Brachial plexus and operative report

When I created masculiknity some time ago in college between commercial breaks of Law & Order: SVU reruns, I had no idea that it would last as long as it has. Much like ballet lessons, shorthand, and my childhood collection of pyrite, I just assumed that it would eventually fade away and join my growing list of abandoned side projects.

And yet, here I am, five years later, obsessing over where I could’ve put a much-needed parenthetical in my two preceding sentences (special victims uknit) and trying to decide which picture (eight year old ballet daniel or san francisco ocean beach) I should insert next to transition from my cold open to the first main paragraph.dsc_0463So, given that there is very little in this world that would stop me from knitting and writing, I took the plunge and bought www.masculiknity.com (no more of this .wordpress.com nonsense)! I tried justifying it by saying it was a Christmas present to myself (along with three button ups, a waffle knit long sleeve, eight skeins of yarn, and two books), but in all honesty, it was really just a treat yo’ self kind of purchase (along with my new raincoat, uniqlo socks, and bluetooth earphones). In addition to the big boy domain name, I also gave my site a hefty facelift, adding a thematically appropriate banner and an edgy yet classic san serifed header. Now all I need is for a celebrity (preferably jessica chastain but will also accept martin sheen as jed bartlet) to discover me and then this stitch is ready to go viral!dsc_0902
If you guys think back to a couple of Octobers ago when I knit a human eye, I recently completed a project that runs in a similar vein, in that it is equally esoteric (esewteric) and exclusively relevant to medical students and professionals. This is the brachial plexus, a network (knitwork) of nerves that supplies the upper extremities divided into roots, trunks, divisions, cords, and terminal branches. When I was in anatomy lab, I remember the brachial plexus being impossibly difficult to memorize (despite frank knetter’s iconic rendition) and how helpful a physical model would have been.dsc_0884Well, thanks to season three of Black Mirror (san junipero amirite?) and the workweek bliss that was my anesthesia rotation, I had ample time to experiment with I-cords, testing out various ways of connecting and branching them. And then, many awkward stares and ninety five hand-stitched letters later, I completed my anatomically correct (albeit simplified) brachial plexus! I can’t say that it’s the most aesthetically pleasing project (pretty sure that yellow is red heart super saver…), but it’s probably one of the nerdiest things I’ve ever done (except for third grade, when i voluntarily skipped recess to help sort mail).

Coming up next in my aknitomy series: the GI tract (that ish is gonna be hard #poopjoke).

I was reminded of the brachial plexus originally during my OB/GYN rotation last month, since some newborns (especially the fatties) are at risk of damaging these nerves during childbirth. The rotation itself was quite an experience. A fluid-filled, miraculous, fluid-filled (so many fluids. just. so many.) experience. One of the more challenging parts of it was my week on nights, which disassembled just about every internal rhythm that I had (i ate a donut for breakfast and was full for the whole day). The first night was particularly brutal, and so to keep from falling asleep (aside from chugging ice water), I decided to write. Here’s what I wrote.

Oh yeah. Also, in case there’s any doubt: as irreverent as I am towards the personal space and privacy of others (one time i accidentally joined a stranger inside what turned out to be a single-use restroom), there are some things, like HIPAA (and boys who do ballet), that you just don’t mess with.


Operative Report

“time out”

The words alone are enough to ice the atmosphere. It happens instantly, like flipping a switch. Even the surgeon stops mid-sentence. We look up at the flat screen bolted halfway up the mint green operating room wall, and the circulating nurse reads from it without an ounce of enthusiasm, her words blurring into one long string of gibberish. We are a room full of scientists, and yet I look around and the whole scene strikes me as oddly ritualistic. The surgeon and I are gowned and gloved, standing on either side of the patient with our hands out in front of us, held awkwardly above her swollen belly. Blessing it, it would seem. Protocol demands sterility, so the room is swimming in every tint of blue, drapes glowing alive from the harsh lighting. And all of us, we are silent and attentive, following along with the words that are being chanted, waiting for something, perhaps seeking divine guidance to instruct us on how best to proceed.

We delineate our incision with a purple marker. At the crease, where her belly folds and reflects over a patch of brown pubic stubble. I hold her stomach up so the surgeon can draw a gentle arc that looks like a smile, and I imagine the boy swimming between my hands, centimeters beneath the surface, breathless and waiting. The scrub tech hands the surgeon a scalpel that gleams beneath the overhead lights and I can’t believe we’re bringing a blade so close to her skin—his skin—that we could potentially cut something so new and unbruised.

