By Dr. James Appel - August 17, 2014

Gillian comes to the door early Saturday morning, “...I’ve been up all night, though, and am exhausted.  There’s two c-sections to be done, can you do them?”

“Sure, that’s why I’m here…” I finish the one piece of French toast I’ve already prepared and go up to Labor and Delivery through the same maze that at first was confusing but is already becoming familiar.

The same midwife is still there.  She’s been on for almost 48 hours since no one came to relieve her yesterday evening.  Many of the staff refuse to come in, scared about Ebola. This one is very good and conscientious and I’m glad to see her.  

“What’s going on?” I ask.

“Dis woman, she been he-uh since yestuhday.  She not progressing in huh laybuh and now dere is fetal distress.  I put huh on huh left side and tings bettuh now.”

“This is the woman with a hemoglobin of 8 yesterday right?”

“Yeah, dat’s right.”

Gillian has called in the OR team already and they’re on their way.  I go to the lab to make sure we have blood.  They have one bag already, but it looks like it’s in a pediatric blood bag which is only half the volume of an adult bag.  Apparently, they are out of adult sizes.  I come back up and the OR team is assembled in the changing room putting on scrubs.  I reach out my hand and shake the hand of one of them who introduces himself to me as “Wheezy” even though his breathing is normal.  A large, stocky man with a weathered face then speaks up:

“Hey man, this is Ebola time.  We don’t shake hands.  Go wash.”

I laugh and comply.  The man then introduces himself as Neal, the anesthetist.  A few more minutes and they are setting up the room.  I pull on my surgical cap I brought from Chad, put on a mask and head into the OR.  It’s small, but clean and seems well equipped, although there’s only one ancient OR light and most of the equipment looks like it may have survived WWII.

“What anesthesia will you use?” I ask Neal.


“What about spinal?”  To me it’s a simple question but it brings forth an aggressive response from Neal as if I’d insulted his mother.  He goes on and on about how he knows what he’s doing and a spinal would be not right in this case of anemia and he’s worked in Britain and who am I to question him, etc, etc, etc.  I’m a bit taken aback by his reply, but bite my tongue.  I’m already wary of his abilities based on his poor handling of the uterine rupture from yesterday but I don’t say anything.  I go downstairs and find some long shoe covers to protect my feet and legs from exposure to bodily fluids and head back up.  Neal is just coming out of the Labor & Delivery and confronts me again aggressively.

“Are you happy with my anesthesia or not?  Huh?  Just let me know, ok?”

I motion him over away from the rest of the staff into the changing room where we are alone.

“Listen, Neal, I’m not sure why you are being so defensive.  I was just asking a question.  For me, that’s good medical practice, one should dialogue, communicate and discuss and that’s all I was trying to do.”

“Ok, man, ok. You say you’ve always done c-sections under spinal and you like them because they relax the lower abdomen.  So will my general.  You’ve never tried a c-section under general, let me show you how it works.”

Deep down, I’m not satisfied, but it’s not a time to pick a battle.  I nod and we move into the OR again where the patient is already on the table.  I notice she just has a small 20G IV in her left hand and an even tinier 22G in her right antecubital fossa.  I mention to Neal that I’d like at least one 18 G before doing surgery.  He doesn’t say anything as he hangs up the bag of blood and gets it ready to give.  I don’t push but watch him warily out of the corner of my eye.  He doesn’t start another IV and the 22G isn’t working at all.  I reluctantly don’t say anything.

“Go scrub!” orders Neal.  I comply.  At first, all I see are hard, plastic scrub brushes used normally for cleaning instruments.  There’s also some old bar soaps on the counter.  I then see a blue covered dish.  I open the lid carefully and inside see two used regular surgical scrub brushes.  One seems to still have some chlorhexadine on it so I scrub with that.  I back through the swinging doors of the OR, by hands held out in front of my chest high and well away from my body.  I pick up a small washcloth folded over the surgical gown and wipe my hands dry.  I then fully dry them in front of the A/C and put on my gown and gloves in sterile fashion.

The woman’s exposed, very pregnant belly is covered in some kind of substance that looks like fine wood chips.  I’ve seen this many times in Chad.  It’s some kind of traditional medicine.  I have the circulating nurse wash it off before prepping with Betadine.

“Dr. James,” Neal begins, apparently ready with some more advice for me. “The faster you do the c-section the better for you and for me…”

“…and for the patient and the infant.” I add.

“Yes, of course,” Neal quickly agrees.

“I always consider c-sections under these conditions to be crash c-sections so I do them as fast as possible.”

“Yeah, and now I’ll show you crash anesthesia too,” adds Neal with a gleam in his eye.

We’ve draped the patient’s abdomen and I stand poised with the scalpel after surveying the instrument tray and finding most of what I’d expect in a c-section kit (although I’d really prefer more than 2 ring clamps).

“Neal, can I start?”

“Of course, I’m just waiting for you.”

“Let’s pray first,” interjects Wheezy who’ll be assisting me. He then rolls off a beautiful prayer in Pidgin English that I mostly don’t understand.

“Amen!” I state at the finish and slice down quickly through skin, fat, fascia and peritoneum.  The woman moans and contracts her muscles.  She’s not fully under anesthesia!

“She’s moving!” I tell Neal.  Then I pull open the wound with my hands, extend it some inferiorly with scissors and fight against the intestines wanting to push their way out and the tight abdominal muscles that would’ve been relaxed with a spinal anesthetic.  I force in the bladder blade but have a hard time seeing the lower uterine segment as we fight against the contracting muscles.  Finally, I am able to get a bladder flap developed and retract the bladder out of the way.  I make a small incision in the uterus, poke through with a clamp and extend it to both sides and superiorly with my fingers and scissors.  The head is right there.

“Push on the top of the uterus!” I tell Wheezy.  His efforts are less than adequate so I reach my left hand up and push down hard as my right hand guides the head out.  A contracting baby with excellent muscle tone who seems to want to cry emerges.  I quickly wipe him off while Wheezy clamps and cuts the cord.  I hand the baby off to the waiting midwife.  I don’t hear a cry but turn back to the placenta.  I tug too hard on the cord and the cord pops off.  No big deal, I reach my hand in the uterus and scrape the placenta off the uterine wall then exteriorize the uterus.

There is a bleeding artery on the left that I clamp with one of the two ring clamps and then get the other edges out with some other clamps they have instead of the normal ring clamps.  I still don’t hear a baby cry.  I look over and the midwife is bringing a limp baby over to Neal who is getting a bag valve mask ready.  

“Start chest compressions!” I order.

“The baby has a heartbeat, he’s just not breathing,” replies Neal.

“How fast is the heartbeat, if it’s under 100/min that’s not enough.  And chest compressions will move air into the lungs in the meantime as well.  It certainly won’t hurt.”

Neal smiles condescendingly and continues doing what he’s doing.  I turn back to the mother, she’s my first priority. Hopefully, the baby will make it despite the lack of protocol.  I suture the uterus and after assuring that the bleeding is controlled replace it in the abdomen.  I verify that there is no bleeding from the wound and close the fascia.  I finally hear a weak baby cry.  Thank God!  I close the skin with a flimsy, tapered needle more suited to thin bowel than tough skin but I eventually am able to finish the job with a very warped needle at the end.

I scrub out and thank Neal who thanks me back.  As I leave the room I hear Neal bragging to Wheezy, “See, I told you that general anesthesia was the best…”  I pretend not to hear.

On coming out, I meet Gillian.

“The woman with the ruptured uterus from yesterday just died.”  

Life and death.