Small Miracles

10:45: Dorothy, an hour before Dr. Quaegebeur "unzippered" her (her word) to rebuild her heart.Photo: Sylvia Plachy

Before pediatric heart surgery begins—before a surgeon slices open the chest, saws through the ribs, and cuts into the heart, and long before the outcome is known—there’s a moment of heartbreak. It happens every time. For Kimberly McCollum, 34, it occurred shortly after she marched into the operating room hand in hand with Dorothy, her 3-year-old daughter.

For Kimberly and Dorothy, the morning had begun at about 6 a.m. at their Brooklyn apartment. It was a crisp October day, two weeks before Halloween. Dorothy, who likes to select her own outfits—“I like dresses and tights and Mary Janes,” she says—wanted to wear the sky-blue dress with white collar, white tights, and her favorite glittery red shoes that recall her favorite movie, The Wizard of Oz.

By eight thirty, Dorothy and Kimberly were waiting patiently in a small room on the fourth floor of the Children’s Hospital of NewYork-Presbyterian, which opens a $120 million, 191-bed facility this week. Dorothy, who stands three feet tall and weighs 32 pounds, has curly blonde hair, giant green-brown eyes, and eerily blue-tinged lips, as if she’d just stepped out of a freezing ocean. “For 80 percent,” said Kimberly, “she’s peachy.” Kimberly was referring to the oxygen-saturation level in Dorothy’s blood. Dorothy might be peachy, relatively speaking; still, she was sometimes short of breath, especially if she skipped too much, which she liked to do.

Kimberly had learned of her daughter’s condition shortly after giving birth. Awaking in the hospital, she found three doctors at the end of her bed. Instantly, “I knew something was wrong,” she says. Like one in 100 kids, Dorothy had been born with a heart defect. Dorothy’s was complicated. A normal heart has two ventricles, one to pump used blood to the lungs, another to pump oxygenated blood to the body. In Dorothy’s case, one ventricle was undersized and unusable. In effect, she had half a heart.

“These kids get into trouble as soon as they breathe,” explained Dorothy’s surgeon, Dr. Jan Quaegebeur (pronounced QUA-ga-bur), director of pediatric cardiac surgery at Columbia and Cornell. The only reason they survive at all is that a second defect—a hole in the heart—allows some oxygenated blood to filter through to the body. Without a series of surgeries, Dorothy probably had no more than a few years of life ahead of her.

Quaegebeur had done Dorothy’s first open-heart surgery when she was just 5 days old to shunt more oxygen-rich blood to her system. Her next surgery, performed at age 1, directed some of her used blood directly to her lungs. It was all part of a planned three-step sequence to rebuild her heart. That left one procedure to go, today’s.

In the waiting room, around 11 a.m., Dorothy busied herself with medical gear stored on shelves on the wall. She stood on the tips of her red shoes, slipped on a pair of rubber gloves, purple ones, and grabbed a blood-pressure cuff. “Not too tight,” said Dorothy, seeming to remember the experience.

She took a Band-Aid and stretched it on her mom’s arm.

“Maybe she’ll be a doctor,” her mother mused.

By now, Dorothy and her mom had developed a special language for surgery. As Dorothy finished applying the Band-Aid, Kimberly explained, “You’ll get unzippered, then the doctor will play with your heart a little. And then?”

“And then they’re not going to give me a shot,” Dorothy said, pushing her belly into her mother’s knees.

“And then?”

“And then Halloween,” said Dorothy excitedly.

Halloween was in fifteen days. Dorothy had already planned her costume.

“Glinda,” she said hopefully, the Good Witch from The Wizard of Oz.

