Chapter 248
Episode 248. How to Save Two People (5)
‘The moment the fetus comes out, the pressure filling the mother's abdomen vanishes.’
This was knowledge I only knew theoretically.
As the volume of the uterus shrank rapidly, the horrific pressure on the inferior vena cava—which had been choked tight under the weight of the heavy uterus—must have been relieved in an instant. If the assumption was correct that a massive amount of venous blood, pooled in the lower body and unable to return to the heart, had suddenly begun rushing toward the right atrium…
Right about now, the heart should be filling with blood.
‘If so, the signal should be coming soon.’
The intern was still pressing down hard on the area just above the mother's epigastrium. Unlike before, when they were squeezing an empty heart, the resistance felt at their fingertips must have fundamentally changed.
I turned my head to look at the EKG monitor hanging on the wall.
End-tidal CO2 (ETCO
2
). It is the absolute indicator that most quickly and accurately reveals the quality of CPR and the return of spontaneous circulation. If this figure had gone up…
Wait.
[ETCO2 : 35mmHg]
“…!”
The number, which had been at a critical 15 when we got off the helicopter, had shot straight up to a perfectly normal 35 as if it were a lie. Even the flat respiratory waveform flowing across the bottom of the screen was now surging up, drawing regular peaks.
This meant blood flow had returned to the lungs, and gas exchange was taking place.
‘Which means the quality of CPR just got better, too.’
However, it was too early to relax. The fact that the heart was beating again meant a horrific, paradoxical dilemma from a surgical standpoint. What was it?
‘If the blood pressure rises, bleeding can burst wide open.’
When I cut open the mother’s abdomen with the No. 10 scalpel earlier, there was only one reason blood hadn't gushed out: because her blood pressure was zero. But once the heart started beating on its own and the pulse returned, blood would spray in all directions from the thick, severed blood vessels and the torn uterine wall that had been suppressed until now.
I whipped my head around, urgently searching for Nurse Jeong.
“Nurse Jeong?”
The nurse, who was checking packs in front of the blood refrigerator, answered hastily.
“Ah, yes!”
“How many blood products do we have ready in the Resusc right now?”
“Right now, we have 2 packs of O-negative pRBCs, 2 packs of FFP, and 2 packs of PC on standby!”
‘Exactly 2 packs of each. A 1:1:1 ratio.’
“Got it. For now, let’s watch the mother’s vitals return, and if bleeding starts bursting inside her abdomen, we’ll squeeze them in with the pressure infuser right away.”
Across from me, Ji Young-eun, a 4th-year OB/GYN resident, thrust her hand deep into the mother’s abdominal cavity, squeezing something hard while furrowing her brow.
“Give me 5 units of oxytocin. The uterus isn't contracting at all. I think it’s atony…”
An urgent order flowed from Ji Young-eun’s mouth.
Uterine atony. Normally, a uterus emptied of the fetus and amniotic fluid should contract firmly to achieve hemostasis on its own. But right now, the mother’s uterus had completely lost its contractile tone, sagging like a loose pouch.
Why on earth? Was there a sign of this when we did the RSI earlier? Or was it because of the cardiac arrest?
Either way, the reason didn't matter right now. If left like this, postpartum hemorrhage would pour from the vessels of the inner uterine wall, driving the mother right back to death.
“It looks that way to me, too.”
I agreed with Ji Young-eun’s assessment, confirming the state with my own eyes from across the table. Even to me, the mother’s condition looked terrible. We had to administer the uterine stimulant, oxytocin, immediately to forcibly squeeze the muscles into contracting.
“Let’s give it slowly for now,” Ji Young-eun added while massaging.
“How slowly?”
The nurse, who was about to insert the syringe into the IV line, paused and asked back.
“I think it’s best to give it as a slow infusion over at least 3 minutes. Absolutely do not push it all at once.”
‘Hmm.’
Hearing Ji Young-eun’s order, I nodded inwardly.
‘Is it because cardiac arrest can reoccur even after ROSC?’
