# Trainwreck #5



## usalsfyre (Oct 29, 2011)

Not a call run by me so some details may be off. BUT....your working on yet another CCT truck with a basic partner in a metro area. 

Your dispatched to the local ED for a 23 YOF with acitve labor and PROM. On arrival you find the patient in a standard ED bed, 27wks G6 TPAL 1-2-2-3. The patient has had minimal prenatal care (i.e. went to the ED to confirm she was pregnant) and has a history of drug abuse, preterm labor and spontaneous abortion, and has had a recent UTI. The patient presented 4 hours ago with contractions and a rupture of membranes. The patient reports contractions are 4 minutes apart, seem to be at least 1+min in duration. The only intervention is an 18ga in the L forearm that is saline locked. Your going to Our Lady of Everything Under the Sun Charity Hospital 25 minutes away.


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## Aidey (Oct 29, 2011)

This girl was a trainwreck looooooooooong before she ever got pregnant. 

Vitals?
Any labs? Maybe a urine dip? 
Any non OB medical history?
Vaginal deliveries or c-sections? 
How far along was she when she delivered before? How long did those labors last?
What drugs does she have a history of abusing? 
Any history of STDs or Group B strep?


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## abckidsmom (Oct 29, 2011)

Everything Aidey said.

Is she dilated?  Have they checked her?  I can see opting not to, just wondering.
What about reflexes?  Edema?  
Fetal movement?

This should be, ahem, *interesting.* I love a good trainwreck.


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## usalsfyre (Oct 29, 2011)

Aidey said:


> This girl was a trainwreck looooooooooong before she ever got pregnant.


As I've seen it in SOAP notes "the patient has a varied social history with a poor support system" 



Aidey said:


> Vitals?


HR 116 ST, B/P of 114/86, SpO2 of 98% on room air



Aidey said:


> Any labs? Maybe a urine dip?


Standard blood chemistry shows nothing remarkable, urine dip was + for glucose, protein and WBCs. 



Aidey said:


> Any non OB medical history?


Substance abuse, and multiple STIs



Aidey said:


> Vaginal deliveries or c-sections?


All vaginal 



Aidey said:


> How far along was she when she delivered before? How long did those labors last?


The first baby was term, the premies were at 28 and 30 wks respectively and the miscaiages were at 19 and 15 wks (estimated, she's not real big on medical care). The last labor was a premie and lasted abour 3.5 hours.



Aidey said:


> What drugs does she have a history of abusing?


Cocaine, alcohol, heroin and occasionally methamphetamine



Aidey said:


> Any history of STDs or Group B strep?


Multiple STIs during pregnancy, no Group B on file and the staff isn't exactly interested in doing one. 



abckidsmom said:


> Is she dilated?  Have they checked her?  I can see opting not to, just wondering.


When she presented four hours ago she was dilated to a 6 and 70% efaced. No cervical exam since then. 



abckidsmom said:


> What about reflexes?  Edema?


+1 edema, normal reflexes. 



abckidsmom said:


> Fetal movement?


Minimal fetal activity, but good FHTs by doppler. 

The facility your at has L&D services as well as a LII NICU.


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## Sam Adams (Oct 29, 2011)

Oh goody! I caught one early enough to weigh in. Before I do, I'm not familiar with some of the abbreviations. What do PROM and TPAL mean? In addition to the aforementioned questions is said pregnancy a singleton or are there multiple train wreck # 5's in there?


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## usalsfyre (Oct 29, 2011)

Sam Adams said:


> What do PROM and TPAL mean?


PROM stands for Premature Rupture of Membranes. TPAL is a scoring system to get more info than the standard "GPA" system
http://en.wikipedia.org/wiki/TPAL_(medicine)



Sam Adams said:


> In addition to the aforementioned questions is said pregnancy a singleton or are there multiple train wreck # 5's in there?


At this point we've only detected one fetal heart tone, no ultrasound is on file to say any further.


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## abckidsmom (Oct 29, 2011)

usalsfyre said:


> As I've seen it in SOAP notes "the patient has a varied social history with a poor support system"



snicker.  The poor dear.



> HR 116 ST, B/P of 114/86, SpO2 of 98% on room air
> 
> 
> Standard blood chemistry shows nothing remarkable, urine dip was + for glucose, protein and WBCs.
> ...



