Small Great Things

by Jodi Picoult

  "I left the money under your welcome mat," I blurt out.

  "I know," Christina says. "I should have superglued it to your palm."

  There's a foot of space, and a world of contrast, between Christina and me. Yet I, too, know how hard it is to peel back the veneer of your life, and to peek at the real. It's like waking up in a room and getting out of bed and realizing the furniture has been completely rearranged. You will eventually find your way out, but it's going to be slow going, and you're bound to get some bruises along the way.

  I reach out and squeeze Christina's hand. "Why don't you come inside?" I say.

  --

  THE NEXT DAY is frigid and clear. The memory of yesterday's snowstorm has been scraped off the highways and the temperature keeps some of the crowd away from the front steps of the courthouse. Even Judge Thunder seems settled, made complacent by either whatever drugs he got for his sore back or the fact that we are nearing the end of the prosecution's witnesses. Today, the first person called is the state medical examiner, Dr. Bill Binnie, who studied under the famous Henry Lee. He is younger than I would have imagined, with delicate hands that flutter during his responses, like trained birds sitting in his lap; and he has movie-star looks, so the ladies in the jury are hanging on his responses, even when they are simply the boring litany of all the accomplishments on his CV. "When did you first hear about Davis Bauer, Doctor?" the prosecutor asks.

  "My office received a phone message from Corinne McAvoy, a nurse at Mercy-West Haven Hospital."

  "Did you respond?"

  "Yes. After retrieving the infant's body, we did an autopsy."

  "Can you tell the court what that entails?"

  "Sure," he says, turning to the jury. "I perform both an external and an internal examination. During the external exam, I look over the body for bruises and to see if there are any marks. I take measurements of the body, and the circumference of the head, and photograph the body. I take blood and bile samples. Then, to perform the internal examination, I make a Y incision in the chest, pull back the skin, and examine the lungs and the heart and the liver as well as other organs, checking for rupture, for gross abnormalities. We weigh and measure the organs. We take tissue samples. And then we send the samples to toxicology and await the results, in order to make a reasonable and factual conclusion about the cause of death."

  "What were your findings of note during the autopsy?" Odette asks.

  "The liver was slightly enlarged. There was slight cardiomegaly and a minimal grade one patent ductus, but other congenital defects were absent--there were no valvular or plumbing abnormalities."

  "What does that mean?"

  "The organ was a little large, and there was a small hole in the heart. However, the vessels weren't hooked up wrong," he says. "There were no septal defects."

  "Were any of these findings something that suggested the cause of death?"

  "Not really," the medical examiner says. "There was good reason for them. According to the patient's medical records, the mother had gestational diabetes during the pregnancy."

  "What's that?"

  "A condition that leads to high blood sugar for a mother during pregnancy. Unfortunately, that high blood sugar in mothers also has an effect on their infants."

  "How so?"

  "Infants who are born to mothers with diabetes are often bigger than other babies. Their livers, hearts, and adrenal glands may be enlarged. These infants are also often hypoglycemic after birth because of increased insulin levels in the blood. Again, based on the medical records I studied, the patient's postnatal lab work indicated low blood sugar, as did the femoral stick done during the code. All of the findings of the autopsy, as well as the low blood sugar, would be consistent with an infant born to a diabetic mother."

  "What about the hole in the baby's heart? That sounds serious..."

  "It sounds worse than it is. In most cases, the patent ductus closes up by itself," Dr. Binnie says, and he glances at the jury. The woman who is a teacher, juror number 12, actually starts fanning herself.

  "Were you able to determine how the baby died, then?"

  "Actually," the medical examiner says. "That's more complicated than most people think. We medical geeks make a distinction between the way a person died and the actual change in the body that causes the termination of life. For example, let's say there is a gunshot and someone dies. The cause of death is the gunshot wound. But the mechanism of death--the actual physical event that ended his life--would be exsanguination--loss of blood."

  He turns his attention from Odette to the jury. "And then, there's manner of death--how it came about. Was the gunshot wound an accident? A suicide? Was it a deliberate assault? That becomes important--well--when we're sitting in a courtroom like this."

