Today was a sad day in LDL. I was planning on sharing about this pair of patients, but I was hoping it would be a better outcome. A patient, K, that had been staying in the discounted housing near LDL for the last few weeks delivered on Tuesday night. She has sickle cell disease and was having multiple sickle cell crises throughout pregnancy. Then she had the misfortune to developed severe preeclampsia and possible HELLP syndrome at 30 weeks gestation. LDL has never had a baby under 30 weeks survive, and few below 3 pounds survive. K was counseled on her risk and her risk to her baby. I placed her cytotec on Tuesday night and we started her on magnesium. There are only 2 nurses and 1 CNA at LDL overnight covering the entirety of Med Surg, Labor and Delivery, and the ER. We discussed that for safety reasons, one nurse would have to be committed to Labor and Delivery. If they were overwhelmed, they would have to call in a second nurse or call me in. She did well overnight and made it to the following day with little cervical change. K was also severely anemic and had a rare antibody that was being explored that made any transfusion highly risky for reaction. The decision was made to perform a cesarean delivery for K. I watched the providers at LDL work together to coordinate the delivery of blood for K from the Red Cross across the country, a process that required the blood to be flown and then driven about 1.5 hours. LDL also doesn't have surfactant, but they were able to get it from the town 1.5 hours away because they were anticipating this delivery. As soon as everything was available, we proceeded with the cesarean delivery. The team included 3 operating providers, one provider administering anesthesia, one scrub nurse, one nurse primarily for the baby, and 4 providers committed to the baby's resuscitation. I watched the ingenuity of the baby's providers as they prepared a bubble CPAP using a canister of water, tongue depressors, and a Y connector for oxygen. It was one of the fastest sections I've seen and it included a tubal libation per the patient's request. She is 25 and this was her first pregnancy, but she decided that a repeat pregnancy would be too high risk, despite knowing this baby had a probable less than 50% chance of survival. Her suction canister had no more than 100 cc of blood in it. The baby had an initial Apgar of 0 and was briefly intubated, but was able to be transitioned to CPAP. He was placed in a Ziploc bag for temperature regulation. He had an umbilical line and NG tube placed. He received his surfactant. He weighed just over 2 pounds. The team was hopeful but cognizant of their last early premature infant that died at 48 hours of life. LDL doesn't have the luxury to ship babies to a different hospital because they are not a level III NICU and cannot take babies under a certain gestational age. So they get creative and work as a team to do everything they can to give baby J the past chance he can get. He was undergoing phototherapy on Thursday. He was stable on CPAP and maintaining his temperature with the warmer alone. He was strong with an opinion. He made it past 48 hours. But this morning, the nurses called a code blue. When I walked in the room (the first provider to arrive and probably the one with the least amount of NICU experience), his oxygen saturation was in the 40s despite bag masking him. He had likely become apneic and there wasn't a quick enough or adequate enough response despite one-to-one nursing. We struggled to get his oxygen above 70% and it was often below 50%. Blood prevented adequate visualization for intubation. His heart rate started to slow. A tech was called in for a chest x-ray. They attempted needle decompression for possible pneumothorax. He got fluids and epinephrine. They had caffeine ready. But he wouldn't breathe on his own and we could barely maintain his saturations even with good chest rise. He was finally intubated but with no improvement. So we took out his tubes and his family came in to hold him as he died. Would he have died in the states? I don't know. I watched heroic efforts and creative thinking. I watched a team commit to this patient. It was beautiful and tragic. I hoped to talk about how well he was doing with his limited resources. I still think incredible work happened for him. But would he have died in the states?