Relatively good news, better than I expected.  This poor dear has mastered a novel induction technique:  poor prenatal care/gestational diabetes precipitating untreated UTIs, which induce labor.



> The first baby was term, the premies were at 28 and 30 wks respectively and the miscaiages were at 19 and 15 wks (estimated, she's not real big on medical care). The last labor was a premie and lasted abour 3.5 hours.
> 
> 
> Cocaine, alcohol, heroin and occasionally methamphetamine
> ...



Yeah, minimal fetal activity because the baby is fully engaged, descending, and about to freaking deliver.  



> The facility your at has L&D services as well as a LII NICU.



So what, they want the baby at a LIII NICU?  Hmmm.  I think they called the wrong transport service, and what we really need to do is call a NICU transport service to transport the baby only after it is outside, breathing air like the rest of us.

Just because you're scared of this baby, or annoyed with the mom's poor choices doesn't mean I have to catch a sick, drug-exposed premie on the highway and then deal with her crashing, septic mother on the rest of the ride.

I'm gonna throw the EMTALA flag on this one.  Slow the labor with meds, confirm that it's working, and call us later.  Sorry.


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## fast65 (Oct 29, 2011)

Well obstetrics is probably my worst area, so I'm afraid I'm gonna sit this one out and just observe 


Sent from my iPhone using Tapatalk


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## Sam Adams (Oct 29, 2011)

time to do some prep before t/p begins:
find and dust off the OB kit(s)
turn the truck on and turn up the pt compartment heat
find/ make sure I have blankets/ means to warm/ keep warm a newborn
find the mec aspirator and make sure the suction is working
start a second peripheral access w/ fluid attached (for the inevitable infusion)


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## firetender (Oct 29, 2011)

Should the little one appear:

#1) Don't let it hit the floor
#2) Beware of bodily fluids; multiple prematures and miscarriages could indicate Syphilis


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## abckidsmom (Oct 29, 2011)

firetender said:


> Should the little one appear:
> 
> #1) Don't let it hit the floor
> #2) Beware of bodily fluids; multiple prematures and miscarriages could indicate Syphilis



Yeah, and 23 yo G6P3 with her recreational pharmaceutical history indicates Hep C.


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## Farmer2DO (Oct 30, 2011)

usalsfyre said:


> Multiple STIs during pregnancy, no Group B on file and the staff isn't exactly interested in doing one.



Because between now and four hours ago, when she presented, they didn't have time to do one.



> When she presented four hours ago she was dilated to a 6 and 70% efaced. No cervical exam since then.



6 cm and 70%, 4 hours ago?  WTH are they waiting for?  




> The facility your at has L&D services as well as a LII NICU.



And she's still in the ED?  Sounds like they just don't want to deal with a complicated patient who won't pay her bill.  Someone needs to lose their job over this one.



abckidsmom said:


> snicker.  The poor dear.
> 
> So what, they want the baby at a LIII NICU?  Hmmm.  I think they called the wrong transport service, and what we really need to do is call a NICU transport service to transport the baby only after it is outside, breathing air like the rest of us.
> 
> ...



I agree with you 100% on this one.  There is no way I'm about to pick up the ball on your case of complete mismanagement.


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## Aidey (Oct 30, 2011)

I'm with you guys on this, someone is getting reported somewhere. 

I want a few things before I even talk to her. Like how about we re-check how effaced and dilated she is? Honestly, if they refused to delay the transfer until the baby was born I would be sorely tempted to move her to my gurney and park it in the hall until she delivers. It would serve them right for trying to pull this crap.


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## abckidsmom (Oct 30, 2011)

Farmer2DO said:


> Because between now and four hours ago, when she presented, they didn't have time to do one.




Exactly.  This is a circumstance where you just assume she's GBS+.



> 6 cm and 70%, 4 hours ago?  WTH are they waiting for?
> 
> 
> 
> ...



Knowing usals and his trainwrecks, I'm gonna guess that the crew decided to do the transport, and caught the baby.  Cause there's no way this could get to be a trainwreck in the face of good transport care, which is, no transport.

This is a departure scheduled that didn't take off, right usals?  RIGHT????