A few minutes later, Kimberly helped Dorothy change into a yellow hospital gown with clowns on it. A nurse put an I.D. bracelet on Dorothy’s wrist. Mom stepped into her own special outfit, a gauzy white hospital suit with hood and mask. A nurse led mother and daughter, hand in hand, along a tiled corridor, through a swinging door, and into a room with theatrically bright lights. Stacks of machines made anticipatory squeaking noises. Masked people in blue uniforms bustled here and there. In the middle of this activity stood an empty bed. “She knew what was up,” Kimberly said a few minutes later. She helped lift Dorothy onto the bed, where she sat in her yellow gown.

“Sitting makes her feel less vulnerable,” explained a thoughtful anesthesiologist—“the sleep doctor,” Dorothy called her—who cradled one arm around Dorothy and with the other covered Dorothy’s mouth with a mask. Kimberly held Dorothy’s hand.

“She was trying to be very brave,” her mother would say. “She’s much braver than I am.” Dorothy let out a soft cry. The anesthesiologist began to tell a story, the same perfectly boring one she always tells, about a child who receives a cat. Dorothy’s eyes closed. The anesthesiologist settled Dorothy’s head onto a blue pillow.

Kimberly turned and pushed through the swinging door, exiting alone. She pulled off her mask and dissolved into tears. (“Most parents hold it together for the kids,” said the anesthesiologist, “until they get outside.”) “You can be as confident as you want,” Kimberly explained. “It’s still heartbreaking to leave your daughter’s life in another person’s hands.”

Heart surgery in kids is spectacularly difficult. In adults, heart disease is epidemic—60 percent of us may die from it—but adults typically suffer from a relatively small number of conditions, and as a result surgeons mainly do a handful of standardized operations very well. In kids, however, heart defects are incredibly varied and bizarre. “Every possible weird anomaly you can imagine exists,” explains Dr. Jonathan Chen, 35, a new fellow in pediatric heart surgery at the Children’s Hospital. “Is it possible to have toilet water come out of the sink and the sink water come out of the toilet? Yes. Is it possible to have all the red blood in your body go to the lungs instead of the heart, the way it’s supposed to? Yes.” Almost every week, the head of pediatric cardiology tells a case-review conference, “I’ve never seen anything like that in my 40 years.”

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As a result, pediatric heart surgeons may do 30 times as many kinds of operations as adult heart surgeons. Plus, while adult cardiac surgeons mainly work on the heart, pediatric surgeons generally operate in the heart. And a child’s heart can be smaller than a walnut.

Every pediatric heart surgeon starts as an adult heart surgeon. “If you do a good job, then you get to be a pediatric cardiac surgeon,” says Dr. Ralph Mosca, 43, Quaegebeur’s partner. “If you don’t, you’re back to being an adult cardiac surgeon.” In New York State, a dozen hospitals do pediatric heart surgery, though Quaegebeur says “some shouldn’t.” He’s probably right. In the hands of some New York surgeons, nearly one in twelve pediatric heart patients will die. “I call them sportsmen,” says Quaegebeur.

NewYork-Presbyterian is one of a handful of elite programs. This year, its surgeons will do 600 operations, making the hospital the state’s busiest facility. It’s also the best, with New York’s lowest mortality rates (adjusted for case complexity).

The stakes, of course, are immeasurably high. “If you fix a 6-month-old, you add 80 years to her life,” says Chen. As if to illustrate the point, the pediatric-heart-surgery suite features snapshots of healthy kids who were once deathly ill. There’s the double-black-diamond skier and the new college grad and the kid in colorful trunks on the beach. “Maybe it’s a cheap heart-tug,” says Chen. “But it’s easy to feel like you want to save children.”

Quaegebeur, 57, is of the generation that helped create modern pediatric cardiac surgery. Short and trim, with a thick head of Ronald Reagan–esque hair, he was born in Belgium and trained in the Netherlands, Boston, and Houston. From the start, he had good hands. “You hear somebody saying it, and then, of course, you believe it,” he says. He’d already trained to be a general surgeon, then a vascular surgeon, then a heart surgeon, when his mentor in the Netherlands, as Quaegebeur says, “pushed me into this congenital business.” This was in the seventies. Columbia recruited him in 1990 because, as then–department head James Malm says, “I was told he was the best pediatric cardiac surgeon in Europe.”

