Perchance to Dream

There’s something about complexity that I find intimidating; impressive as it may be, I don’t crave the complicated. I don’t even understand it. Of course, that may be part of its fascination for some: a facet of the instinct that leads to worship of that which is mysterious. Unknowable to the uninitiated. The awe of a dark night full of stars.

Perhaps it’s the structural intricacy, or maybe the number of parts and their varying relationship to each to each other that I find confusing, but not compelling. Inexplicable, but not awesome.

I sometimes think that complexity is a necessary first attempt at something –a way we initially endeavor to solve a problem: throw all our resources at it and then cobble together a solution using as many of them as we can. But in time, that jungle of interacting parts usually resolves itself into a skeletal framework that does the same work, but more economically. In a way, it’s like a sentence in which, instead of a subject a verb and an object that succinctly communicate a message, there are a whole host of unnecessary words thrown in -for colour, not clarity.

In short, simplicity -at least in a device- almost always trumps complexity: less to go wrong, simpler to understand and fix, and usually cheaper to produce. Of course those are some of the more important characteristics of equipment that would be useful in less well developed countries. Places with large needs but small budgets and even smaller infrastructures.

If, for example, a machine is clever, but complex, helpful but profligate of energy, it would be of limited use where electricity is sporadic, or non-existent. Or where, after prolonged use, there are no people trained to maintain it, or no accessible spare parts for that matter. And if the parts themselves are so complex and intricate that they don’t lend themselves to innovative adaptations with available local items, the machine is effectively useless: flashy new cars without wheels. Or engines…

Our society thrives on complexity simply because it can. It reveres new technology both because of its utility in solving old problems –often not appreciated as problematic before its inception- and because it can support its necessary underpinnings. And if the infrastructure is not yet in place, there is usually some facility locally extant that is wealthy enough to create it. For a price, of course.

But there are some regions of the world where babies die needlessly. Low birth weight babies, for example. Some are born prematurely, some are disadvantaged in the womb and never grow properly. And among other requirements, what their small size and lean body cannot provide, is warmth. The inside of the uterus where the baby has been developing is warm –it’s the mother’s body temperature. Normally, when mammals are cold, they shiver to produce heat. But, shivering, which is an attempt to warm the body by contracting skeletal muscles, is energy expensive -energy depleting. And these babies in particular have minimal energy stores when they are born. They are thin and have no extra fat to use as fuel. If they become hypothermic, they can die.

One answer, and one known by every new mother, is to cuddle the baby next to her skin –let her own body’s heat warm the baby. But suppose the mother is unable to do this –say she’s hemorrhaging, or convulsing from pregnancy induced hypertension (eclampsia)? And unfortunately, among other problems, these complications are far more common in poor countries with inadequate antenatal care programs –or at least health clinics that are relatively inaccessable to many in isolated rural communities, even if they could afford the care.

So low birth weight infants need warmth; if the mother can’t provide it, they need to be in incubators until they can fend for themselves. But incubators are expensive and energy-intensive. They require a fairly complex infrastructure for both their performance, and their maintenance. The idea may be intuitive, but the ultimate product is complex; it is usually merely a transplantation of a device that is taken for granted in a labyrinthine, infrastructure-laden country, into one whose poorer inhabitants may not have adequate sewage disposal, let alone electricity, even in the larger towns. And conditions are seldom better in the distant rural villages where roads or communication facilities may not allow reception of news of an emergency or access to provide timely help.

What to do? Well, fortunately dire need spawns ingenuity and there are several ingeniously simple devices created that may well help to fill some of these gaps. An article in the BBC News outlines some of the innovations:

http://www.bbc.com/news/business-23817127

I think my favorite is ‘Embrace’, a product envisioned during a class assignment at the Stanford Institute of Design in 2007. It is basically ‘a sleeping bag with a removable heating element’. It only requires 30 minutes to heat it up, and a phase-change material maintains the bag at 37 degrees C. for up to six hours. And ‘More importantly for mothers, it allows for increased contact with their child, unlike traditional incubators. So it also encourages Kangaroo care, a technique practiced on newborn, especially pre-term infants, which promotes skin-to-skin contact to keep the baby warm and facilitate breastfeeding and bonding.’ It costs about $200 the article asserts, and is reusable. Furthermore, ‘Embrace is a non-profit venture. The product is not sold, but is donated to impoverished communities in need.’ And apparently the organization has even set up educational programs to teach the mothers about hypothermia. Wow!

