“Oh, hi,” she said. “I’m Melissa. I’ll be in here or in the call room if you need me. Probably the best thing for you to do is keep an eye on patient Garcia. She’s a twenty-two-year-old, here with preterm labor and twins. Everyone else is pretty standard.”
Between bites, Melissa briefed me, a barrage of facts and information: The twins were only twenty-three and a half weeks old; the hope was to keep the pregnancy going until they were more developed, however long that might be; twenty-four weeks was considered the cusp of viability, and every extra day made a difference; the patient was getting various drugs to control her contractions. Melissa’s pager went off.
“Okay,” she said, swinging her legs off the couch. “I gotta go. You can hang out here, if you like. We have good cable channels. Or you can come with me.”
I followed Melissa to the nurses’ station. One wall was lined with monitors, displaying wavy telemetry lines.
“What’s that?” I asked.
“That’s the output of the tocometers and the fetal heart rates. Let me show you the patient. She doesn’t speak English. Do you speak Spanish?”
I shook my head. Melissa brought me to the room. It was dark. The mother lay in a bed, resting, quiet, monitor bands wrapped around her belly, tracking her contractions and the twins’ heart rates and sending the signal to the screens I’d seen at the nurses’ station. The father stood at the bedside holding his wife’s hand, worry etched on his brow. Melissa whispered something to them in Spanish, then escorted me out.
For the next several hours, things progressed smoothly. Melissa slept in the lounge. I tried decoding the indecipherable scribbles in Garcia’s chart, which was like reading hieroglyphics, and came away with the knowledge that her first name was Elena, this was her second pregnancy, she had received no prenatal care, and she had no insurance. I wrote down the names of the drugs she was getting and made a note to look them up later. I read a little about premature labor in a textbook I found in the doctors’ lounge. Preemies, if they survived, apparently incurred high rates of brain hemorrhages and cerebral palsy. Then again, my older brother, Suman, had been born almost eight weeks premature, three decades earlier, and he was now a practicing neurologist. I walked over to the nurse and asked her to teach me how to read those little squiggles on the monitor, which were no clearer to me than the doctors’ handwriting but could apparently foretell calm or disaster. She nodded and began talking me through reading a contraction and the fetal hearts’ reaction to it, the way, if you looked closely, you could see—
She stopped. Worry flashed across her face. Without a word, she got up and ran into Elena’s room, then burst back out, grabbed the phone, and paged Melissa. A minute later, Melissa arrived, bleary-eyed, glanced at the strips, and rushed into the patient’s room, with me trailing behind. She flipped open her cellphone and called the attending, rapidly talking in a jargon I only partially understood. The twins were in distress, I gathered, and their only shot at survival was an emergency C-section.
I was carried along with the commotion into the operating room. They got Elena supine on the table, drugs running into her veins. A nurse frantically painted the woman’s swollen abdomen with an antiseptic solution, while the attending, the resident, and I splashed alcohol cleanser on our hands and forearms. I mimicked their urgent strokes, standing silently as they cursed under their breath. The anesthesiologists intubated the patient while the senior surgeon, the attending, fidgeted.
“C’mon,” he said. “We don’t have a lot of time. We need to move faster!”
I was standing next to the attending as he sliced open the woman’s belly, making a single long curvilinear incision beneath her belly button, just below the apex of her protuberant womb. I tried to follow every movement, digging in my brain for textbook anatomical sketches. The skin slid apart at the scalpel’s touch. He sliced confidently through the tough white rectus fascia covering the muscle, then split the fascia and the underlying muscle with his hands, revealing the first glimpse of the melon-like uterus. He sliced that open as well, and a small face appeared, then disappeared amid the blood. In plunged the doctor’s hands, pulling out one, then two purple babies, barely moving, eyes fused shut, like tiny birds fallen too soon from a nest. With their bones visible through translucent skin, they looked more like the preparatory sketches of children than children themselves. Too small to cradle, not much bigger than the surgeon’s hands, they were rapidly passed to the waiting neonatal intensivists, who rushed them to the neonatal ICU.
With the immediate danger averted, the pace of the operation slowed, frenzy turning to something resembling calm. The odor of burnt flesh wafted up as the cautery arrested little spurts of blood. The uterus was sutured back together, the stitches like a row of teeth, biting closed the open wound.
“Professor, do you want the peritoneum closed?” Melissa asked. “I read recently that it doesn’t need to be.”
“Let no man put asunder what God has joined,” the attending said. “At least, no more than temporarily. I like to leave things the way I found them—let’s sew it back up.”
The peritoneum is a membrane that surrounds the abdominal cavity. Somehow I had completely missed its opening, and I couldn’t see it at all now. To me, the wound looked like a mass of disorganized tissue, yet to the surgeons it had an appreciable order, like a block of marble to a sculptor.
Melissa called for the peritoneal stitch, reached her forceps into the wound, and pulled up a transparent layer of tissue between the muscle and the uterus. Suddenly the peritoneum, and the gaping hole in it, was clear. She sewed it closed and moved on to the muscle and fascia, putting them back together with a large needle and a few big looping stitches. The attending left, and finally the skin was sutured together. Melissa asked me if I wanted to place the last two stitches.
My hands shook as I passed the needle through the subcutaneous tissue. As I tightened down the suture, I saw that the needle was slightly bent. The skin had come together lopsided, a glob of fat poking through.
Melissa sighed. “That’s uneven,” she said. “You have to just catch the dermal layer—you see this thin white stripe?”
I did. Not only would my mind have to be trained, my eyes would, too.
“Scissors!” Melissa cut out my amateur knots, resutured the wound, applied the dressing, and the patient was taken to recovery.
As Melissa had told me earlier, twenty-four weeks in utero was considered the edge of viability. The twins had lasted twenty-three weeks and six days. Their organs were present, but perhaps not yet ready for the responsibility of sustaining life. They were owed nearly four more months of protected development in the womb, where oxygenated blood and nutrients came to them through the umbilical cord. Now oxygen would have to come through the lungs, and the lungs were not capable of the complex expansion and gas transfer that was respiration. I went to see them in the NICU, each twin encased in a clear plastic incubator, dwarfed by large, beeping machines, barely visible amid the tangle of wires and tubes. The incubator had small side ports through which the parents could strain to reach and gently stroke a leg or arm, providing vital human contact.
The sun was up, my shift over. I was sent home, the image of the twins being extracted from the uterus interrupting my sleep. Like a premature lung, I felt unready for the responsibility of sustaining life.
When I returned to work that night, I was assigned to a new mother. No one anticipated problems with this pregnancy. Things were as routine as possible; today was even her actual due date. Along with the nurse, I followed the mother’s steady progress, contractions racking her body with increasing regularity. The nurse reported the dilation of the cervix, from three centimeters to five to ten.
“Okay, it’s time to push now,” the nurse said.