# Obestetrical Scenario



## coffeegal (Oct 21, 2016)

Here is a scenario I came up with for my capstone project, tell me what you think:
TOPIC: Obstetrics
DISPATCH: MED 123 respond emergency traffic to a sick person at 123 Hawthorne Ln. Cad Notes: 20 YOF, nauseated and vomiting. Caller hung up. 
BSI/PPE: Gloves
SCENE SIZE UP
Scene is safe
MOI/NOI: N/V
# of patients: 1
Additional Resources: Fire Department is on scene
C-Spine: not indicated
PRIMARY
GI: You arrive to the pt’s residence and go inside the house. Your patient, 20 YOF, is in the hallway bathroom leaning over the toilet vomiting. 
LOC: Alert and oriented
CC/Life Threats: N/V
A: Patent
B: 22RR, normal, 98% on room air, L/S clear and equal. 
C: Strong radial pulse, no major bleeding, skin pale, diaphoretic, cool. 
HISTORY
Onset: Started about a week ago with N, just started throwing up yesterday morning, but it went away about 11, and came back this morning. 
Provocation: “Nothing helps”
Quality: N/A, no pain
Radiation: N/A
Severity: N/A, no pain. Threw up three times yesterday, hasn’t stopped today
Time: Started again when I woke up this morning.
S: N/V, approx 100mL fluid loss noted in the toliet
A: Codeine, Ibuprofen
M: Multivitamin, Allergy meds, Birth Control
P: No history
L: Dinner last night
E: Just woke up
SECONDARY
-Cardiovascular: Sinus Tachycardia 124HR
-GI/GU: Last ate a chicken and rice for dinner, staying hydrated with water, urinating normally, LBM yesterday.
-Reproductive: LMP last month, supposed to start 5 days ago for this month. Just got married last month, sexually active, but takes birth control. 
VITALS
110/62; 122HR; 20RR; 98% on room air; BGl 74; Sinus Tachycardia
116/64; 110HR; 18RR; 98%; Sinus Tachycardia
DIAGNOSIS: Hyperemesis Gravidarum (Morning Sickness)
INTERVENTIONS: IV, Fluids, Zofran, Oxygen
TRANSPORT: Routine to closest facility.


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## Handsome Robb (Oct 21, 2016)

If she's compliant with her BC it's highly unlikely she's pregnant. If she's taken a round of antibiotics that can reduce the effectiveness. Women can be irregular with their menstrual cycles and not be pregnant. 

I guess I don't really see what you're getting at. Do you have a question you need answered? 


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## coffeegal (Oct 21, 2016)

Realistic? I know it might be hard to figure out what the problem is because it could be a lot of things from a bug to food poisoning, but I tried to make it kinda obvious.


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## Handsome Robb (Oct 21, 2016)

Yea, it is but like you said there's a lot that could be wrong here. Is this a scenario you're presenting to classmates for them to answer? 


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## coffeegal (Oct 21, 2016)

It's a scenario we are going to go through for practice.


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## SpecialK (Oct 22, 2016)

From the information presented the only specific treatment I'd give her is an ondansetron wafer.

My recommendation would be she continues oral fluids and see her GP within the next few days to get a bHCG to check she is not pregnant (not usual if somebody is on OCP but I've seen it before .....).  Certainly doesn't need immediate referral, nor ambulance transport, anywhere.


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## BobBarker (Oct 22, 2016)

Why are we giving Oxygen to a person with a level of 98% on RA?


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## NomadicMedic (Oct 22, 2016)

Yeah, she'd get (at most) a zofran ODT and a yak sak. Nothing particularly worrisome here. I'd assume, since she called 911 and is a millennial, she at this point "can't even" and "OMG" needs to be taken to the ED post haste. 

Maybe a BLS call if she's not puking and I hold off on the zofran.


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## Handsome Robb (Oct 22, 2016)

coffeegal said:


> It's a scenario we are going to go through for practice.



If you want it to absolutely be pregnancy but not make it blatant and make your classmates think and provide a teachable moment I'd make it so she's compliant with her BC but had a respiratory infection or something that she was on abx for. 

Like the others have said I'd give her a zofran ODT and a ride if she wanted it. Otherwise I'd probably just give her the ODT and recommend she makes an apt with her PCP or goes to an urgent care. 


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## VentMonkey (Oct 22, 2016)

Handsome Robb said:


> If you want it to absolutely be pregnancy but not make it blatant and make your classmates think and provide a teachable moment I'd make it so she's compliant with her BC but had a respiratory infection or something that she was on abx for.


And instead of calling it BC, give it a name brand like Depo™, or Marena™. Instead of the obvious "morning sickness" angle, perhaps she's tachypneic, and dyspneic.

If they go further into their assessment they find that she'd recently completed a long road trip as well...see where I am going here?

Either way, again like the others said, you gotta blind side people. This is what helps develop a strong clinical base, index for suspicion, and critical thinking capabilities.

Side note: this was a scenario question I would give to my cockier paramedic interns as part of their internship; many stop at Marena™, as they had no clue what that was. My answer to them was almost always "look it up".