  The prosecutor enters another exhibit. "What you're about to see," Odette warns the jury, "may be extremely disturbing."

  She sets up on an easel a photograph of the body of Davis Bauer.

  I feel my breath catch in my throat. Those tiny fingers, the bow of the legs. The acorn of his penis, still bloodied from the circumcision. If not for the bruises, the blue tint to his skin, he might be asleep.

  I had taken this body from the morgue. I had held him in my own arms. I had rocked him toward Heaven.

  "Doctor," Odette begins, "could you tell us--" But before she can finish, there is a crash in the gallery. We all spin around to see Brittany Bauer standing, her eyes wild. Her husband stands in front of her, holding her shoulders. I can't tell if he's trying to keep her subdued or keep her upright.

  "Let me go," she shrieks. "That's my son!"

  Judge Thunder raps his gavel. "I'll have order," he demands, and not unkindly, "Ma'am, please sit back down..."

  But Brittany points a shaking finger directly at me. It might as well be a Taser for the current that runs through my bones. "You fucking killed my baby." She stumbles into the aisle, approaching me, while I stand caught in the spell of her hate. "I'll make you pay for this, if it's the last thing I do."

  Kennedy calls out to the judge as he smacks his gavel again and calls the bailiff. Brittany Bauer's father tries to calm her down, too, but to no avail. There is a shudder of shock and gossip as she is escorted from the courtroom. Her husband is frozen, caught between comforting her and staying for the testimony. After a moment he turns and runs out the double doors.

  When the judge calls order, we all face forward again, riveted by that giant poster of the dead infant. One of the jurors bursts into tears and it takes two others to calm her, and then, Judge Thunder calls a recess.

  Beside me, Kennedy exhales. "Oh, shit," she says.

  --

  FIFTEEN MINUTES LATER, everyone but Brittany and Turk Bauer has returned to the courtroom. And yet their absence is almost even more visible, as if the negative space is a constant reminder of why we had to break in the first place. Odette leads the medical examiner through a series of photographs of the baby's body, from every angle possible. She has him explain the different test results, what was standard, what was deviant from the norm. Finally, she asks, "Were you able to determine the cause of death for Davis Bauer?"

  Dr. Binnie nods. "For Davis Bauer, the cause of death was hypoglycemia, leading to hypoglycemic seizure, leading to respiratory and then cardiac arrest. In other words, low blood sugar made the infant seize, stop breathing, and that in turn stopped his heart. The method of death was asphyxiation. And the manner was undetermined."

  "Undetermined? Does that mean the defendant's actions had nothing to do with the baby's death?" Odette asks.

  "On the contrary. It just means that it was not patently clear whether this was a violent or a natural death."

  "How did you go about researching that?"

  "I read the medical records, of course, as well as a police report that provided information."

  "Such as?"

  "Mr. Bauer told the police that Ruth Jefferson was aggressively beating on his son's chest. The bruising we found on the sternum
could support that allegation."

  "Was there anything else in the police report that led you to fill out the report the way you did?"

  "According to multiple accounts, there was an indication that the defendant did not take any resuscitative efforts until other personnel came into the room."

  "Why was that important to the autopsy results?"

  "It goes to the manner of death," Dr. Binnie says. "I don't know how long that infant was in respiratory distress. If the respiratory failure had been alleviated sooner, it's possible that the cardiac arrest would never have occurred." He looks at the jury. "Had the defendant acted, it's possible that none of us would be sitting here."

  "Your witness," Odette says.

  Kennedy rises. "Doctor, was there anything in the police report that indicated there was foul play or intentional trauma to this infant?"

  "I already mentioned the bruising to the sternum..."

  "Yes, you did. But isn't it possible that the bruising might also be consistent with vigorous, medically necessary CPR?"

  "It is," he concedes.

  "Is it possible that there might be other scenarios--other than foul play--that might have led to the death of this baby?"

  "It's possible."

  Kennedy asks him to review the neonatal screening results she entered into evidence earlier. "Doctor, would you mind taking a look at exhibit forty-two?"

  He takes the file and thumbs through it.

  "Can you tell the jury what you're looking at?"

  He glances up. "Davis Bauer's newborn screening results."

  "Did you have access to this information while you were performing your autopsy?"