And there was another article in the BBC News talking about yet another innovation by a student names James Roberts; this one won the ₤30,000 2014 James Dyson Award (which, as Wikipedia explains ‘is an international student design award, organised and run by the James Dyson Foundation charitable trust. The contest is open to university level students (or recent graduates) in the fields of product design, industrial design and engineering, who “design something that solves a problem“’.[ ). The design is for an inflatable baby incubator called Mom.

http://www.bbc.com/news/technology-29900968

‘The device is designed to be delivered as flat-packed parts that are assembled at their destination. At its heart is a sheet of plastic containing inflatable transparent panels that are blown up manually and then heated by a ceramic element. This wraps around the interior of the unit to keep a newborn warm. “When it’s opened it won’t collapse in on the child and will maintain its shape,” Mr Roberts stressed. An Arduino computer is used to keep the temperature stable, control humidification, and manage a phototherapy lamp that can be used to treat jaundice, as well as sound an alarm. The electronic components are designed to use as little power as possible and can be run off a car battery for more than 24 hours when mains electricity is not available. The modular design of the kit allows damaged parts to be replaced without compromising the whole unit. And after the child is taken out of the incubator, it can be collapsed and the plastic sheet sterilised so that Mom can be easily transported for re-use elsewhere.’

Impressive!

So, take an ‘old’ design, and simplify it so it can satisfy a need elsewhere. “How far that little candle throws its beams. So shines a good deed in a naughty world.” How prescient, William…

 

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Pregnancies can be Miracles

The older I get, the more I wonder at the different Magisteria in which we become entangled. I am using the word in a metaphorical sense to mean sacred domains: sacrosanct issues rarely subject to closer interrogation -things we know because it is how we were raised, how our society apportions its sanctions and which, confirmation biases in tow, we could, were we so inclined, verify for ourselves with our own investigations.

Miracle, I suppose is another such metaphor. Its etymology is from the Latin mirari: to wonder at. Drawn as I am to Shakespeare, I remember Hamlet’s words to Horatio very early in the play: There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy. It is Hamlet commenting on the ghost of his murdered father; and perhaps Hamlet commenting on the limitations of the human mind as well…

So when I assert that in the course of my long career in obstetrics and gynaecology I have seen the occasional miracle, I do not want it misconstrued as religious, New Age, or even anti-scientific. With all the retrospective obfuscation that memory affords, I mean it in the original sense: something I wonder at.

Very early in my career, when I was wet with knowledge but experientially dry, I was on call for a colleague at the hospital. Those were exciting times when the textbook in my mind came alive. When the scenarios envisioned in the explanations blossomed into three dimensional reality, complete with an angst no writer ever mentioned. These were real people -real situations, jammed with emotions and consequences. An inaccurately assessed situation, an inexpertly performed procedure, an inability to decide on an appropriate course of action in what might seem to someone else as the blink of an eye, could be catastrophic. They were bewildering times, actually.

I was asked to see a woman -a patient of my colleague- in heavy labour who seemed to be making no progress. The cervix was not opening despite strong and regular uterine contractions, and the baby’s heart was beginning to show some signs of distress. There is a pattern and a progression to labour, and when things begin to deviate, the caregiver’s antennae begin to lengthen. We look for clues in the disparity: the fetal heart rate patterns associated with contractions, the mother’s condition, the amount and type of pain relief she both needs and received, the contractions themselves… Sometimes what clues exist are hidden -like they had minds of their own and did not want to be found. It can take patience to unearth them. Analyse them. Act on them. And that discovery time is sometimes fraught with danger to the mother – but more especially, to the baby. Occasionally the need to act, the need to intervene, is difficult to define and so difficult to explain to the parents. And yet it needs to be done. In older clinicians, there is probably an intuitive grasp of the situation -and not only a feeling that things are not right, but the vocabulary to explain it. I was not an older, experienced, battle-weary clinician. I did not yet have the words to justify my unease to the parents.

But I had to decide, and given her lack of progress in labour so far, I made the only decision I could under the circumstances: a Caesarian Section. She was only in her early twenties, as I recall and it was her first pregnancy. She and her partner saw the look on my face and readily agreed to the surgery.

I had done many Caesarian sections in my training -it is one of the operations with which most new consultants feel at least mildly comfortable. The procedure, though complicated and one requiring skill and good assistance, is simple enough in principle. One must gain access to the uterine wall by cutting through the abdominal skin and then separating the abdominal muscles to create enough space to see the uterus. Then the uterine wall is cut, the internal cavity entered, and the baby removed. But then the work begins: things have to be repaired -put back in place. And to do that, the placenta -the organ that has been feeding the baby until now- has to be removed. Normally, it is attached to the inner surface of the uterus like glue and comes free either with a little traction, or more commonly nowadays, by the anaesthesiologist adding something to the intravenous to make the uterus squeeze it out.

Her baby, a little boy, cried as soon as his head cleared the incision and I breathed a sigh of relief at his obvious health. Better a well-timed Caesarian operation that delivers a crying newborn, than one performed too late that doesn’t! Now I just needed to extract the placenta and close the incisions. But the placenta wouldn’t come out! I tried every trick I had been taught, and so did the anaesthesiologist but to no avail. And she was continuing to bleed. Heavily! Because of the amount of blood being lost, I realized I had to act quickly. The placenta seemed firmly attached to the wall, seemed to enter the uterine muscle, in fact.

