Monday, January 30, 2017

Uterine Rupture

This post conforms to the blog rules.
The other day I was scrubbed to do an orange repeat C-section (urgent, not scheduled but not a life-or-death emergency). The patient had a history of two C-sections and was in spontaneous labor. Women aren't supposed to go into labor with two cesarean scars: their risk of uterine rupture (breaking open their cesarean scar while they contract) is too high to be generally accepted.

I stood next to the patient on the OR table as the sterile prep solution dried on her abdomen, before I covered her with a sterile drape and began the surgery. Opposite me was my chief resident and the MFM fellow, also both scrubbed. The attending was standing next to the door, not scrubbed, on the phone. I have no idea where the sub-intern was, but she wasn't ready yet.

Suddenly the fellow pointed to the patient's abdomen as a very dramatic fetal movement changed the contour of her pregnant belly. Her water suddenly broke all over the table. "Well," said the attending, "now we have to move faster."

"I'm worried she ruptured her uterus," the fellow said under his breath, as he walked up to the table.

I draped the patient and the fellow and I put our hands on the uterus. "I can feel baby with a lot of definition," I said. I could feel little elbows way too well, as if there weren't enough layers between me and the baby.

"Go stat," the attending said. The C-section priority changed from orange to red, and in a moment I had my hand in the patient, fishing for a fetal head without having to cut any uterus. It was clear: she had ruptured her uterus. I felt the head in her pelvis and started to lift it up. The moment I did, the baby swam away and then all I felt was buttocks. I extracted the baby breech, and then I got a chance to look at the uterus. She had broken open her old scars.

I've never seen a uterine rupture, I've never seen it happen right in front of my face, and I've never had a baby who had room (and cheek!) to swim away from me during a delivery. Wow! Baby and mom were fine.

Sunday, January 15, 2017

Suffering and Joy in Catholic Medicine (CMA Conference)

I went to the CMA conference last October and spent most of the time with my poster and networking with people. I was late to almost every talk! There was lots to take away, but there were also things missing.

From Ashley Fernades' talk before the first panel began, I took away that not all hard days are bad days. The idea that suffering and joy are not mutually exclusive is still hard for me to integrate with my life. When I am exhausted, I have no energy to be happy. My reason accepts that happiness and joy are not the same, but when there is no reason for satisfaction besides God it is rather hard for me, a sinner, to be joyful. Dr. Fernandes made it a point to say, on day one of the conference, that joy is a choice made each day.

Bishop Conley drilled this further. Joy seems like hard work, he said, but it is possible with Christ. He can work a total transformation in us. Our entire lives must be missionary joy, it's an unshirkable responsibility. This doesn't have to be overwhelming, the Bishop said. This is cor ad cor missionary work--one heart to one heart at a time.

Michael Aquilina spoke on the emergence of the hospital, which paralleled the rise of Christianity. Mr. Aquilina observed that there were resources for hospitals in the ancient world, but the hospital only came about once a religion that valued solidarity, charity, human dignity, and the redemptive value of suffering became legal. He asked a rather chilling question: will the hospital survive in a post-Christian world? I think it's already gone in most ways. The hospital now is a cog in healthcare and research systems, embedded with lots of bureaucracy for the purpose of payment and prestige. Of course, as long as there is illness and as long as there are charitable caregivers, there will be that spirit of merciful care of the sick. But the hospitals of St. Basil, St. Pio, and even St. Theresa of Calcutta are not the ones that western doctors work in now.

Then came the practical advice of John Travaline, a physician and deacon who spoke about practicing like a real Catholic. He stressed the importance of seeing opportunities to restore human dignity to those with diminished personhood, to look for chances to be present to others (e.g. don't double book, imagine the workplace as a holy place, make your office accessible). He stressed that wounds are a sign of God's presence, chances to participate in Christ's restoration of man.

Finally, Dr. Greg Burke reviewed a sample examination of conscience for physicians. Several things were relevant to this theme of missionary suffering and joy. Am I ashamed of my Catholic identity? Am I plagued by guilt without sin (blamed or self-blaming for a case when you acted according to your conscience)? He reminded his audience that it is humanly impossible to know everything. "Don't beat yourself up for being human," Dr. Burke said. Strive to become more and more a saint instead, consult appropriately, avoid scurrilous conversation, and don't worry about the messiness of how it plays out.

All these men encouraged attendees: find in medicine a chance to become Christlike. It was a great message.

This post wouldn't be complete if it ended without my personal reflections on going to the conference. Perhaps this is because I'm used to the breakneck pace of residency, but I found the conference a little slow and a little repetitive. For the first time I was frustrated with the CMA for ignoring a few elephants in the room. Why wasn't anyone talking about NPT and evidence-based gynecology? Why wasn't anyone talking about virtue-based pediatrics? The conference was refreshing because it was more anecdotal and had a looser schedule (very effective for burnout prevention), but I was still hungry for more at the end. Going through the talks again was helpful, but I wish there was more original research and open discussion at these conferences.