The Horn of Africa

Craniotomy and Reflections on Reacting to Surgery

This morning, I went on maternity rounds with Dr. Qaws instead of the medical rounds I'd been doing with Dr. Derrick for the last week.

We examined a patient who was 8 months pregnant and had intrauterine death of the fetus four days ago. Since then, we tried to induce labor using an oxytocin analogue, Syntocinon, and had no success. Today, I put my fingers inside her and felt that the cervix was fully dilated, with the head of the fetus low, pressing against it, in something between a face and brow presentation. Dr. Qaws said that with this presentation, the space required in the birth canal is too great and the fetus cannot be delievered vaginally anyway. The presentation was missed on earlier examinations.

When I removed my fingers, a bit of the fetuses skin was stuck to my gloves. Four days was already really pushing it and the fetus had to be removed, pronto.

We were left with two choices. Either we perform a c-section and risk a likely infection, or we perform a craniotomy and risk rupture of the uterus. Since she's had no bleeding, and the risk of uterine rupture seems low, we opt for the latter.

A craniotomy is not a pretty procedure. The goal is vaginal removal of the fetus without labor. Labor would push the baby out; a craniotomy pulls it. The method is to cut into the skull of the fetus with very large, pointed scissors, remove some of the brain matter and fluid to reduce the size of the skull (for easier extrication), and then insert what amounts to a large pair of vise-grip pliers. The pliers grip a stable portion of the skull and then a tug-of-war ensues, doctor against uterus.

In our case, the whole procedure took almost half an hour. Dr. Qaws was trying to grip the back of the skull instead of the more readily available face -- a personal proclivity not medically indicated and one which lengthened the procedure.

With a strong heave, the fetus finally came out, skull split nearly in half, face badly misshapen, head like a deflated soccer ball forgotten under a porch. One eye bulged out of the socket. Brain matter littered the basin and table like so much pudding.

I started to imagine the psychological trauma that would result if a mother saw her baby in such a state. This patient was a calculating realist. When Dr. Qaws had explained the procedure to her before hand, she'd remarked, "My baby is already dead. If this (the destruction of the baby's body) is what you must do to save my body, so be it."

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Strangely, this procedure didn't phase me in the least. I found the first c-section and first D&C much more difficult to stomach.

I wonder, idly, if I'm over the hump in terms of having strong physical reactions to highly invasive procedures.

There's a big disconnect here between fantasy and reality. In my fantasy, it's a few years down the road and I'm alone in a war-torn country nobody could find on a map. I'm in a refugee camp, coldly calculating in triage, struggling to get a handle on an epidemic, performing surgery under abysmal conditions. I'm working 18+ hours per day and I'm positively masterful -- but it's still not enough. I'm stretched too thin despite giving my all. Every day is a struggle simply to keep my head above water, but I secretly love it. (To deal with the stress, I take up zazen instead of smoking, of course... haha!) I develop a "thousand yard stare" and later, in old age, I write a seminal book on philosophy informed by my experiences.

In reality, I'm sometimes a wet chick quaking in a cage, small in the world. (That overstates the case, but the idea is the same.) I've had two or three instances -- a bunch biopsy that became 15 minutes of digging with a scalpel, the elective c-section here in Somaliland -- that have left me woozy and flushed with sweat and needing to take a moment to breath and relax. Each time, it's struck me as painfully absurd, discordant with how I view myself. I've seen nasty traumas, gore, incredible messes, but these relatively minor, elective procedures have thrown me for a loop. I don't feel mentally or emotional distraught, but my body reacts: my temperature rises, I feel beads of sweat sliding down my legs, my forehead is wet.

I wonder if it's that they're elective? The punch biopsy was for a small, fatty nodule under the skin in the back. Invisible. He'd had one removed from the same place a few years previously and this time we used a scalpel to remove scar tissue. At first, I was fine, but the more my mind had a chance to wander... Perhaps an inability to turn empathy off completely? I can't make heads or tails of it.

In any case, I think, realistically, it's simply a matter of exposure. The first few times you compete in athletics, you're a mess of nerves and anxiety. Later, you realize that the "butterflies" are a positive sign, a symptom of excess energy raring to go, blood shunted away from the GI tract and into your biggest muscles, your body champing at the bit, ready for perform.

Perhaps surgery is the same. Either this stuff will simply stop happening or I'll learn to recognize the onset and channel it into something positive.

I also think I'm probably not alone in this. That it might be common for people coming into medicine. Besides, some people faint when they see, or even think about, blood, so getting woozy when liters of blood flood the floor and bodies are sliced upon is, at the very least, a step up from that. :)

posted by daviduri @ 5:28 AM