Despite his imposing reputation, Quaegebeur has an almost shy presence. His small stature (he’s five feet six inches at most) invariably makes him the shortest man in the OR, and he still misfires on the occasional English expression (“Umpossible,” he says). He doesn’t travel with a mob of residents in tow, and “gee” is an expression he uses to introduce a thought. When not in the OR, he has a tendency to vanish, disappearing down the stairs in his OR clogs, too impatient to wait for the elevators.

Quaegebeur loves New York—he lives on Riverside Drive and has a house in Sagaponack—and he collects wine (mainly so he can afford to drink good wine) as well as contemporary art. “There’s too much art in our apartment,” says his girlfriend, Annetine Gelijns, a scientist at Columbia (Quaegebeur is divorced). He also dines regularly at Jean Georges and is an ambitious cook—he hopes someday to spend a week in the Jean Georges kitchen learning culinary technique the way he once learned surgical technique.

Still, Quaegebeur says, “Operating is the core of my life.” Indeed, he does 300 operations a year, which means he’s literally in the operating room most daylight hours (he usually skips lunch). He operates at Stony Brook and Cornell, and every couple of months he flies to Europe to operate. He’s delivered lectures on surgical technique only to have his hosts turn to him and, impromptu, ask, “Doctor, we have a difficult case, would you mind operating?” And he will. He also takes cases others refuse. Once, a surgeon had repaired a 12-year-old’s leaking heart, but within a month the heart became infected. The kid’s aorta was rotting. His surgeon refused to reoperate. “He said it was too hard for him,” the patient, now 22, recalls. So in the middle of the night, the patient was shipped to Presbyterian. “You don’t let a patient die,” says Quaegebeur. “You can be wrong. Things don’t always work out. But if you don’t try, you have no chance.”

Before Quaegebeur got involved in the field, heart surgeons hesitated to operate on very young kids. Newborns, it was thought, were too fragile to undergo open-heart surgery. Instead, surgeons palliated and waited. Unfortunately, waiting to operate had high costs. As these kids grew, their diseases undermined their hearts—walls thickened, muscles weakened. Surgeons still occasionally see an older kid who’s survived congenital defects without surgery, and it’s not a pretty sight. “They’re just so blue and their blood is so thick and sludgy that doing anything is very difficult,” says Mosca.

For Quaegebeur, the imperative to operate early crystallized in the mid-seventies with a specific defect. In some instances, the arteries that should go to a child’s lungs connected instead to his aorta, the big vessel that feeds blood to the body. Basically, the kid’s system was backward. The solution was obvious. You had to switch the arteries—and you had to do it immediately.

“The old guys would say, ‘In a neonate?’ ” says Chen, taking their scandalized tone. “And Dr. Q would say, ‘Sure, why not?’ ”

Others saw reasons. The operation was considered extremely difficult, if not impossible. A British cardiologist writing in a British heart journal even called it “unethical.” There were alternative operations to offer these kids. They might not cure, but at least the procedures killed only 5 percent of patients.

Quaegebeur’s initial mortality rate in this procedure was 30 percent. Still, he pressed ahead, spending hours in the lab studying some 7,500 defective hearts in jars. And whenever he did an operation, he stayed up all night, hovering over the recovering child in the ICU. Killing kids is depressing. But Quaegebeur selected the most difficult cases, those who seemed the least likely to survive without intervention. He reasoned that he was, in effect, their best shot. Plus, he says, he was “absolutely convinced that the mortality rate would come down quickly.” Unethical? That was shortsighted, he says. “Just because you failed, you’re not going to say, ‘Sorry, I won’t do it again.’ You learn from it. We were sure we were doing the right thing.”