Sometimes the placenta attaches a little too strongly to that inner wall -penetrates it, even. And then the nightmare begins: the invasive quality of the placental attachment can take it right into, or even through the wall of the uterus so it can be seen on its outer surface.  And under those circumstances, there are very few options -especially if she’s bleeding uncontrollably. The medications to make the uterus contract do not work in the area of perforation of the placenta (called a placenta percreta in the instance I am describing ). It’s usually deeply attached over a large area of the lining, even though only a small portion of it may have managed to reach right through the uterine wall. So, if all attempts to stop her hemorrhage fail -as they usually do under these circumstances- the only thing that can stop her from bleeding to death on the operating table, is a hysterectomy.

A caesarian hysterectomy is far more difficult than a more routine hysterectomy done at some temporal distance from a pregnancy. The tissues are more edematous and vascular for one thing -everything bleeds. And the anatomy is obviously altered and deformed by the size and shape of the just-pregnant uterus: rather than fist-size, it is basketball-or-bigger-size. And it bleeds uncontrollably until all of the arteries supplying it (with the same amount of blood it needed to nourish the baby) are cut and tied off. Lumps and bumps that would be easily recognized as fibroids (benign local overgrowths of muscle tissue) in the non-pregnant state often loom as large swellings sometimes indistinguishable from the rest of the huge mass of bleeding tissue that is a uterus in such distress.

Things were difficult, but controllable. I managed to find the requisite blood vessels supplying the uterus and systematically addressed them one by one to cut and tie them off. But just as I was about to tie one of the major ones, I noticed an unusual lump that, in the mad scramble to stop her hemorrhage I must have ignored. Now it seemed important. I hesitated to clamp the blood vessel on that side of the uterus, and instead examined the lump more closely. It didn’t seem to be a fibroid, or anything else I could think of. And then I saw the Fallopian tube. A normal uterus has two -one exiting from either side. Each one is charged with connecting the ovary to the uterine cavity. Charged with allowing sperm to travel along it to find an egg in the ovary, fertilize the egg, and then facilitate its way back to the uterus to implant in the inner wall as a pregnancy. The lump had a Fallopian tube attached to it.

She had, I guessed, what is commonly called a double uterus, joined to its baby-carrying twin at the cervix -sharing it, in fact. It hadn’t grown as large as the other side because it didn’t have a baby to accommodate. Of course I had never seen one before, but it looked like what I would expect it to. Actually, I’m not really sure what I expected one to look like, but on the spur of the moment, I decided to save it. To work around it. To take its bleeding, placenta-carrying sister out without its shared cervix and hope that the bleeding would stop.

The bleeding did stop and I finished the operation and then spoke to her frantic husband who was waiting in the lounge. We had asked him to leave the operating room when the bleeding had started because we’d had convert the spinal anaesthetic -with which we’d started for his wife- to a general anaesthetic to deal with all of her problems. I explained the need to remove her uterus to save her life and how close we’d come to losing that battle. Almost as an afterthought I mentioned the little nubbin of tissue I’d saved. He smiled wanly, probably not really understanding anything I’d said except that although his wife would live, they would not be able to have any more children. I don’t think he really understood how close she’d come to dying -after all, she was young and healthy and had only come to the hospital because she’d been in labour. People didn’t die in labour in this country. Nobody had mentioned it in their prenatal classes…

I suppose the reason I have come to regard this as extraordinary, is that after subsequent investigations, that little lump did turn out to be a uterus, albeit only half of what had been intended. But it did have its own Fallopian tube and an ovary. And she recovered well from the surgery. There’s always a silver lining if you look hard enough.

I subsequently lost track of her over the years. I’d heard from her family doctor that her menstrual periods had eventually returned, but as time and circumstance dictate, I eventually forgot about the incident.

And then one day she appeared in my office for a consultation. I didn’t recognize her at first, but I did remember her broad, engaging smile. She was one of those rare individuals who can make you feel both welcome and happy just by looking at her face.

I was obviously delighted to see her again, but puzzled by her visit. She looked well -radiant, in fact. Her face was ruddy, and her gait… familiar. She had a contented aura -almost visible- that extended far beyond her expression. Her eyes twinkled, as she sat on the other side of the desk and stared at me. Her face almost cracked with the smile.

“I didn’t get a note from your family doctor,” I stammered, not quite sure if I could believe what I sensed. I was no longer a neophyte. No longer an inexperienced beginner in my specialty.

“I told her not to,” she managed to say through the smile, and reached for my hand across the too-wide desk and across the vast bridge of time that separated us from our last meeting. She blinked slowly and contentedly and her face -her being– seemed to glow. “But you know, don’t you?” she added contentedly, softly – electricity travelling along her hand into mine.

My smile was no match for hers, but it was as big as my face could handle. I nodded, my eyes now locked on hers. “You’re pregnant, aren’t you..?” And we laughed together, like two children who realized they had shared the same secret.

I delivered a vigorously crying little girl four months later by another Caesarian section -a bit premature to be sure, but apart from being miraculous in both our minds, otherwise rather routine…