Chapter 49

Just Breathe

Nolan 12, Ryder 8, Olivia almost 5.

Annabelle Grace, 2 weeks old

Baby Two, hours old. Born at 34 weeks gestation.

January 25th

"And here…she…comes!" Addison declared after removing the baby from Amelia's womb. Up to this point, the C section had been textbook. They had scheduled it right after Addison reviewed the ultrasound from the 22nd. Because many weeks had passed since the in utero surgery to address Baby Two's spinal bifida, all of Amelia's doctors anticipated that the internal and external incision sites would be healing well. However, Addison noticed that the area around Amelia's uterine incision site was abscessed and located in the area where Amelia was having pain. The previous Friday, Emma had immediately begun IV antibiotics when the abscess was discovered; however, Addison was concerned that the abscess was not contained and was spreading. The best option in that case was to address it surgically. Not wanting to take any chances, Addie scheduled a C section for the 25th, the following Monday. Amelia was amenable to the arrangement as long as the surgery was in the morning. She didn't want to starve all day waiting to get in the OR. The careful and intentional planning and textbook C-section ended the moment Addison pulled Baby Two from Amelia's womb.

The previous Friday, after consulting with Addison, Arizona agreed to discharge Amelia for the weekend. Annabelle had passed the carseat test, so Karev was fully willing to discharge her and send her home. The family spent two full days together at home simply watching movies, playing games, napping, and chasing the dogs.

On Monday morning, Ryder and Olivia were bursting with anticipation. They begged to stay home rather than go to school and daycare, and Olivia graciously offered to babysit Anna Banana while Asha was "being borned." Nolan, being 12, pretended his sister's birth was just another day.

The Actual Delivery

"And here…she…comes!" Addison declared after removing the baby from Amelia's womb. As Addison lifted the baby up for her doting parents to see, the delivery began its downhill slide. Both Addie and Alex immediately noted that the baby was not breathing. Karev stepped over promptly and grabbed the baby from Addison's hands as soon as the nurse cut the cord, stating, "We've got her."

Amelia's beaming excitement at the vision of her daughter darkened quickly as she and Owen exchanged surprised and fearful glances. Owen looked seriously at Addison and observed aloud, "I don't hear crying."

Alex set her on the warmer and ordered louder than intended, "Start the clock." His first effort was to dry and cover the baby and then replace the initial towel with a dry and warmed one. As he did so, the nurse suctioned the baby's mouth and nose. The team continued to work on the baby, bagging her and attempting five inflation breaths. Alex listened for a heartbeat. He shook his head and mumbled quietly, "Heart rate's there, but only at 80. Keep bagging. Have surfactant at the ready but don't administer yet."

In those moments, the words "Start the clock" haunted Owen and Amelia's ears. They both knew that meant the 10 minute window for reviving the baby had begun. Owen grasped Amelia's shoulder firmly. As tears filled his eyes, he attempted to smile and reassure her, "Alex has her. It's just a step by step process at this point. She'll be fine."

"I still don't hear crying," Amelia stuttered. "And look at how many people are surrounding her and working on her." The couple could not even see the baby because so many medical providers were surrounding the warmer.

Assessing the other APGAR signs, Alex stated stoically, "1 minute APGAR is 4 with 0 at breathing."

After two rounds of masking the baby, Alex began CPR, quietly encouraging the newborn, "C'mon, little girl. C'mon… Start responding, baby, you can do it… You're a fighter… C'mon, baby, c'mon… Breathe." As he was performing CPR, Alex turned to his resident and ordered, "Get the umbilical catheter in and start a slow bolus of 2.5 ml/kg of 10% glucose. Have epi ready if I call for it."

"Deep, slow breaths, Amelia. You've got a highly skilled team working on her. Deep breaths," Addison attempted to reassure her friend as she closed the incision.

"Addie?" Amelia's voice shook and her lips trembled, "Addie?" Addison simply looked at Amelia and mouthed, I know. Straining to listen, Owen heard Alex continuing to encourage the baby, "Big breath, baby girl…take a breath, take a breath…you can do it little girl…c'mon…"

Amelia looked up at Owen, whose eyes were momentarily closed. When he opened them, he stroked Amelia's head and whispered, "She'll come around."

After three rounds of CPR, a loud cry burst out of the baby's mouth. Everyone in the room let out a huge sigh of relief, and Owen kissed his wife numerous times. Alex, knowing the baby was not yet out of the woods, began setting up a vent as he ordered quietly, "Let's place the endotracheal tube and get the vent underway. Then make sure the heart monitor is powered up – I just attached the lead. Attach other monitor leads and wires. Run the bloodwork to the lab and order a rush on the results."

"Alex, how is she?" Amelia asked with a quivering voice.

Alex took in a slow breath and responded as confidently as he could, "I've got her. She's breathing. We're working on her."

Before heading to the NICU, Alex assessed the baby for the 5 minute APGAR, and wasn't sure what to do about the baby's limited response in her lower right leg and foot. The leg's peculiarity was likely a result of the spina bifida. "Note 5 minute APGAR as range of 7-9 with a note so I can research later. Grimace and muscle tone could be 1s or 2s depending how I figure in her leg and foot," he explained.

"What are her APGARs?" Owen inquired.

Alex partially answered, announcing the positive details and offering vague updates on others, "Heartrate 105, 4 pounds 12 ounces, 18 ¼". Mostly pink, solid motion and grimace. No signs of bleeds or PDA at this point."

