Friday, July 18, 2008

My FIRST C-Section (Day 3)

My first C-Section

I’m still shaking…my first C-section really as the primary surgeon.

And here’s how it went.

(WARNING: The author has chosen the use of strong language to convey the intense emotions of the story. Consider yerself warned, pilgrim. ;)

It was a packed Wednesday. The orthopedic surgeon from the regional hospital was in town and he had crammed 12 surgeries for our 1 OR. My day began before all the ortho cases, however, with an early morning C-section. They called me from home. Everything went fine, I assisted, no big deal. I told the surgeon I wanted to do the next one, and he said ok.

After the day of ortho surgeries, the day was ending around 5pm, and I went with the on call doctor to evaluate another pregnant woman in labor for possible C-section. We decided to give her a trial of labor and then if it didn’t work, we would go to surgery. We gave her 2 hours. And let’s not forget—if she needed the section, I was the surgeon…

I was kinda excited at the possibility. Finally, MY turn to be in charge and do the section, making all the incisions, pulling out the kid and sewing the mom up. We do this to some extent in residency, but we’re very well guided and told what to do, where to cut—it’s hardly all me. At this point, I thought that’s what I wanted. I was ready.

I seem to do this to myself a lot—intentionally get in over my head so that I have no other choice but to really see what I’ve got, survive and learn. Throwing myself in countries where I don’t speak the language, running a half marathon without training—for better or worse, these kind of things.

With the possibility of me doing my first section, I went home and took a nap. I was riding some weird high of being in my international dreamland here plus jet-lagged with a bus overdose. I passed out.

I de-hazed about a hour and half later, and had little desire to go in. But I had told the doc I’d go back, and I wanted my word to be good, so a little drudgingly, I returned to the hospital.

When I got there, it was on. The patient had not progressed at all in 2 hours despite adequate contractions, and she was already in the OR. IT WAS ON! He told me to change and get in there.

As I went to the men’s changing room, a little smirk snuck out on my face. It was time, here we go, I’m a surgeon. I could have been humming “I’m a little surgeon” to the tune of “I’m a little teapot” really. I was excited.

After I changed, I got a little nervous. Was the on call attending going to be there scrubbed in with me, or did he think I would do it alone? They really don’t know what a third year resident is, and what I should and shouldn’t be able to do. Some thought I was a veteran OBGYN coming to give a lecture on obstetrical emergencies, while others thought I was a medical student. I hoped this guy wasn’t erring on the side of giving me too much credit. My desire to do it all by myself was…uhm…reconsidering its relationship with reality.

I scrubbed in and one of my numerous prayers of the hour was answered—he was going to be across the operating table with me. Dr Ogendo—the same one I challenged initially with the pneumothorax diagnosis, and the one I had bonded with about international affairs and Barak O’Bama—would be in the OR with me. Thank you Lord.

Since I really haven’t been the boss, my OR personality is weak. WEAK SAUCE. I should have rolled in and been like, “Shall we begin everyone?” and just gotten started. Instead, I kinda stood there by the table, and they had to prompt me with exactly how to sterilize the skin, put on the drapes, etc. The whole language barrier didn’t help. Their doubts in me, along with my doubts in myself, were growing.

A little bit about the patient, which I neglected to mention before because I TOO DIDN’T THINK ABOUT IT BEFORE GETTING IN THE OR!!! She was a tough case. A thin 25 year old female G2P1 with prior C-Section for dystocia/failure to progress, it was thought she had an inadequate pelvis and had little chance of having a vaginal delivery in the first place. A couple other kickers: she had severe scoliosis—a curved or crooked back—so much so that they couldn’t do spinal anesthesia and had to do general. Also, she had some chest wall deformity from previous trauma complicated by lung abscess.

Wonderful first case. Straightforeward and all. Remember, I asked for this.

Dr Ogendo asked me if I wanted to assist him instead of doing it myself. Not thinking enough about the patients medical history, I insisted I could handle it, and he said ok.

We prepped and draped—which I kind of faked my was through—and were ready to begin.

With the knife, I opened with a lower transverse incision both above and below her previous section scar, excising it. As I later found out, they were impressed with my speed and skill initially. That’s nice. I hope they were impressed with the pool of sweat collecting at my feet cuz SHIT WAS I NERVOUS. But things were going ok. Hey, I’m doing this.

Then we got down to the rectus, her abdominal muscles. They were a mess. Her prior C section had left her severely scarred, and she was so skinny that I wasn’t sure I hadn’t already transected it just going down through the subcutaneous tissue.

This is where things started to go bad. I was lost. I couldn’t see the difference between the fascia above the rectus, which you are supposed to cut, and the rectus itself. It looked like a bunch of yarn all mixed together. If I cut through this woman’s abdominal muscles, she’ll never be able to do a sit up again. I still had the knife, and after dabbing off what seemed to be more than usual bleeding (although probably was my nerves), I was making little small incisions around looking for the rectus fascia.

I started to panic. The pool of sweat was flowing like a waterfall, from my head and pits down my front and back. What is this? I don’t sweat. I don’t get nervous. I’m always cool, calm and collected.

Well, not in Africa doing my first C-section as the primary surgeon.

Ogendo grabbed the knife from me and got through the fascia to the rectus, which was a scarred mess itself. We could barely make out the midline to cut and separate, but we did. Somehow, we had gotten inside.

