The whole family sat tensely in the waiting area. Leo and Theresa stood beside Charlottes incubator.
"We love you so much baby girl," Theresa smiled.
"You are so strong Lottie," Leo said, "I love you."
"Hugs then we're going," charlotte's nurse said.
She wheeled the incubator away after Leo and Theresa had a moment to hug their daughter.
"Annie said 99% survival," Leo whispered.
"99," Theresa agreed.
The tiny baby was brought into the OR.
"Hi Lottie," Annie smiled as the baby was laid on the table, "you're going to be so good for auntie Annie aren't you."
"Auntie Annie," an intern asked.
"She's my niece," Annie said, "Leo Altman-Hunt is my brother and Allison Blouin is my sister. I got special permission to do this on my niece."
"Why," an intern asked.
"Because I'm the only person in the state who can do this," Annie replied, "there is no viable alternative."
Annie turned her attention to the baby on the table. Once she was under anaesthesia she made her small incision near the baby's groin.
Teddy and Owen slipped into the NICU.
"Everyone is downstairs," Teddy whispered, "praying."
"Allison came by," Theresa said.
"She dropped of bags and bags of milk for our kids," Leo said.
"Where did it come from," Theresa asked.
"Her freezer stash," Teddy replied, "she has more for you but the NICU only lets her bring so much at a time. You let her know when you run low and she'll bring more."
"Asher will appreciate having some freezer space back," Owen said.
"I don't know how she does it," Teddy replied.
"Over achiever," Ellie laughed as she came into the NICU.
"Ellie," Theresa asked.
"I couldn't get today off but I'm trying to find another internal medicine person to look at Jacob because he's my cousin," Ellie replied, "I have lots of boy clothes for Jacob."
"We knew," Leo admitted, "it was just fun to keep it between us."
"Leo," teddy gasped.
"We wanted some things kept between us," Leo said.
"I knew before Allie did with Ev and kept it a secret," teddy replied, "Annie, dad and I. "
In the OR Annie backed her instruments out, "she's too small I'm going open but between her ribs."
"Dr Altman," the intern asked.
"I have a plan, Fogarty," Annie replied, "I've done this probably 200 times."
Annie called for the supplies she needed, as she got to the rib cage she realised she couldn't go between the ribs, the spacing was too tight. She adjusted again and began the sternotomy fully opening the tiny girls chest.
"I know Lottie this wasn't our plan sweet girl," Annie whispered, "but you're doing so good. I have you. I've got you. I love you. Should I sing?"
"Sing," the intern asked.
"I often sing to my littest patients," Annie replied, "in French."
"Why," the intern asked.
"It seems to keep them calm and more stable," Annie replied, "there's no research but it always works for me and surgeons have superstitions. I talk and sing to my paitents, I have since I was an intern."
Annie began singing the ancient tunes her Grandmere had sung to her and her babies.
Josh leaned against the window looking into his wife's OR. The baby was open this wasn't the plan. Annie caught his eye and gave her head a small shake. Josh knew right away that Annie had hit a complication but she was calm she was still singing.
"It's taking too long," Theresa fretted.
"It is," Leo agreed rocking Jacob slightly in his arms.
"Does your sister always go this slow," Theresa asked.
"Annie is meticulous," Teddy replied, "but it is taking a while. I'm wondering if she had to go to an open procedure."
Both new parents eyes went wide.
"Annie wouldn't do that unless she was 100% certain it was needed," Teddy replied, "she's always done cutting edge stuff but she's conservative and careful.
In the gallery Josh leaned against the window.
Josh got on the intercom, "Annie what's going on?"
"I'm waiting for bypass and Morgan," Annie replied, "I could do the VSD with out stoping her heart but there's a malrotation of her aorta. I'm better to do it now. There's a couple other issues that are minor with Morgan coming up we'll be about two hours once we're on bypass."
"Have you done this before," Josh asked.
"Probably 200-300 of them," Annie replied, "common in premies. Josh I have this. I wouldn't do it if I wasn't."
"Chances," Josh asked.
"95," Annie replied, "risks are standard for by pass. I have O neg coming up. She's AB positive Leo could donate."
"Should I go tell Leo and Theresa," Josh asked.
"Yes," Annie replied.
Josh jogged to the NICU.
"Leo, Theresa," Josh said, "I've been in the gallery."
"Is she okay," Theresa asked tears in her eyes.
"It's going to take longer. Annie has to put Lottie on bypass," Josh explained, "she has a malrotated aorta. Annie's going to fix it all now. There's a couple other minor issues. She can do it all in one surgery."
"Did she say chances," Leo asked.
"95% survival," Josh said, "she indicated that it's lower risk to do it now and have the larger surgery now. Once she gets bypass and her fellow it will go quickly."
"She went in with out a fellow," Theresa gasped.
"She took 2 5th year residents, 4 other 3 and 4th years and 6 interns," Josh said, "she has hands for the procedure she planned but wants her fellow to have more experienced hands."
"How long," Leo asked.
Josh decided to give Annie some extra time and padded her estimate, "three to four hours."
"Can you keep checking," Leo asked.
"I will," Josh promised, "leo Annie wouldn't do this if she wasn't confident. Annie likes to push boundaries but she's not reckless. She's done this before."
"It's dr Altman," a NICU nurse asked.
"Yes," Josh replied.
"You have Grace Altman," the nurse said sitting with Leo and Theresa, "we have kids flown from states away for her and our team. She'll be your surgeon and follow up then you'll also get ongoing care with one of our nurse practitioners Ava Mitchell. You will get a whole cardiac team to follow up and support you."
"They're both surgeons here," Josh said, "adults. Leo is trauma and Theresa is ortho."