If oxytocin is pushed rapidly into a vein, it causes vasodilation, temporarily triggering extreme hypotension and tachycardia. If we slammed a drug that forcibly drops blood pressure all at once into this mother, whose heart had just barely returned and whose myocardium was still flaccid, the heart we worked so hard to revive would undoubtedly stop again.
Was it just my imagination, or did I feel a sudden urge to compare her to a certain 1st-year resident?
Mm-hmm. A 4th-year should at least be at this level.
Thump—
Thump—
In the midst of this, regardless of the medication orders flying around, the intern kept pressing down on the chest. I quietly placed two fingers on the mother’s carotid artery.
Every time the intern pressed the chest, a pulse was felt. But in between those pulses—during the relaxation phase when the intern lifted their hands—a faint tremor brushed past my fingertips.
Thump.
Thump.
The EKG waveform on the monitor was also regularly drawing narrow QRS complexes.
Is this… beating on its own again?
I was certain.
“Stop compressions!”
“What?”
The panting intern looked up at me with a classic, dazed intern expression.
“Hands off!”
“Ah, yes!”
At my command, the gasping intern removed their hands and stepped down from the bed.
“Checking rhythm! Measure the blood pressure!”
Everyone’s eyes locked onto the monitor.
Beep—
[ BP : 90/60 ] [ HR : 115 ]
Numbers flashed on the screen.
“ROSC achieved!”
“Ha.”
The heart had come back.
“Uh, bleeding is bursting out!”
Before we could even savor the joy of ROSC, the voice of Yoon Yoo-jung, the 1st-year OB/GYN resident, rang out.
“Ah, fuck…!”
A curse ripped from my mouth.
As the stopped heart began beating on its own and resumed pumping, the rising blood pressure caused the thick vessels in the uterine wall and incision lines to start pouring out blood. I could see the blood pooling inside the mother’s abdominal cavity at a terrifying speed with my own two eyes.
‘This is really awful…’
A true catch-22. Revive the heart, and the bleeding erupts. Do nothing, and she just dies.
Yeah. The former is still better.
“Hang the blood on the rapid infuser right now!”
I hurriedly pressed my body close to the mother’s abdomen. The emergency room nurses placed the packs of packed red blood cells and fresh frozen plasma into the rapid infuser, cranking the pressure to the absolute max.
“I think the blocked bleeding burst as cardiac output returned. I’ll grab both edges and clamp them!” Ji Young-eun, standing across from me, shouted urgently as she grabbed Kelly forceps.
“Yes, please do!”
I immediately agreed with her judgment. An OB/GYN resident would be far faster and more accurate than me at precisely locating and clamping arterial bleeding points.
As for the 1st-year, Yoon Yoo-jung… well, let’s not talk about her.
‘Anyway, she’s a 1st-year, so it’s hard to call her a completely independent OB/GYN doctor yet.’
Yoon Yoo-jung quickly took an assistant's position to help Ji Young-eun.
“Give me 1 gram of tranexamic acid!” I yelled toward the nurse.
“Yes!”
“IV push! Keep the fluids on full drop!”
“Yes!!! Doing it now!”
The hemostatic agent to stop the bleeding traveled through the vein. For now, the delicate task of clamping the most dangerous arterial bleeding would be handled by Ji Young-eun, the OB/GYN specialist.
Then, what should I, an emergency medicine doctor, do? I just needed to perform a very crude and simple procedure that happened to be my specialty and expertise.
Packing.
Think about the empty space inside the uterine cavity that had lost its elasticity. To physically block the capillary and venous bleeding seeping out from there, which method would be the most direct?
Needless to say. You just have to tightly pack the bleeding void without leaving any gaps to induce pressure hemostasis.
“Give me laparotomy pads! Quickly!”
“Yes, here they are!”
The nurse ripped open the sterile packaging and shoved a bundle of pads into my hand.
As soon as Ji Young-eun controlled the major bleeding by clamping the Kellys onto the branches of the uterine arteries on both sides, I began stuffing the lap pads inside the uterine cavity for packing.
