Read an Excerpt

'We need another nurse,' Laird muttered.

He had one standing right beside him, checking the two resuscitaires, plugging in tubing for oxygen, laying out the plastic wrap that would help keep the twins warm once they'd been born. He could see the nurse mentally confirming that all the equipment on the resuscitaire trolleys was in place—laryngoscope, endotracheal tubes, Magill forceps—and she moved adroitly around the awkward positioning of various fixtures in the operating theatre.

She looked as if she knew exactly what she was doing.

All well and good, but one nurse wasn't enough. The scrub nurse and circulating nurse adding to the crowd in the operating theatre would be fully occupied on the surgical side. They weren't here for the babies themselves. This patient was about to have a Caesarean delivery.

Two paediatricians, one NICU nurse, two twenty-seven-weekers about to be born—it didn't add up, especially when the babies had stage three twin-to-twin transfusion syndrome. You really needed two medical people for each twin when they were going to be so fragile and small and ill and would need transfer to the NICU as soon as they were stabilised after birth. At least Sam Lutze was a good doctor, and the one neonatal nurse they did have seemed unfazed by the whole situation.

But she'd heard his muttered complaint.

'Sorry, but there's only me,' she said, calm and matter-of-fact, still checking her equipment. 'Someone's just gone off sick. We have a supernumerary and we're shifting things around, but for now… Yeah. You've got me.'

'It's not good enough,' he muttered again.

'I know. But we have a whole NICU full of sick prems. Someone's on the phone, seeing if there's anyone we can transfer to another hospital. We're doing our best.' She glanced over at the operating table, where their pregnant patient was about to be delivered, by Caesarean. 'Give Dr Lutze the recipient twin, if he's the strongest, and you and I can take care of the donor. Would that be the way to go?'

'We'll see how it pans out. I haven't met you before,' Laird said.

He couldn't help turning the statement into a challenge. It was one in the morning and Sam Lutze had called him in half an hour ago—Laird had only left the NICU two hours before that—when Fran Parry's obstetrician had decided her labour was unstoppable.

Laird had seen the latest scans and tests on the babies. They would have needed an emergency delivery within the next few days anyway, because the recipient twin had heart problems developing, while the donor twin just wasn't getting enough blood.

This woman…

What was her name? He discreetly checked her badge. Tammy Prunty. Was he reading that right?

She had better be more than competent at her job.

'No, you haven't met me,' she answered. 'But plenty of people at Royal Victoria NICU have. Dr Cathcart, Dr Leong, Dr Simpson. I was there for eight years, on and off, before I came here.'

Here being Yarra Hospital, several kilometres northeast of Melbourne's city centre, while Royal Victoria was closer in.

'Sorry, I wasn't pushing for your résumé.'

'Well, I can understand why you wanted it.' She unkinked a cable, switched something on. She had a comfortable figure—some people might call it plump, others voluptuous—but her movements were fast, deft and sure, and Laird had the grudging realisation that she seemed to know her way around the equipment better than he did.

'Don't tell me this is your first shift here, though, please!' He could hear all too well how crabby he sounded, but the prospect of staffing issues affecting a high-risk birth like this one always got to him.

'Nope,' she said. 'Second.'

'Oh, great!'

'But so far it's pretty similar to how we did things at RV Everything's the same colour!'

Her calm good cheer soothed his irritation, and his impatience seemed to have affected her like water on a duck's back, thank goodness. Her disposable cap stuck out all around her head, like a cross between a pancake and a Madonna-blue halo, and her pale forehead was shiny above a pair of brilliant blue eyes. If she had hair, he couldn't see it.

They were ready for the babies now.

Or as ready as they'd ever be.

'Everything all right, Mrs Parry?' asked her obstetrician, Tim Wembley.

'I can't feel anything now.' Her voice sounded shaky, and her husband squeezed her hand and hissed out a tense breath. Both of them were understandably frightened and emotional. They were in their late twenties, which was starting to look young to Laird at thirty-four.

'That's the way we want it.'

'Good to go here,' the anaesthetist said.

'Not long now,' said one of the two theatre nurses, giving Mrs Parry's shoulder a pat. She was circulating, not scrubbed and sterile like her colleague. Both women had kept up a cheerful stream of reassurance, explanation and general chat as preparations for the Caesarean birth were completed.

'Dr Burchell, Dr Lutze, how are we over there?' Dr Wembley asked.

'We're good,' Laird answered, and Sam nodded, too.

