Destructive Delivery11/29/2017  In the developing world, pregnancy-and the complications thereof- kills more women than motor accidents (the leading cause of death population wide). In terms of death per 100,000 persons engaging in a particular activity, it is more dangerous than SCUBA diving, sky diving, extreme rock climbing, and motorcycle racing. I recently spent a full day learning all the ways a fetus can kill its mother, and practicing techniques to prevent or manage these situations. The danger begins at conception. Implantation in the wrong place or orientation can lead to massive hemorrhage and death of both fetus and mother. Ruptured ectopic pregnancy is a silent killer of women and a true medical emergency. This occurs when the embryo has implanted somewhere along the reproductive tract, outside of the uterus (often the Fallopian tube). As the fetus grows, the tube will stretch until it eventually ruptures. It is a silent process, as often the woman may not even be aware she is pregnant, or may not as yet sought prenatal care. I’ve experienced this first-hand in my practice. I was called to the ER for a young woman who had reported a sudden sharp pain in her abdomen, followed by rapidly progressing weakness. A quick ultrasound revealed a massive amount of blood in her abdominal cavity, and she was in shock from blood loss. Not knowing the source of the bleeding, but with no time to waste, we rushed her to the operating room where I performed a laparotomy (surgical opening and exploration of the abdomen). There were approximately two liters of blood in her abdomen, and after scooping out the clots and packing with gauze sponges, I located the source: an amniotic sac containing a fetus was extruding from the torn edges of her briskly bleeding right Fallopian tube. The fetus was well-formed. Facial features, fingers and toes were clearly visible. It was curled into a ball, floating in its liquid cocoon, and it was moving. Here in front of me was a part of life few will ever see with their own eyes- and I marveled at it. But I also knew there was no way it could ever survive. It was doomed from the beginning. And right now, it’s mother was bleeding to death. I had two choices: end one life to save another, or lose them both. The blood supply to the Fallopian tube (and thereby the placenta implanted into it) is the uterine artery on each respective side. In surgery, we stop arterial hemorrhage by controlling the feeding artery with clamps or ligatures. “Clamp!”, I called. The scrub tech looked at the fetus, then at me. Our eyes met, and in that instant we agreed. The snap of clamp striking palm was followed immediately by the click of the clamp locking closed on the artery. Bleeding stopped. “Hemorrhage controlled.” “Call the OB/GYN.” “What’s her pressure?” “Two more units of red cells and a STAT ABG, please.” As the anesthesiologist worked to correct the damage done by blood loss and shock and we waited for the OB/GYN to arrive, I wanted to look away, but found I could not. My eyes rested on the tiny form until it stopped moving. If all goes well and the fetus and mother survive to term, birth can still be deadly. Our practice sessions focused on situations in which birth does not progress normally. There are several scenarios which are common in the developing world. Uterine rupture may occur when the uterus has been weakened by multiple pregnancies or by prior Caesarean sections. As labor contractions intensify, the walls of the uterus may rupture from the pressure. In this instance, the fetus must be delivered within minutes to save it, and the bleeding stopped quickly to save the mother. This is done via an abdominal incision similar to a Caesarean section. As time is critical and access to care is limited, this condition is frequently fatal for both fetus and mother. Another major problem encountered in the developing world is intrauterine fetal demise, which most often occurs when the fetus is unable to be delivered vaginally due to malposition (breech or transverse) or to anatomical limitations in the mother. Child marriage (and pregnancy) is common, and the underdeveloped, small pelvis of a young mother often prevents passage of the fetus. if labor begins but cannot progress to birth, the fetus will die. At this point, the danger to the mother is death from sepsis if the dead fetus is not expelled. Today I learned a new term: Destructive Delivery. This is a procedure that facilitates passage of the dead fetus with the least possible risk to the mother. Before today, I would have thought that extracting a dead fetus from its mother would be similar to extracting a live fetus which could not pass through the pelvis- namely, by Caesarean section. But Caesarean section, as with any surgical procedure, carries inherent risks. And in a mother who is likely already anemic, malnourished, and susceptible to infection, those risks multiply. The safest thing for the mother is to facilitate a vaginal delivery. Most of the time, the head is the largest part of the fetus, and it becomes wedged in the pelvis once labor has begun and is unable to pass. Reducing the size (volume) of the generally results in subsequent vaginal expulsion of the fetus shortly thereafter. This reduction in volume is accomplished by creating an opening in the skull of the fetus, through which the contents of the extrude. We practiced the technique on grapefruit. From a human standpoint, this process may seem distasteful, traumatic, even brutal. From a technical standpoint, it's a simple, elegant solution which is easy to perform. From the perspective of a physician and surgeon, it is a safe, practical and sound approach to solving a problem in a living patient. From a societal perspective, it is the tragic outcome of social and cultural practices that encourage child marriage. From a humanitarian standpoint, it is an indictment of local, regional, and global politics that make child marriage, multiple pregnancies, lack of birth control, poverty, malnutrition, and poor or non-existent healthcare a daily reality for millions of women worldwide. I never want to cut open the skull of an unborn, dead fetus. But I know now that I can. Most of us in the Western world will never be faced with this situation. But we should all be aware of it. We should consider how our lives- our habits, choices, actions, and politics contribute to ideologies, practices, and organizations (including governments) which either promote, facilitate, or allow the conditions that lead up to it.
