Obstetrics

Week 1

My 5 week rotation in obstetrics started with 3 births and a cesarian section on my first day. I was thrilled and amazed by the process. It had been my goal to witness my first birth while down here and today I finally had that opportunity. I was surprised by the amount of blood. It just never had occurred to me that it might be extra bloody due to the placenta leaving on top of the bleeding of the mother. Later in the week, I watched a tubal ligation, which was interesting to see, but was not nearly as invasive or intense as what I had seen in the surgery rotation.

Week 2

During my second week I unfortunately witnessed my first miscarriage. A lady in her late 20´s was at 34 gestation and gave birth to a dead fetus. While the doctor´s knew that the fetus had died, the reason was still not clear before the birth. When the baby was born, we found the umbilical cord wrapped around its neck. Even after a week of experience in obstetrics, I could see the stark contrasts between a live baby and a miscarriage. The fetus was limp, without the normal rigidity of a normal baby; and had a dark blue skin color. Possibly the hardest part was watching the mother both experience the enormous physical pain of childbirth while crying for the life of her dead child. Even still, none of the nurses or doctors went to her side to hold her hand or encourage her. Generally, I strongly support the Mexican health care system; however, this experience with the mother who miscarried was an exception. The doctors knew upfront that the fetus had died, yet they still didn´t allow the husband to join the mother into the delivery room. I understand that the rule is there in order to protect the privacy of the 5 other women in the adjacent room, but I think they should be able to make exceptions. This is one of the downsides of a system that cuts costs at the expense of privacy and emotional well-being.

Earlier this week, during a cesarean birth, a baby was born with respiratory issues. Normally, the baby cries within 30 seconds of birth. However, even after 30 seconds, it was not responding, nor breathing on its own. The pediatrician rushed it to the other room and immediately began using a mask to artificially breath for the baby. Five minutes later, when the mask was removed, the baby took 3 strong breaths on its own and then stop breathing. During normal births, there is a whole array of measurements and tests that must be done. However, for this child, many of the tests were skipped in order to focus on keeping the baby alive. Unfortunately, I never found out what the baby had or whether it would live. When I asked the pediatrician, she thought the child would live, but she was still unsure.

When I arrived Friday, a mother was screaming in pain from the contractions. While usually painful, rarely do the mothers scream at the top of their lungs. The baby was born without problems; however, the mother continued bleeding even after the placenta had been removed. When the doctor checked the cervix, it was cut in 3 or 4 different parts. I was impressed by his ability to work in such a small area and with limited mobility, and twenty minutes later, the bleeding was largely stopped and the mother was ready for recovery. Earlier, one of the interns had laughed at the loud screams of the patient, but little did he know that her cervix was being torn. I understand how the screams sounded a little obnoxious, but we have to remember that more might be going on than we realize and that it is never appropriate to laugh or smile at the suffering of a patient.

Week 3

Week 3 was much more calm than week 2. Besides watching a number of births and cesarians, I had the opportunity to count contractions and listen to the fetal heart rate. While I had seen the process down repeatedly over the last 3 weeks, the doctor explained what I needed to do and the intervals of contractions they were expecting. It was a little uncomfortable at first to touch the stomach of a pregnant mother but I got used to it fairly quickly.

Week 4

During my fourth week in obstetrics, the doctors began giving me some more freedom and hands-on experience. I started the week by scrubbing in with the attending doctor during a cesarian section. It was just me, him, and the nurse. Before the baby came, he had me push down on the mother´s abdomen in order to create pressure for the baby to be removed. Then, when we were stitching the mother up, he let me hold the separators and remove the blood from the incission with a towel. The operation took around 2 hours.

The next day I the same doctor invited me to scrub in to a tubal ligation. This surgery is fairly routine and is done through a small incision in the belly button. After securing the fallopian tube, the doctor stitched a section. When it came time to cut, he handed me the scissors and let me cut the section of the fallopian tube. It was a strange sensation cutting perfectly healthy tissue for the first time, but everything went well.

Possibly the most exciting moment of the week was when the doctor let me deliver a baby. During the birth, it was my job to recieve the baby, clear the fluids, clamp the umbilical cord, cut it, and hand the baby to the pediatrician. After the birth, I removed the placenta. Through the whole process, I was fortunate to have the doctor´s help. While none of it was very technical, it took a lot of coordination.

Week 5

While week 5 was a little shorter as I was leaving on vacation with my family at the end of the week, I did get a second opportunity to attend a birth. This time they let me do the episiotomy. It was strange being given this much responsibility. Typically when I am scrubbed in I would hold clamps or cut surgical thread, but this time I was doing the cutting with no help. The consequences of messing up were quite higher. If I did this procedure in the U.S., the doctor and I could be in big trouble. Nevetheless, it might have been the medical highlight of my trip. In the end, the baby came out fine and episiotomy was sewed up without problems.