  "I did not."

  "You work at the state lab where these tests were performed, don't you?"

  "Yes."

  "Can you explain the highlighted section on page one?"

  "It's a test for a fatty acid oxidation disorder called MCADD. The results were abnormal."

  "Meaning what?"

  "The state would return these results to the hospital nursery, and the doctor would have been immediately notified."

  "Do infants with MCADD show symptoms from birth?"

  "No," the medical examiner says. "No. That's one of the reasons the state of Connecticut screens for it."

  "Dr. Binnie," Kennedy says, "you were aware of the fact that the infant's mother had gestational diabetes, and that the baby had low blood sugar, correct?"

  "Yes."

  "You stated earlier that the diabetes was what caused the hypoglycemia in the newborn, didn't you?"

  "Yes, that was my conclusion at the time of the autopsy."

  "Isn't it also possible that hypoglycemia might be caused by MCADD?"

  He nods. "Yes."

  "Isn't it possible that a newborn's listlessness and lethargy and poor appetite might be caused by MCADD?" Kennedy asks.

  "Yes," he admits.

  "And an enlarged heart--is it potentially a side effect not only of maternal gestational diabetes...but also of this particular metabolic disorder?"

  "Yes."

  "Dr. Binnie, did you learn from the hospital records that Davis Bauer had MCADD?"

  "No."

  "Had these results come in in a timely manner, would you have used them to determine the cause of death and manner of death in your autopsy results?"

  "Of course," he says.

  "What happens to an infant who has the disorder yet has gone undiagnosed?"

  "They are often clinically asymptomatic until something happens to cause metabolic decompensation."

  "Like what?"

  "An illness. An infection." He clears his throat. "Fasting."

  "Fasting?" Kennedy repeats. "Like the kind of fasting done prior to a baby's circumcision?"

  "Yes."

  "What happens to a baby who is undiagnosed with MCADD, and who suffers one of these acute episodes?"

  "You might see seizures, vomiting, lethargy, hypoglycemia...coma," the doctor says. "In about twenty percent of cases, the infant can die."

  Kennedy walks toward the jury box and turns so that her back is facing them, so that she is watching the witness with them. "Doctor, if Davis Bauer had MCADD, and if no one at the hospital knew it, and if the medical protocol was to have him fast three hours prior to his circumcision like any other infant without the disorder, and if an acute metabolic episode occurred in his little body--isn't there a chance Davis Bauer would be dead even if Ruth Jefferson had performed every conceivable medical intervention?"

  The medical examiner looks at me, his gray eyes soft with an apology. "Yes," he admits.

  Oh my God. Oh my God. The energy in court has changed. The gallery is so quiet I can hear the rustle of clothing, the murmur of possibility. Turk and Brittany Bauer are still gone, and in their absence, hope blooms.

  Howard, beside me, breathes a single word. "Day-umm."

  "Nothing further, Your Honor," Kennedy says, and she walks back to the defense table, winking at me. I told you so.

  --

  MY CONFIDENCE IS short-lived. "I'd like to redirect," Odette says, and she gets up before Dr. Binnie can be dismissed. "Doctor, let's say that this abnormal result had come into the nursery in a timely fashion. What would have happened?"

  "There are some abnormal results that require a letter to be sent to the parents in due course--suggesting genetic counseling," the medical examiner says. "But this one--it's a red flag, one any neonatologist would consider emergent. The baby would be monitored closely and tested to confirm the diagnosis. Sometimes we send the family to a metabolic treatment center."

  "Isn't it true, Doctor, that many children with MCADD are not formally diagnosed for weeks? Or months?"

  "Yes," he says. "It depends on how quickly we can get the parents in for a confirmation."

  "A confirmation," she repeats. "Then an abnormal result on the newborn screening is not a final diagnosis."

  "No."

  "Did Davis Bauer ever come in for more testing?"

  "No," Dr. Binnie says. "He didn't have the chance."

  "So you cannot say, beyond a reasonable medical doubt, that Davis Bauer had MCADD."

  He hesitates. "No."

  "And you cannot say, beyond a reasonable medical doubt, that Davis Bauer died of a metabolic disorder."