By the early eighties, Quaegebeur had brought down the mortality rate dramatically—to close to 5 percent (today, it’s closer to 2 percent). He does 60 percent of his operations in the first three months of life, and the “arterial switch,” as his pioneering procedure is called, is his signature operation. “He does this operation that takes most people twelve hours in two hours and fifteen minutes,” says Chen. “The result looks like it should have been that way in the first place. It’s like watching Tiger Woods.”

Raising a child with a heart condition hasn’t been easy. For one thing, it proved impossible to find a nanny. So Kimberly has stayed home with Dorothy for most of the past three years. She works part-time as assistant to a real-estate developer, a job she sometimes does from their snug apartment. Kimberly and Dorothy share the bedroom.

“I want my own room,” says Dorothy.

“So does Mommy,” says Kimberly.

For a time, Kimberly took care of a couple of kids after school, which was nice because Dorothy had built-in playmates, and Kimberly earned a little extra money. This year, Kimberly found a preschool in the neighborhood where she sends Dorothy a couple of times a week. Dorothy seems to fit right in. She thinks of herself as normal, and mostly she is.

When she’s not in school, Dorothy likes to watch movies. She loves The Wizard of Oz, and she’ll act out the parts. She plays Glinda. Her amiable mom plays the Munchkins. “Motherhood,” says Kimberly, “ is the job I seem to excel at.” By the time Quaegebeur enters the operating room toward noon, Dorothy’s gown, the yellow one decorated with clowns, has been removed. Her eyes have been taped shut, her 36-inch body turned into a workplace. Ten people scurry around her, inserting tubes down her nose, into her lungs, into her bladder, a couple into blood vessels, which in small kids sometimes have to be located by shining light through the flesh. Her procedure is scheduled to take about four hours.

The first assistant, an adult cardiac surgeon training to be a pediatric surgeon, paints Dorothy from groin to neck in Betadine, the iodine-based disinfectant that looks like orange war paint. A cardiologist slips a probe with a tiny camera down Dorothy’s throat, setting the device in position in the esophagus just behind her heart.

To one side, a stack of rolling monitors registers blood pressure, heart rate, and half a dozen other functions. To the other, perfusionists prime a cardiopulmonary-bypass machine with blood donated by Dorothy’s mother. The bypass machine is five pumps, each as big as a car battery—“the one on the right is the heart,” explains the perfusionist in charge, who sometimes refers to himself as a member of “the pump team.”

The team pulls dark-blue sterile drapes over Dorothy, focusing attention on the only bit of real estate that matters for the next few hours: the slender bit of chest that peeks through.

Draping the patient provides the surgeon with a psychological cushion, too. Better to operate on a heart than on a 3-year-old with big eyes and a fretful mom. It’s the paradox at the center of pediatric surgery: Help people but don’t get too close. To function at his best, Quaegebeur enforces a kind of emotional no-fly zone. “Trust me, I’m going to fix your baby’s heart” is all he told Kimberly during a brief stopover before surgery.

“To make good decisions day after day, you have to, for your own stability, keep a certain distance,” he says. After all, not every sound medical decision is a pleasant one. Recently, a young patient was rejecting her transplanted heart; her new heart had stopped three times in one day. A sibling, who’d also received a heart transplant, had already died at the end of a similar process. Still, the desperate family implored the surgeon to put the child on a life-support device. A dispassionate surgeon had to step in. “We can’t save everybody,” the surgeon said. “It’s time to cut our losses.” Pediatric heart surgeons like to say that their work is graceful and precise—not like clunky orthopedic surgeons who smash around in the knee—but the beginning of surgery is hardly delicate. To operate, Quaegebeur stands on a stool to Dorothy’s side. He uses an air-powered oscillating saw to cut bone, careful not to cut into the heart, and an electric cautery to stop bleeding. The room smells of singed meat, like a barbecue.

