August 7, 2017

Written by Courtney Pasco (class of 2016-2017)

I want to preface my summary with a quick warning: one of the procedures I saw and have described in my summary below was a D&E after a 22-week fetal demise.  I know that can be a sensitive topic and skipping those paragraphs or this summary entirely is definitely an option.  

The morning meeting focused on why giving blood volume can be an appropriate treatment for many different conditions.  Dr. Harken walked us through the natural homeostatic response to a drop in blood volume: renin in the kidney acts as an enzyme to convert angiotensinogen from the liver to Angiotensin 1. Angiotensin 1 is converted to Angiotensin 2 in the lungs and Angiotensin 2 stimulates vasoconstriction, ADH production in the pituitary, and aldosterone production in the adrenals. ADH increases the water retained in blood, increases the feeling of thirst in the hypothalamus and aldosterone increases the amount of sodium retained in blood–all of which function to increase blood volume.  The discussion went far beyond this one pathway, but I wanted to at least include this in my summary because I think it is so cool how many different (not traditionally cardiovascular) areas of your body are involved in maintaining blood volume.    

The first procedure I saw was a Dilation and Evacuation after a 22-week fetal demise performed on a 30-year-old woman.  The attending, Dr. Amy Kane, began by removing the gauze and grouped tampon-like packing from the patient’s vagina. Aaron, the medical student assisting her, was standing by with the ultrasound machine so Dr. Kane could have a view of what she was doing.  Before placing the speculum and grasping the cervix with Allens, she mentioned that the patient was already 2cm dilated and the demise occurred almost 3 weeks prior.  Next, she injected vasopressin to stem uterine artery blood loss.  Then she began the suction and a huge amount of blood and tissue came pouring out.  Some of the tissue was suctioned out, and other pieces were pulled out. At one point she stopped and noted that the grayish fluid leaking out was brain matter.  After she was satisfied that the fetal remnants, placenta, and cord had been removed, she began scraping the walls of the uterus with a curette to remove the lining.  The entire procedure took maybe 15 minutes in total.

I’m not sure how much is appropriate to share in these summaries, but I feel I should say that I wholeheartedly believe in a woman’s right to choose.  This D&E was not an abortion, but I wanted to share what I felt when I was watching it with the understanding that my emotions do not come from a place of judgement.  I recognize that this is a sensitive issue and I would feel a little strange only writing a clinical description of what I observed and not acknowledging that procedures like this can carry a lot of weight and emotion.  With that said, I felt a lot of different things during those 15 minutes–sadness for the woman on the table, anxiety and shock at what seems like a violent, undignified end to a little life, awe at the tiny, perfect human arms and legs that were still intact (albeit strewn amongst other unidentifiable pieces of tissue) after the procedure, and finally gratitude that attendings like Dr. Kane exist and are able to give women the care they need–whether they miscarry, have an abortion, or carry the pregnancy to full term.

The next procedure I saw was a bilateral ovarian cystectomy, partly done with a laparotomy and partly done laparoscopically. The attending, Dr. Lerner, made a 2-3in incision at the bikini line and immediately located one ovary with a cyst about the size of a baseball on it.  He made a small cut and inserted suction to drain the fluid.  Then he cut away the cyst from the rest of the ovary and Fallopian tube.  Then, using the laparoscope, they explored further up her abdomen and located the other ovary and cyst and moved it back down toward the bikini line incision.  This one was totally insane. It was like the size of a volleyball and when he made the incision and inserted suction, the fluid gushed past the suction and sprayed all over the floor like a geyser.  My notes literally just say, ‘Okay that was AWESOME.’   Finally, the last procedure I saw was a laparoscopic hysterectomy and bilateral salpingo-oophorectomy, which may be my new favorite word. Basically, the patient’s uterus, ovaries, and fallopian tubes were removed. This surgery just consisted of cutting around the cervix and pulling out the attached uterus, tubes, and ovaries through the vagina.  However it  took a couple of hours, mostly because the attending had to suture laparoscopically which took an incredible amount of dexterity and patience.             

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Posted on October 15, 2017, in Uncategorized and tagged , , . Bookmark the permalink. Leave a comment.

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