Clinical, Featured, Internal Medicine, OB/GYN
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24 Weeks

Just under six months. The difference between the current pitch of winter on Manhattan’s icy, sullen streets and a summer day along the Hudson. Any earlier and you’re caught in the struggling transition of thawing Spring days, any later and you’re well on your way into the season’s thicker heat. It’s the turn, the consummation of what came before it, the moment of summer’s realization.

In the NICU, a cacophony of beeping machines kept the room in an air of confused austerity.  Walking into an empty room at 8 a.m., the crowd of technology and plastic-shaded cribs made it difficulty to tell if there were any patients around at all. Looking around the room for a sense of orientation or understanding, I felt even more lost. My first week back in the hospital after over a year’s absence left a short but palpable learning curve, and critical care was totally foreign to me — let alone caring for newborns. Nodding myself slowly into the confidence that, yes, I am at least probably in the right place at the right time, I see a group of nurses at the far end of the hallway wheeling a crib down the corridor. One woman trots ahead at an awkward half-run and, passing me with a brief glance, immediately attends to rearranging a befuddled pile of wires and outlets. As the rest of the pit crew rolls by me, I can barely see in between their shoulders to the impossibly small focal point of all this excitement. Almost just a convergence point for the innumerable lines, tubes, wires, there in the center lay all 900 grams of him. Let’s call him Nelson. Or maybe, let’s first assume he had a name. A premie, to say the least.

Calmly walking in at the end of this cavalcade is the fellow, sunken eyed and unfazed — but for all that, still a picture of her own grace and comfort — amidst the seeming gravity of the situation. Sidling up to her flank to catch the scraps of an ongoing conversation between her and the nurse, I learn that Nelson was born PPROM (premature preterm rupture of membranes) from a mother struggling through her own acute pneumonia. Without the benefit of an antenatal steroid course, the baby was delivered with almost immediate respiratory distress, intubated and brought across the hall to the NICU shortly after morning sign out. Now properly surrounded, he would receive round the clock monitoring, antibiotic therapy, ventilator support and nutritional aid, all before even the first eruption of a voice. He was 24 weeks’ gestation.

I think to almost exactly two years’ prior to my NICU experience in that same city hospital. In front of me is a patient much like my NICU mother — young, Hispanic, alone, scared — but we are in the outpatient laminaria clinic. She is crying. Already a mother to a 3-year-old boy, she started explaining in a few broken words that she cannot, cannot support another, that there is no other way. In that emotional moment, none of that seemed clear, to us and least of all to her. Biting my lip and looking to the ground, unsure what to say or if it was my place to say anything at all, I let myself just sit there with her (and my) developing feelings. The OB/GYN resident at the desk next to the exam table asked if she’d like us to give her a few minutes to think about it. Realistically, however, I think this young mother knew that if she wasn’t cared for this week, this process was just going to get a whole lot harder than it already was. So she composed herself and, wiping her tears, said no. She was ready. Now just what the hell are laminaria? I was about to find out, and so was she.

Two days and 40 sticks of blood-soaked seaweed later, we are in the operating room, some of us asleep, others just waking up. I am front and center, another set of hands in the effort. After having been disabused of my expectations earlier in the clerkship of being a big member of the team, at this point I was used to being a sideline hero, seen but not heard. This, as much as anything else, is what surprised me at being so intimately involved in this morning’s procedure. And while I was used to/getting better at being a more graceful Tag-Along-Tom in the operating room, today I was actually stopped by my resident before washing up. “If it gets tough to handle in there, it’s okay to step out. A lot of students have trouble with this one.” I hadn’t chosen this for my specialty clinic week, but in my mind I had prepared for it, and even felt privileged to be at an institution that was living on the farthest edges of the frontlines in this territory. It was, I felt, in line with my personal values, so all the better that I should truly understand it from a medical perspective.

As in most affairs, intellectual understanding and direct experience are two distinct things, and reflection perhaps a third, with its own power. In spite of my perceived fortitude, and even an admittedly seamless performance in the operating room that morning, what I saw I was not ready for. And now, with two years past since then, and my most recent month offering the most intense exposure to children I’ve ever had in my young life, I’m even less prepared to internalize that experience. Seeing these newborns thrive into increasingly active and aware infants and toddlers, seeing those school-aged kids spout off these remarkably lucid and hilariously honest reflections of their new world, seeing the timidity and budding self-conscious ways of teenagers that remind me so much of my own maturity (and not-so-occasional immaturity) — all of this points in a continuous straight line back to that fetus, that first struggling, nascent life, the spark. The journey is the miracle, and it has been an ever-growing revelation to look at an adult, to look at myself, and see the accumulation of all these unique but predictable experiences in development: from walking, talking, mimicking, socializing, playing, reading, romancing, all the way down to just that first long confused, scrutinizing look the baby has into the face of a stranger smiling, giving her that first smile, and her giving it back. It is in the turn, in that first click of new understanding, that the child shows the miraculous, and flexes the impossible genius of her organism. It has been the privilege of this experience working with kids to trace their journey all the way back and appreciate it in its most primitive forms, the raw reception of a new world. It has a dignity and a simplicity I could not have anticipated, and it mirrors the same incredible orchestra the body demonstrates in organogenesis: the dancing ballet of bilaminar disks bending and invaginating, hearts folding into chests, intestines exploding from and involuting back into the abdomen during those first critical eight weeks.

These two processes — the rich development of an internal environment and then the dynamic interplay of conscious organism and external environment — are bridged by that precarious waiting room called the womb. Transitions are usually predictable and manageable, and give us a gauge for when the nascent can unfold into its full glory, when it cannot, and what we in medicine can do about it. And the answer, apparently, is that we can do a lot. Studies show that at roughly 24 weeks, a newly born fetus has about a 50 percent  chance of survival, depending on the supports available.

Back in that operating room, I am dutifully holding onto the basin just beyond and under the table edge. What I see is what the mother would never wish to see; being a part of her care, we accept that burden for her, and in a much different way that she ever could from her intimate connection with it. It is our service to her, to alleviate that pain, to be an open support to her health and well-being. It is an acceptable cost, but a cost all the same.

In recovering the placenta, the resident has some difficulty. In calling the attending over, an ultrasound reveals some retained POCs (products of conception), and some difficulty evacuating them. A brief assessment by manual exam and ultrasound proves the unfortunate — this is an accreta, and we will not be able to deliver the placenta without the uterus attached to it.  An emergency hysterectomy is performed, and in the process the uterine artery is nicked. Two hours of attempted tamponade and blood products later, the patient is in frank disseminated intravascular coagulation (DIC), and all but dies on the table. One termination on the verge of two, she is successfully extubated in the OR, 12 hours from whence we began. She is sent to the PACU, the specimens are sent to pathology, and the rest remains with us, with me and this reflection.

The fetus was 24 weeks.

Image credit: Labor by george ruiz licensed under CC BY 2.0.

Jafar Al-Mondhiry, MD, MA Jafar Al-Mondhiry, MD, MA (1 Posts)

Resident Physician Contributing Writer

New York University School of Medicine

Jafar Al-Mondhiry, MD, MA, is a second year internal medicine resident with the New York University School of Medicine. Originally pursuing graduate training in Continental Philosophy and Medical Ethics at Pennsylvania State University, he has maintained a thriving interest in the medical humanities throughout his time as a medical student and resident with NYU. Particularly areas of interest include issues in medical education/training, medical history, and drug and alcohol recovery.