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.

Interns Can't Move Meat

'Moving Meat' is a phrase for quick discharges in the ED. It's a prized skill and one that I, the Intern, do not have. Dear God did I have trouble with dispo last night. We're starting off with an orientation month in our program, and I guess I took 'starting slowly' literally to mean 'wait six to eight hours to dispo your patients'. Horrible.

So what? Well, a recent article in slate pointed out that people who are boarded (kept in a bed) in the ED are 4% more likely to die. There is a mortality effect to keeping patients around when they don't need to be there. Not to mention the experience of angst over discharge ruined my whole shift and probably those of my attendings and the nurses.

Why couldn't I send the quadriplegic with a UTI and no fever home? Root cause? I felt sorry for her. What, compassion bad in an MD? Well, feeling sorry for someone isn't compassion, it's pity. And pity kills. Compassion would've been to see her as a capable human being, and if she said she was OK to go home alone and handle her own follow-up and get her own drugs (as she hadn't last time) I should've probably let her. It sure was simpler watching dispo as a student then doing it. Sigh.

MedFlight Tribute Page

UW Health has posted a tribute page where anyone can post remembrances, here. It also contains a link to the page itself to read what others have submitted. Thanks to commentators here and to those from around the country who have sent their condolences.

Dear God, No. No, no, no!

At the risk of losing anonymity, I have to post the passing of one of those docs I most admire, one of the best I've worked with or seen, who will truly be missed. There was a crash last night, just to the west of La Crosse, Wisconsin; one of UW Madison's EC-135 copters went down with few details known yet. As of what I've heard now, there were three crew members lost.

It's covered in this article in the Wisconsin State Journal. I didn't know the other two crew members, who will be sorely missed as everyone I've ever interacted with has been pure class at Med Flight. Dr. Bean was a leading light to me, a mentor, an example of what I want to be. He was a doctor and a teacher I will sorely miss.

The best way I can think to memorialize Dr. Bean is to tell stories about him. He helped me see that EM was the field for me. I never saw him treat anyone badly, patient or colleague. When he talked to a patient, he sat down as if he had all the time in the world for them, but damn if he didn't know how to run trauma, and how to run a department. As with so many EM docs, he was also the local EMS director. At conferences with other services, his was the honest question, the insightful comment, always in the spirit of increasing cooperation, coordinating.

My fourth year rotation on EM was awesome. Dr. Bean would regularly 'hold court' after shifts, even those that ended in the middle of the night. My best memory of teaching in the ED was at 3 am after a 4-1 shift. Patients were all 'purple' (admitted) or 'green' (discharged). The Intern, who was awesome too, decided to run a session on airways because he had just been re-taught. He took me into one of the trauma bays and we picked tubes, discussed doses. The other intern came in and joined in. Dr. Bean came last, and the first thing he did was listen to the interns teaching me. Then, he ran cases for at least half an hour. What induction drug, what dose, what are you worried about. 'If you're worried,' he said, 'take out a pen and write your doses on the gurney while they're bringing the patient in. Better to take the time to be sure than get the dose wrong. Believe me, we all get rattled sometimes.' He said that, but I never saw him be rattled. More than the teaching points, which I loved, I noticed that this attending was there, two and half hours after his shift, teaching. And I also noticed that he carried himself as an example. Confident, not arrogant.

He also took the time to do the little things right. Wound exploration was a great example. It's not enough to clean the wound; explore, look for tendon injury. He would take time to discuss the proper tension on a nailbed repair, for example, along with suture choice. His attention to detail was impressive, and it pointed out that even though we're generalists, that shouldn't prevent us from taking pride in our work.

My father-in-law said, 'not all those that die, deserve to.' Amen to that. So the next time you're drinking, raise one for these folks. The next time you have a moment, make it a moment of silence. I sure will. I'll be lucky if I'm half the doc Dr. Bean was, but I'm damn sure going to try.

I'll try and keep up announcements, if any on this topic.

Entitlement

150 people in an auditorium, I asked the prof a question, and then pointed out when he responded that his explanation didn't match the book or some such 2nd-year med student snarkiness. I got, in response, a long, loud, diatribe about how we were the most entitled bunch of whining babies he had ever seen come through the school. I achieved enough notoriety that some smart fellow yelled out to tell the doctor, quick, as I went up to read my match day assignment.

