A night to remember

The first ambulance came into the parking lot and the evening began. My first patient was covered in sweat, only semi-coherent, and in obvious distress. She was rolling from side to side saying what a lot of the patients here say when they're in pain, "Why?! Why?!

The first ambulance came into the parking lot and the evening began. My first patient was covered in sweat, only semi-coherent, and in obvious distress. She was rolling from side to side saying what a lot of the patients here say when they're in pain, "Why?! Why?! Why?!" as if what they're suffering through is retribution for some unknown grievance.

According to her history she was three months pregnant but a quick ultrasound showed an empty uterus and lots of free fluid in her abdomen. Her hemoglobin was the lowest I've seen here so far, 2.6 (remember, normal is usually around 12 to 15). Her blood pressure was only 60/30, very low, and her heart rate was over 150.

It was obvious that she had lost a great deal of blood which accounted for the abdominal fluid on her ultrasound. Since she had so little blood in her blood vessels her heart was going at double speed trying to pump the little blood volume she had to all the critical organs. Basically she was bleeding to death and was already close to being in shock.

I'll say this about the OT team: they can move when they need to. Most of the time it seems like nobody here has any sense of urgency. Things will get done when they get done. But in this cases the nurses had her bladder catheter in, her IVs started and fluids running in wide open in record time.

We had her back in the OT in less than 10 minutes and under ketamine anesthesia we had her abdomen open within 15 minutes. The second I made a small opening in the peritoneal lining, the thin layer of saran-wrap like tissue underneath the muscle wall of the abdomen, a geyser of blood shot out. We were prepared and caught most of the initial flood in a bowl and while I started filling a second bowl the scrub tech and the circulating nurse were running the blood through the filter and filling up an IV bag to start the auto-transfusion. We filled up a total of three bowls, gave all of it back to her, and probably lost as much blood as we gave back. We checked her blood counts again during the operation and they were a little better but still low so we also ordered some blood from the blood bank to give her in the Recovery Room.

All the time so far had been geared toward salvaging as much of the blood she had lost as we could but finally I could now try and find the source of her bleeding. She had a lot of adhesions [fibrous bands that form between tissues and organs] in her pelvis, probably reflecting some old infection which would predispose her to exactly what had happened. When there's infection in the pelvis, usually from a sexually transmitted disease, scar tissue forms around the tubes and ovaries but also inside the tubes. Ordinarily the fertilized egg spends several days making the trip through the tube and into the uterus where it implants and continues to grow. When the Fallopian tube is full of scar tissue the fertilized egg gets held up in its journey and may end up implanting in the Fallopian tube instead of in the lining of the uterus. The lining of the fallopian tube wasn't designed to support a pregnancy, at least not for very long, and inevitably the tube ruptures open, usually causing heavy internal bleeding.

This patient's pregnancy had implanted in her left fallopian tube. The tube looked like an inner tube that had been inflated past the point where it could withstand the pressure. It had burst in its middle section but still attached by its umbilical cord and placenta to the lining of the tube was a small fetus, about the size of a thumb. The fetus and placenta were removed and then the portion of the tube that was damaged and bleeding was removed and sutured closed, essentially stopping the bleeding.

The rest of the operation was focused on removing as much of the blood and clots as possible in order to minimize the risk of postoperative complications. After finishing that and closing her abdomen I went back to Labor and Delivery where I'd heard two more ambulances come in while we were operating.

The first of those two patients was a 16 year old girl who was referred from one of the government clinics where she had been in labor for almost two days. She had pushed for over five hours and the midwife had put a suction apparatus on the baby's head to try to help pull it out but had not been able to get the baby delivered. The mother was running a fever and the baby's heart rate was very fast. The OT was still 20 to 30 minutes away from being ready for another operation; we still hadn't even moved the last patient out.

I was able to get the baby out with forceps relatively easy but the baby was not in good shape. We had a heartbeat but not much else. While calling for the pediatrician we started resuscitation on the baby, sucking the thick meconium out of its mouth and nose, breathing for it, stimulating it and right at about the time the pediatrician arrived the baby let out a pitiful little cry.

So those two cases alone would've constituted a remarkable evening but the best was yet to come. By now it was about 1am and the nurses took me to the other patient who had been brought in by ambulance. She had labored at home for over 24 hours. Her water had broken and one of the baby's arms had come out first along with the umbilical cord. The baby was no longer alive. The arm was dark blue and some of the skin was already starting to peel suggesting that it might have actually been dead for a while before she even went into labor.

There was no heartbeat. The ultrasound measurements were consistent with a term pregnancy. The patient was 38 years old. This was her 7th pregnancy and she had delivered six children before this one but only had one living child. I didn't want to take her to the OT for a Cesarean but it seemed like the only real alternative. It's not possible to delivery a child with the arm coming first.

There was one other option but I wasn't very optimistic about it being successful. There wasn't a significant down side so I decided that once the anesthetist got the spinal block in, before we started the Cesarean, I would try to convert the baby to a breech presentation and delivery it vaginally. This is another one of those things that I had only read about before now but I knew that it had been done for cases such as this when the fetus is not longer alive. It involves reaching up into the mother past the arm that is hanging out and trying to find on of the baby's feet. Once the mother was relaxed from the spinal I was able to reach up and follow the arm to the shoulder then follow the shoulder to the back, down to the buttocks and finally down the leg which was high in the uterus.

My biggest concern was rupturing the uterus from the pressure I was creating by pushing deeply into the uterus but the mother had no longer been contracting when she came in and if there had been a complication like a uterine rupture I was already set up to open her abdomen without any delay. Once I found the leg I was able to follow it to the foot. Keep in mind that this is all by "feel". I found myself constantly second-guessing myself, questioning whether that was a hand or a foot, but I was pretty sure that I didn't feel a thumb so I starting pulling, knowing that I couldn't hurt the baby.

At first there was no movement at all. I pulled a little harder, thinking to myself that it had been worth a try even though it didn't look like it was going to work, when all of a sudden there was a massive shift and the baby's arm just sort of vanished up into the mother just as the foot came out. Once I had one foot out I was able to keep pulling until the hip delivered. Then it was easy to pull the other leg down. The baby delivered to the shoulders easily and both arms came out. The head was the only part that didn't go as smoothly. The cervix by now had contracted down and was holding the head in its grip but with more traction on the baby's body and pressure on the abdomen to help push the head from above we finally got the baby out. The baby had obviously been dead for several days. The placenta subsequently delivered easily. And once again I had new respect for the all the skills that were standard for the doctors that practiced long before I was born.

And then it all stopped. It was about 2am by then and for the rest of the night not a single new patient came in. I got to sleep for about five hours and at 8am I turned the reins back over to my replacement. I'm craving a big juicy hamburger with french fries and an ice cold diet Pepsi but I'll probably have to settle for peanut butter and jelly. But I've got a diet Coke that I put in the freezer when I got home this morning. The electricity got turned back on about an hour ago so by the time I get home I'm hoping little ice crystals have formed inside. My eyes are watering and my throat is burning just thinking about it.