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MacConnell's11/29/2017 It’s 2:30 on Wednesday afternoon. I’ve spent the day meandering through Glasgow’s Kelvingrove park, making my way along the river with the pigeons and squirrels. It’s a beautiful, crisp fall day with frost dusting the leaves on the path. After a few hours and miles, I fancy a pint. The exterior of MacConnell’s proclaims it to be a “traditional Scottish haunt”, which sounds like just the place. Behind the bar is a dark-haired woman in a black tank top who I expect is likely younger than she appears. She greets me with a warm “Hiya” and serves up a frothy pint of Guinness as she banters with the two older men at the bar. They each have a partially completed crossword in front of them, but have paused in their progress in favor of jaunty discourse. Peals of laughter erupt from the only other occupied table in the small pub, where four gray-haired men in jumpers are deep in joyful debate. The guffaws are punctuated with frequent “Fowk Yewh!“s. The controversy seems to involve the height of a particular sporting figure, from what I gather. "Hey, Natasha! Come Google this for us!” “Aye, I will do. Give me two minutes.” The liquor delivery has arrived and her attention turns to the transaction. Meanwhile, two new arrivals have joined the group. Standing height comparisons are made, bets taken, and I catch something about “allowing for shrinkage” which provokes much loud applause. Natasha returns, serves the newcomers their beer, pulls out her phone, and the question is posed to her: How tall was Italian footballer Franco Baresi (whose stellar career ended in 1997)? The answer comes back: 5 feet, 9 inches, and there are cries of triumph and consternation as bets are won and lost. One may well ask, “Who Cares?”. But they would be missing the point. Of course it doesn’t matter how tall Franco Baresi was. What matters is these people, right here and now, taking these moments as they are and enjoying them in their companionable perfection. I silently bow to them, grateful to have been a party to it. My glass is empty. Time to move on.  Craniotomy11/29/2017 I drilled holes into a human skull with a hand tool today. As the burr dug deeper into the bone, my arms shook both with the effort and with the fear of plunging suddenly into the brain as the bone gave way. Trepanning (trepanation, trephination)- making a therapeutic hole in the skull- has been practiced for millennia. Evidence and records indicate that Incan, Mayan, Egyptian, Greek, Chinese, Neolithic European, and other cultures engaged in it. Skulls have been found with carefully created holes (some even with multiple holes in varying stages of healing) dating back to 6500 BCE. Today, the procedure is called “craniotomy” in medical practice and is performed to relieve pressure on the brain caused by swelling or bleeding as a result of injury. Historically, records indicate it was also used to treat conditions such as headaches, epilepsy and mental health disorders. These were often believed to be caused by spirits which possessed the afflicted and could be released by opening the skull. I lift away the flap of bone I’ve created to expose the brain beneath. I mentally bow to its owner. He offered it up when it was no longer of use to him, in order that my brain could acquire the skill to save the injured brains of strangers to the both of us. From his brain to mine, from mine to theirs, and onward.  Ballistics11/29/2017 “Ballistics: the science of the motion of projectiles in flight; the flight characteristics of a projectile.”– Merriam-Webster Dictionary
In the span of forty minutes, I’ve learned the ways in which firearms and explosives are specifically designed to damage the human body. Cold, scientific descriptions of velocity, joules of energy, blast pattern, range, fragmentation, cavitation, are punctuated with chilling descriptions of injury patterns and death rates, and illustrated with images of mangled bodies. There are greater than 125 million Kalashnikov assault rifles in circulation worldwide. A variety of mines are available, providing three distinct patterns of injury from which to choose. Many are designed to look like toys, because the maiming of children is a good strategy for crippling a population, both physically and psychologically. I feel I’m staring into the very face of evil. What allows someone to disengage so completely from their humanity that they can even consider and discuss such things as if they were designing a toaster? If shown a photograph of a mangled human body, how does one think, “We can do better.”?  I will spend the day in the anatomy lab, where the fresh-frozen bodies of seven civic- and science-minded folk will be the training ground work I will do abroad. They are Americans, too, I’m told. So we are eight.
The other 29 participants of the course are from all over the world: Lebanon, Palestine, Italy, Brazil, Iran, Canada, Switzerland, Hong Kong, Nigeria, India. This collection of surgeons has come to hone their skills and learn to adapt them to “austere environments ”- poor, disaster-stricken, war-torn regions where the need is great, the resources few, and devastating injuries requiring prompt surgical care come in a flood. Manchester11/29/2017  It’s raining this morning in Manchester as I walk the mile or so to the University. The city is waking up. I pass groups of men with reflective vests and hard hats, women in business wear. Young people laden with backpacks huddle around the Starbucks. Cyclists weave between delivery trucks. A jogger splashes me as he runs through a puddle. I’m struck by both the sameness and the difference in how people live their lives here and at home. The familiarity is comforting, the strangeness exhilarating. 
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Musings on my travels and experiences as a Zen practitioner, trauma surgeon, and citizen of the world.
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