“skin”

A flash of white. Adipose tissue like cotton batting emerges from the incision, released from its epidermal confines. For a moment I think we’ve torn open a stuffed animal, and then, sleepy vessels stir awake, and it begins to bleed. Bright red, pouring out like velvet. She cuts deeper, undeterred by the trauma we’re inflicting. I dab the area with soft squares of white cloth and watch as blood races along the fibers.

The surgeon is liberal with the scalpel, to the point where I’m nervous on her behalf. Doesn’t she know how sharp that is? How irreversible that is? Everything it touches melts away, and I think about how long it must have taken to connect everything the first time around. Muscle fibers, arteries, veins. All weaving together. And then, in a single stroke, they’re gone. Regardless, we press on, identifying and dividing the various layers as we tread deeper, inching our way to him. At times we use the bovie, frying strings of fascia and fibrotic bands, cauterizing weeping blood vessels. It sizzles through tissue with an energetic hum, cooking it brown, then black, then crispy with a metallic sheen. I hold the suction close but it doesn’t really make a difference. It still smells of burning flesh. Like Doritos. Cool Ranch.

After getting through the fat and superficial fascia, we at last reach the rectus abdominis: a long, striated muscle bathed in intra-abdominal fluid, glistening, emanating something between a deep mahogany and a bruised purple. Unlike everything else we’ve encountered, this seems vital, ostentatiously alive. I put my fingers on it and it’s warm through my gloves, which, for some reason, surprises me. I’m not sure what I was expecting. The muscle has two bellies, so we find the gap between them and pull. Hard. The force we use is astonishing. I am on one side of the table and the surgeon is on the other, and together we lean back, putting our full body weight against the integrity of this woman’s abs. I think about what we’re doing for a second too long and at once feel nauseated. What if we rip her apart? I don’t even know what that would entail, but the question alone makes my stomach turn.

“uterus”

The surgeon picks up the scalpel again, which reflexively sends my heart rate back into the hundreds. The neck of the uterus is a speckled lavender. She makes very small incisions. One cut, then two, then, without warning, fluid jets out and splatters across the plastic guard in front of my face. It lasts only a moment, the gush of amniotic fluid immediately waning into a gentle outpouring that fills the plastic gutters hanging off the sides of the table. The fluid is clear and tinted a pale yellow. Flecks of blood and whitish pieces like lint are carried away by the current.

I see the top of the head first, which is covered in dark, drenched hair. The baby turns and I see his geriatric face, which is blue and grey and seems to be etched in granite, severe wrinkles furrowing his brow, forcing his eyes shut. The surgeon puts a forearm on the woman’s belly and pushes his arms and torso out. They, also, are a dusky blue, lined with generous folds. A clean, white umbilical cord stems from his stomach, and the helix formed by the arteries and vein within the cord is absolutely beautiful. The surgeon pushes again from above, and this time the legs are delivered. Fat thighs, dimpled knees, terminating in ten pea-sized toes. I hold him while the surgeon clamps and cuts the umbilical cord. He’s shimmering from a nine-month bath, and I struggle to keep him from slipping away.

He feels warm and familiar in my hands, like a hug or a handshake. His eyes are still closed and his limbs outstretched. His hands grasp the air—tiny fingers, tiny fingernails. He opens his mouth to reveal a pair of empty gums. It’s like he’s still floating in a world of fluid, used to the ease of weightlessness and the darkness of the womb. I suction his mouth and nose, which he detests. He grimaces, adding even more folds to his brow. And then, he cries, and it reaches every corner of the room. It’s loud and altering, like my ears popped and I realize that I’ve been listening through layers of wool for who knows how long. Tension melts away. Somebody laughs. Time continues and we return.

A nurse takes the baby to a clear crib off to the side while we deliver the placenta, pulling out an off-white, filmy sac, engorged with bulging vessels red and deep blue, torn from the walls of her rapidly shrinking uterus. We drop it into a blue plastic bin, ring forceps still attached, which quickly gets shuttled off and tucked away into a red biohazardous bag.

We explore the uterus for any placental remnants and then replace it gently into the peritoneal cavity, a task that all of a sudden feels painstakingly tedious. It’s that post-anticipatory exhaustion—the drive home after Christmas dinner—and it hits me like a brick wall. My back starts to ache and my arms feel abruptly awkward and strained holding the retractor so still. At last the surgeon sews up the uterus and imbricates the incision, leaving only a neat, tram track of black suture in its place.

