one baby in her care a recent immigrant from a small town outside Guadalajara? There’s Lupe speaking to him in Spanish and saying, “What a coincidence, that’s the same town where my parents grew up.” Has the mother of the baby in the neighboring incubator just returned from vacationing in the Caribbean? There’s Lupe swapping cruise-ship horror stories with her: “All you do on those cruises is eat. Nothing in my suitcase fit me by the time we got to port.”

Lupe is the oldest daughter of Mexican immigrants, who raised their children on L.A.’s Westside, sending all eight off to college and professional careers. She bridges culture, class, language effortlessly. Her conversations with parents slip from personal chitchat to the fine points of abdominal surgery or treatment for respiratory distress, and Mom and Dad find the daunting medical talk less threatening. They are not speaking to a distant, authoritarian physician but to someone with whom they share common ground. With the staff, she is different but no less inspiring: She is a relentless nag, staying on top of every detail, even if it means fiddling with the dials herself instead of having a technician do it, because Lupe wants things just the way she wants them. “It’s that control-freak thing,” she says apologetically, then continues whatever it was she was doing. The nurses and respiratory therapists sometimes get irritated, but one thing is certain: They never have to worry that they are being left too much on their own when Lupe is around.

Still, for all her abilities, her calm, her take-charge manner, nothing is working at the moment. Four minutes have passed since the code began, and there is no heart rate, no respiration. Nothing.

“Let’s have some bicarb, please,” Lupe says. “Four mEqs.” A needle with an infant-size dose of sodium bicarbonate is emptied into the umbilical line. Bicarb counters the acids building up in the baby’s blood — a dangerous by-product of poor circulation and no breathing. It also helps the epinephrine do its job. Albumin is pushed through the catheter next to replace the volume of lost blood, then dextrose — a shot of sugar to improve circulation and brain function — followed by another dose of epi. And another. The kid should be turning handsprings from these drugs by now, but still there is no response.

It has been five minutes since the baby was delivered, though it seems much longer. Lupe makes a mental note of the baby’s five-minute Apgar score, a one-to-ten scale (named for its inventor, pioneering neonatologist Virginia Apgar) used to assess the physical reactions, vital signs and neurological state of a newborn. Points are awarded for the strength of the baby’s heartbeat, cry, respiration, color, reaction to stimuli. The scoring is done at one minute of life, then five minutes of life. If there’s a problem, it continues at five-minute intervals until the score — and the baby — are stable. An average healthy newborn usually scores a nine or eight. No one gets a ten, the nurses say, except the children of obstetricians and neonatologists. Anything below a five indicates a problem.

Baby Girl Berger’s one-minute Apgar was four.

Her five-minute Apgar, Lupe notes, is zero.

Zero means no heartbeat, no respiration, no movement.

No life.

“Hello, baby, you’re out,” Lupe cajoles the still child. Baby Girl Berger’s skin is no longer gray but chalky white, bloodless, waxy beneath the glare of the operating room lights. Lupe peels back one of the eyelids, looking to see if the baby’s pupils are wide open and nonreactive to light, a sure sign of massive brain damage. She smiles grimly, finding one encouraging thing to report: “No, they’re not blown.”

In the center of the room, the obstetrician, her assistant and the nurses are sewing their patient up. They are chatting, laughing, relaxed. For them, the drama is over. The OB looks up from her work and casually asks, “So how’s the baby doing?”

Lupe remains silent and shoots a look at the OB. Lupe doesn’t know if the mother is awake or not and hesitates to say what she is thinking, which is, “We’re losing this baby. And if we don’t lose her, there may not be much left to take home.” Instead, she simply says, in a voice that sounds almost unconcerned, “We’ll be right with you,” then returns to work, asking another neonatal nurse, who has come to provide backup, to draw more epi. The supply brought for the delivery has been exhausted. Blood is ordered from the blood bank, more bicarb is administered. Greg sucks more crimson liquid from the baby’s lungs. Martha continues her compressions. “God, she feels cold,” Lupe says, the baby’s skin icy beneath her touch, even through the latex glove. Baby Girl Berger is now 10 minutes old. Her Apgar score is still zero.

WHEN THE OFFICIAL CODE report is filed in the chart the next day, her condition at this point will be termed “severe neonatal depression.” But physiologically speaking, she is dead. The effects of lengthy periods without respiration and heartbeat are known to everyone in the room: The vital organs, beginning with the brain and progressing to the heart, lungs and kidneys, start to die. If enough of the brain is destroyed, the baby can suffer from cerebral palsy, developmental delays, paralysis, blindness and worse — assuming the child can be resuscitated at all. Lupe’s efforts are not pointless, however, because babies, particularly full-term, outwardly normal ones like Baby Girl Berger, are remarkably resilient. They can recover from insults that would destroy an adult. Still, there is a limit. Time is running out.

