PRECIOUS MIRACLES

Level 3 is not a floor. It's a condition.

PHOTOS BY JIM MCLAUGHLIN /FLORIDA WEEKLY AND LEE MEMORIAL HEALTH SYSTEM

People in Level 3 lie in clear plastic cocoons, not necessarily unconscious but unable to respond.

They're wizened, shriveled, sometimes shrunken to the size of a Coke can. That description falls short, however, because they're not really shrunken. Instead, they're as big as they've ever been — shrunken only from their potential, not from some larger reality.

They appear as old as the hills, too: tiny and bald, so fragile and feathery, so lined and leathery, that even mortality seems to lie light beside them. But it's always near, asserting its presence in 10 or so electronic beeps and alarms that indicate vital functions, or their failure.

Nothing about these people is normal. Their wide-open hands would span the circumference of a quarter. Their hearts are roughly the size of a pea. Their sexual organs, exposed in unselfconscious nakedness when they lie unswaddled, are smaller than a fingernail clipping. To say their veins and arteries are no thicker than the eye of a needle is gross exaggeration.

"We aren't trying to save just one life, we're trying to save many: the parents who love this child, the future generations — an entire history — that this child might represent." — Nancy Scribner, 21-year NICU nurse

And perhaps most unusual of all is this: Each appears to be loved in every full minute of every long hour of every momentous day by a clan of surrogate mothers — mothers mostly, since 88 of the 90 nurses among a devoted staff of 150 are women. Few in this world can ever say that.

These nurses are the elite corps of the NICU, the Neonatal Intensive Care Unit at The Children's Hospital of Southwest Florida at HealthPark, the campus of Lee Memorial Health System in South Fort Myers. The Children's Hospital and its NICU serve families from all five counties in the region — Collier, Lee, Charlotte, Glades and Hendry.

Throughout the five rooms of this offlimits, 48-bed unit, babies cling to life in conditions defined as Level 3 and Level 2 (slightly less fragile). Those for whom things have gone very well graduate to the NICU Progressive Room, which means they'll likely soon go home.

JIM MCLAUGHLIN/FLORIDA WEEKLY NICU nurse Aubrey Brown, left, stands by as Bryan and Danielle Lee check on their 2-month old son, Caleb, who weighed 1 pound and 7 ounces at birth.

Around them work the nurses, nurse practitioners, doctors of various stripes (including a neonatal ophthalmologist), respiratory therapists and occupational therapists, who can help shape and loosen little bodies that would normally do so alone and naturally, while suspended in amniotic fluid. There are even social workers and case managers, all devoted to these children.

Or perhaps they're devoted to something more than these children, suggests one nurse, Nancy Scribner. "I take the long view," she explains. "We aren't trying to save just one life, we're trying to save many: the parents who love this child, the future generations — an entire history — that this child might represent.

JIM MCLAUGHLIN/FLORIDA WEEKLY Six-week-old Brianna Hinojosa's tiny feet get a reassuring caress from her mother Nereida's hand.

"It's like an old parable, where three men were laying bricks. When asked what they were doing, the first man said, 'I'm laying bricks.' The second man said, 'I'm earning a living.' And the third man said, 'I'm building a church.'"

A singular breed, called to their unit

Some NICU babies begin the arduous climb toward normality — toward those someday churches — as early as 23 or 24 weeks after conception, weighing as little as a pound or a pound plus a few ounces. For them, life may never be easy. Children who once would have died when delivered at 28 or 30 weeks are now pretty good bets to come out of the NICU and grow into beautiful, fully capable young people. Their pictures crowd a bulletin board in the unit, gazing out in unassailable proof that this is all worth it.

No one receives better care — care of mind and heart — than these babies. Even statistics (which usually have so little to do with love) bear it out: The Children's Hospital NICU has had the lowest mortality and morbidity rates of any NICU in the state of Florida two years running, says Michelle Waddell, herself a 20-year NICU nurse and the unit director.

COURTESY PHOTO Some NICU babies begin the arduous climb toward normality as early as 23 or 24 weeks after conception, weighing as little as a pound or a pound plus a few ounces

Trained specifically for Level 3 with hyper-mentoring by veterans on the NICU, Mrs. Waddell's nurses complete year-long internships — much of that time spent in the unit — that follow their four-year nursing degrees.

