Celebrating Birth

Lyol is nine years old. Almost double-digits. I feel all at once very old, and all at once way behind, as so many of my friends have kids driving vehicles already! (I can’t imagine…)

He thinks he had a great birthday, but his parents might not remember this as the best.

The day started with me keeping my streak of morning worship attendance alive (although I’ve missed the two days since). And I had even showered within the last 24 hours, so I had a lot going for me. After my typical couple hours of menial administrative tasks, I came home to watch the kids so Danae could go up to the hospital. She very badly wanted to finish by 2 or 3pm so we could take Lyol to the river for his birthday.

I cleaned the house cleaner than it had been in ages and I baked two cakes for the birthday boy and iced them. Danae made it home a little late and did what she does most birthdays, she made some absolutely awesome decorations for the cake, including one which was a camping scene in the mountains, with river and tent and bonfire and all the rest. Very impressive!

We hustled out to the river with Grampa and played for a good little bit. Even the Dietrichs came to play! We came back to the house and all the volunteers came over (except for Christian, Sarah and Sonam, who were still working hard with emergency cases over in the hospital). Danae ran up to the hospital to make sure Christian and Sarah had a good plan for a pregnant lady. The lady had a dead fetus in her uterus that had to come out, and the options were either to induce her to deliver vaginally or to do a cesarean. Danae virtually always gets these out vaginally, but I think the lady didn’t want any more babies and wanted a tubal ligation and I’m sure there were some other reasons too, like I think she wasn’t progressing in her labor with misoprostol and oxytocin is pretty dangerous here and people don’t watch it closely and it can rupture the uterus, something which rarely ever happens in America due to people not having as many babies and nursing care being able to be more diligent with less patients per nurse. 

(Danae’s addendum: She had an abruption and had already gotten 4 bags of blood, continued to bleed, and was definitely an indication for a c-section since she wasn’t progressing on oxytocin.  But she was stable and had a hemoglobin of 9 preoperatively).

Anyway, both Christian and Sarah know how to do a cesarean, so they were left to do it while Danae came home for the party. Lyol opened presents, we sang the song, he blew out the candles, we ate cake and frozen fruit salad. Everything was perfect.

Then Sonam called. They were doing CPR in the operating room. Well, that’s not good. But I start speed-walking to the operating room. I’ve learned running is rarely warranted. It just gets everybody excited and then mistakes happen. I’m there soon enough and Christian is pushing on the heart through the diaphragm. The dead baby is out and between the mother’s legs. Philippe is trying to breathe for her and Sonam is drawing up epinephrine, she already gave one. The lady has three IVs running. Sarah is poised to do CPR from on top if necessary.

‘Check a pulse.’

Christian pulls his hand out and feels her femoral artery.

‘Dude, you just had your hand on her heart for CPR. Get your hand back in there and feel if it’s beating on its own now.’

He puts his hand back in. ‘Yeah, it’s beating great!’

‘Philippe, cycle the blood pressure. Sonam, be ready with the epi. Actually, Sonam, dig in that drawer and pull out a Mac 4 and a 7.0 tube with a stylet and a 10cc syringe on it.’ Oh, how I’ve missed having an ER nurse. Sonam is spoiling me and has it ready within seconds. I ease Philippe out of the way and intubate the lady easily.

Blood pressure comes back low. ‘Stick the epi into the ringers and start a drip.’ Sonam is used to being able to control the epinephrine down to the microgram per kilogram per minute, but we can’t do that here. Just turn the spin dial to what you would guess is appropriate and then make minor adjustments as needed.

Danae comes in. Well, I guess we might as well finish. Christian and Sarah do a great job finishing the surgery while Danae and I try to piece together from everybody what happened. High spinal in a cesarean. Happens so often. Philippe is a great nurse and he knows to give a lower dose spinal for cesareans, and he did, but it still went high. It would seem we weren’t sufficiently aggressive when we noticed she started having breathing difficulty as the spinal anesthesia started to go high and weaken her diaphragm. As her breathing decreased and her circulating oxygen decreased, her heart stopped. That’s when I got called. Philippe had insisted to Christian and Sarah that it was imperative to get the baby out quickly. He was probably thinking to get pressure off of her inferior vena cava to reestablish normal venous return, but that wasn’t really her probably. What she needed was to have her airway secured via intubation and just be assisted in breathing for a few hours until the spinal anesthesia went away and she could breathe on her own. However, we’ve never taught Philippe to intubate. He still should have been able to breathe for her with a bag valve mask, but apparently it was too little, too late.

At any rate, I had her intubated now and could breathe for her as I like, she had her epinephrine drip running to keep her blood pressure up. It’s not an ideal situation and I’m hoping to get her off of the epinephrine as soon as I can. By the time they finish the surgery, she’s off the epinephrine and I have her endotracheal tube disconnected and she is breathing through it perfectly fine on her own. So I extubate her.

We put her out in the prep room with Sonam while we do another emergency surgery. I sent Philippe home and do the young girl under ketamine, since the gas is expired and the girl is too fidgety and nervous to really tolerate a spinal. We finish that surgery while Sonam is meticulously attending to the other patient in the prep room.

After the next surgery, we bring our lady back into the operating room to monitor her. She’s still breathing on her own, satting 100% on room air and with a perfectly normal blood pressure. But she’s not waking up. She’s not making urine. She’s not well.

A few hours later, a little after midnight, I head home and leave the patient with Danae and Sonam. Sonam just spent the night before with a post-op patient with a typhoid perforation. The poor patient went septic and died. Sonam also spent years in an ICU and knows what can be done. She knows this patient shouldn’t die. She did her best. And the girl still died. She had a hard time with that. And she’s not going to leave this patient either. Danae is stubborn. She won’t leave. She’s the one who had the conversation with the patient about continued oxytocin versus cesarean. She truly thought cesarean would be best for her. And except for a high spinal, it would have been. But Danae won’t leave her. She has that annoying sense of responsibility. So Danae and Sonam spend the night with the patient, just looking at her. There isn’t anything to do. We did all we can here. She won’t wake up. 

Danae crawls in to bed at 5:30. ‘She died.’

‘I’m sorry, honey.’ And I am. But I can’t really offer more than that.

At 9am, Danae comes out of the bedroom. I’m not really doing a very good job keeping the kids quiet. She puts on a fresh pair of scrubs and goes back up to the hospital for another day.