Some surgeons curse merrily through surgery as if in a locker room, some play music, some throw fits. Quaegebeur can get annoyed—on occasion, he’s been known to growl, “I am surrounded by assassins”—a phrase he uses for effect—but usually he doesn’t speak much. Rozelle Corda, a nurse-practitioner who often works with him, says, “I can go through an entire case with Dr. Q without exchanging a word.” Assistants learn to interpret his few words. “If he says ‘Okay,’ that means he’s very happy,” says one. Sometimes Quaegebeur turns the silence on aggressively. “If he doesn’t really respect you, he’ll make believe you’re not there,” says Mosca.

Quaegebeur’s quiet suits his personality, but it’s also a conscious technique. “I watched surgeons where there was a tremendous amount of activity, a lot of talking and music and two or three different instruments passing hand to hand,” he says. “If you watch carefully, absolutely nothing happens. I decided very early I was going to develop a simple style of operating, with minimum movements, but always doing something.” In this, he is meticulous—“no wasted moves,” admirers of his OR technique repeat—which is his idea of beauty. “You can make an operation look beautiful,” says Quaegebeur. To do this, he can be demanding about the smallest detail. Once, when the supply of operating-room scrubs ran out, he made a point about slipping standards in a dramatic way: He showed up in the OR in his boxers.

Within a half-hour, a couple inches inside the hollow of her chest, Dorothy’s heart appears. It’s the color of uncooked chicken. Dorothy’s heart is enlarged and globular. It will never look like a normal heart, but hopefully it will work like one. Quaegebeur plans to convert it from a two-pump heart, the normal setup, to one pump. Some force may be lost, but if the reconstruction is successful, Dorothy will get more oxygenated blood. Conceptually, as one surgeon says, “it’s a crazy idea,” but usually, it works.

“You can be as confident as you want,” Kimberly explained. “t’s still heartbreaking to leave your daughter’s life in another person’s hands.”

Surgeons sometimes operate on a beating heart, stitching as it moves—“working on a beating heart is like landing a plane on a moving aircraft carrier,” says Chen. During part of most surgeries, though, the heart is stopped, and the bypass machine takes over cardiac function. Dorothy goes on bypass a little before 2 p.m. Her temporary heart sits a few feet from her body, in one of the sterilized clear-plastic pumps connected to her real heart by polyvinylchloride tubes. In a few minutes, the pump team applies cardioplegic solution (“the plege,” they call it), arresting her heart, which sags into her chest. At 2:08 p.m., an anesthesiologist points to the screen monitoring Dorothy’s heartbeat. The rhythmic line goes flat.

Before recirculating Dorothy’s blood back into her body, the pump team cools it, plunging Dorothy’s body temperature to near 64 degrees fahrenheit. At that temperature, metabolic demands are greatly reduced, which helps protect against the insult of surgery. Quaegebeur pours a pitcher of refrigerated water into the hole in her chest, cooling her heart further.

During some operations, a patient’s entire blood supply is dumped into the bypass machine. “We do what people call suspended animation. All their metabolic processes essentially stop,” explains Mosca. Basically, you kill a kid for 30 or 45 minutes. Under such rigorous time constraints—dawdle and a kid might never remember her phone number—surgery can seem like a kind of athletic contest with knives.

To be a great pediatric heart surgeon, you must be a technical virtuoso. That alone eliminates all but a small percentage. One surgeon described the first time he saw Quaegebeur operate: “It was like seeing my favorite symphony performed perfectly.”

“Cardiac ORs are full of crisis,” says Chen. “Things happen that are very dire.” Improvisation is often called for, and often, in the nick of time. Every heart surgeon needs to know that he can, as one puts it, “remain calm and fix the problem when all hell is breaking loose.” And, of course, you must do that, as Mosca says, knowing “that one stitch is the kid’s entire life.”

Quaegebeur believes he’s calmer in the OR than out of it. “I have to be,” he says.

No matter how gifted you are or how calm or how hard you train, some of the time you must tell a family they’ll be going home without their child. How a surgeon deals with failure may, as much as anything, determine his effectiveness.