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## usalsfyre (Oct 30, 2011)

abckidsmom said:


> This is a departure scheduled that didn't take off, right usals?  RIGHT????


Well...no. The medic assigned to a very similar transport went ahead and took the call. He caught a relatively healthy baby in the driveway of the receiving facility. I told him he had bigger stones than I did, I would have refused the call. 

The point of #5 was to catch the patient dumping and realize you don't have to, nor should you, transport every patient. Despite EMTALA, there's still dumping the goes on. The onus on you to recognize it. 

So while we're here, against your better judgement you transport. Midway through, via precipitous delivery out pops a male child who's the size of your palm, cyanotic, pulse of 74, no grimace when stimulated, flaccid and with slow irregular respirations. What's the APGAR and how do you resus the kid? Anything you want to do for Mom at this point? She seems to be having a lot of post-partum hemorrhage...


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## abckidsmom (Oct 30, 2011)

usalsfyre said:


> Well...no. The medic assigned to a very similar transport went ahead and took the call. He caught a relatively healthy baby in the driveway of the receiving facility. I told him he had bigger stones than I did, I would have refused the call.
> 
> The point of #5 was to catch the patient dumping and realize you don't have to, nor should you, transport every patient. Despite EMTALA, there's still dumping the goes on. The onus on you to recognize it.
> 
> So while we're here, against your better judgement you transport. Midway through, via precipitous delivery out pops a male child who's the size of your palm, cyanotic, pulse of 74, no grimace when stimulated, flaccid and with slow irregular respirations. What's the APGAR and how do you resus the kid? Anything you want to do for Mom at this point? She seems to be having a lot of post-partum hemorrhage...



Technically speaking, precipitous delivery means less than 90 minutes from beginning of active labor to delivery.  Thus, this is not technically a precipitous delivery.  

I'll wait a sec on the rest.  What a poor judgment call this was.  I'm really kicking myself for taking this kid and his mom across town.  I am forever the source of my own bad days.  SMH.


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## usalsfyre (Oct 30, 2011)

abckidsmom said:


> Technically speaking, precipitous delivery means less than 90 minutes from beginning of active labor to delivery.  Thus, this is not technically a precipitous delivery.


You got me there. How about "explosive delivery".



abckidsmom said:


> I'll wait a sec on the rest.  What a poor judgment call this was.  I'm really kicking myself for taking this kid and his mom across town.  I am forever the source of my own bad days.  SMH.


Yeah, I have a hard time learning from others mistakes sometimes lol.


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## abckidsmom (Oct 30, 2011)

usalsfyre said:


> So while we're here, against your better judgement you transport. Midway through, via precipitous delivery out pops a male child who's the size of your palm, cyanotic, pulse of 74, no grimace when stimulated, flaccid and with slow irregular respirations. What's the APGAR and how do you resus the kid? Anything you want to do for Mom at this point? She seems to be having a lot of post-partum hemorrhage...



I can't leave well enough alone.  Here goes:

APGAR is 2.  Let's get to work.  I'm gonna warm, dry and stim the babe, and then I'm gonna have to attemp to manually ventilate the punk with an impossibly large mask, into stiff little lungs, in a cold, dirty environment, and pray to God in heaven that that is all we need to do.  It works, because the train wreck is over, and we're about to live happily ever after.

Meanwhile, to my left, mom is exsanguinating.  I'm gonna vigorously massage her uterus and see if it encourages the placenta to deliver at all.  I would expect that the hemmorhage would lessen significantly when the placenta delivers.  If not, I'm going to get mom to stimulate her nipples with some less-than-gentle pinching.  Ideally, the baby would stimulate her nipples, but I don't think he's up to it.  In a major pinch, she could get a room with her loving and supportive life partner and HE could do it, but give her varied social history and limited support system, I'm guess that's a no.  

Since I was a forward-thinking idiot before I took this mom out for a road trip, I have a bag of saline hanging with 20 u of pitocin in it.  I'll bolus that in if she doesn't respond to her intrinsic oxytocin.

The poor dear.

How are we doing, usals?  I love OB scenarios.  I believe the dispatch fairies have determined that I will never see an imminent delivery in the field.  Or any overly pregnant person, honestly.


