FMOE, OB: Shoulder Dystocia

This is the second in a series called FMOE, which stands for For My Own Edification. Read on, but the post may be boring to anyone past an Intern, as I'm doing these to further my learning.

Coming off of OB, the next few will likely have something to do with pregnant women, who are total rock stars in my book, none more than my wife who has done things I would never have been able to do even if I had been born a woman. Too much of a wimp.

Shoulder dystocia (greek, dys for difficult plus tokos for birth) describes the failure of the shoulder to pass below the pubic symphysis during a spontaneous vaginal delivery with the head already delivered. In practical terms this is terrifying. The largest baby I delivered was 9 pounds, 12 ounces, and I had to pull like, a lot more than I expected to get her out despite excellent work by mom. It's scary when the baby feels stuck and you are hauling on its head. Normal deliveries require much more traction than you expect as a neophyte.

A truly stuck baby can have a severe shoulder injury or can asphyxiate and die. Badness, terrible badness. It's also hard to predict. If I had a 400 pound diabetic primigravid at post-dates in my ER delivering, I could say it's a good bet, but other than that, it can surprise anyone. What, oh what, to do?

Initial maneuvers. Of course, delivering the anterior shoulder requires a great deal of downward traction normally, so as a newbie, I have to remember to have may cardinal movements right; down for the anterior shoulder, up to the ceiling for the posterior. Simple suprapubic pressure from an assistant can help. The Gaskin Maneuver is mentioned on Wikipedia and via Google searches; the laboring mother is repositioned on all fours in order to create more space. I have not seen or heard of this maneuver in my EM textbooks or on the OB floors, but it makes great sense and should work--in a mother with no epidural! A Google search turns up anecdotal evidence, but this is no reason to disbelieve; midwives have been at their job a long time and much of OB is not evidence-based--try doing studies on pregnant women. Difficult.

Other initial options include the McRoberts maneuver, which is achieved by flexing and abducting both hips while laboring on the back. In practice, all deliveries were done in this position on the OB floor. If still stuck, the Woods Corkscrew maneuver is an option; reach in past the head with two fingers behind the stuck shoulder and rotate the baby about 180 degrees. Fingers go behind the shoulder to collapse the torso rather than open it up.

Truly horrible options then ensue. Keep in mind that by this time everyone is likely freaking out and the baby is probably quite literally dying in front of you. You can attempt to push the baby back into mom in order to go for a c-section--the so-called Zavanelli maneuver, which according to the namee was perfectly safe. This one is particularly funny since if you had such immediate access to any OB doc, you wouldn't be trying to push a large baby back into the uterus in the first place.

According to whonamedit.com, this maneuver was invented in the 70's by somebody named Gunn, and Zavanelli heard about it and told it to some other guy while he was volunteer teaching. So, if you want to use it, go ahead. Me, I'll put it in the same category as other things that should've stayed in the 70's, like the Pinto and Fleetwood Mac.

You can also deliver the posterior shoulder, by reaching up and grabbing the hand. Or, you can deliberately fracture the clavicle. Terrible sounding, but better than death. Actually, one of my deliveries had a fractured clavicle, and they heal well if there are no complications at the time.

The last option, a symphysiotomy, should scare everyone, not least because one of the tools needed is a finger guard. The pubic symphysis is the anterior joint of the pelvis and is just above the urethra and vagina. Apparently, in the late 1500's difficult deliveries were relieved with this method--using a scalpel to sever the ligament joining the two sides of the pelvis together anteriorally, allowing it to open so the baby can be delivered. I would have a hard time with this.

May we all have happy, quick but not too quick, ED deliveries, with no lacerations or post-partum hemorrhage.

Reichman and Simon, Emergency Medicine Procedures, McGraw-Hill

Shoot. Can't Vote for McCain.

And I sort of liked McCain, too. He seems honest, and straight-talking. But his health policy advisor apparently had this to say about the uninsured:

"anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)

"So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.

I can't really even respond to this idea. Those who are mandated to be seen in the ED are not funded, for one, and basically saying that being seen in the ED is akin to insurance is a touch daft. Sigh. If only I had enough energy for a true rant, but alas, I'm too tired already. Too many patients to see. Where could they be coming from? I wonder. See the post on the Movin' Meat blog here.

