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June 15, 2011 / calebdresser

A Knife in the Desert

The abdomen opened in a thin white line. Little spots of red appeared, and Dr Tanmay deepened the incision with smooth, concise strokes of his scalpel. Soon he was able to widen the opening with blunt dissection, an opening I held wide with retractors as he moved deeper into the body, separating fascia and muscle and peritoneal tissue, searching for the life within.

 As usual, I couldn’t shake the feeling that some cosmic mistake was responsible for my presence in his operating room. I was excited, to be sure, and had jumped at the opportunity to scrub into surgery again. Nonetheless, I couldn’t help but feel that I was a poor substitute for an assistant with years of experience. Dr Tanmay – and the patient – deserved better.

 The unfortunate reality is that surgical staff here is very limited. Dr Tanmay has to call an anaesthesiology technician from elsewhere in Hargeisa, and other than this, his only other consistent team member is a scrub nurse that he has been training since early May. Assistants with surgical training are sometimes available. However, emergency C-sections tend to come at odd hours, and in these cases the positions of first and second assistant often fall to whichever medical students or intensive care nurses happen to be available. Last night, one of those people was me.

Dr Tanmay paused to re-assess when he reached the uterus. We were gathered around the table in a tight group, focused and silent. Erin stood on my left side, her outstretched arms covered in sterile cloth. Dr Tanmay stood directly across from me, leaning over the right side of the patient’s abdomen. To his right stood the scrub nurse, silently passing instruments from a rolling table near the patient’s feet. In her cap, gown, and face mask, she was as invisible as the women who come into the hospital wearing full hijab and then bare their abdomens for an ultrasound.

After the uterus was open, things began to happen with a speed that passed through my mind like a ragged volley of gunshots. The baby’s head became visible, was enveloped in the tentacles of a white rubber glove, and emerged in Tanmay’s hands. A shoulder appeared, pallid brown skin emerging into harsh artificial light on a desert evening so many miles from nowhere. The torso came quickly, followed by the legs and cord, and the whole mess was placed in Erin’s waiting arms. Silver clamps dug their lifesaving teeth into the cord, and it parted under a single slice from the scissors. The baby, gray and unmoving, gave a faint gurgle as Erin disappeared into the resuscitation room.

We did not pause to think about the baby. Others would take care of it. The placenta was still inside, and its delivery represented as great a threat as the baby’s. When we paused a few minutes later so that Tanmay could do a final check for active bleeds in the uterine tissue before he closed, I looked at the placenta again as it sat in a round steel tray on the instrument table. It looked like the fat red jellyfish I’d seen in the summers of childhood, the sort I had stared at in fascinated terror as I stood on the quaking surface of a log raft my father had built with a chainsaw and a length of mildewed nylon rope.

A pale, veined tube like the body of an enormous salamander crept into our surgical field as the uterus, relieved of its load, shrank down to a more normal size. A needle puncture in the intestinal wall would have been a tremendous problem, and Tanmay stopped suturing. With the retractor in my right hand, I eased the slippery white intestine back from the uterus with the last three fingers of my left, and Dr Tanmay went back to work. He tied off the visible bleeds with smooth efficiency, but blood continued to pool at the lower margin of the incision as fast as it was suctioned it out.

“The uterus is much engorged from the prolonged labour. We will have to get a better field,” he said, and proceeded to gently lift the uterus up and out until it’s upper surface was fully exposed and the lower portion was easily accessible. Under his instruction I held the firm ball of pink muscle up and away from the bottom of the incision, and one by one he tied off the remaining bleeds. He pointed out the ligaments, major blood vessels, and fallopian tubes and then returned the uterus to its proper place, where it sat like a fat pink softball at the end of a game played on wet grass.

I held the thread taut after each suture as he reconnected layer upon layer of tissue: membranes, peritoneum, rectus muscles, fascia, and warm brown skin riding atop a yellow layer of subcutaneous fat. Erin came in to show the woman her new son, who was wrapped up in a colourful blanket and looked much better than he had a few minutes earlier. Tanmay swabbed the woman’s abdomen with alcohol when he finished closing the wound, and we applied a large gauze dressing to her bare skin. We removed the drapes and the screen that had separated her head from the drama occurring in her abdomen and her eyes stared back at us, wide and dark and tired. With fingers linked beneath her body, five of us moved her from the operating table onto a waiting gurney, wrapped her up, and pointed her toward the recovery area.

Afterward, with clean hands and a proper pair of shoes on my feet, I walked down the hall to Maternity to see the baby. The patient’s family stopped me in the hallway and the eldest son grabbed my hand, looked into my eyes, and said thank you. I stared back in stunned confusion, an inexperienced imposter being thanked for helping with something that, in a better world, I would never have been involved with. I nodded, smiled at the family, and walked past as I was swamped by a rising tide of guilt. I did not know how to respond.

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4 Comments

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  1. Dee McCandless / Jun 16 2011 5:54 pm

    Dear Caleb,
    Wow and wow and wow. What an experience[s] for a pre-med!

    I love the way you write about things. I feel right there with you. Your words are engaging and clear and sweet.
    I can’t say enough except that I haven’t been reading enough. So I will begin to treat myself with going through your blog day by day.

    Please keep writing and thank you for spending the time to do so!
    Much much love,
    Dee

  2. bengolas / Jun 17 2011 10:08 am

    Guilt is something all good doctors deal with; guilt that they could not do better, guilt that they could not do more. When you first get to scrub in with a C section in the states, I imagine you’ll have a lot of theory and more information in your head, but you’ll likely still feel dumbstruck at what you do not have yet. The experience is everything. Enjoy it while the bulk of the responsibility is in the doctor’s hands and just the uterus is in yours. 😉

  3. Margaret McCandless / Jun 22 2011 1:41 pm

    What do you wear on your feet during surgery? The thoughtful, meaningful comments above are wonderful, and your blog post is vivid and important. The rich and serious parts matter to me, too. It’s an odd part of my thoughts that says I can’t help wondering what shoes you changed from in order to have a proper pair of shoes on your feet when the eldest son was thanking you.

  4. Joyce / Jul 12 2011 6:12 pm

    Whew Caleb! I am worn out after reading your tension-filled account of your experience. You should be thanked! What would they have done without you?
    Your prose is vivid and almost musical, even with the graphic descriptions. Good job! xo Joyce

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