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## Farmer2DO (Oct 30, 2011)

Seeing that you are bound and determined we are going to transport this, I would insist on a second provider for the transport, at the very least.  Even an EMT-B would be enormous help here, since it it sounds like mom and baby will both need resuscitation.


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## usalsfyre (Oct 31, 2011)

abckidsmom said:


> How are we doing, usals?  I love OB scenarios.  I believe the dispatch fairies have determined that I will never see an imminent delivery in the field.  Or any overly pregnant person, honestly.


Your doing great so far.

The only thing I might add is if the HR doesn't increase with stimulation you might want to consider chest compressions. Fortunately the HR came up, but your sats are still poor. Time for a 5 min APGAR. Pt is still cyanotic, HR  is 140, pt is grimacing with your ventilations, some muscle flexion is noted with occasional, gasping respirations.

Pit is going in on Mom, seems to be helping (although, the family services folks might think a hysterectomy would be a blessing). 

Anything else we can do for the kiddo? I'm thinking of two more particular interventions...


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## Sam Adams (Oct 31, 2011)

I don't think it was mentioned, maybe it was assumed, but bulb syringe the little one, also would like a heel CBGL.


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## abckidsmom (Oct 31, 2011)

Sam Adams said:


> I don't think it was mentioned, maybe it was assumed, but bulb syringe the little one, also would like a heel CBGL.



Good catch.  It's hard to remember to state these things when you can't see the goo in his little airway.


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## BeachmedicJB (Oct 31, 2011)

given this patient's history of preterm delivery, drug abuse, and overall health. Along with the contractions being so close and the appearance that the fetus is descending and delivery pending. I would ask the sending facility to perform another cervical exam, standby a NICU rig, and hold on for the ride. Although her vitals are stable, it doesn't seem like a good idea to transfer her at this time. Other variables would play into my decision such as traffic, weather, etc. but overall my general impression is that it is better to deliver this child in a controlled environment rather than risk both the child and mother's lives for a transfer.


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## Sam Adams (Oct 31, 2011)

I'd also consider a neonatal dose of naloxone see if that picks up the respiratory drive.


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## abckidsmom (Oct 31, 2011)

usalsfyre said:


> Your doing great so far.
> 
> The only thing I might add is if the HR doesn't increase with stimulation you might want to consider chest compressions. Fortunately the HR came up, but your sats are still poor. Time for a 5 min APGAR. Pt is still cyanotic, HR  is 140, pt is grimacing with your ventilations, some muscle flexion is noted with occasional, gasping respirations.
> 
> ...



So the 5 min APGAR is 5.  We could probably go ahead and intubate him, though I'm loathe to do so in our current environment.  In a moving ambulance, it takes at least 2 pairs of hands to care for an intubated neonate safely, and I'm not loving our odds.  

I like the idea of checking his sugar.  If it's low, we'll get some access (yeah right) or consider an IO (is there a gestational limit to IO?  I seem to remember something, but a quick google isn't turning it up?  Can this 27 weeker get an IO?).  Then we can give him a little D12.5 if he needs it.

I'm down with the narcan, but I seriously doubt that's his little problem.

It's early for him to be feeling the pain of sepsis, but we can give him a little tiny bolus and see if that helps his perfusion.  

I'm breaking open some hot packs and wrapping them in towels with this kid, too, cause he is cold. 

This was a bad decision, driving this woman across town.  Are we there yet?


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## usalsfyre (Oct 31, 2011)

Almost there. I'm not sure we have a heck of a lot of choice besides intubate, provide small amounts of PEEP and use artificial surfactant it's available at this point. 

BGL and a small bolus seems like a good idea. I seriously doubt we're still seeing significant respiratory depression from any opiates at this point.

You pull in the drive and find the NICU crew eagerly awaiting your arrival with all of their toys. You breathe a massive sigh of relief...and start making phone calls.

Hopefully #6 tommorow. Review the Parkland formula .


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## Handsome Robb (Oct 31, 2011)

usalsfyre said:


> Hopefully #6 tommorow. Review the Parkland formula .



I'm hoping it doesn't get posted when I'm in class so all the smarties get to have their way with it before I get to play 

Funny you say parkland formula, we have been doing burns/trauma for the last week or so


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