The MD-patient Relationship

Intersting post on the doctor-patient relationship on M.D.O.D. here.

Seriously, patients aren't customers! Drives me nuts.

FMOE: Obstetrical Bleeding, >20 Weeks

This entry is as much for me as for you, since I have to learn and retain information, and somehow putting it on a webpage helps.

So, a 18-yo (just so it's not too depressing, and she's 14) comes to the ED for sharp, constant pain just above the waist of her hipster jeans on the left that doubles her over and came on like a tornado on a midwestern summer night (sorry, can't give a canned case). No nausea, vomiting, or fever. She doesn't remember when her last period was, and she says she's not sexually active.

VS: 98.6, 54, 18, 80/50, 98% RA.

A brief physical exam reveals a rigid abdomen with guarding and rebound tenderness low in the left lower quadrant as awesome life-saving ER nurses place two large-bore IVs and run in liters of normal saline before she gets whisked off to the OR.

Not so common, probably too Grey's Anatomy-like, although if we were on TV then one of the residents would've just splashed betadine on her tummy and opened her up in the parking lot with the help of the nurse who's carrying the baby of her fiancee. Ectopic pregnancy can present as frank shock but is more likely to present unruptured, which means the differential for vaginal bleeding in pregnant women at less than 20 weeks gestation is simple: ectopic pregnancy or some permutation of a spontaneous abortion (threatened, inevitable, possibly missed). Less likely but possible choices include a molar pregnancy or a GU problem masquerading (UTI, pyelo, stone).

Overall, ectopic pregnancies are the second-leading cause of maternal demise in the US and complicate 2% of all pregnancies. For some reason the data is old but in 1986 that meant over 75,000 hospitalizations.

Medicine likes threes, and amenorrhea, abdominal pain, and vaginal bleeding is the ectopic triad but it's not very reliable--the patient may not be amenorrheic--at least not for the most typical six to twelve weeks--and may not be bleeding, at least not visibly. In the case above, the ruptured ectopic causes a bradycardic, hypovolemic picture due to the vagal stimulation caused by blood in the peritoneum. Not sure if it's real but I'm lookin' out for it.

Obviously, in the case above as in every female of child-bearing years plus five in either direction as well as drag queens a urine beta-hcg is the initial test usually done in the parking lot. A quantitative serum beta-hcg can be used but as Tintanelli's is very clear to point out (it's in bold for the idjits like me who skim) there is overlap and no level can reliably exclude an ectopic in favor of an IUP.

Ultrasound! Grand rounds last week, endovaginal U/S can find a gestational sack in the uterus at 5 weeks. Five weeks! That's barely long enough to start wondering and run to Walgreens, even if all our patients leveled with us and told us when they had last been sexually active or had a period.

Ectopic pregnancies can implant in the tubes most often, or interstitially in the uterine wall, or elsewhere; however, if there IS an EP, then the endometrial stripe should be thickened and without a gestational sac. That, along with the story, is likely enough to at least get an OB consult.

Treatment. In the above case, go directly to OR, do not pass GO, I would suppose. But most cases aren't like that. Options are laparoscopy which I would advise or IM methotrexate, which has a success rate quoted at 91%, but can cause a lot of pain as it aborts the EP chemically. The last 'detail' is to type and screen mom, and give her RhoGAM if she is Rh negative to prevent from alloimmunization.

Can't help but wonder how EPs are viewed by people who champion the rights of the unborn. If life begins at conception and this is an abortion would treatment of EPs be legal in the setting of a Roe v. Wade reversal that did not have an exception for the life or health of the mother? Hopefully they'll be smart enough to specify IUP abortions. I actually had a colleague in med school who was very strong in her views and said she would not offer methotrexate as it somehow was more abortion-y than laparascopy in this case.

Sorry for the boring post. I'm on medicine now, I don't have any good stories anyway. Besides, it's not all about you. Sheesh.

Umm, Not Our Fault, So Much

A colleague is on trauma which is OK except there is one resident who always rips on the ED. Recently he was taking us to task for waiting to call them for an appy in a 3rd trimester pregnant lady--they were called at 4 am for a patient that arrived the previous evening late for a 'classic' presentation.

Ah, the medical record. I must now enumerate with the alphabet and count with my fingers.