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## EpiEMS (Oct 22, 2016)

DEmedic said:


> Yeah, she'd get (at most) a zofran ODT and a yak sak. Nothing particularly worrisome here. I'd assume, since she called 911 and is a millennial, she at this point "can't even" and "OMG" needs to be taken to the ED post haste.
> 
> Maybe a BLS call if she's not puking and I hold off on the zofran.



Wouldn't bother me to take it BLS if the transport time is <30 minutes or so. I only have so many emesis bags, you see 

I feel like this scenario could use some fleshing out, story-wise, but I'm not strictly sure what. I think Robb and VentMonkey had some good thoughts on this one.


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## VentMonkey (Oct 22, 2016)

EpiEMS said:


> Wouldn't bother me to take it BLS if the transport time is <30 minutes or so. I only have so many emesis bags, you see
> 
> I feel like this scenario could use some fleshing out, story-wise, but I'm not strictly sure what. I think Robb and VentMonkey had some good thoughts on this one.


In all seriousness, true hyperemesis gravidum can be at least something worth IVF, Zofran IVP, and some D50 if they had been in fact vomiting for days on end (it can happen), but as others mentioned this would start as a Zofran ODT, simply cardiac monitor, and a BGL-type of call; there's not much else to do.

Op, perhaps brush up on your critical thinking skills a bit? Good luck.


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## coffeegal (Oct 22, 2016)

Thanks for the replies. I wound up changing up the scenario to a preeclampsia that goes to eclampsia call. This way it is cut and clear on ALS, and also will required meds if they don't assess correctly, as she will start seizing again. 

It's hard to paint the picture I was going for in the scenario above. I was thinking along the lines of been throwing up so much for days and haven't been able to keep much down, so she is dehydrated from hyperemesis gravidarum. Maybe I needed to paint that picture a little better in the scenario. Thanks for the feedback, showed me I needed something a little better.


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## VentMonkey (Oct 22, 2016)

coffeegal said:


> I wound up changing up the scenario to a preeclampsia that goes to eclampsia call. This way it is cut and clear on ALS, and also will required meds if they don't assess correctly, as she will start seizing again.


Fair enough, just remember as others pointed out clear cut scenarios sometimes make foe "cut and dry paramedics", which also does nothing for their critical thinking abilities.

I understand perhaps at this phase, you may not want to confuse their moldable brains too much, but perhaps even throw some differentials at them once you wrap your scenario up. 

Also, let us know how it goes.


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## Handsome Robb (Oct 22, 2016)

VentMonkey said:


> In all seriousness, true hyperemesis gravidum can be at least something worth Zofran IVP and some *D10* if they had been in fact vomiting for days on end (it can happen), but as others mentioned this would start as a Zofran ODT, simply cardiac monitor, and a BGL-type of call; there's not much else to do.
> 
> Op, perhaps brush up on your critical thinking skills a bit? Good luck.



Fixed that for ya. 


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## VentMonkey (Oct 22, 2016)

ChrisCon89 said:


> just failed the Nremt -b for the 3rd time , what now?


Wrong thread.

http://emtlife.com/threads/having-trouble-passing-nremt-b-suggestions.8740/


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## CALEMT (Oct 22, 2016)

ChrisCon89 said:


> yeah sorry bout that just frustrated and feel like i'm losing hope with becoming a FF.



Totally not related to this thread but this is a pet peeve of mine. Not the grammar, but becoming a EMT or paramedic just to get on with a FD. You should become a EMT or paramedic because you want to, not because you have to. 

Anyway, carry on with the OB scenarios.


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## Alan L Serve (Oct 23, 2016)

Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat again: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test.

"I can't be preggers! It's _IMPOSSIBLE_! I'm on b-control, he uses condoms, and I'm a lesbian who has never had sex with a man, and I live in seclusion on the top of a mountain with not a single human being around doing yoga 24/7/365!" Turned out she was preggers and they did an abdominal CT scan for her abd pain while believing her story that she couldn't possibly be preggers. The baby waved and gave the middle finger to the CT tech for the unnecessary high dose of radiation and for believing the mom.

Say it again with me, ok?: *Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test.*

Once get those confirmed laboratory results back which show negatives for pregnancy then you can consider others items on your differential such as food poisoning, viral GI, etc.


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## gotbeerz001 (Oct 23, 2016)

Sometimes an AMA can reveal more about a medic than a call with a definitive answer


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## gotbeerz001 (Oct 23, 2016)

Alan L Serve said:


> Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat again: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test.
> 
> "I can't be preggers! It's _IMPOSSIBLE_! I'm on b-control, he uses condoms, and I'm a lesbian who has never had sex with a man, and I live in seclusion on the top of a mountain with not a single human being around doing yoga 24/7/365!" Turned out she was preggers and they did an abdominal CT scan for her abd pain while believing her story that she couldn't possibly be preggers. The baby waved and gave the middle finger to the CT tech for the unnecessary high dose of radiation and for believing the mom.
> 
> ...



OP, this advice will get you past the OB section of the registry...