Dr Wembley made the initial incision, working cleanly and with no fuss. When the babies were so fragile, they needed speed as well as a gentle touch. Being born could be a jarring process, even for a healthy baby at full term.

Laird watched, standing at the resuscitaire so that he'd be ready to work on the first baby as soon as he was freed from his mother's womb. The latest scan suggested this would be the smaller and frailer of the two—the so-called donor twin.

The Parrys understood the terminology by now. Laird had seen them in his office last week after it had become clear that the amniotic fluid reduction procedures weren't doing enough to help the babies.

They seemed like a pretty sensible couple. They knew that roughly fifteen per cent of identical twins developed TTTS, with varying degrees of severity, and that it occurred when the webbing of blood vessels in the babies' shared placenta grew unevenly, creating a circulation system that favoured one twin at the expense of the other.

They'd asked him a whole lot of questions, which he'd done his best to answer. Unfortunately there'd been a couple of factors, including a badly positioned placenta, that had made laser surgery on the placental blood vessels a very risky option. This had meant that any treatment, including the amnio reductions and steroids to develop the twins' lungs, had only been an attempt to head off worsening problems, and had done nothing to deal with the underlying condition.

Scans showed that the donor twin—the one sending too much of his own blood into his brother—was undersized and passing too little urine, while the recipient twin's heart was enlarged and working way too hard as it attempted to deal with the excess fluid.

The Parrys already knew that their boys were lucky to have survived this far, and that one or both of the babies could still die.

'OK, here we go,' Tim said. 'Yes, this is the donor twin.'

'Adam,' said Chris Parry firmly. 'His name is Adam, for heaven's sake, not The Donor Twin.'

Adam,' Tim echoed at once.

Parents were sensitive at a time like this. Laird had seen the racking emotions they went through over and over again, and it kept him humble. He wasn't a father himself. Not yet. Or not ever? Insufficient evidence to reach a conclusion on that one.

From what he regularly saw in the NICU, parenthood seemed to him like the dramatic, uncharted territory of an undiscovered island—alluring and frightening at the same time. He wondered if he'd have the same strength he saw over and over in the parents of ill babies.

'Nice. Look at that movement!' Tim said. It was feeble, but it was there. The baby was very pale. 'Hey, Adam, going to breathe for us?'

He wasn't.

No surprise.

He was blue and so small, well under a kilogram at a guess.

'What's our other one's name?' Tim was asking. After the dad's moment of anger and Tim's own carelessness, he'd recovered his sensitivity. These parents needed everyone to treat these tiny, fragile creatures as beloved human beings right from the start.

'Max,' Fran Parry said.

'Here comes Max.'

Laird didn't waste time waiting to see whether Adam's breathing would happen on its own. The NICU nurse took the tiny baby from the obstetrician's gloved hands into the dry, pre-warmed towel she had waiting, then laid him in the heated resuscitaire and folded the nest of plastic wrap over him, leaving his head and umbilical cord exposed. Laird decided he didn't need to suction the tiny nose and mouth. There was no evidence of meconium staining in the waters or blood visible at the baby's mouth.

In the resuscitaire, baby Adam seemed lost in a wasteland of white mattress. The nurse dried his head and covered it with blue tubular bandage, while Laird began the resuscitation process. He found a pulse at the umbilical artery—roughly sixty beats per minute—and said after a moment, 'We have a nice heartbeat.' He heard tearful sounds of relief from Fran Parry. 'We're going to get some oxygen into you right now, little guy.'

He found the heart-breakingly small premmie intubation equipment ready for him right at the moment he needed it and took it from the nurse. He had already forgotten her name. Something a bit odd and comical, which belied her wonderful competence.

'That's nice. That's good,' he said, just to reassure the parents.

OK, here we go, tube going down. Such a tiny distance, seven centimetres, and the tube was only 2.5 millimetres wide. Gently… gently…

The nurse—Plummy, he was going to have to call her for the moment, in his head, even though he knew it wasn't quite right—clamped and cut the cord, leaving several centimetres intact to allow umbilical line placement.

'Max is going to need some help here…' Tim was saying.

One of the theatre nurses took the recipient twin into a second warmed towel, laid him in the resuscitaire and wrapped him, while Sam Lutze checked his responsiveness on the Apgar scale. At a quick glance, Laird expected the one-minute score to come in at two or less. Adam's had squeaked to three, and he wanted it higher soon. His colour had begun to improve, some pink radiating outwards towards his little limbs.

