Old News: Past Blog Posts

Saturday, July 26, 2014

Cerc You Very Much

For decades now, women with inadequate mommy parts have been on the receiving end of a procedure called a cervical cerclage.  Allow me to educate you on the two basic types: 

1) A surgical stitch that reinforces the cervix at the level of the cervix, known as either McDonald or Shirodikar depending on the type of stitch.  

2) A stitch above the cervix known as a TAC (transabdominal cerclage).  

If you think this sounds barbaric, you should know that a woman who's desperate to carry a baby to term will agree to just about anything.  

Friday, I receive a 'modified modified McDonald' which was developed by and is the signature move of the specialist I am seeing, who is considered to be the reigning King of Cervical Issues in our area and is credited by countless woman for his ability to work reproductive miracles.  Dr P was referred to me by a friend who'd had him deliver her a beautiful rainbow baby last winter, and my local Facebook moms groups seem to worship him.  I actually told him that before we went into the OR and I think he was embarrassed.  He then asked how many of those ladies had him place a cerclage and I said it hadn't come up.  He gave me a look that I wasn't sure what to do with and next thing I knew, I was suited up in a heavy purple gown, matching non-skid socks and surgical cap, tucked under about forty heated blankets, being pedaled down a hallway of fluorescent lights.

A very sweet and friendly nurse anesthetist introduced herself and proceeded to give me excellent instructions and a play by play of how she'd administer the spinal tap.  I was first seated up at the edge of the OR table and instructed to slouch ("like your mother always told you not to do" -- it's a line I use sometimes in my practice, so it made me chuckle) to prep me for the spinal tap.  Dr P had told me earlier that the length of the procedure can depend on how long the spinal tap takes and with 'skinny patients' of which 'I was on the list' (he obviously either didn't see my weight from my admission that day, or he deals with an abnormally obese population) things usually go more quickly.

I had been particularly worried about the spinal tap, having heard my fair share of epidural horror stories, but the anesthesiologist put some of my concerns to rest when he explained that the spinal tap is less complex than an epidural and there's less room for error.  When the nurse pricked me first with the lidocaine injection ("little bee sting with a burn," which should have made me extra nervous given my last bee sting experience) then told me the worst part was over, I relaxed and even heard my heart rate slow over the beeps of the monitor which echoed in the cold, sterile room.

Next, the OR team situated me on my back with my legs up in the stirrups as my lower body quickly warmed and numbed, starting with my buttocks and working down to my toes.  I could still feel pressure as the doctor aggressively prepped my nether-regions with Betadine which worried me for the moment it took him to mention that I should feel pressure in my skin, but not cold.  Then I had a brief flashback to my neurology class during the first year of PT school when we learned that the spinothalamic tract of the spinal cord carries both pain and temperature sensations together to the brain.  The fact that I no longer felt the frigid cold air of the OR on the lower half of my body (despite being so vulgarly exposed) was now extremely comforting and again, the beeping of my heart rate slowed.  

As the pressure sensations continued and seemed to climb north into the expected area, I was able to turn my attention to the conversation my nurse anesthetist had seemed to deliberately be initiating, probably as part of her job.  I had mentioned previous visits to an OR as an observer when I was a student and she easily chatted me up about my job and recent family vacation.  She mentioned her nephew had married a PT who had graduated from my alma mater around the time I was there and we had one of those small-world St Louis moments when you realize there's only 3 degrees of separation between yourself and everyone in the room.  This discovery also served to earn me the little respect that is sometimes given when people discover I have a doctoral degree, without me mentioning it (which I rarely do...except for just now).  

After about 20 minutes, the procedure was complete and for some reason everyone kept congratulating me for how well I'd done.  I suppose it's just a talent I have, lying still with my feet in stirrups.  

*Insert obvious dirty and probably degrading joke here.  Go ahead, I clearly set you right up for it*

From the OR, I was wheeled under a different set of beaming fluorescent lights to the recovery room.  There, I was greeted by a new team of nurses, one of whom asked if I felt like I could sleep.  I laughed and told her as a pregnant, working mom of a one- and two-year-old I always felt I could sleep.  

Which of course, turned out to be totally untrue.  

Instead, I discovered I was feeling too wired to sleep.  I was wired, bored, and wondering how I would last another hour or so lying flat on this tiny cot without access to social media...or any form of media for that matter.  Oh shit, I am a slave to my iPhone!  I tried sleeping, I really did.  But when that failed, I just butted in on the nurses conversation with each other. They had been discussing American Girl dolls and (not that I have any particular interest on dolls) I saw an opening to break up my boredom.

The chatting passed just enough time for my sensation to return and it didn't take too long for me to regret not having napped when I had the chance.  The nurse anesthetist had told me that the wearing off of a spinal block was like taking off a pair of pants and that sensation would return from my hips down.  As the warm and comfy 'pants' slowly peeled away, I discovered that they were being replaced by a giant, freezing vice grip clamping down on my trunk.  At the same time, I was apparently also donning a nice fuzzy nausea shirt that came all the way up to my throat (a nausea turtle neck?)

