I am awakened at 4:35 am with an urgent call from the Emergency Department. An eleven month old baby has arrived in respiratory distress, and a chest Xray reveals a pneumothorax. Without prompt intervention, he may die.
I'm there in ten minutes, arriving to find a team gathered around the child, who is pale, listless, and fighting to draw air into his lungs by using every muscle in his chest/neck/abdomen. In children, this is called “retracting” and is a very bad sign. I glance at the chest Xray and see that the left lung is nearly collapsed.
“Let’s get a chest tube set up.”
“I need an 18 gauge angiocath.”
I insert the needle between the second and third ribs on the left side, just below the clavicle. As the needle enters the chest cavity, there is a rush of air through the catheter. The child’s breathing immediately eases, and oxygen saturation improves. This is a temporary measure, sufficing to relieve the pressure on the lung until the chest tube can be inserted.
“He’ll need to be transferred to the children’s hospital. We should intubate him first then insert the chest tube.”
The Emergency Physician agrees. We administer medications, perform further Xrays, draw blood, insert a breathing tube, connect it to a ventilator, and insert a chest tube. Within an hour, the Pediatric ICU transport team arrives to take him to the Children’s Hospital in Portland.
FONDE BAPTISTE, HAITI
An eighteen month old baby girl comes to or clinic with her parents. She’s had a cold and cough for several days, hasn’t been eating or sleeping well, and they believe she has worms.
We’re holding the clinic in an unfinished concrete building in this village in the mountains above Port-au-Prince. Two days before, we came up the mountain in a pickup truck, and had to get out and walk several hundred yards five different times while the driver eased the truck over rocks and ruts. The distance is about nine kilometers, but the trip took us over four hours. Locals make the journey on foot or on motorcycles, which can navigate the rocky, rutted terrain more easily than larger conveyances.
There is no medical care available on the mountain, but the community is hoping to change that by building a clinic to provide basic treatment of common problems. We have come to administer what care we can, assess the medical needs of the community, and assist with strategy/planning for the future clinic. We don’t have much in the way of equipment/supplies/medications, but are able to provide diagnosis, relief, advice, and reassurance to many of those who come to see us.
It is a disheartening endeavor. For this team of six Americans, the daily reality of the villagers is appalling. The community is poor, and living conditions are primitive. Lice, scabies, intestinal parasites and malnutrition are endemic. We see children who are shockingly underdeveloped for their age, and who suffer from a host of chronic illnesses related to malnutrition.
The baby girl with a cough is typical: she appears at least six months younger than her stated age. We administer de-worming medication, provide a sample of over-the-counter decongestant, and instruct the parents on the importance of hygiene, clean water, and how to use steam as an aid for cough/cold symptoms.
An hour or so later, they return with the child, who is having a coughing fit. The mother reports the baby started crying and then began to cough. This has happened before, as recently as last night, and usually subsides in a few minutes. I listen to the child’s lungs and determine she is having an asthma attack. I have brought along an inhaler, but they can be difficult to use, even for adults. For children, it is nearly impossible to use an inhaler correctly. We need to add a spacer-- a closed chamber which affixes to the inhaler and has a mouthpiece or mask on the other end, through which the child can breathe the misted medication mixed with air in the chamber.
We do not have a spacer.
Looking around, I see an empty plastic water bottle. By cutting the bottle in half, I create a mask. I connect the mouthpiece of the inhaler to the mouth of the bottle with the finger of a latex glove, then place the mask over the child’s mouth and nose. The mist from the inhaler fills the mask chamber, and as she inhales it, her wheezing subsides. She drifts off to sleep in her mother’s arms for the next hour. When she awakens, she begins to cry and her respiratory distress returns. This time, the inhaler treatment is not helpful. Her breathing becomes more and more labored. We have no further diagnostic or treatment resources, and I advise the parents she needs to go to the hospital in Port-au-Prince as soon as possible. A motorcycle taxi is arranged, but they have no money to pay the driver, nor to pay the hospital once they get there. The team takes up a collection for the trek down the mountain, which will take about an hour and a half. The temperature is dropping as the sun goes down, and the father wants to go home to get a blanket for the baby. Delay is not prudent, so I wrap her in my sweater and the family heads down the mountain on the motorcycle.
The next day is Sunday. We are invited to church, the hub of the community, and there we are informed that the child reached the hospital but died during the night. While the community is saddened, no one is surprised. Children die often there. Two other children had died that week. The parents of the child we treated had lost another child last year.
Two weeks later, I walk through a cemetery in Edinburgh, Scotland. The graves date back to the late 18th century, and many belong to children. There are several family monuments to multiple children. I'm struck by the fact that the death of a child was such a common occurrence back then. It seems so strange in this era of modern Western medicine.
As I stand over the baby boy in Oregon, I see the baby girl in Haiti before me. One child lives, another dies. It’s nothing new, only new to me.
The question comes from a patient in the Emergency Department. She has come because of two days of abdominal pain, and diagnostics have revealed the cause to be appendicitis. As the surgeon on call, this is where I come in.
After introductions, history-taking, examination, and discussion of test results, I lay out the treatment plan. In this situation, the only curative course is surgery, which I explain in detail. She poses a few intelligent, pertinent questions which I answer. She expresses understanding and agrees to proceed. Then she hesitates, fixes me with her gaze and asks, "Are you a Believer?"
Up to this point, it seemed we had established a therapeutic rapport- she was prepared to allow me to operate upon her. And now this....
I hesitated a moment. I didn't want a conflict. I didn't want to get into a religious debate. Most of all, I didn't want her to refuse treatment because of me. I didn't want it to be personal. Then I realized that choice was entirely hers to make. It wasn't really about me at all. She asked the question -- I would give the answer.
To be entirely clear, I asked "What are you referring to?"
"Do you believe in Jesus Christ as our Lord and Savior?"
"No, I do not."
A look of distrust, contemplation, then resignation. The moment passes. I assure her I will do my very best for her. She thanks me.
I am baffled- why is my religious affiliation or personal belief relevant? Most people ask, "How long have you been a surgeon?" or "How many of these operations have you done?". But that was not what mattered to her.
As as I continued to mull it over, I came up with a number of clever or evasive responses. But that just makes it about me, or rather how I want her to think about me. The fact is, nothing I say is likely to change her way of thinking, nor should I try to do so. If my beliefs don't matter as her surgeon, neither do hers matter as my patient. They are a force of division, and of no use here.
We've become so polarized -- always looking for reasons to separate ourselves from others. We feel that separateness sets us apart not only as different, but as better. The inclination is to find fault, to condemn or exploit anything we feel is unlike ourselves-- nationality, religion, race, gender, sexuality. It is the holding on to those identities for ourselves and the labeling and rejection of them in others that divides us and causes so much suffering.
These judgements and hatred poison our hearts and minds, much as my patient's rotten appendix was poisoning her body. Had she chosen not to overlook my lack of faith in Jesus Christ, and refused to allow me to remove her appendix, her condition would have deteriorated. So must we all rid ourselves of the poisonous delusions of identity and separateness if there is to be any healing of the world.
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.
“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.
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.
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.
“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.
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.