I was hurt at the time; I had worked hard to get there--working full-time and completing pre-reqs as well while trying to see my newborn daughter every once and a while--and he was telling me I was entitled?

But now that I've seen more patients, and seen more of the system, I see that I was--admittedly a bit spoiled--but also just the last straw for an ID doc who was sick of people whining about wanting antibiotics, vaccines causing autism, people not doing their jobs and patients wanting more, better, faster, and cheaper.

Over at M.D.O.D., the posters have little, if any, patience left for the people we treat as a community, who think health care is a right, and that anything less than perfect, enjoyable care is not good enough. This goes in line with the 'quality' movement sweeping through health care based loosely on the six-sigma line of thinking.

I don't know yet how much this affects the field. I will note, however, that the ED I'm about to begin training at has all private rooms, with flat screens and cable TV in each one. I'll also note that they hand out consumer satisfaction surveys to patients. In theory, this may sound great. In practice, it worries me.

Patients are not customers. Putting cable TV in the rooms certainly improves the wait, I'm sure, but aren't we sending the wrong message? When we spent trillions on health care with only so-so outcomes, are flat screen TVs really where we should put our money?

I happen to favor national health care a la the system seen in the UK, the NHS. However, I also acknowledge that this is often advocated in a very indignant way, as if it is an injustice that we don't yet have it. I used to feel the same way. How can the US, which is so advanced and spends so much money, not yet have universal care? Being a schizoid combination of realism and idealism, I like the idea of universal health care, but having watched our government screw up a lot of other things--public education, welfare, land management, and so on--I'm pretty sure we'd screw up health care, too. Instead of decreasing idiotic subjective meaningless griping surveys, it would probably increase them, and JCAHO would metastasize, becoming totally inoperable.

We are becoming a nation entitled. They say it's bad parenting now to tell your children that there are starving kids in Africa that would gladly eat those carrot sticks, but isn't it totally true?

We should tell patients that, too. You just waltzed into this ED at 2 am because you need a refill on your Percocet and got seen within an hour while you sat in your private room and watched the Top Chef marathon on the Food Channel. You personally will not be charged for this visit because we won't be able to find you, and because I am totally exhausted you might even get some narcs out of me. Then, you'll complain how I wasn't compassionate enough on the survey the nurse is required to hand you, knowing full well that the parent of the pediatric resuscitation that went perfectly down the hall won't have the time or energy to fill out a survey because they have more important things to worry about. There are patients in Africa who would gladly take this level of health care.

It's nice going into residency being pre-jaded. At least I won't feel the pain of my ideals burning away.

Iron Man = Hypomania

Had a rare day 'off' today after getting the house ready to sell, and I went to see Iron Man. That guy is totally hypomanic.

First, he's the millionaire playboy who engages in exaggerated risk-taking, especially sexual, and has an exaggerated sense of self (mania, anyone?) After finding his purpose in life, he's able to work for days, perhaps weeks on end, without anything but coffee (lots, makes me feel better) and a nice trinket from his assistant (who happens to be Gweneth Paltrow) to keep him going, in which time he makes a cool suit of flying armor.

The movie was fun and not too bad. Interestingly, though, he's totally symptomatic. Watching the movie, I wondered about the continuum between disease and benefit. In his case, hypomania was totally profitable and benefited those around him--there was no way that anyone normal would've been able to do what he did, and there was a significant amount of risk-taking involved in innovation. The NY Times, if a search is completed on hypomania, notes that there may be an abnormally high amount of hypomania in the U.S. population since we tend to be risk-takers as the descendants of immigrants. So, this is an example of a disease state--acute mania, treated with an IM injection of haldol and lorazepam--that is on a continuum with arguably one of the most important personality traits known, since the hypomanic folks were the ones who likely talked us onto the boat, invented the lightbulb, the atomic bomb, and PopTarts.

Being nerdy ruins everything. I can't even enjoy a good blockbuster without wondering about diseases. The lady who sold me vases this afternoon has Parkinson's, treated, I'm sure after watching her fill out the receipt, which she insisted on doing by hand. It sucks being a med student.

Why I Love My Gal

A Jeep pulls up next to us, the driver's hand on the wheel with a cigarette between digits 2 and 3.

"How can people smoke? What are they thinking? Why not just wear a T-shirt that says, 'I'm a total f@$*ing idiot?"

That's why I love her. Well...one of the many reasons, actually.