We take a minute to breath and watch, looking for any signs of residual bleeding, any last surreptitious trickles of blood. Nothing. So we wash out her abdomen with saline and prepare to close. The surgeon picks up a large plastic ring and waves it around with the flair of a lackluster magician, checking the open abdomen for any misplaced tools. Nothing. We leave the way we came, closing the various layers behind us. For the skin, the surgeon uses a straight needle, the same kind used to darn a pair of socks, and despite everything we’ve just done, this disturbs me. But the result is impressive, just a thin grey line, the edges kissed together perfectly, at a glance nothing more than an innocuous fold or slim bruise. We cover our closure with stereostrips and fluffy gauze and seal it with clean white bandages. I apply pressure while others break everything down around me, tearing down drapes, unhooking the various monitors and tubing, throwing them all indiscriminately into oversized garbage bags. With everything gone, I can see the patient, now a new mother. Her head is turned away from me and looking at her son. His eyes are glued shut from erythromycin drops, but every once in a while he pries them open to reveal curious brown irises.

I remove my gloves and gown, my mask. The operating room is frigid in just my scrubs. With help from the nurses, we clean and dress her, sliding her over onto a bed and covering her with warm blankets to stop her shivering. I take one last look around the room, now in disarray, a story written on its walls. Bloodied debris strewn across the floor, soiled blankets tossed aside and leads left dangling from knee-high monitors, a plastic bucket three quarters full with murky serosanguinous fluid. I hold the door open as they wheel her into the recovery room.

It’s not until later that I notice my right forearm out of the corner of my eye. A flash of dark, a birthmark I’ve never noticed before. The size of my thumb and the color of an old penny. Well-defined borders making out the shape of a hazy rhomboid. I touch it absentmindedly. It’s blood, but I’m not bleeding.

I race to the bathroom and keep my forearm under running water for a full minute, lathering it with soap and letting the warm wash rinse it away over and over again. The stain is definitively obliterated, but I keep it in the sink because I’m nervous. Why? I turn the faucet all the way to the left. Seconds later I feel warm get hot.

My arm is bent at the elbow to fit inside the basin, careful not to touch the bottom. Water splashes and casts abstract art on my scrub top. But I don’t care. I’m thinking, trying to remember, playing back the events of the past hour: her skin, bowing inwards just slightly, relenting and separating smoothly beneath the blade; the tepid fluid as we break the sac, shallow warmth flowing between my fingers like checking the water of a running bath; and him, the newly born, recently non-existent, unnamed novelty—predated by nothing else in the ever-expanding universe—one hand feeling the gaping sutures of his skull and the other at his ankles, each malleolus like a marble pressed into my palm. The entire journey to the center of her, all of it’s there, documented and redundant. Except for this. This is gone. Our singular collision, lost in the blind spot of my memory. Maybe at the end, I think, when I was turning her so they could remove the epidural, my elbow dropping just an inch too low. Maybe, but I’m not sure.

I turn off the water and inspect my arm closely. Not a trace of her remains. Water pools into droplets, and fine, dark hairs lay neatly down beneath their own weight. There’s a scar on my wrist that I’ve had for so long I only see it half the time—a thick dash from my sister’s marshmallow roasting fork that one summer we camped at Big Sur. A bolded hyphen branded along my distal radius when I was twelve or thirteen. I vaguely remember the scorch, the chaos around a smoky fire pit beneath ponderosa pines, the sweet relief of the water spigot. I don’t remember when I realized that it would scar.

I take a final glance in the mirror before I go, checking my other arm just in case. I clean my glasses and adjust my scrubs. It’s almost time for the next case: a twenty-year-old at thirty-eight and two. Sweet girl, I remember. We met briefly this morning. Running through the details of her case in my head, I recall that she doesn’t know the sex of her baby. Neither does her boyfriend. Neither does anyone. I make my way to her room with anticipation in my footsteps, eager to begin. I guess that’s something we’ll all have to find out together.

Advertisements

2 thoughts on “Brachial plexus and operative report

  1. I am too a medical student and I make things to remember when my brains capacity to memorize by reading or hearing or watching is exceeded. I enjoyed your c-section account – you have a way with words.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s