First Weekend with Allie

Emergency

After my April rotation in surgery, I spent the month of May working in the emergency room. The following are short stories of my month in the emergency room. Unfortunately, I don´t have any pictures, but I think the stories will make up for it.

Motorcycle Accident (May 7th)

In my first 10 minutes in the emergency room, I assisted a doctor as he stitched up the forehead of a 18 year old male who had hit a pole while riding his motorcycle. He had a hole in his forehead the size of a half-dollar all the way to the bone and a irregular line ran from his forehead to the back of his head. After numbing him with lidocaine, the doctor began the hour long process of suturing his head back together. Near the end he let me do a stitch. As I pushed the needle through the skin, I guided the needle between the skin and the cranium. It was great to get the experience, but my excitement was muted by this patient´s prospect of living with a nasty scar the rest of his life.

All in One Day (May 13th)

When I arrived in the emergency room this morning a lady was screaming. I thought it was temporary, but she kept screaming for the next hour. It set the tone for the rest of the day.

Around 9 AM, a 55 year-old-man entered the emergency room on a stretcher after arriving in an ambulance. After taking x-rays of his head and chest, we learned that he had a fractured cranium, fractured clavicle, and 3 fractured ribs. When initial observations were done, an intern and I had to insert a urinary catheter. He showed me the process and let me do it. However, after getting the catheter half-way in, we realized that the catheter was too large, due to the man´s enlarged prostate, which had narrowed the urethra. The problem was later fixed with a smaller catheter.

As I was leaving the room of the man, another doctor called me over to hold the head of an 80-year-old woman who was in a car accident with her daughter. The lady was moving her head and was complicating the doctor´s attempt to stitch her right ear. After 3 minutes, she had stopped moving and began drooling. The doctor realized there was a problem when the daughter tried talking to her mom and there was no answer. The woman was quickly moved to the room with life-support and immediately intubated. According to the doctor, the woman had a brain aneurysm and was now in a coma. A day later, I saw the patient´s daughter crying outside of the hospital. I never found out if the patient came out of the coma, but reflecting back on what happened that day, it´s frightening to think that a blood vessel was rupturing inches from my fingers, an event that might have killed her. It reminded me that everything that happens here is permanent and the consequences can be severe.

The Patient and the Finger (May 15th)

Despite seeing several suturing done nearly every day here at the hospital, I had not had the opportunity to serve a patient completely by myself. Today that changed. A 35-year-old man entered with a 8 cm cut along his finger. After filling the syringe with lidocaine, I injected it in the crevices of the cut. For simple cuts like this one, this part is typically the hardest, as the patient usually registers the pain. Also, while the risk is low, injection of lidocaine into an artery can be fatal. In order to avoid this, we pull on the syringe before injecting. If the syringe fills with blood, the point of the needle is an artery and needs to be repositioned. In the end, I made 4 sutures. While the cut of this patient was very innoxius, it was great practice and this level of contact with the patient.

Electrocardiograms (May 21th)

Over the last few weeks I´ve been doing several electrocardiograms per day. While I began accompanying the other doctor´s, they now let me do them by myself. Today, I had my first solo electrocardiogram with a woman. As we need to put 6 electrodes across the chest of the patient, it was very uncomfortable to be serving a patient in an exposed state. However, by the 5th or 6th woman, I had adjusted. It is one of the realities of the job all doctor´s must adjust to eventually.

The Good with the Bad (May 25th)

Near the end of my shift today, an elderly man arrived by ambulance in the emergency room. After finishing with a another patient, I went to his room to observe the doctors. The first thing I noticed was blood all over the floor near his bed, where he had vomited just moments before I arrived. Despite the vomiting, the doctors had gotten him an IV of a glucose/water solution and intubated him, and were working on placing a catheter to his heart. With a yellow tint to his skin, it was clear something had either gone with his liver or kidneys. The doctor told me that he had cirrhosis of his liver; however, since he was talking, it seemed like the doctor´s had things under control. After the catheter was successively placed, I left the room to help with another patient. An hour later, I heard crying from the room and looked over to see the man laying in his room without any of the machines that had been supporting him and his daughter crying by his side. He had died. It was almost surreal. Two hours earlier he was talking and now he was gone. Maybe it was because I did not know the man personally or maybe I´ve become desensitized to death, but I was not bothered by this man´s death. While I felt bad for the family, it´s part of the job when you´re working with the sick. I just hope I don´t become too distant from the patient to see feel for the grieving family.

