Saving Jane Doe230
Saving Jane Doe230
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|Publisher:||Morgan James Publishing|
|Series:||Morgan James Fiction Series|
|Product dimensions:||6.10(w) x 9.10(h) x 0.70(d)|
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The EMTs found her unconscious, huddled in a corner of the second-floor hallway at the Downtowner Motel. Her hand half-held a paper cup, and orange juice spilled onto her dress. As they lifted her from the dirty linoleum floor, a rat scurried down the hall, leaving footprints in her blood. They called her Jane Doe, as the pockets of her dress were empty and her handbag, if she had carried one, had been stolen. Her flowered, short-sleeved dress was faded by many washings, but clean except for the orange juice and blood. Long sable curls loosely framed her heart-shaped face, with skin as white and delicate as Bradford pear blossoms. She looked to be about thirty years old.
Jane Doe's low blood pressure and fast heart rate suggested shock from the blood loss, so they started an intravenous line with Lactated Ringers solution. They knew what had caused the problem. Betty the Butcher worked out of the Downtowner; they had done this run before.
It was August 1971, the first week of clinical clerkships for the new third-year medical students at the University of Kentucky Hospital in Lexington, and only the second month for the interns in the emergency room. Fortunately, Bertha Jones, an experienced ER nurse, met the ambulance. Knowing the gynecology team would be needed, she caught us before we left the ER. We had just seen a woman with bleeding during her first trimester of pregnancy.
"You'll need to see another patient. They found her at the Downtowner," Ms. Jones told Dr. David Armstrong, the chief resident in GYN, as she entered the doctors' workroom.
"Did you find Betty the Butcher's red rubber catheter?" Dr. Armstrong signed the record, though you would not have known it was him from reading the signature.
"I haven't looked. I wanted to catch you before you left."
"Is she conscious?"
"What are her vital signs?"
"Her blood pressure is 90/60, heart rate is 110, temperature is 103 degrees, and respirations are 20."
"Get her ready for her exam. I'll just be a minute more here. This is Dr. Cara Land. Cara, you go watch what Ms. Jones is doing." I followed the nurse.
As a third-year medical student on call for the first time ever, I felt far from being a doctor, and nothing I had ever seen or heard prepared me for this Jane Doe. Though it was a hundred degrees outside, the emergency room's small operating room was cold — and not just in temperature. Its green tile walls stood bare except for stainless steel cabinets and equipment. The white tile floor, spotless at first, quickly became littered with bandage wrappings, alcohol swabs, and packaging for disposable sterile equipment. Bright lights glared overhead, showed every detail, and kept us from freezing.
I watched. With giant bandage scissors, Ms. Jones cut away the flowered dress, the blood-soaked slip, bra, and panties. With each cut she took Jane Doe's remaining possessions until she was left with only her failing body. Ms. Jones covered her torso with a hospital gown and sheet; her dependence was complete.
"Who is Betty the Butcher?" I asked.
"She's the woman who does illegal abortions at the Downtowner Motel. She forces a red rubber catheter through the cervix and then sends the women out. The catheter is supposed to stimulate contractions that cause the uterus to empty itself."
"Does that work?"
"Sometimes ... sometimes not."
"What happens if it doesn't work?"
"They come here. If they are lucky they get a D&C which completes the abortion; if less lucky they get a hysterectomy."
"And if they aren't lucky?"
"Do many die?"
"Not many here in Lexington and not as many since antibiotics and other modern treatment, but some still do. I saw more die when I worked in Philadelphia several years ago."
"No wonder they call her Betty the Butcher. Why doesn't somebody stop her?"
Before Ms. Jones could respond, Dr. Armstrong arrived for the exam. He listened to Jane Doe's lungs and heart. When he pulled the sheet down to look at her belly, he said, "You always want to look closely for surgical scars. Ah, she has a low midline surgical scar. It could be from a number of things, but in a young woman, often it is from a Caesarean section." When he pushed on her lower abdomen, she winced. "Well, she is responsive to pain," he said. "Cara, feel how hard her belly is. This is an acute abdomen. She either has blood or pus or both in there." As I felt, it was easy to tell how rigid it was. He finished looking briefly at her legs and ankles for signs of trauma or swelling. Turning to Ms. Jones, he said, "Set her up for a pelvic exam. I'll go order blood tests, antibiotics, and a type and crossmatch for blood transfusion."
Ms. Jones opened a tray with a sterile speculum, ring forceps, and a uterine sound. She added sterile culture tubes to the tray and more trash to the floor. Then she placed Jane's feet into stirrups and pulled her body down to the edge of the table.