A, the patient did'nt have 'classic' symptoms initially. She had vague abdominal pain which, hmm, could be some other things besides an appy in the 3rd trimester, like, oh I don't know, labor or preeclampsia.

B, the OB attending had been consulted and agreed the patient had an appy within an hour or two of the patient showing up which was pretty good, thanks. Then, she spent hours--literally four hours--arguing up and down with radiology about getting a CT, which, frankly, she needed in a 3rd trimester pregnant lady who was about to get filleted for an appy or rupture. Totally the ED's fault, clearly. As if we got a 'classic' case and then waited around for the five or six hours until it was totally inconvenient to call.

C,while we're on the subject, why the heck is a radiologist arguing with an OB of all people about getting a scan on a pregnant lady? Wouldn't the OB know more about pregnant ladies? Perhaps? Sheesh.

Sometimes we absolutely get things wrong, I admit, me more than most since, as an Intern, it takes me six hours to disposition a hangnail or toothache. However, we actually do know what we're doing and we actually do make good decisions. Often. Sigh.

Total Cluster Averted

Sorry for the long breaks between posts, life is hectic. I'm on OB which was been a great rotation overall. The other day, though, there was an interesting situation that could've turned out badly.

We were called to the post-partum floor for a woman who was having an (air quotes)allergic reaction(air quotes) after having some percocet. She was complaining of trouble breathing and tongue swelling. Her tongue did seem swollen and she did sound a bit stridorous but I could hear her talking from the hallway and she was moving air well. Blood pressures were high, not low as they would be in anaphylactic shock. Her O2 saturation was 100% the whole time. She was given 50 mg of Benadryl.

It got interesting when the OB and the anesthesia resident disagreed. OB didn't think the patient was anaphylactic--neither did I, frankly--but was more concerned about the airway. Anesthesia was worried about an epidural hematoma from the spinal anesthesia. Management differed. Anesthesia wanted an MRI, STAT (ha, I thought at first) which I managed to actually get within 15 minutes, yay me.

So the OB attending asked me to go with the patient to the scanner. Now, I didn't think the patient was in shock, but the MRI was fifteen minutes away through a maze of corridors. So here I was, wheeling this patient through the hallway with nothing but a bag-valve mask and a portable O2 monitor. So?

Well, in retrospect, that could've been a total disaster (especially since we went right past the cafeteria, which has giant glass windows). What's the treatment for anaphylaxis? Epi and airway. Did I have an airway? No. If she were to swell up? Bag-valve mask wouldn't work. I'd be doing impossible CPR on a pregnant lady in front of the whole cafeteria. IF WE THOUGHT SHE HAD AN AIRWAY ISSUE, SHE NEVER SHOULD'VE GONE TO THE SCANNER.

Nothing happened. She could'nt get the scan becuase she was claustrophobic and there wasn't a nurse and the anesthesia attending didn't want the scan anyway, so we just wheeled her back. But the important lesson was to make a decision about the plan and stick to it. The half-assed business of getting a scan but sending an Intern with a bag-valve mask with her--well, that could've been horrific. In the ED with all resources around me, frank shock would be a challenge for me right now. In the hallway?

No Hay Ganadores

An article in the NY Times today discussed the story of a TBI victim who was repatriated to his Latin American home for care after a stay that cost $1.5 million. Arguments from most people said that the hospital was dumping the patient, since their agreement to accept Medicare and Medicaid obligated them to care for this person.

The other unspoken mandate behind this story is EMTALA, which requires hospitals that have Emergency Departments to treat and stabilize patients with emergency conditions--in this case, two broken femurs, internal injuries, and a head injury. This mandate is poorly funded, as well.

Medicare payed $80,000 of the $1.5 million.

That's why I said no winners. What was the hospital supposed to do? No long-term care facility will take this patient that requires intensive rehab; their hospital, like ours, costs roughly 2K per night for an inpatient. Is that a good use of resources? The hospital shouldn't 'dump', but if emergency care is mandated then all of the downstream consequences must be mandated as well, including follow-up care, and, wait for it...reimbursed.

We have a serious discussion on our hands in this election. Do we change how we care for everyone regardless of insurance coverage in the ED, and continue to have these situations? Or do we stop seeing people without coverage? I vote for funding the current mandate because I love the fact that I see people regardless of who they are based on need. I don't love getting reimbursed at a 5% rate.