Scorpion Bite (May 27th)

Probably the most common single reason for emergency room visits here in Morelia are scorpion bites. While they often cause temporary discomfort in the majority of the patients, some can be fatal. During my first few weeks I observed several bites and the treatment process. The doctors taught me symptoms for the 3 levels of severity of scorpion bites. The first begins with weakness and ranges to asphyxiation in the 3rd level, due to the swelling of the throat. The standard treatment is an injection of an anti-venom enzyme that breaks down the poison of the scorpion. Typically, 30 - 60 minutes after the injection, the patient walks out cured. During my last week in the emergency room, the doctor let me give the injection. While it was not hard, it was another opportunity to get first-hand experience with the patient.

The Volcanoe/Ruins

In 1943, a volcanoe erupted and buried a town at its base. The only building left standing was the town´s church, which is now covered in 20 - 30 feet of lava rock. As we walked from the town to the ruins of the church, we got glimpses of the churches one remaining tower. When we arrived, I was struck the amount of rock that now covered the church. Between the 30 feet of lava rock that now buried the church and missing church steeple, the force of the eruption was very clear. All in all, it was great to get out of Morelia and see some of the diversity of Mexico´s rural scenery and culture.

Video (1 of 2)
http://youtube.com/watch?v=ISj9X-EY8Gc

Video (2 of 2)
http://youtube.com/watch?v=ISj9X-EY8Gc

Uruapan National Park

Last weekend I left Morelia to go to Uruapan National Park. The park is supplied by a natural spring near the entrance. As we travelled through the park there were another beautiful waterfalls draped by beautiful tropical foilage. While we did not see much wildlife, there were these gorgeous white butterflies. Near the end, there was a clavadista diving from a tree. It was very Mexican. All in all, the walk took about an hour.

Despite enjoying the park, I left the park a little unimpressed. I think we are spoiled by beautiful scenery in the Northwest and the park here seemed almost like an imitation of what we have in the Northwest. I´m so used to our parks, being largely untouched by man and left in it´s completely natural state. However, the National Park at Uruapan had man-made waterfalls beside the scenery. It felt like they were trying to compensate for the nature. It was still beautiful, and I enjoyed the time there, it just made me appreciate more the beauty of the Northwest.

Check out two videos of the Park. The first is at the base of a waterfall. The other is of a clavadista diving from a tree. Enjoy!

Video (1 of 2)

http://youtube.com/watch?v=3eMUKXcUVt4

Video (2 of 2)

http://youtube.com/watch?v=yZdG97WuHbs

Another Tumor...

The day after the kidney transplant, I scrubbed in to my second surgery with Doctor Garcia. The patient was a middle aged man with a tumor the size of a volleyball on his right inner arm. During the course of the surgery, the doctor showed me different important nerves and arteries of the upper arm as he cut away the diseased tissue from the normal tissue.

The first nerve we reached was the ulnar nerve. After watching several surgeries, I was always amazed that the doctors were able to identify the nerves from connective tissue, because the look so similar. When I asked the doctor how he was able to do it, he explained that the cauterizer they use to cut through tissue will illicit a electrical impulse along the nerve and cause a muscle contraction. After this happens, the surgeon knows they are in a region with a nerve.

An hour later and after much more cutting, we reached the brachial artery. It is often crucial that they find arteries before cutting in order to avoid excessive bleeding. The doctor explained to me that they can identify arteries because they actually move with the beat of the heart. In the case of this patient, the artery was in a fairly tough to reach area as it ran through the middle of the tumor. After they had successfully removed the brachial artery from the tumor, the doctor actually showed me the phenomenon of the artery moving with the beat of the heart.

In the final stage of the surgery, the surgeon uncovered the median nerve of the upper arm. The tumor was finally completely removed after 3 hours of sugery. Before the surgery ended, the gaping hole left by the tumor had to be closed. In a surgery like this, some care must be taken in making a cut to allow enough skin. At the beginning of the surgery when the surgeon initially cut, I noticed that he didn´t cut an area as large as I had expected. In the end of the surgery, there was barely enough skin to cover the huge hole left by the tumor. The preservation of the skin is a component that´s crucial to the surgery, but something that never occurred to me until this surgery.

This surgery was incredibly interesting because I got to see and touch the intricate parts of the body in a live patient. I don´t anticipate having this kind of experience again until the thrid or fourth years of medical school.

Fútbol

I have been to two Monarch soccer games during my time here. Soccer to Mexicans is what the NFL is to Americans. The fans are passionate and hate seeing their team lose. The stadium reminded me of Reser, but only a lot older.

Throughout the game, venders sell a number of items from beer to noise makers. A popular snack during the game is garbanzo beans with salsa and limes. They sell them unpealed, so you have to removed the shell in your mouth like sunflower seeds. I thought I would give them a try. Needless to say, it can become very messy.

The first game I saw was with my host dad and his two sons. The game was a tie at 0 - 0. The second game I went with some friends. Unfortunately, Morelia let San Lois score in the first 2 minutes, and the game ended on a 1-2 loss for the Monarchs. Overall, I love sports, but watching the fans and being in the culture of the stadium was equally as fun.