When Dr. Armstrong returned, looking at me, he said, "You can see best if you stand behind me. I will try to explain what I'm doing." Jane gave no reaction as he placed the cold metal speculum into her vagina. Huge blood clots rushed out, splattering his white coat, scrub pants, and shoes before creating a sticky pool on the floor at his feet. There, crawling out of the cervix like a snake out of a garden drain and not looking the vicious killer it was, lay the red rubber catheter. One end was still in the cervix, which was slightly dilated and filled with bloody-looking tissue. Dr. Armstrong clamped the tissue with the ring forceps and pulled gently. After the tissue was removed, he placed it in formalin and sent it to pathology for identification.
"What is that tissue?" I asked.
"It looks like placenta."
He touched the cervix with a culture tube and removed the catheter. Next he clamped the top of the cervix with the forceps and inserted the uterine sound through the opening.
"This measures the depth of the uterus," he said. "It is eleven centimeters." He turned the sound, and with what looked like no pressure it moved much deeper into the cervix. "Oh, she has a perforation; the sound just went through a hole. That is probably what caused her problem."
After removing everything, Dr. Armstrong finished the exam by feeling the pelvic organs between his fingers, two placed in the vagina and the other hand on her abdomen. For my benefit he said, "The uterus is eleven weeks' size and soft. There are large masses involving both ovaries. When you do an exam you always relate the size of the womb to how big it would be if the patient were pregnant, even if she's not. That way you always have a frame of reference. If a non-pregnant woman has fibroid tumors, which enlarge the uterus, we still talk about the uterine size in weeks. In this case she is pregnant, or has been. Now, you repeat her bimanual exam while I call the attending physician. She will have to go to the main operating room." Looking at Ms. Jones, he said, "Have you called her family? We will need permission to operate."
"We can't call her family. She's a Jane Doe."
"We'll have to document everything well and proceed. She will die if we wait for a court order."
"Are we doing a D&C?" I asked.
"No, she will need an exploratory laparotomy; that's an open procedure to identify the cause of the rigid belly and fix the problem. In this case that will almost certainly be a hysterectomy and bilateral salpingo-oophorectomy — removal of the uterus, tubes, and ovaries."
This was my first trip to the operating room. A nurse showed me where to change into scrub clothes, leave my things, and get a hat and shoe covers. The female doctors shared the dressing facilities with the nurses. The whole area felt like a refrigerator. In the operating room country music played as the anesthesiologist inserted an endotracheal tube and gave Jane only oxygen and pain medication. I was told that this was because she was unconscious and too sick for deeper anesthesia. Dr. Armstrong told me how to scrub my hands, put on sterile gloves, and prep her abdomen. I hadn't even seen an abdominal prep before I had to do one. Fortunately, it was simple.
I used sponges soaked in Betadine soap to wash the whole area from just below her ribs to the top of her legs, starting at the center and working my way out to the edge without going back over the center. Then I blotted off the soap with a sterile towel. In the final step I started over the incision area and in circles out from the center I painted the scrubbed area with a Betadine solution. After I removed those gloves, I put on a sterile gown and new sterile gloves.
We placed sterile towels along the edges of the incision area and clamped them into place with towel clamps. After we placed sterile sheets over the towels to cover her legs, sides, and chest, we placed one final drape over everything. It had a hole in the center to allow access.
When we were ready to start, Dr. George Gray, the attending physician, arrived. He scrubbed, gowned, gloved, and stood across the table from Dr. Armstrong. I stood beside Dr. Armstrong on the patient's left side, and the surgical nurse stood next to Dr. Grey.
Dr. Armstrong incised the skin from just below the pubic hairline up to the belly button by cutting along the sides and removing the scar. He then incised the thick fascial layer followed by the peritoneum. When the abdominal cavity was opened, a terrible odor filled the room and confirmed the infection. White patches of pus that looked and acted like glue covered her bowel, which spilled out through the incision like a white garden hose coiled across the surgical drape. The bowel was covered with a damp towel and packed into the upper abdomen, exposing the pelvic organs. The masses turned out to be abscesses involving the fallopian tubes, which were four times normal size, red, dripping pus from the ends, and stuck to the surrounding organs. A red, rough-edged hole was visible in the top of the uterus, where it had been perforated. I felt both fascinated and horrified and, fortunately, not at all sick.
After Dr. Gray explained these findings to me, he said, "We'll have to clean her out," meaning removal of the uterus, tubes, and ovaries. With that one sentence, he destined her reproductive future to the stainless steel pan sitting on the back table.
"Is there no other way?" I asked. "We know nothing about this woman. Does she have children? Does she want children, if not now, then in the future? Would she consent to this, if she could be asked?"
"She'll die if we don't. Antibiotics cannot reach areas where there is no blood supply, like these abscess cavities, and as you can see everything is stuck together so we can't really leave part."
Dr. Armstrong added, "We do know that she has at least two children, probably three."