I wanted to make a bladder flap, where we dissect off a small layer of tissue and separate the bladder from the uterus, to avoid accidentally nicking the bladder during the surgery (that would be bad). But they don’t do bladder flaps here. I didn’t like this—the scarring continued on the uterus as well, and I would have felt better having a flap. Because I was a little paranoid about the bladder and was still quivering nervous, I made a high incision in the uterus. Instead of taking a couple thin slices and then hitting the amniotic sac, when you go to high you cut into the thicker muscle layer of the uterus. It took several cuts to get in. I was afraid of going in too far because I didn’t want to cut the kid’s head inside, but I was looking like an idiot that couldn’t do a section. I was a head case. Things were not going well in that little primary surgeon brain of mine.

I finally got in, smiled up the uterus by opening the incision with my hands, and I went in to get the kid. Now the good thing is that the baby was not in distress. This was not an emergency C-section done because the baby was suffering. But the bad thing was that mom had been in labor several hours and the head was jammed down in the pelvis. These little ones are hard to remove. I dove my hand in, and as I did, the kid’s arm flailed outside the Cesarean incision. I was able to lift the head, but was worried I was going to crush or break the arm. So I backed off.

The baby was stuck. I couldn’t get her out. Just what was I going to do? The mom’s bleeding, the baby was going from fine to distressed, and the pool of sweat now left everyone in the room wading in my nervousness. I was panicking again.

Turns out, there is a god. And God sent Ogendo to me that day. He reached in and grabbed the kid out, nothing less than saving the day. Ok, ok, it wasn’t that easy, he struggled, I thought he broke the girl’s arm, but she came out, thank God.

Or so I thought. She came out blue. FUCK! I’m ruining this woman’s uterus and abdominal muscles, and now because I was a pussy futzing around with delivering the kid, the little girl’s going to die. Panic again. I was freaking out. In case you didn’t know, yes, African babies do turn blue, too. She wasn’t crying or moving either. FUCK ME!

Alright Lorenz, get a hold of yourself! Ogendo grabbed me to return to the BLEEDING UTERUS—HELLOOOOO—that I had forgotten about while I was watching the not alive yet baby in carried off by the nurses in slow motion. You’ve still got a job to do, pal. Finish. I returned my attention to the bleeding uterus, and tried to get oriented. It was still a bloody scarred mess. I tried to externalize it, but it got stuck. GREAT! So we just started suturing it back together inside the abdomen, which isn’t uncommon.

Things started to get better.

Alright, I know how to do this. I’ve done it at home a hundred times. More like 40 to be exact. Thank god for the training I’ve had. I felt quite comfortable suturing up the uterus—and did a fine job, despite dropping the pickups 20 times because I was in shock/PTSD. Really, my hands were so shakey. At any rate, bleeding was controlled. They still do a two layer closure of the uterus, using only one suture for both down and back. Impressive. Mine made it across once. Not impressive. I needed another one, and in this resource-scarce part of the world, I broke the needle, wasting the suture. Nice, Lorenz!

As we closed, things continued to go more smoothly. Then the nurses shouted out, “Apgars at 1 minute—2, at 5 minutes—10.” Thank you Jesus. The Apgar is a measure of how well the baby is doing. Out of 10 (although by convention, we give a max of 9 in the US), it’s not uncommon to have a score of 7 at 1 minute after delivery. But a 2 sucks and means the baby isn’t doing well. The 10 at 5 minutes began to put me as ease—everything was going to be allright.

I survived. More importantly, so did the baby and the mom. Because things do go wrong, sometimes it’s hard to trust that everything will be allright. A little more faith—in god, life, Ogendo, my training—wouldn’t have been a bad thing. Surviving myself, I grew a little in faith in me.

As we were closing, the anesthesiologist was complimenting me on the surgery. Said he was impressed with my speed and skill, and had demonstrated clear experience and expertise. I said thank you (asante), and told him he was kind. I’m not so sure about the expertise part. Afterwards, Ogendo and I talked about the surgery. He said it was a tough case and that’s why he suggested I assist him. I apologized. I’m still a little punk American doctor with much to learn.

I thanked him, again, saying I’d see him tomorrow. I reminded him to call me for any emergency surgeries or C-sections—not sure what I was thinking, as I type this. On my way out, I went by the newborn nursery and checked in on my little miracle. That was a new experience—feeling attending level responsibility for another life. She was sleeping peacefully. Sorry, sweetheart, but it’s time for your newborn exam so Dr B can sleep tonight. Heart and lungs, normal. Arm reflexes—equal on both sides, no apparent birth injury. See you tomorrow, little one.

The last thing Ogendo said to me on the way out was that I did a great job, and that on the next uncomplicated C-section, I could do it by myself.

I told him, “Sure,” as I have apparently learned nothing. “As long as you’re in the room nearby, rafiki.”


Allie said...

Brother - We both know I wouldn't make it in the third world but I love that the thought even crosses your mind. You're silly! Reading your c-section story makes me appreciate my prenatal care and Dr. Eckert! That whole getting caught in the pelvis thing will probably give me nightmares. Do they have epidurals in Africa??? Baby Clark is doing well - flipping around and kicking a lot. Only about 10 more weeks to go! We love reading your stories and can't wait to see you and hear about them in person. We miss you, love you, and pray for you a lot!

jack said...

habari gani, larry. good job, buddy. it take a lot of courage to get through that milestone and i think you passed with flying colors. tutaonana, rafiki yangu

Natasha said...

not so much weak sauce as SPICY SAUCE! strong work.