Teddy had sat quietly being there as normal support, "here's what we're going to do. Leo and Theresa you are going to go back to Theresa's room, shower, eat and take a nap. Dad and I will sit with Jacob. If you're okay with it we will continue kangaroo care."
Theresa looked at her mother in law. Teddys long white hair was pulled into a low ponytail and she was still tall and slender. She reminded Theresa of an elderly ballerina. Teddy was still tall and slim and dressed stylishly even in her late 70s. While the woman's personality was warm and loving she didn't look particularly cuddly.
"Theresa," Teddy said softly, "I need you to listen to me. You have to eat and shower and rest tone good for your babies. This is a marathon. Sweet heart you need to care for yourself. Right now you are going to eat, shower and rest. Owen and I have Jacob. We can snuggle and help with his feed."
"Leo I'm pulling rank," Owen said, "you and Theresa are going back to her room to rest and care for yourselves. This will take a long time. We will set up a family rotation to help you out. Right now showers, food and rest. I've already ordered Theresa's favourite to be delivered to your room in about 20 minutes."
"But if were not here," Theresa whimpered.
"We are," Teddy replied, "he's stable. He's okay. If something changes we will come get you right away."
Annie stopped singing as she got to the trickiest part of the surgery, "okay Lottie hold on. Almost done. Let auntie get this patch in. There's my girl. You're so good."
"Dr Altman," another intern asked, "why do you talk to patients like that?"
"I always hav," Annie replied, "I'm a mom and a grandma. You talk to them. We still don't know what gets through when they're under. But babies need love. Kids need to be made to feel safe. If you come into the OR anxious or upset you're not focused on the patient or making them feel safe. Babies pick up on the adult's emotions and need us to be their calm. Some talk, others recite nursery rhymes, I sing French Canadian lullabies."
"Why French Canadian," an intern asked.
"I grew up in Canada, my dads mom was French Canadian and taught me to speak québécois French," Annie replied, "with a bit of Michif the Métis language sprinkled in. My lullabies have a mix of French, Michif and Cree."
Annie closed the chest cavity and secured the ribs. She closed the skin as carefully as she could. She sent the tiny girl to post op and went up to the nicu.
"Annie," Leo said watching his older sister come towards them.
Annie sat down with Leo and Theresa, "the surgery was more extensive then I had planned."
Theresa gulped, "is she?"
"She's in post op," Annie replied, "she'll be back up within the hour. She's going to be fine. I will have her sedated for a couple days. But she will be fine. I did a complete repair of the VSD and there was a malrotation of her aorta, it was minor but it's fixed."
"You put her on bypass," Leo confirmed.
"Yes," Annie replied, "she did beautifully. Leo, Theresa she's going to be okay. She's so young her body will never know the difference. She'll have a small scar but it'll fade."
Theresa began to cry. Annie wrapped her sister in law in a hug, "shhh, shhh it's okay. She's okay. The sedation is just to let her heal. You'll still be able to hold her and she'll eat through her NG tube. Lottie is okay."
"I hurt her," Theresa began to sob.
"You didn't," Annie assured, "Theresa you did everything right. You love her and took care of yourself. You did it right and are doing it right. These things just happen sometimes. You made the right choice today by letting me operate."
"Her aorta," Leo asked.
"Very slight," Annie replied, "but we fixed it before it could become a problem. It wasn't even showing on scans. I didn't see it until I had dissected down to her heart. The VSD is common in premies. Hers was just too big not to do now. But we have it fixed. Her stats look fantastic. She was stable through the whole thing and she was never alone. Josh is in post op with her so I can be here. She has been with family the entire time."
"It's major surgery," Theresa said.
"No less than your c-section," Annie replied, "yes i had to spread her ribs but thats okay. I've spread Leo's when he was little two. And does it ever bug you now?"
"No," Leo replied, "I'd like the old leads out but they took the pace maker out in highschool school."
"I know," Annie replied, "mama and I agreed that the leads should stay incase you ever need one again."
"They'd run new ones now anyways," Leo said.
"But they've been there so long we don't even know if they could come out lion," Annie replied, "we will watch Lottie for it. Once she's through the post surgery period I will be passing her to Dr. McQueen who has been my right hand in my department for 20 year. You will be on Ava's patient load."
"Will she live a normal life," Leo asked.
"There's nothing stopping her," Annie assured.
A nurse rolled an incubator into the room.
"Here she is," Annie smiled, "see she's doing well. Look at those numbers."
The nurse parked the incubator, "you can hold her. She's still out of it from the medications and will be sedated for the next 48 hours."
"Hold her," Annie encouraged, "let her know you're here. She's going to be just fine."
"How do you know," Theresa asked, "the complications."
"If there are we cross that bridge when we get to it and not until." Annie replied, "I don't play that game with my patients and you are not going to start. She will be fine."
"Thanks Nee," Leo whispered.
"Your welcome," Annie replied, "I'm needed back on the floor."
Annie joined Allison in the peds ER.
"How's Lottie," Allison asked.
"Stable," Annie replied, "it was extensive. Jacob will go home first. They'll need our support."
"I dropped milk off today," Allison replied, "we're making meals."
"A meal train would help," Annie agreed, "when they get home."
"I just want to go to them," Allison said, "seeing your baby post op from major surgery."
"I know," Annie replied, "give them today. Tomorrow go sit with them."
"I'm on over night," Allison said, "I'll check in later. Over night is the worst for this. When the hospital is quiet, your family goes home and you're just watching your sleeping baby's monitors."
"Okay," Annie agreed, "who ever is here does over night check ins."
"It's surgical," Allison said changing the topic once the scans came up, "those ribs."
"I'm coming," Annie agreed, "there's damage to at least one lung and the pericardium."
Together the sisters prepared their patient to head up to the OR.