I took a quick inventory of the status of the remaining patients. Mr. Nu?ez was going home. The three waiting room patients had normal vital signs with no life-threatening complaints, so they could wait. Two patients had already been admitted to the hospital and were just waiting for beds to open up. Two more patients were waiting to go to Radiology for CT scans.

“Okay, let’s prep the Resuscitation Room,” I said, heading there with my crew of nurses. “Crystal, can you please make sure we have suction? Make sure the code cart is at bedside. Let’s bring out the neonate tray. And let’s lay out the Broselow tape here,” I directed. “Who’s gonna write?” I asked the crew.

“I will,” Pam responded, already wheeling over a bedside table with a code sheet, the document that records a chronology of all resuscitative efforts during a code in hand.

“Excellent. Okay, are the meds there? Ready with the pediatric pads?” I asked.

“Yup,” said Mark, the tech, holding up the pads for pediatric defibrillation from the pediatric code cart.

“Let me grab my mask and gloves. Miller and ET tube ready.” Then I noticed something. “Wait, there’s no Miller zero in the department? All I have is a one. Good to have a zero in case the kid is small,” I said as I laid down the Miller laryngoscope, the tool used to open and visualize the airway, and the endotracheal tube, which is inserted into the trachea for ventilation, both at the head of the bed near my right hand.

Mark looked around the code cart, grabbing different trays—to no avail: There wasn’t a size zero to be found in the ER.

“Well, then, this will have to work!” I grabbed the Yankauer, the long plastic suctioning tip used in various oral medical procedures, and tested it against my gloved hand. “Suction is good,” I said, tucking it under the mattress head. “Ready!”

Then we stood there staring at one another.

The hardest moments are those right before the code arrives, when the air is thick with anticipation of all the terrible things that could happen and we have time to wrestle with each grisly scenario. I secretly preferred it when the EMS team rolled a patient in unannounced. Sure, we would whine and moan because we had to scramble to prepare everything while treating the patient at the same time, but in reality, such a scenario afforded us the opportunity—really, the luxury—of just being in the moment, of doing our job without getting tangled up in the story of the job. Most of the time, though, EMS teams have the courtesy to call ahead. So we stood around the stretcher, reminding ourselves to breathe.

“What a shitty thing for a Wednesday night,” Pam said.

A cascade of beeps broke the silence. A convenient feature of this resuscitation room, apart from being spacious, was that it offered a clear view of the ambulance entrance. We stood there at attention as the ambulance backed up to the ER, flashing lights that whirled across the bay doors and floors in a dizzying rotation. Then, with a whoosh, two medics swooped in, pushing a small gurney with a tiny patient swathed in white.

“Newborn baby, twelve days old,” the first medic reported. “Called for not breathing. Not breathing on scene. No pulse. CPR started. Family is on the way. We didn’t get the baby’s name; we just got to work. Family can fill in those details when they get here.”

“Okay, we’ll just register him as Doe, like we always do,” Pam interjected.

They parked the gurney next to our stretcher and transferred the baby as one medic continued to ventilate the patient by securing the bag valve mask over his face while squeezing the little chamber of air connected to it in order to deliver oxygen to the baby’s lungs.

“How long was the baby down?” I asked.

“We don’t know. Parents went in to check on him and found him like this,” he responded.

“How long were you coding in the field?”

“Ten minutes at the scene. About six minutes en route. No return of circulation.”

“Okay. What did you give?”

“Three rounds of epi. Accu-Chek eighty-two, so no need for glucose. IO left lower extremity. Unable to tube in the field.”

As the medic and I talked, Deb was frantically connecting leads from our monitor to the infant. Placing my fingers on the inner aspect of the baby’s upper arm, I noted no pulse at the brachial artery. Moving my fingers to the crease at the upper thigh on the same side, I noted no pulse at the femoral artery. Shifting my gaze to the monitor briefly, I saw no shockable rhythm on our monitor. The skin was warm and soft. So smooth—just like a baby’s. I listened to the chest to observe that nothing was moving. There was no heartbeat, no sounds of breathing.