"Remember what I said about scars. She has both medio-lateral and midline episiotomy scars, which would suggest two children. She also had that scar on her low abdomen that may be from a Caesarean section. If she were not so infected, we would be able to tell if she had a C-section from adhesions, but we can't in this case. Besides, this situation would lead one to believe she doesn't want any more children."
"She may have lost some of those babies," the anesthesiologist added. "She has an anti-D antibody in her blood and probably shouldn't have any more babies, even if she wants to, at least not with this father. She was pregnant at least once before Rho-gam was available."
During three exhausting hours, they tediously separated the uterus, tubes, and ovaries from the attached bowel as I held a retractor. When the reproductive organs were free, they clamped the blood supply and removed them.
Dr. Gray stepped back from the table. "Dr. Land, step up here and help close the incision. I'll see you at rounds in the morning."
"Cara, this patient is too unstable to let you close the incision," Dr. Armstrong said. "Maybe next time." He failed to notice my sigh of relief.
I sat in the recovery room and then the intensive care unit (ICU) with Jane Doe most of the night and wondered if I had what it took to do that work day after day. By four in the morning her once pear-blossom skin had turned to rose-petal pink with the flush of fever. Her blood pressure was stable at 110/70; her heart rate was 120. Though she did not regain consciousness, she did breathe on her own, and the endotracheal tube was removed.
By morning rounds we were hopeful she would survive. During the day her fever reached 105 degrees, and alcohol baths barely affected it. A white blood cell count of 20,000 showed that she was fighting the infection. After receiving two units of blood her hemoglobin level, 10.8 grams and stable all day, confirmed that we had stopped her bleeding. As we monitored her vital signs, gave her antibiotics and IV fluids, measured her urine output, and watched for recurrent bleeding, I prayed.
After evening rounds, I was exhausted but wanted to stay with her. "I'll stay to check the evening labs and watch her a while," I said to Dr. Armstrong. I wanted her to wake up.
"No, Cara, you need to go home. You've been up for thirty-six hours, and you need to rest. Hers is going to be a long recovery."
I lived five minutes' walk from the hospital. Home by six o'clock, I skipped dinner, went straight to bed, and slept twelve hours.
Back at the hospital at seven the following morning, I found Jane struggling to breathe. We ordered a chest X-ray and continued rounds. By midmorning as we were paged to her bedside, she stopped breathing altogether. Her nurse called a code 500, so named in those days because it cost five hundred dollars, and breathed for her with an Ambu bag until the crash cart came. When the anesthesiologist got to her room, he inserted an endotracheal tube and placed her on a ventilator. The chest X-ray showed that her lungs were completely filled with fluid — shock lung we called it then, adult respiratory distress syndrome now. By either name, this was bad.
Every Friday afternoon off-duty medical students, interns, residents, and hospital staff gathered at Schu's, a bar across the street from the hospital. During the first two years of medical school I rarely attended this social part of my education, but I did this week, not needing a beer so much as I needed to have some fun. I sensed that I took too much of the cares of the hospital home with me. At first we all did, and then somehow we learned to relax, to leave the intensity of our work at the hospital. This Friday I was quiet but enjoyed listening to the jokes and gossip about which doctor was dating which nurse. Friday afternoon happy hour ended around seven as everyone went home to family.
Every Friday evening I visited my great uncle, Henry Land. Uncle Henry was eighty-one years old and perhaps the wisest and most loving man I have ever known. He and my Aunt Edna had been pillars in Christ Church Episcopal Cathedral. He lived in a big old mansion on Third Street over by Transylvania University. I loved his home. Giant columns accented the front porch and stood tall and white against the red brick. Since someone else had to clean up the acorns and rake the leaves in the middle of winter, I loved the pin oak trees that filled both the front and backyards and made wonderful shade in the summer.
My Aunt Edna had died four years before, and Uncle Henry was lonely. He and Aunt Edna were childless, and I was the only great niece close to them. Usually Uncle Henry and I had dinner and played Scrabble. We used the giant screened porch at the back as long as the weather allowed and the library when it was too hot or cold outside. I could rarely beat him, but I was good enough to make it a game. The Friday after Jane Doe came into the ER, I didn't even make it a game. Distracted and exhausted, I struggled to make three-letter words and excused myself to go home and early to bed. I was on call again on Saturday.
That Saturday, three days after the initial surgery, we realized Jane would need the respirator for an extended time, and because prolonged use of an endotracheal tube can damage the vocal cords, we placed a tracheostomy tube through her neck to connect the airway to the ventilator. There had been signs that Jane was about to wake up before this second surgery. She was clearly more responsive to pain; however, she had to be put back to sleep so as to prevent struggling against the respirator. For days we had to increase the pressure that forced oxygen into her rigid, fluid-filled lungs. Then, as her lungs healed slowly, we began to decrease the pressure.(Continues…)
Excerpted from "Saving Jane Doe"
Copyright © 2016 Morgan James.
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