They reach the 12-minute mark, 12 minutes without breathing, without a heartbeat. If Martha’s compressions are just right, if the lungs are working and the blood is being oxygenated and if that blood gets to the brain and the other vital organs despite the lack of a working heart, it’s still possible the baby can make it. A lot of ifs, Lupe knows, which is why she is beginning to wonder when she should call the code. At 15 minutes? They can’t keep flogging this poor child forever. Calling the code means bringing the efforts to revive Baby Girl Berger to a halt. Lupe will look at the clock and pronounce the time of death, and one of the nurses will dutifully write it down, then they will all stand there and stare, dreading what comes next — with a mother under a surgical drape just six feet away, her belly still big from the child just taken from her.

“Come on, come on, you can do it,” Lupe urges the child. It is the first time anything resembling urgency has crept into her voice. Then, resuming her excruciatingly calm tone, she asks for a sixth and final dose of epi, please. This is one for the breathing tube again, like the first, a slam to the bleeding lungs and the idle heart, a jolt of liquid electricity. In it goes, and Martha stops her compressions. She and Greg and Lupe bend over the motionless child, searching for a response. For a moment, it seems, all the people in the room hold their breath, an eerie, silent pause.

The only sound in the room comes from a nurse stowing the disposable epinephrine syringe the doctor just injected into the baby. The syringe comes with a peel-off laser-scan tag, just one more item to be counted and tallied on the forms that accompany every piece of equipment in the hospital. “Come on, baby,” Lupe says again.

Lupe has her crisis look on. Her chapped lips are pursed, her forehead is a field of furrows. Her face is both serious and expectant, a poker face that betrays nothing but intense interest. Only those closest to Lupe know just how bad things have to be for this look to appear.

Lupe inherited the look from her father, a self-made man with a tendency to scatter the unusual in his wake. An accountant by trade, Jose Luis Padilla is also a self-taught architect and a quirkily talented homebuilder who doubled the size of his own home over the course of three years’ worth of weekends to accommodate the growing Padilla family. Then he built a house for one son and renovated another for one of Lupe’s sisters. (“Okay,” Lupe says, “so the toilet has hot water in one of the houses, and in the other, the electrical system is haunted — you never know which light will come on when you flip a switch. But we like to say that adds to the charm.”)

In OR-9, she is watching and waiting for Baby Girl Berger to live or die. How far this code will continue is strictly up to Lupe now, doctor in the uneasy role of God. When it is known ahead of time that a baby is in trouble, when tests have shown a birth defect so bad that a life worth living is just about impossible, the neonatologists meet with the expectant parents and have terrible discussions: How much in the way of heroic measures should we do? When should we stop trying to revive your child? Should we try at all? Even then, with sufficient time and knowledge to consider the options and probabilities, the parents find it hard to absorb, harder still to say anything other than Do everything you can to save my baby. Even when there is no hope, they pray that the predictions will be wrong, that a well baby will magically appear. But in this code, a crisis so out of the blue, so impossible to predict, there was no reason for any such discussions with the parents. Lupe must rely on her own knowledge and instinct to do everything possible to save the girl’s life without going too far. But where, she wonders, do you draw the line? Here? In another minute? Or have I already crossed it?

“Come on, baby,” Lupe urges one more time, and a moment later the infant’s mouth opens slightly.

Everyone leans forward a little, as if they aren’t quite sure of what they saw. It is just past the 12-minute mark. The mouth opens a little more and Baby Girl Berger’s chest appears to shake. Then, with a shuddering gasp, she begins to breathe. The last dose of epinephrine at the last possible moment did the trick.

“I’ve got a pulse,” Martha calls out. Lupe listens to the faltering heart with her stethoscope and watches Martha silently signal the pulse rate by raising and lifting her index finger in time with the beat, the silent, efficient communication of a neonatal Code Blue. The pulse rate starts at 40, then rises to 80. In less than a minute, she’s over a 100 and holding. The code is over, as abruptly as it began.

“Let’s get her in a warming blanket and over to the unit,” Lupe says.

With Greg still bagging the child, Martha lifts the baby, IV lines trailing, into the transport incubator. In a moment, the infant is wheeled from the room, the respiratory therapist jogging alongside, continuing to supply oxygen.

