A Sad Tale

They could've been twins, but the outcomes couldn't have been different. Sarah had come to get me just after I'd fallen asleep Friday night.

"I think I have a case for a symphysiotomie for you." She said.

I dragged myself out of bed trying desperately to sweep the cobwebs from my mind. I was so adrenaline depleted after the long day in the OR that I could barely summon enough reserve to pull on my scrubs, slip on my Crocs and stumble through the moonlit night towards the hospital.

That morning I had taken out two huge prostates from a couple of old Arabs before being called back to the clinic to see a man with a strangulated hernia. We took him immediately to the OR where I sliced open his groin to reveal a hernia sack the size of a medium size Ziplock filled with stale, bloody inflammatory fluid and a portion of small intestine hanging onto life by it's teeth. As I cut open the internal inguinal ring I watched carefully to see if the dusky intestine would pink up. I watched as slowly, but surely, the tiny capillaries on the glistening intestinal surface started to pump back to life. While the intestine didn't return completely to normal color it was encouraging enough that I shoved it back in his belly, sutured closed the hernia in three layers and closed the skin.

I then took out small ovarian cysts on a young woman and cut out a weird, cystic mass on a three year old boy right below his belly button on the midline.

Tuesday through Thursday had also been brutal with two hysterectomies, a double sided recurrent hernia after a 10 year old repair, three c-sections with one of them being a ruptured uterus requiring a hysterectomie with some much shredded abdominal wall on the rupture side that I despaired of stopping the bleeding for a long time. Another one of the c-sections had an allergic reaction to the lidocaine spinal anesthetic causing her lungs to clamp down and her blood pressure to plummet. Only after intubating her, giving her steriods and adrenaline and bronchodilators and a ton of IV fluids were we able to get her back and do the c-section pulling out a 5kg screaming monster of a newborn. I also took out another prostate the size of a baseball (each of the three lobes would've qualified as an enlarged prostate itself).

So, I clumsily find my way to the labor and delivery suite. The girl is in her mid-teens and tiny. Her legs are midget sized. She has to be under 5 feet tall. I learn it's her second pregnancy. Two years ago she had labored at home for days before going to another hospital where they somehow managed to extract the dead fetus. This time, she's been in labor for three days. I feel the belly. It's tender and she has lost her normal uterine contour. A ruptured uterus.

David, the night watchman, calls in Simeon and Abel and we start to prepare for surgery. As I attempt to insert the urinary catheter I find it won't pass more than an inch. I check and the head of the baby isn't blocking it at all. As I push up the head of the fetus, a gush or urine comes out. Apparently, she had a fistula from her previous long delivery and her urethra is completely scarred down with the urine leaking out her vagina uncontrollably. We are forced to abandon the urinary catheter.

I place a spinal anesthetic, prep and drape her abdomen, Abel prays and I cut down quickly in a midline incision. Dark blood gushes out as I enter the abdominal cavity. Abel aspirates it up with the suction catheter while I pull out the large dead baby and look at the dark edges of the uterine rupture which look like an exit wound from a shotgun blast. Fortunately, it's anterior, almost exactly where we would've made our uterine incision for a normal c-section so I trim off the dead muscle and suture up the tear. She should recover fine but will have to come back in a couple of months to have her fistula repaired. In the mean time, she will leak out urine uncontrollably having already tragically and needlessly lost two newborns.

I go back to sleep a little after midnight.

At three, I am woken from an even deeper sleep by my lovely red-headed wife. However, she brings bad news. Another girl has arrived in labor since this morning. I manage to again drag myself out of bed and accompany Sarah back to the hospital. She says this girl is from the same village over 40 km away and is practically the same size.

As I enter labor and delivery I'd swear this girl was the other girl's twin. However, for this teenager, it is her first pregnancy, the fetal heart beat is still there and her uterus appears intact. However, her pelvis is small and the head is completely deformed from trying to be squeezed out a too small opening.

I grab the symphysiotomie tray, inject local anesthetic over her pubic bone, insert a urinary catheter, move the catheter to the side with my left hand inside and cut through the skin down to cartilage with my right hand. I then cut through the fibers from top to bottom until I'm mostly through the pubis (which connects the pelvis together in front). I then have Sarah and David, the night watchman, pull her legs out and down effectively opening her pelvis 2-3 cm. I attach a hand pump vacuum that we've used for over a year now but is still trucking along (it's a single use item in the US) and the head descends and a fat, screaming baby comes out less than 5 minutes later.

I suture up a couple of small vaginal lacerations and the symphysiotomie wound, help mop up the blood and fluids spilled all over the floor and table and head home.

Two teenagers, practically twins, but different outcomes based on a simple thing like coming to the hospital before it's too late. Same situation but one has two dead babies, urinary incontinence from a difficult to repair fistula, a huge abdominal scar, a recently sutured large tear in her uterus and a long recovery ahead of her with dismal prospects for more children and if she does become pregnant will die if she doesn't have a scheduled c-section before boing into labor. Her twin has a healthy newborn, a small pubic scar and can deliver vaginally safely for however many children she and her husband decide to have.

God also gives us choices. Each choice has it's consequences. God wants us to see that his recommendations are actually in our best interests but if we persist in our rebellion we'll see the consequences like these two girls, one of whom decided that maybe we were right when we suggested it was in her best interests to deliver at the hospital and the other who thought she'd do it her way like everyone has always done it and now has unfortunately seen the results of her poor decisions.

May God protect us all from our own foolish "wisdom".

James