Alex whispered in the ear of the nurse, "Could you hand me a pen and paper?" He jotted note for Addison that read, 1 minute APGAR 4, 0 breathing. 5 min AP 7-9 - ask me. Glucose running, 2 rnds bagging + 3 rounds CPR, heartrate was 80 now 105. On full vent.

The nurse nodded as Alex motioned toward Addison and handed the nurse the note. She walked calmly over to Addison, "Dr. Montgomery?"

Addison nodded and the nurse held the note in front of her. Her response was simply, "Thank you." Continuing the final stitches to close the inner C-section incision, Addison quickly examined the abscess and noticed it had burst during the delivery. "Suction!" she ordered firmly as she alerted her team to their challenge.

At the same time and without a word, Alex and his team rushed the baby out of the room and to the NICU. Amelia noted the lightning speed of the transport and grasped Owen's lower arm, "Go." He nodded, kissed her, and ran to the hallway.

"Amelia? Sweetie, we're going to attack this abscess now so I need you to count backwards for me," Addison announced without fully explaining the seriousness of the situation and the upcoming anesthesia. Once Amelia was sedated and intubated, Addison exclaimed, "This is a damn fine mess. How's that baby?"

"I'll call NICU, Doctor," one of the nurses promised.

Another nurse shared, "There were 3 rounds of CPR and the baby left on a vent, Doctor. Dr. Karev appeared fully in control of the situation."

"Hard to believe how far our boy Alex has come, huh, ladies?" Addison mused as she attempted to address Amelia's situation. "Our little resident, Alex Karev, all grown up and competent."

~~~~~~~~~~~~~~'

Owen ran to catch up with the NICU team but was unable to catch the same elevator. The adrenaline pumping through his body helped him fly up the stairs quickly. He saw the baby and Alex's team exit the elevator just as he came through the stairway door. Staying just behind the group, Owen ran and tried to hear the words being spoken about his daughter. As he had attempted to do after Annabelle's birth, Owen tried his best to be unobtrusive. In this instance, however, the team working on the baby was larger and there was a higher level of intervention.

"Hunt, I'm sorry, you need to step out," Alex barked. "We'll be happy to find you when she's stabilized."

With respectful seriousness and resolve, Owen stated, "I'm not leaving, but I will observe silently from over here." Owen was holding Annabelle and standing next to the crib. Anna was admitted to the NICU casually that morning so she could be monitored and fed while Amelia and Owen were tending to Twin Two's birth. The nurses had joked that her real reason for coming back was because Anna missed them.

Alex shot Hunt a look of disgust. He didn't have time to get in an argument and Hunt knew that. Alex barked out various orders, heard a variety of responses from the team about the latest stats, and rotated his attention between the baby's breathing, color, and heartrate.

As Owen listened in, his phone alerted him that Recovery wanted him STAT. He set Annabelle in her crib and whispered his situation to one of the NICU nurses. So much for my great insistence to stay, Owen thought to himself.

About 90 minutes after the baby had entered the NICU, an intern arrived and announced, "I have the bloodwork results."

"That tells me nothing," Alex snapped. "Read the damn results out loud. Only the ones of concern."

"She's anemic, low blood sugar. Sodium imbalance and indicators of possible protein issue. Kidney function on the border," the intern reported.

"Infection? Liver?" Alex asked

"No red flags, Dr. Karev," the intern responded.

Alex ordered, "Let's repeat the bloodwork for an update and check blood gases. Page urology and have them weigh in on the kidneys after you have an initial bladder ultrasound for them to review. That ultrasound needs to be repeated every 4 hours around the clock for 48 hours to determine if she needs a cath. As long as you're taking her to ultrasound, get an initial ultrasound on her head and page neuro for a review. Repeat blood gas in 30, 60, and 90 minutes then we'll reassess where to go from there. Page me with all results as they come in and let me know about any changes whatsoever immediately. I'll be back in about 30 minutes. Tag each other out - Rotate breaks with one another as much as you can. Great work everyone. "

The birth and immediate response to revive the baby had been exhausting for the whole team. As he stepped out of the NICU, Alex sent Jo a text that read, Meet me in cafeteria? I got 30 mins. Jo responded immediately that she was already down there and she asked what she could grab for him. For just a few minutes, Alex wanted to listen to Jo's laugh, give her some crap, and step away from the intensity. Grabbing something to eat and drink would be a nice side benefit.

When he arrived at the table and saw his order waiting for him, Alex smiled and thanked Jo. As he reached for Jo's hand and sat down, he slouched in his chair. Closing his eyes, he shared, "You can't ever repeat what I'm about to say."

"You got it," Jo promised.

Alex continued, "I was scared as hell we were going to lose the Chief's baby."

Jo looked at Alex sadly, "But you didn't. You saved her."

Keeping his eyes closed and not moving, Alex inquired with disbelief, "How do you know?"

"Because it's already all over the hospital how stellar you were and how you blew everyone away with your leadership, skill, and presence," Jo shared as she scooted her chair right next to his.

"Oh, go to hell. That's a load of crap," Alex scoffed.

Jo flicked her index finger off of the top of her thumb so that it popped Alex in the cheek. He opened one eye skeptically and raised his eyebrows. She insisted, "No, it's not a load of crap. Good job fooling everyone, Dr. Cool as a Cucumber. Nobody saw your fear. Even more important, that little girl is alive right now because of you. Deal with it."