There is a plethora of tests to do, but Lupe feels the likely cause is pulmonary hypertension, a serious ailment in newborns that results in high blood pressure in the arteries leading to the lungs. When the pressure gets high enough, the vessels constrict tightly and blood is shunted away from the lungs, depriving the body of oxygen. It can be caused by the sort of pulmonary hemorrhage Baby Girl Berger experienced at birth. Hearts, livers, stomachs, intestines, most of the vital organs can be surgically repaired, more or less. Not lungs. Whatever you come into the world with has to keep you alive. The lungs can be assisted, they can be given a chance to heal, but they cannot be fixed the way a surgeon can untwist a bowel or repair an aorta.

THE BABY IS TAKEN TO THE neonatal unit’s small treatment room, crammed with monitors, a digital scale and a miniature operating table, which lies under mercilessly brilliant lights and a warmer that instantly turns the area around the baby into a sauna, making scrubs, masks and surgical hats nearly unbearable.

Baby Girl Berger is weighed, measured and given a second umbilical line. She is placed on a high-frequency oscillating ventilator, which looks like a blue-and-beige box crammed with electronics sitting atop a pedestal on wheels. This is one of the newest and most expensive pieces of equipment in the NICU; it is radically different from the conventional ventilators that force air into and out of a baby’s lungs, in a rhythm that at least resembles normal respiration. In contrast, the oscillator delivers and sucks out tiny puffs of oxygen hundreds of times a minute rather than whole lungfuls of air. The lungs are not emptied and filled with each breath, but their contents are continually recycled through this oscillation of the air inside. It is thought that the tiny bursts of oxygen cause less trauma to the lungs, although there is still debate among neonatologists as to the value of this machine and how — or even why — it works. The physics of breathing, such as it is understood (and surprisingly, it is understood far less than the physics of space flight or computer chips), suggests that this ventilator shouldn’t help at all, but it often does. The force of the high-pressure oxygen should act as a kind of gaseous tourniquet to slow, perhaps stop, the deadly bleeding inside the girl’s lungs. A conventional vent at pressures high enough to accomplish this could blow the baby’s lungs apart, but the oscillator allows these settings to be used more safely.

When the lines are in and the oscillator is chugging away, Baby Girl Berger is wheeled into Room 288 and parked in Position Four. After a bit, Harry Berger tentatively walks into the unit, looking at his daughter. He is in shock. One minute he was standing in the delivery room with his video camera. Now he is in this terrifying place, trying to make sense of what he is seeing. They haven’t chosen a name yet; the tag on the incubator simply reads BG BERGER. His new baby looks so remote, so far away from him, hidden behind the technology, the hoses, the fear. The oscillator is hardest of all to get used to: His baby does not appear to be breathing. Rather, she vibrates from the action of the machine, her chest and the rest of her body thrumming like a drum skin.

Lupe takes Mr. Berger into the coordinator’s office and explains what has been done, the tests they will need to run, how they can do little more for the moment other than wait and see what happens next. She knows this is not the conversation any parents ever anticipate. All they expected to hear was girl or boy, pounds and ounces, blue eyes or brown. She watches him try to take it all in as she tells him it is likely that Baby Girl Berger’s brain was affected by the long minutes without a heartbeat. Seizures in the next 12 hours are likely, and she will need high doses of phenobarbital to control them. Other symptoms of brain trauma may become apparent in days to come; some may not appear for months or even years.

When they emerge from the office, Lupe is still talking about epi and bicarb and albumin, but Mr. Berger appears incapable of absorbing any more. His eyes are fixed on the terrible vibrations shaking his daughter’s entire body even as they keep her alive. Lupe has told him, as gently as she could, that the baby’s life has been saved but that her prognosis is up in the air. She might recover completely. She might have suffered irreparable damage. She might fall somewhere between those extremes. They just don’t know.

“Her lungs are the priority for now,” Lupe says. “We can worry about longer-term problems later.”

Afterward, in a moment of reflection away from patients and parents, Lupe sounds particularly gloomy. The adrenaline high of the code has passed, and she looks tired — with a full night on call still ahead of her. She tries to remember if she took her own heart medication, takes her own pulse, decides that she must have swallowed the requisite pill, then mulls over Baby Girl Berger’s future.

“There’s no way to predict her long-term outlook,” she says. “Twelve minutes without a heartbeat is a very long time, though. If I were a betting woman, I’d have to say the prospects are not good.”

Then she brightens a bit. “Of course, I’m the unit pessimist, everyone knows that. This way, I get to be pleasantly surprised instead of disappointed. And if there’s one thing I’ve learned here, it’s that you just never can tell.”

TWO MONTHS LATER, BABY GIRL Berger went home. She had recovered from the lung damage and showed no signs of brain damage. She has a good shot at a full life.

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