John - Week 6 - ED & Labor

ED:


Rounding with the emergency department (ED) had a much different feel. Unlike in the specialized units, patients here have a wide variety of ailments, with some significantly more serious than others. Some less life-threatening conditions include severe migraines, or chest pains. One patient even had a stiletto wound to his left flank. Other patients had more pressing medical needs.

One in particular was a patient with Crohn's disease. He came into the ED with a fistula on his left groin that was emitting pus, as well as a painful swelling of his left buttock. He had developed a fever two days before, and had been taking tylenol to alleviate it. Although his latest temperature reading indicated he was afebrile, the two doctors who evaluated him indicated that he was warm to touch. He had also not eaten for the past two days because eating caused him to have severe diarrhea. This patient had been treated previously for leukemia, which was presently in remission. He also had surgery previously to remove portions of his small intestine. The attending doctor suspected that the fistula on the patient's left groin was connected to the swelling in the patient's left buttock. She recommended a CT scan of his abdomen, but due to numerous CT scans in the patient's history, changed her recommendation to an MRI at the patient's request. It was likely that the patient needed to undergo surgery to drain the pus-filled fistulas.

Despite the severity of this patient's problems, things were rather calm in the ED until it was about time for the next change of shift. A geriatric male patient had just been admitted into the ED. Though alert and responsive, he had a heart rate of 40 beats per minute and an electrocardiograph with the P and QRS waves out of sync, leading the attending doctor to activate the emergency cardiology team. Within minutes, a crowd of doctors had gathered. They scrutinized the ECG printouts, evaluated the patient's condition, and concluded that a pacemaker was in order.

Labor:

During our rounds in the Labor and Delivery unit, two very kind mothers allowed us to observe their delivery. 

The first case was a vaginal delivery, and the baby was full term. Throughout the labor, the frequency and intensity of the contractions, as well as the baby's heart rate, were monitored and recorded. During the initial phase of delivery, despite the mother's contractions getting stronger and more frequent, there seemed to be little progress in terms of the baby moving out of the birth canal. The resident placed her hand in the mother's vagina to feel for the baby, and commented that the baby's head was slightly tilted upwards, which would make the delivery a little harder, but not cause any problems. The resident did try to turn the baby's head a little, but did not manage to alter its position.

Due to the pain from the contractions, the mother then requested for an epidural administration of an analgesic. 8% bupivacaine was used because it is longer-acting than lidocaine. The drug was injected into the epidural space (between dura and bone)) between vertebral discs L3 & L4 (L1 to S2 are involved in labor) to locally numb the sensory nerves of the lower body. In the administration of local anesthesia into the spine, the cerebrospinal fluid (CSF) has to be avoided, otherwise the drug will travel together with the CSF throughout the central nervous system, causing general numbness that can affect breathing instead. If given intravascularly, the analgesic could affect the heart. 

To ensure that the needle is not in the cerebrospinal fluid, the anesthesiologist attempted to push and pull air into the space. If the plunger barely moved, it would mean that the needle was not deep enough. If cerebrospinal fluid entered the needle, it would mean that the needle was too deep. A catheter was left in place, so as to allow subsequent boluses of analgesics were the labor to last a long time (i.e. > 2 hours). The epidural alleviated the pain from the contractions, but it also reduced the frequency and intensity of the contractions. As such, the mother was given oxytocin, a brain neuromodulator released in large amounts during labor, to counteract this effect and increase the frequency and intensity of the contractions. Not long after, the baby was born. 

The mother's girlfriend had the honor of cutting the umbilical chord after the doctor had tied a tourniquet on both sides surrounding the planned incision site, so as to prevent excessive bleeding from the mother and the child. After the infant had been delivered, the mother still had to wait for the placenta to be expelled. After that, the doctor ensured that there was no serious tissue tears that needed to be treated.

The next case observed was a cesarean section (c-section). The mother had a previous c-section, and thus needed a c-section this time round as well, since having a c-section once renders the womb and the surrounding tissues more susceptible to rupture if the baby were delivered naturally. It was not apparent whether there were other complications that necessitated a c-section.

While the anesthetic was also administered via a lumbar puncture, this was done to the depth of the intrathecal space (between arachnoid and pial layers), so that the anesthetic is able to mix with the CSF and numb most of the body. After the mother had laid down on the operating table, a blue sheet was placed vertically above the mother's chest to separate the sterile area where the surgeons would work, as well as to block the mother's view of the operation itself, since she remained conscious during the procedure with her husband by her side.

During the procedure, the surgeons first removed the scar from the mother's prior c-section before proceeding to cut through the fascia. The left and right rectus abdominis were spread apart for access to the womb, which was then cut to reach the baby. Because of the position of the opening in relation to the baby, the surgeons had some difficulty removing the infant. Apparently, once the womb has been cut, there are only a few minutes to remove the baby. Potential problems include the baby not having enough blood supply, that the umbilical cord may strangle the baby, and that the baby may choke on the blood from the c-section. As such, the time elapsed since the womb was incised was closely monitored and frequently reported. As the seconds went by, the tension in the operating room began building up. When the three-minute mark was reached, the medical team went into emergency mode. The experienced nurse practitioner who had been explaining the procedure to us moved over to assist the residents, while another nurse paged for the Labor fellow to intervene immediately. Thankfully, as the fellow rushed in mere seconds later, the residents successfully removed the baby. A team of pediatricians and nurses immediately suctioned fluid from the baby's mouth, performed a blood test, and cleaned the baby up simultaneously.

Meanwhile, the residents sutured the womb back up. It was interesting seeing the womb, as it was visually a large and highly-vascularized organ that would shrink significantly in size over the next couple of months. The womb was replaced into the mother's abdominal cavity, and the fascia, and finally the skin were sutured back up. 

The blood test indicated that the baby was hypoglycemic, which may have been due to the birthing process. Regardless, the baby was brought to the NICU for monitoring.