The intensity helps shape them, and define them, as a singular breed. These nurses arrived at the NICU because they were called to it, they say. Those who come and aren't called to the unique work quickly discover the fact, and leave.

Why?

"It's a very scary world here," replies Mrs. Waddell, who then breaks into quiet laughter.

"People think sometimes we sit around in rocking chairs, rocking babies," adds Chris Lee, another 20-year veteran of the NICU. "No, not quite."

Once on the NICU, they tend to remain for decades. Turnover is very low. This is a life's work, not just a day's job.

Combining hands, hearts and skill

"I could never peel people off the pavement or work in oncology," explains Mrs. Scribner, the church builder. Tall and slender, her long fingers stretch almost the length of a patient's torso. "And I quickly found out (21 years ago when she came out of nursing school) that pediatrics was NOT what I wanted. This is what I wanted — it's the only thing I want to do. I think most of us would say we're called to it."

About five minutes later, Mrs. Scribner reappears, her eyes bright, the cloud of auburn hair that framed her head now covered. A mask hangs from her uniform that will soon hide her nearly dazzling smile — juiced, perhaps, with a touch of adrenalin: One of the coded bells has rung.

"I'm going to a stat C-section — I'm off to save a life," she announces before she disappears. (An NICU nurse is called for every premature C-section, in case her special brand of care is required for the baby.)

NICU nurses are pragmatic, cool under pressure and, in many cases, brainy enough to have gone to medical school. After all, it's a high-tech environment where understanding how to integrate complex machines and regimens with the highest technology of all, the human being, takes a lot of smarts.

But these nurses are singularly addicted, if you will, to care and intimacy, not just technology. They will tell you themselves that the work requires their hands and hearts all the time, along with their sophisticated nursing skills. Compassion is a thing they don't restrain, although sentimentality is, since outcomes are uncertain.

"I've had to pull myself back from all this sometimes, pull my emotions back a little, just for self-preservation," says Charlene Martin, a 30-year veteran of NICU nursing in the northern Midwest who arrived at The Children's Hospital at HealthPark only a year ago.

Why they're here

Five nurses arrange themselves on either side of a hallway, in a rare attempt to explain why they're here. The morning is quiet, but that could change in a heartbeat, they warn. Each open room carries one of the plastic cocoons, most of them covered in quilted baby blankets to close out light and sound, and all of them flanked by an arrangement of machines.

These women rarely give themselves to self-reflection.

Aubrey Brown, just 12 days shy of carrying her second baby to full term, struggles to find words that explain her love of the NICU.

"There's so much… LIFE here," she says.

"There's so much HOPE here," adds Sandi Barkye, a 30-year nurse who found her way to the NICU 22 years ago.

As they talk, their eyes rove up and down the hall, checking babies and rooms. Each nurse turns slightly, unconsciously, every time an alarm sounds. There's a bed alarm, two alarms off the bedside monitors, two pump alarms, a jet alarm, an oscillator alarm, a ventilator alarm and two different C-Pap alarms, each with a different tone, like instruments in an urgent symphony. When one sounds out, a nurse spins away and moves swiftly in.

None of these nurses are ever entirely relaxed; they'll maintain this level of vigilance for 12 hours, the length of a shift in the NICU.

That's how they want it and like it, they admit — which might be why few ever take the additional step to become doctors.

Normally, doctors appear in Level 3 only in the morning for their rounds (neo-natal doctors do not have outside practices). That's not enough for these nurses, who want to offer their handson compassion continuously — and not just for babies but also for the emotionally beleaguered and sometimes panicked parents.

The agony and the ecstasy

About two minutes by elevator and hallway from the HealthPark maternity ward where most babies are born at full or close-to-full term, the NICU might as well exist on a different planet, one where compassion is the only thing left, sometimes, when things don't go right.

"These little people who struggle so hard, and whose parents are struggling along with them — it just strikes my heart," says Mrs. Barkye, who came to the NICU at a time when the technology was much less sophisticated. "Losing a baby whose parents have struggled so hard to get it… I'd say that's the hardest thing, or the worst thing about this job."

All of these nurses remember the parents who were on their eighth try to complete that hardwired biological marching order: to bear a child and give it love. Theirs was born at 24 weeks.

But what started as an unlikely question began to show promise, and even to firm up as a declarative sentence: I will live.