  "Not entirely."

  "And in fact, the defendant and her legal team might be grasping at straws to try to throw some shade in another direction, any direction that doesn't point to Ruth Jefferson intentionally harming an innocent newborn first by withholding treatment and then by reacting so forcefully she left bruises on his tiny body?"

  "Objection!" Kennedy roars.

  "I'll withdraw," Odette says, but the damage is done. Because the last words that jury has heard may as well be bullets, shooting my optimism out of the sky.

  --

  THAT NIGHT EDISON is silent on the way home. He tells me he has a headache, and almost as soon as we have walked in the door and I'm starting supper, he comes back through the living room with his coat on and tells me he is going out to clear his head. I don't stop him. How can I? How can I say anything that will erase whatever he's been through, sitting behind me every day so far like a shadow, listening to someone try to make me into someone he never believed I could be?

  I eat by myself, but really, I just pick at the food. I cover the rest with tinfoil and sit at the kitchen table waiting for Edison. I tell myself I will eat when he returns.

  But an hour passes. Two. When it is after midnight and he does not come back and will not answer my texts, I put my head down on the pillow of my arms.

  I find myself thinking about the Kangaroo Suite, at the hospital. It's a room with an unofficial name that has a mural of the marsupial on the inside. It's where we put the mothers who have lost their babies.

  I have always hated that term--lost--to be honest. Those mothers, they know just where their infants are. They would in fact do anything, give anything, even their own lives, to get them back. />
  In the Kangaroo Suite, we let the parents spend time with an infant who has died for as long as they'd like. I'm sure Turk and Brittany Bauer were put in there with Davis. It's a corner room, next to the charge nurse's office, intentionally set aside from other labor and delivery rooms, as if grief is a communicable disease.

  This isolation means that the parents don't have to walk past all the other rooms with healthy babies and mothers in them. They don't have to hear the cries of newborns coming into the world, when their own child has left it.

  In the Kangaroo Suite, we put the birthing mothers who knew, thanks to ultrasounds, that their babies would be born in a way that was incompatible with life. Or the mothers who had to terminate late, because of some gross anomaly. Or the ones who delivered normally, and who--to their great shock--lived both the greatest moment of their lives and the worst within hours of each other.

  If I was a nurse who was assigned to a patient whose baby died, I'd do handprints of the baby in plaster. Or hair samples. I had professional photographers I could call, who knew how to take a picture of the deceased and touch it up so that it looked beautiful and vibrant and alive. I'd put together a memory box, so that when the parents left the hospital, it was not empty-handed.

  The last patient I had who had used the Kangaroo Suite was a woman named Jiao. Her husband was getting a master's degree at Yale and she was an architect. For her entire pregnancy, she had too much amniotic fluid, and would come in weekly to have an amniocentesis to check the baby, and to siphon off fluid. One night I took four liters of fluid off her, to give you a sense. And obviously that's not normal; that's not healthy. I asked her doctor what she thought it was--was the baby missing an esophagus possibly? A baby in utero normally ingests amniotic fluid, yet clearly if that much was accumulating, the baby wasn't swallowing it. But the ultrasounds were normal, and no one could convince Jiao that this was a problem. She was certain the baby was going to be fine.

  One day she came in and the baby had hydrops--fluid collection under his skin. She stayed with us for a week, and then her doctor tried to induce, but the baby couldn't tolerate it. Jiao had a C-section. The baby had pulmonary hypoplasia--the lungs just didn't function. He died in her arms quickly after birth, puffy, swollen, as if he were jointed of marshmallows.

  Jiao was put in the Kangaroo Suite, and like many mothers who had to come to terms with the fact that their babies had not survived, she was robotic, numb. But unlike other mothers, she did not cry, and she refused to see the baby. It was as if she had this image in her mind for a perfect little boy, and she could not reconcile anything less than that. Her husband tried to get her to hold the baby; her mother tried to get her to hold the baby; her doctor tried to get her to hold the baby. Finally, when she was on her eighth hour of catatonia, I wrapped the baby in warm blankets and put a tiny hat on his head. I carried him back into Jiao's room. "Jiao," I said, "would you like to help me give him a bath?"