While I was slipping into something a lot less comfortable, the recovery team hooked my IV up to a PCA (patient controlled analgesia) pump loaded up with Fentanyl and gave me doses of some version of Tylonal (also for pain) and of Toradol (to quiet the cramps in my outraged uterus).  I was entering a whole new world of pain and it seemed like a good time for me to get acquainted with a whole new world of painkillers.*

Apparently, monkeying around with one's cervix does not make the rest of the reproductive team very happy and the uterus takes revenge by contracting rather angrily.  Also, coming out of a spinal block can trigger nausea.  I had been told to expect cramping, but I had not been prepared for the fact that the cramps would be continous rather than coming in somewhat predictable waves as they do during labor.  In fairness, the possibility of nausea had also been mentioned, but I have a tendency to assume things like that won't apply to me.  You know, because I am an idiot.

I think the best way to describe how I was beginning to feel would be to equate it to a really super extreme case of food poisoning with nausea, stomach cramps, and extreme temperature swings.  One minute, I was requesting more heated blankets, and the next I was kicking them away and asking for a cool compress.  At one point, I was struck by such an intense moment of nausea that I was certain I had about a milisecond before I would be covered in vomit.  While one nurse dashed away to find an emesis basin, another heroically tore open an alcohol swab and held it under my nose.  

"This seems a little strange, I know. But it usually helps" 

And I'll be damned if it didn't help.  Next time you're nauseous, find a bottle of rubbing alcohol to sniff on.  You can thank me later.  I didn't yak.  At least, not right then.

It's my understanding that the whole point of the surgical recovery room is to monitor patients coming out of anesthesia just to be sure they don't die (or get covered in vomit).  It's probably a mostly boring gig, watching people sleep and monitoring their vitals.  Occasionally, there are probably patients like the man they wheeled past me and parked about three spots down, who was disoriented and wanted to take off his oxygen and get up.  But mostly, they're probably like the little lady across from me who just seemed to be quietly asleep.  I was supposed to stay just long enough for my sensation to return and for my doc to come back with a sonogram machine to check in on the baby.  This was predicted to be just about an hour if not a little more. Unfortunately, while my doctor is widely known for many, many good things, punctuality is not on that list.  I overheard that his next proceedure was a D&C and immediately decided I had no reason to be annoyed with his tardiness and also that I should be grateful for every moment of pain because it meant I would ultimately end up with a beautiful little person. 

After over two hours of waiting, it was determined that I could be taken to the room where I would stay for my overnight admission and that the doctor would just have to come find me later.  It's also possible the recovery nurses were tired of watching me wriggle around and moan uncomfortably and on a Friday evening, most of them were also probably interested in leaving themselves.

By the time they were wheeling me to my room on the antepartum unit, I was literally writhing in pain.  It seemed like all of my senses were consumed by the pain, I couldn't hear or speak or see.  It was agony.  As we wheeled off the elevator and I peaked out at my surroundings, I had this wild and unreasonable thought that maybe if I could just make it to my room, the pain would stop.  And I think maybe it's possible that the nurses transporting me felt the same given the speed and sense of urgency they had.  Or maybe they just wanted to minimize the amount of time they'd be associated with the squirming, moaning lady.  (Or maybe their shifts were supposed to be over as well) 

As it turned out, the pain didn't get better when I got to the room.  (Raise your hand if you're surprised)

It's also interesting to note here that while I might be a giant baby in the face of pain, my mama raised me to be a polite young lady.  Therefore there were a number of pleases and thank yous and if it's no bothers that sputtered out between moans and groans.  I even tried to crack a joke at one point--maybe to prove that the cervical terrorists hadn't won. The joke fell pretty flat in it's delivery and was met with only vague chuckles.  I sort of doubt the formalities or pathetic attempts at jokes made me any easier or more desirable to work with me though.

The crescendoing cramping near the base of my abdomen made me wonder if a full bladder wasn't partially to blame for my discomfort.  After all, I am used to peeing every five minutes and it had now been over 3 hours.  When I mentioned the possibility to my new nurse, she suggested we give the bathroom a shot. Unfortunately, my knees buckled when I stood from the bed (giving both me and the nurse a bit of a scare) and I was forced to try a bedpan.  The attempt failed at emptying my bladder but succeeded in making me even less comfortable (have you ever been on a bedpan? I think it's pretty miserable under the best of conditions), I just resigned myself to the pain.

After an indeterminate amount of time my husband arrived.  At that point, I almost lost it and spent a whole lot of time apologizing to him for reasons that were unclear, even to me.  Sorry I am acting like a small weepy child?  Sorry I splattered neon green vomit on you (no joke, that's what vomit from an empty stomach looks like)? Sorry my cervix is so grossly incompetent?  Sorry you feel obligated to sleep on a paper thin mattress atop a cross bar and prickly, squeaky springs while I inevitably keep you up all night navigating my way to and from the bathroom? 

Finally, I was brought a dose of my new best friend: percocet. I eagerly swallowed the pills and (reluctantly) a saltine cracker and soon my suffering dampened enough to allow for sweet, sweet sleep.