'Swap,' Sam muttered to Laird, about Max. The one-syllable request acknowledged Laird's extra year of experience and his reputation for superhero skills at resuscitating the sickest babies. 'Look at him, it's his heart. And he's floppy, no reflex. Give me Adam, he's almost ready for transfer. Tammy, you'll stay with Max and Dr Burchell.'

She nodded, finished what she was doing at Adam's re-suscitaire and switched straight to Max, wrapping the plastic, slipping the tubular bandage onto his tiny head with a couple of soft movements.

Laird devoted a critical few moments to repeating Tammy, Tammy, Tammy, over and over in his head, as he moved to the unresponsive baby. Max was a darker red than he should have been, filled with the excess of blood he'd innocently robbed from his much smaller brother. Thick blood, they often called it, because a baby's tiny liver couldn't process it and remove the waste. His heart had been struggling, and even without the TTTS the simple fact of prematurity could often present its own cardiac issues.

'Right, let's do this,' Laird muttered. He understood the junior doctor's reluctance. Max was going to be much harder.

He looked down at the baby, willing it to show some strength and fight, willing the parents' love to make a difference, to have some power over life and death. Later on it would. Premature babies responded wonderfully to the familiar voice of their mother or father, and to the right kind of touch. Now, though, it was more about medicine than hope.

'What's happening? Is he OK?' Chris Parry had sensed the increase of tension in the medical personnel, and he could probably see for himself that the second baby, although larger, wasn't looking as good as his twin.

His wife moaned. 'Max?' she said. 'Hang in there.

Mummy's here, and Daddy. We love you so much.' Her voice cracked and she couldn't speak any more.

'Is he going to be OK?' Chris asked again.

'We're going to do everything we can,' Laird said. Terrible words. Yet false promises were even worse, he considered. 'Tammy, start cardiac massage while I tube him.'

He hoped she'd sense when he needed her to get out of the way and that she wouldn't need to be talked through it.

'Adam's looking good,' Sam said, after a moment. 'I'm getting 85 bpm, his chest's moving. I'll get an umbilical line into him now. Then you can go for a ride, little man.'

Laird heard more sounds from the Parrys. Relief and anguish. Then from Tim a suspiciously calm 'All right, we're going to have to pack this. Do we have some blood, Helen?'

Mrs Parry had begun to bleed too much, a reasonably common side effect following the procedures she'd had over the past few weeks to reduce her amniotic fluid. 'What's happening? What's going on now?' Chris demanded, distraught. Like his wife, he had fair, freckled colouring, which made him look very pale under the harsh lights. Fran's lips were white.

Laird couldn't spare a thought for them right now. Max needed him too much, needed the tube, needed the massage, needed treatment for that thick blood and some relief for his heart as soon as they had him stable.

At every moment, the Tammy nurse was there. Hands in the right place. Voice pitched low enough to soothe the baby but loud enough for Laird to hear. Fingers nimble and delicate. No unguarded exclamations of doom to scare the stricken parents. Laird spared her a glance and managed a muttered 'Thanks.' She nodded, and there was this odd little moment that he didn't understand. More than mere relief at being paired with a competent colleague. More like… recognition?

He didn't have time to think about it now.

Chris had tears streaming down his cheeks. Fran was pressing her dry lips numbly together and clamping a death-like grip on her husband's hand.

'Come on, darling,' Tammy cooed to the baby. Her fingers seemed to flutter against his miniature sternum, and her voice was delicious, soft and musical and honey sweet. 'Come on, sweetheart, let's see what a big strong boy you are. Let's try really hard…'

'OK, he's tubed,' Laird finally said. Like Tammy, he'd almost been holding his breath. He saw her nod and look of relief. She cared. 'Heart rate's coming up. Not counting chickens…' he added quietly.

She understood. 'Want the umbilical line?'

'Can you? I'll give a first dose of adrenalin via the ETT, but let's have that UVC.'

She got the line in with incredible speed and dexterity and he delivered a carefully calculated dose of adrenalin through the endotracheal tube. Next, Tammy nested the baby in a rolled and warmed towel and adjusted the radiant heat setting.

Time had passed, ceased to have meaning. All of this took longer than a non-medical person would expect.

'Let's move him now,' Laird murmured. 'We need to get him stable and quiet, get him under bili lights to get his blood sorted out, and this is torture for the parents.'

'I know.'