“Mark, please start chest compressions,” I said, bracing myself and trying to sound calm.

Mark placed what seemed like a giant’s fingers on the child’s tiny sternum and began to rhythmically press.

“Okay, another dose of epi,” I instructed. “Pam, please let me know when it’s time for another. Just give a heads-up about the epi at five-minute intervals,” I requested. “Can we just confirm that blood sugar? And I’ll start intubating.”

I looked down at the little boy’s face for the first time. Dark eyes that were wide-open. Beautiful brown skin with a bluish cast. If this child had still been alive, he would have borne a strong resemblance to my sister’s infant son, Eli. He was the specter of the child I didn’t have, the ghost of What Might Have Been. His beauty welled up in my eyes, and I had to blink myself back to reality. This was little angel Doe. At first glance it was impossible to tell if his eyes were black or merely dark from the pupils being fixed and dilated; in either case, there was nothing behind them. His little purple, pouty lips were half-parted where he’d exhaled good-bye long ago. His face was still encircled by the white of the baby blanket that crowned his head. There was no baby here, just a blanket around the body of a departed cherub.

I looked up at Deb. She knew it, too. Everyone around the stretcher knew. We know when a lifeless pod is brought through the door, but we’re supposed to make heroic efforts at resuscitation as they do on TV, when the body is already stiff and blue, but the family is not ready; when arms that have lost the current of life fall limp to the side rails. Still, we push several rounds of meds into them, just to document to the family, peer review boards, and the courts what we already know to be true.

I took a deep breath as I positioned the baby boy’s tiny head and gently placed the Miller blade between his lips. The blade seemed far too large for his mouth. As I advanced the laryngoscope and lifted it up to expose his vocal cords in order to insert the breathing tube, there was tension at the corners of his lips from the size of the blade. I withdrew, opened his jaw, and advanced again. Again, the blade seemed too big. I didn’t want to force it through his mouth.

I couldn’t believe what was happening. Shortly after starting this job, I had completed Dr. Rich Levitan’s difficult airway course, in which this renowned guru of emergency medicine gave us his pearls of wisdom regarding endotracheal intubation. The chairman of the hospital’s emergency department had been kind enough to send any interested faculty members to the lab Rich ran in Baltimore to attend this class. Even before the course, I had never missed a pediatric intubation during my residency. Outside of some anatomic abnormality, children were the easiest to intubate. Because the pediatric airway is shorter and more anterior than in adults, the epiglottis, the landmark we often use to locate the vocal cords for endotracheal intubation, is typically so easily visible that you can see it when kids laugh. Given that you didn’t usually need a blade to see their epiglottises, technically speaking, there was nothing to most pediatric intubations. And yet now I couldn’t do it.

My heart pounded in my fingertips, and I could feel everyone’s eyes on me as I struggled to avoid harming the baby. I knew he was gone, but I couldn’t bear the thought of making one tiny cut or scratch on this immaculate little being. I couldn’t mar perfection.

Resuscitations can be brutal: Ribs are broken with chest compressions, skin is contused, mouths bloodied, even teeth knocked out, for God’s sake. And then, only rarely, after all this medically induced trauma, are people electrocuted back from the dead.

I had long been inured to the assaults that medical teams perpetrate on patients for what is considered the greater good—until now, when the thought of rendering the tiniest blemish on the body of this dead infant made my hands seize up.

“Is there a smaller blade? Do we have a Miller zero?” I asked again, muting my panic. It was an absurd question, as I already knew the answer.

The nurses scrambled to search the cart again, but still found nothing. We continued the resuscitation, with me holding the mask over the baby’s face, squeezing the bag of oxygen to ventilate the child until an advanced airway could be secured with an endotracheal tube.