In my experience, there's always some hospital device that wins out above the others for the Extreme Annoyance Award.  In this case, the clear winner was my pulse-oximeter (a plastic device clamped on the tip of your finger which measures heart rate and oxygen saturation in the blood).  Once the percocet and exhaustion mercifully kicked in, I found myself finally dozing off only to be roused by my husband who'd been instructed to ask me to take deep breaths if my heart rate or SPO2  dropped.  I didn't hate him for it specifically, especially because he was coming from a place of obedience and probably genuine concern, but it did make want to give him a good whack alongside his stupid head. He was spared for the following reasons: 
A) I was afraid to move least the pain would return and kill me.
B) I was so exhausted that each time, I basically slipped back to sleep each time and barely remembered later.
C) Whacking him would have required me to open my eyes.

Dr P eventually surfaced sometime during this period just in time for me to tell him horsely that I hated him and to also show me that baby was doing great (which made me hate him a lot less). He also reassured me that things couldn't have gone more smoothly and that what I was experiencing was normal.  Only one of those things was comforting to me.  I had secretly been hoping all the pain he had been promising over the past few weeks was sort of like an up-selling technique where if he assured me extreme pain, then any discomfort would be construed as no big deal.  Turns out, he's just a straightforward guy.  So when he promised I would feel much better in the next couple of days I was beyond relieved. Overall, his visit was hazy through my narcotic/exhaustion cloud I remember watching a dancing baby on a black and white monitor and him pointing out a full bladder.  Sometime after that, I experienced my first (and God willing, last) 'straight catheter' which didn't seem nearly as terrible as it sounds, either because I was still somewhat numb below deck or because I was still floating away on my fluffy cloud of narcotics and fatigue. 

I also barfed a couple times.  If you ever have the opportunity to vomit up stomach bile while being crushed across the middle by a giant metal clamp, you will know exactly how much fun I had last Friday night. 

At some point in my delirium, I overheard a conversation about food that made me gag a little and awoke at some point later to a dark room and a tray of what might normally (if not been served up at a hospital) have been really tasty choices including hummus and veggies, yogurt and fruit, an omelette and a strip of bacon clearly ordered by my thoughtful husband who knows (but doesn't appreciate) my love of breakfast foods at all hours.  

Unfortunately, after more than 24 hours without even a bite to eat, I wasn't ready to tackle more than a cold and crumbly piece of stale toast and a few spoonsful of yogurt.  

The rest of the night was a blur of epic, hourly trips to the bathroom each of which included an elaborate tango with IV tubing, an IV pole, the PCA pump, SCDs (sequential compression devices which act as both leg massagers and shackles, neither of which is their intended purpose), and my new nemesis: the pulse-ox clamped on my finger (a necessary evil due to my use of the PCA).  

I quickly discovered that in order to reach my feet and un-shackle my legs from the SCDs (which was less than comfortable for my contracting belly) I had to remove the pulse-ox, which immediately unleashed the infuriating beeping that had earned it the Extreme Annoyance Award earlier in the evening.  By the time I would arrive in the bathroom, the amount I could void and the comfort that resulted didn't really seem worth all the trouble.  The whole fiasco would come to a pause when I would crawl gingerly back into bed, resituate myself, click my PCA button, and say a silent prayer for sleep.  Generally it would take less than an hour before the whole process repeated itself and occasionally, my routine was interrupted by my nurse with pills or a blood pressure cuff.  

Morning came too quickly and although I felt better, I was still pretty quick on the PCA trigger to keep the vice grip from returning in full force.  The hubs (who amazingly didn't file for divorce sometime in the night) and I even ordered up an actual meal while we waited for the doc to return.  The nurse encouraged me to lay off the PCA and I agreed to do so, partially because I was ready to rid myself of the devil pulse-ox and have all my digits back.  It was after noon before the good doctor arrived, but all was forgiven when he admitted to having come down with the flu -- and kept his distance while giving me my discharge instructions.

I was pleased to hear I would be leaving with a prescription for narcotics* and permission to resume normal activities as I felt able.  I spent the rest of the weekend shuffling around the house looking and acting like a drugged up housewife and relying heavily on my husband and mother to pick up the slack and keep my kiddos alive and happy.  True to form however, it took me until Sunday night to figure out that I was still basically worthless (when I failed at a simple laundry folding task) and should probably call in to work for the next day, rather than drive in and try to treat patients while on OxyCodone. 

I surveyed my fellow IC mamas on FB who reported it took most of them 1-2 weeks to feel 'normal' again after a cerclage.  But you know what?  Not one of them said it wasn't worth it.  It's very likely that the pain of this procedure will soon be a distant memory, much like the pain of childbirth (they're pretty parallel experiences actually) and all that will be left worth remembering will be this amazing little person who I'd already do anything for.  

*before freaking out about my taking prescription analgesics as a pregnant woman, please remember that I am under the close supervision of a skilled physician who specializes in high risk pregnancies.  Unless you are also a skilled physician who specializes in high risk pregnancies and are intimately familiar with my medical history, then kindly remember your opinion has no baring on my situation.

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