"But suddenly one day, at 32 weeks, the baby just stopped," Mrs. Barkye recalls. "She just died, and it surprised everybody. Even after, they weren't sure what happened."

And that wasn't the worst of it.

While the other nurses nod or pause to study their colleague for a moment, Mrs. Barkye finishes the story.

"It was the end for the parents. THE end. The end of their marriage, the end of the mental health of that mother." She pauses to say one more thing.

"I wish that everybody knew how much we care about helping a baby come through."

There is, of course, the flip side of the coin. Every nurse in the unit slaps a single word on it, whether or not that nurse is strictly religious: The word is "miracle."

Mrs. Scribner recalls watching as a baby was coded blue and died in front of the parents, the doctors and the nurses, its pulse flat-lining on a screen, along with its respiration and blood pressure.

"They had walked away," she says of doctors and the parents. "That baby was gone, and about three minutes passed." As she recounts the incident, all the nurses begin smiling and nodding. "About three minutes passed, and suddenly, the monitor came back on."

Boom! The numbers came up, the flat line jumped to life, and everyone rushed to the baby's side, in startled disbelief. Today, that child is home, healthy and happy.

"There's no explanation for that. It's just a miracle," concludes Mrs. Scribner.

"They have a tremendous will to live," says Mrs. Barkye. "Will has a great deal to do with what happens to them."

High-tech, high-love

Technology helps, too, as does the application of resources, know-how and money, which often comes in a great tide of caring from philanthropists who have figured out that money given here is money used to celebrate life, Mrs. Waddell, the NICU director explains.

She gestures at several newly completed rooms, equipped with the latest life-saving machines.

"This was built through the philanthropy of Jack and Shelly Blaze," she says. "Jack and Shelly … matched every single dollar of (a) Boston Red Sox fundraiser… they just fell in love with the NICU, and they saw that we take seriously what we do."

The entire unit sparkles, but it's a calculated, deeply considered sparkle — a research sparkle, perhaps.

"Although we're not a research hospital, we're always looking at best practice, and we do collaborative research," Mrs. Waddell says.

She describes this while standing on a seemingly hard tile floor, made like the ceiling, with the highest acoustic rating in the world so that sharp noises will not intrude on the senses of Level 3 babies.

"One collaborative study we did, published in a medical journal, looked at the effects of light and sound on ear and brain development of these babies," she says. Light and sound in these children inhibits brain development, just as touching inhibits it, too, which is why "minimal touching" is a common practice until they get older.

Soon, this NICU will begin deep body cooling of children who suffer hypoxic brain injuries resulting from oxygen deficiencies, the newest and a promising technology.

If it sounds like science fiction, a glance into any room will dispel that notion, since yesterday's science fiction is today's reality for every child.

Everything in the right measure

As the morning disappears into afternoon, nurses move from little human to little human, sometimes pausing to communicate with one another other, sometimes adjusting machines or greeting parents or staff, and always eyeing the computer monitors above each little cocoon.

The screens broadcast neon numerals that dance upward or downward above digital lines for pulse, blood pressure and oxygen-saturation levels in the blood. Most people on Level 3 have tiny sensors fixed to their feet, their ribs or chests, along with tubes running from their noses or throats into machines that cannot be understood at a glance.

Often by some exercise of extraordinary skill, they also have tubes that are threaded into two of the three natural lines — the arteries and veins — that supply each human navel. These deliver nourishment or allow nurses to draw the arterial blood that so clearly reveals a multitude of conditions, without hurting or pricking the patient.

Above each little person, at one time to another, bright lights shaped like cactus paddles direct light to the little body, to help prevent jaundice. That in itself reveals the great paradox of care in the NICU. Too much light, the same as intrusive sounds or even human touching, can slow brain development and injure these human beings.

But like everything else here, that light is doled out with so much love and so much efficient precision, that something in the little bodies — something immense and dormant seeded in their tiny hearts and minds — can awaken against all odds, to bloom in a full life.

Mrs. Brown, and every nurse here, will see to that outcome if it's the last thing they do, because they never stop watching and caring.

She's standing in the dimmed light of one room, cooing to a baby in need, when an alarm sounds in another room nearby.

"Charlene," she calls, "who's that?" "It's Girlfriend here. I'm on it," responds the nurse.