One.
Two.
Three.
Four…
Like pouring sand into a bottomless pit, I pushed the pads in, starting from the deepest part of the uterus until the empty space ballooned taut. Praying that the force of the pressure would somehow stop the bleeding.
Once the packing was roughly sorted out, I spoke to Ji Young-eun, catching my breath.
“We do need to close the uterine incision now. The packed pads can’t be allowed to slip out, either.”
We had forcibly plugged the bleeding uterus, but if we didn't close the open incision to maintain the pressure, it would all be for nothing. I picked up the needle holder and thick suture handed over by the nurse.
“Oh? Are you going to do a double-layer closure?” Ji Young-eun asked, sounding puzzled when she saw how I held the suture.
“Ah, that, when I observed C-sections, I thought they usually reinforced and sutured the uterine muscle layer twice to make it sturdy…”
“Could you do a running locking suture all at once instead?”
“Ah, right, yes. I’ll do that.”
I instantly discarded my textbook knowledge. The OB/GYN teacher is the boss right now, the absolute boss. I am just an extra here.
I gripped the instrument properly for the suture. As Ji Young-eun and Yoon Yoo-jung pulled both sides of the tissue with forceps, I used a snap of my wrist to pierce the uterine wall and began stitching.
Swwish—
Clack.
Just like that, I closed the uterus so the pads couldn't push their way out.
“Suction.”
As the nurse lowered the suction tip into the abdominal cavity, the pooled blood and remnants of amniotic fluid inside the belly were sucked away. Visibility was barely secured.
I quickly darted my eyes around, thoroughly scanning the inside of the mother’s lower abdomen. The most important verification step remained.
I had to check with my own eyes whether I had accidentally caused a laceration or perforation in the upper part of the bladder, which I had forcibly pushed away when cutting the belly open with the scalpel earlier.
‘Please, please let there be nothing wrong.’
Fortunately, around the bladder wall tucked beneath the fatty tissue, there were no horrific signs of leaking urine or torn tissue.
“Uterus is closed. Suturing the abdominal incision layer by layer will take too long, so I’ll do a temporary closure and move her immediately.”
Everyone nodded at my words. I took the thickest, toughest nylon suture. Then, I pierced through from the mother’s skin down to the deepest fascial layer all at once, securing a tight knot with only the bare minimum of measures.
The skin bunched up into a grotesque, uneven shape, but it didn't matter. Preventing the internal organs from spilling out was all that counted.
Normal hemostasis and perfect layer-by-layer closure would be taken over and handled by the OB/GYN and general surgery teams in the actual operating room, where anesthesia could be perfectly maintained. So as an emergency medicine physician, this exact level of intervention was more than enough.
Probably.
“Haah…”
I let out a sigh as I tossed the surgical scissors onto the tray. I’m about to die here, seriously.
“Give 2 grams of ceftriaxone and 500 milligrams of metronidazole on full drop.”
Since we had sliced the belly open without even proper sterilization, administering broad-spectrum antibiotics was a must.
Once again, Section Chief Cho Kyung-woon, I’m sorry.
‘I’ll handle the infection with antibiotics. Sorry, Chief Cho.’
As I gave the order, the nurses quickly began pouring the antibiotics through the IV lines.
“We need to move her to the OR now. Did OB/GYN say to transfer her immediately?”
“Yes. They said the OR setup is completely finished. The professor is on standby, too.”
…
…
“Moving her. One, two, three!”
Several medical staff members began pushing the stretcher where the mother lay.
I took one last look up at the main EKG monitor hanging on the Resusc wall.
[ BP 95/60 | HR 105 | SpO2 96% ]
Numbers that, while precarious, were sustaining life. The unstable heart rate had found relative stability at 105 beats per minute, and the oxygen saturation was also pointing to a normal range of 96%.
Two lives that had been halfway across death's threshold had been forcibly pulled back.
I clenched both fists tight.
We actually did it.