The patient hadn't been doing well; the fetal heart tracings weren't reassuring at all (the baby's heart was beating frighteningly slowly), and it couldn't be explained away by any of the usual suspect - a slipped electrode, a strange position of the mom, etc. The nurse was agitated and restless, lacking the practiced composure of the doc who, though he calmly watched the fetal heart monitor for a few moments, was in a bad mood. My father is a doc, and so I've gotten to understand the difference between when a doc is pissed at me, and when he's just pissed. Our OB today fell into the latter category, and so the best course of action, as always, is to (1) stay out of their way, and (2) to do what they say right away. So when he said for us to go scrub in, the three of us ran back to the surgical suite.
We'd decided to take turns assisting, and today was my turn. As saffron flecks of iodine flew from my furious lathering, I sort of kicked myself; maybe this wasn't the best surgery to be my first time assisting. Nevertheless, as the risk of sounding crass, I figured it was time to show I had a pair. I finished and had assumed the position - fingers spread and dripping hands held above my shoulders - when one of the other surgeons came in and said not to scrub in yet. They hadn't figured out which OR they'd be using, and it'd be best to wait. So the three of us (the girls dressed for observation; they didn't scrub) headed back to L&D, and nearly ran into the patient's bed as they wheeled her back for her surgery. I checked with the other surgeon - a recent transplant from Cuba who had done some plastics (as evidenced by his beautiful sub-cuticular stitches), and he said to go ahead. So I went and re-scrubbed (cleanest hands in the whole hospital), and went into the other OR, hands up, and waited.......and waited....... I was going to go ahead and gown-up, but the Cuban doc told me just to wait - and then he and the neonatologist left the room.
Apparently, at that exact same time, there was another woman in labor, and her baby wasn't doing well either. I found this out later from Nicole and the P.A. student - the baby came out, and was silent. The placenta looked all wrong, and everyone held their breath until, by the time the neonatologists arrived, the little one started screaming.
The surgery was back on - the Cuban doc came back, scrubbed in, gowned-up, and helped me gown (there's a lot of twisting involved; it's like learning a new dance), the OB arrived and gowned-up, and the electrocauterization got underway. I was right up at the table for this one; last time I was observed from the side of the room, trying to stay out of people's way. The smell of burning flesh isn't that bad at all, and it the cautery keeps blood loss down. They sliced through the patient's lower abdominal skin, and then zipped through layers of fat. The surgeon pulled apart the layers of muscle and fascia using a surprising amount of force. C-sections aren't pretty at all; they look harsh and even violent - but the prettiness of incisions doesn't mean a damn thing if that baby isn't alright. After the barbarism of dividing the layers of sinew and muscle, there shone the bluish, almost nacreous membranes covering the uterus. Incidentally, there's this fascinating tool composed of two bendable plastic hoops connected by a tube of transparent plastic. One of the loops is encircled about the uterus, and the other end lines the surgical opening, providing a perfectly clear window into the site of interest.
the OB took a scaplel and incredibly delicately knicked the near-gossamer membranes layer, drawing a hair-thin line of bright-red blood. Another knick, and another crimson line, and the earlier roughness was completely forgotten.
And then we were through the walls of the uterus, and there was the baby's hair head. In one swift motion, the OB pulled the baby from the artificial opening in his mother's womb, through the plastic hoop. In a flash, the cord was clamped and snipped, and they baby whisked away for his apgar score. The placenta quickly followed, and then the real work began. The reason for the baby's low heartbeat was because the umbilical cord was wrapped around his neck (nuchal cord). Fortunately, the young fellow was alright.
So many layers were breached for this procedure, and just as many must be repaired. The Cuban surgeon first began by suturing up the walls of the uterus. Here I assisted by holding tension on the suture cord and maintaining the surgical field with retractors. Like I said yesterday, these surgeons' fingers flew - neat and precise when they slipped the curved needle through paper-thin layers of fascia or flesh, I couldn't follow what they were doing as they knotted and re-knotted the stitches. It was difficult for me at first - now knowing exactly what was required - but the suturing surgeon and I soon fell into a rhythm between applying tension and applying stitches. My heart was pounding through my chest during this whole thing, and as i watched them push suture and push around her organs, I realized that there is nothing more beautiful - more perfectly, magnificently exquisite, than loops of healthy, pink bowel. I was shocked at how wonderful it was; the intestines I'd studied in the lab were old, and dead, and slack - but this was the living, breathing, inside of a person; the way God made it. Man was never supposed to see such wondrous awesomeness.
We closed up layer by layer, until all that was left was the skin. After placing staples, the surgeon applied beautiful sub-cuticular stiches. Instead of interrupted stitches, these were buried within the layer of the skin, winding sideways from one side of the incision to the other and back again. when the suture cord was drawn taught, it was as if the wound was closed by an invisible zipper. I believe I blogged about these stitches the first time I did them back on the island, but watching the closure of pink and healthy flesh was significantly more impressive than zipping up the leathery skin of cadavers.
This is by far the most fun I've had in medicine. Thus far.
The rest of the day passed relatively quietly; we went back to the OB's office and saw some patients there. Then we returned to mother/baby, rounded on patients, and went back to L&D to wait. Earlier in the day, the doc had asked us three what we felt we needed from him to further our learning. Nicole blurted out that she wanted to deliver a baby - and she got her wish later on that day. The last case of the night was a woman who was ready to deliver. To prep her, the OB had given her some Pitocin (oxytocin) a few hours prior - thus, when we got there, it was game time. Nicole threw on some sterile gloves, and once the nurse said the baby was crowning, we called the doc to let him know. He showed up and guided Nicole through the whole process, and this lady - much like that first one - pushed out her little girl like a champ. I keep forgetting that childbirth is a natural process that's been going on for ages without docs - and the OB reminded us of that, teaching us as he guided Nicole to allow the baby's natural motions as she descended the birth canal.
Today was an awesome day.
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