One evening at Jean Georges, Quaegebeur recalled a period when failure shook him. He was wearing a knit tie and khaki-colored pants—he looked like a prep-school English teacher. He chatted amiably with the sommelier and the maître d’, but the topic of failure set him on edge.

Half a dozen years ago, Quaegebeur said, he lost control of a specific operation for kids born with half a heart, a condition not dissimilar to Dorothy’s. “I’d had a very good run for a while. I’d had excellent results,” he said. “Then suddenly, bang, bang, bang, we had several kids die in a row.” Other types of cases would go fine. But in this one complex procedure, “I could technically have a very good operation and still run into trouble. I wasn’t sure that even with a good operation the outcome was going to be good.”

NE?d?ke of those deaths, his confidence seemed to erode. “That’s the worst thing that can happen,” he says. “If in your heart you’re uncertain, you make more mistakes.” The humbling outcomes seemed to arrive out of nowhere, like a curse. He’d done just what he’d done before. “That was one of the most upsetting parts.”

Quaegebeur isn’t the type to cry with disappointed families. He prefers to be upset on his own. He would go home, sit in front of the TV, and zone out—there was always surgery the next day, so you could hardly let loose. He’d reoperate the cases in his mind. Could I have done something else? Something different?

He hunkered down with his team and picked through details, desperate for a clue. But Quaegebeur couldn’t find any clear-cut error. In the end, it seemed that a few little details and very fragile kids had collided. “You can start with a small error,” he said. “Then you might, yes or no, do the right thing. If you don’t, you get into a little more trouble.” Quaegebeur changed one aspect of the procedure, adjusting blood flow. And anesthesia, bypass, ICU bored down on every aspect of care. Little by little, they seemed to get the procedure under control.

When kids stopped dying, Quaegebeur’s confidence bounced back. His mood lifted, which it did again at dinner, as if he had passed, again, out of that difficult phase. Suddenly, he liked the wine from Alsace. And his duck was very good, and he’d never seen turnips so delicate and small. “Now I’m pretty confident that the outcomes are going to be very good,” he said. Though he can’t keep from adding, “Unless some mistake is made.” Three hours into dorothy’s surgery, Quaegebeur’s blue gown is sprayed with her blood—at one point, it jumped out of her chest. He wears loupes, glasses from which black magnifying scopes protrude. His eyes shift around the scopes. He looks at Dorothy’s deflated heart. Then he glances at a piece of bovine pericardium, the lining of a cow’s heart, which is spread over her abdomen. He sizes it up, glances back at her heart, then snips a patch that will enlarge the pulmonary artery, in effect creating a new passageway for blood.

“I’m a glorified plumber,” Quaegebeur says, “though I emphasize glorified.” Still the artistry may be understated. “Most normal mortals would measure a lot. Dr. Q will look at the pericardium and then look at the patient and then cut some crazy shape that looks like a grand-piano top,” says Chen. “When you fold it all up and sew it in, it actually reconstructs the aortic arch, and you think, How does he do it?

Quaegebeur lowers the pericardium onto the heart and starts sewing. Pediatric heart surgeons sometimes sew vessels not much larger than the diameter of a pencil lead, and they have to get it just right. Too loose, it leaks; too tight, it kinks.

in any heart operation, there is, as Mosca puts it, “a moment of truth.” It’s the moment when, the repair complete, the limp heart must again take over. The pump team turns off the artificial heart and lungs—“Bypass off,” you hear. Inside the plastic casing, wheels stop spinning. In the OR, people think of the heart as having a will, a desire. They say the heart wants to work. Or it doesn’t.

Just 24 hours earlier, Quaegebeur had walked into a case with a stubbornly uncooperative heart. From the start, it had been a disaster. As soon as 8-month-old Joey (this name has been changed) was put to sleep, his heart had stopped. The OR team had to crash him onto bypass, cutting his chest open and sewing a couple of tubes into his heart, and simultaneously keep him breathing. Dr. Sorin Pusca, the fellow assisting that day, compressed Joey’s tiny chest, one-two-three-four, then paused so Quaegebeur could quickly make an incision. They repeated the drill: resuscitate, pause, operate. With the chest open, Pusca massaged the heart directly, then paused while Quaegebeur sewed.

By the end of the repair, echocardiography showed that Quaegebeur had established good blood flow. And so he instructed the pump team to take Joey off bypass. Within minutes, his heart muscle collapsed, as if exhausted. Quaegebeur tried five times to get him off bypass. “Whatever we did, the heart didn’t want to recover,” said Pusca.

Maybe, as one perfusionist put it, “not all kids are meant to live.” Still, a fatality, says Chen, “sucks the life out of everybody.”

At 3:30 p.m., Dorothy’s repair is done, and Quaegebeur instructs the pump team to bring her off bypass. Time for the flabby muscle to kick again, which it seems to want to, though not regularly. “It’s bouncing all over the place,” says a concerned anesthesiologist. An out-of-kilter heart can be dangerous.

“We need a bit more volume in the heart,” says Quaegebeur, who plucks it with a finger, stimulating the heart’s electric impulses. The echo shows a good repair. Still, for a few anxious minutes, the heart won’t settle down. When finally it finds a regular rhythm, one observer unconsciously starts to shake her leg in time.

Upstairs on the ninth floor, Kimberly had tried to sleep during surgery but couldn’t. She’d refused the offers of relatives and friends to accompany her. She would have just had to comfort them, she felt. She wasn’t really upset, or didn’t think she was, anyway. She told herself that she was glad the day was finally here. Still, when a member of Quaegebeur’s staff stopped by to tell her the surgery was over, she burst into tears for the second time that day. Perhaps heartbreak was behind her now.

By 5 p.m., Dorothy had reached the ICU. She was dressed again in the yellow robe, though this time there were two drain tubes poking out of the new scar in her chest. Already she looked pinker.

Quaegebeur breezed by. “This is hopefully the last. There were no surprises. An excellent result, I think,” he told Kimberly. “I hope the one pump stays as strong as it is now,” Quaegebeur said.

No one has any experience with what happens 25 or 30 years out; the operations haven’t been done that long. But so far, most kids who have had similar procedures lead normal lives, without limitations. “She’ll be fine,” Kimberly said. “That’s all I can think.” For the next two nights, Kimberly slept on a foldout chair next to Dorothy’s bed. Occasionally, Kimberly would hover over her. “I’m a little teapot,” she would sing, just in case Dorothy could hear.

It’s Halloween night in Brooklyn Heights. Dorothy arrived home eight days after surgery, and preparations have been going on ever since. Dorothy’s godfather made a crown that looked beautiful even with the staples showing in the back. Her mom found a wand for $3, which lit up and played music. Kimberly and Dorothy picked up a dress at a tag sale. It wasn’t pink (authentic Glinda), but Dorothy loves it just the same.

Before stepping into her costume, Dorothy rests on the couch in a T-shirt and tights, keeping an eye on the Harry Potter movie that plays on the TV. Her scar peeks out just over her T-shirt. She says it doesn’t hurt, and it hardly looks like anything at all. Her color is terrific. She really is peachy.

“When are we going trick-or-treating?” Dorothy suddenly wants to know. She jumps off the arm of the couch. “Where’s my wand?” she asks.

Her mom does her makeup. Dorothy expertly smacks her lips together.

At 5:30, Dorothy grabs her wand in one hand and Kimberly’s hand in the other. On a block of brownstones, families sit on just about every stoop, while hundreds of kids file by. There are baby Batmans and kids in pirate costumes and a Santa Claus. And there are ghosts.

“What do you say, Dorothy?” Kimberly asks as they approach a stoop.

“Trick or treat,” Dorothy shouts and opens her bag.

Small Miracles