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## ERDoc (Oct 23, 2016)

Alan L Serve said:


> Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat again: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test.
> 
> "I can't be preggers! It's _IMPOSSIBLE_! I'm on b-control, he uses condoms, and I'm a lesbian who has never had sex with a man, and I live in seclusion on the top of a mountain with not a single human being around doing yoga 24/7/365!" Turned out she was preggers and they did an abdominal CT scan for her abd pain while believing her story that she couldn't possibly be preggers. The baby waved and gave the middle finger to the CT tech for the unnecessary high dose of radiation and for believing the mom.
> 
> ...



This.  I had a woman in her late 30s who had a tubal ligation and was on OCPs for cycle regulation come in with abd pain.  Admitted to OB for her ectopic.


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## Carlos Danger (Oct 23, 2016)

Alan L Serve said:


> Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat again: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test.
> 
> "I can't be preggers! It's _IMPOSSIBLE_! I'm on b-control, he uses condoms, and I'm a lesbian who has never had sex with a man, and I live in seclusion on the top of a mountain with not a single human being around doing yoga 24/7/365!" Turned out she was preggers and they did an abdominal CT scan for her abd pain while believing her story that she couldn't possibly be preggers. The baby waved and gave the middle finger to the CT tech for the unnecessary high dose of radiation and for believing the mom.
> 
> ...



I think a better way to put this is that every pre-menopausal female _has the potential_ to be pregnant. 

This possibility may or may not be clinically relevant. But the fact is, when a female says "I know I'm not pregnant", the vast majority of the time they are right.


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## Anjel (Oct 24, 2016)

Remi said:


> I think a better way to put this is that every pre-menopausal female _has the potential_ to be pregnant.
> 
> This possibility may or may not be clinically relevant. But the fact is, when a female says "I know I'm not pregnant", the vast majority of the time they are right.



Agreed. 

As to the OP... you said you changed the scenario to preeclampsia...eclampsia.  I'm curious how you changed it. 

The original one could be good. If like Rob said you include the fact that she was on antibiotics. Also, you could hint towards signs of metabolic alkalosis if the vomiting has been so severe, and lasting for days.


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## savemachine (Oct 24, 2016)

coffeegal said:


> Here is a scenario I came up with for my capstone project, tell me what you think:
> TOPIC: Obstetrics
> DISPATCH: MED 123 respond emergency traffic to a sick person at 123 Hawthorne Ln. Cad Notes: 20 YOF, nauseated and vomiting. Caller hung up.
> BSI/PPE: Gloves
> ...


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## savemachine (Oct 24, 2016)

That was an amazing report that you reported about.  It was well in depth and very thorough in the reporting status.  I can remember doing those very in depth nursing reporting and I also remember doing nursing care plans as well; especially with my patients when I was in clinical rotations as a student nurse.  I was in obstetrics and geriatric and I had to do the complex reporting and case work too.  We did lots and lots of scenarios like this and it was extremely helpful in nursing critical thinking and it also helped me in my critical thinking skills.  I really am thankful for this scenario because it helps so many nursing students.


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## Handsome Robb (Oct 24, 2016)

savemachine said:


> That was an amazing report that you reported about.  It was well in depth and very thorough in the reporting status.  I can remember doing those very in depth nursing reporting and I also remember doing nursing care plans as well; especially with my patients when I was in clinical rotations as a student nurse.  I was in obstetrics and geriatric and I had to do the complex reporting and case work too.  We did lots and lots of scenarios like this and it was extremely helpful in nursing critical thinking and it also helped me in my critical thinking skills.  I really am thankful for this scenario because it helps so many nursing students.



Uhhhh....this is an EMS forum ....


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## VentMonkey (Oct 24, 2016)




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## ERDoc (Oct 24, 2016)

savemachine said:


> That was an amazing report that you reported about.  It was well in depth and very thorough in the reporting status.  I can remember doing those very in depth nursing reporting and I also remember doing nursing care plans as well; especially with my patients when I was in clinical rotations as a student nurse.  I was in obstetrics and geriatric and I had to do the complex reporting and case work too.  We did lots and lots of scenarios like this and it was extremely helpful in nursing critical thinking and it also helped me in my critical thinking skills.  I really am thankful for this scenario because it helps so many nursing students.


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## savemachine (Nov 23, 2016)

ERDoc said:


> This.  I had a woman in her late 30s who had a tubal ligation and was on OCPs for cycle regulation come in with abd pain.  Admitted to OB for her ectopic.



I hope that they are going to be OK.  I can remember when I was called into work one morning very early and it was because my co-worker called in with abdominal pain and was in the emergency room.  When they checked her, they found out that she was pregnant, but the embryo was in her fallopian tubes and that was causing the pain.  I believe that they had to take the baby and do a D@C. She was about 3 weeks pregnant I believe.  It is hard when that happens.  I truly hope that the patient will be OK and will be back on their feet soon.


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## ERDoc (Nov 25, 2016)

savemachine said:


> I hope that they are going to be OK.  I can remember when I was called into work one morning very early and it was because my co-worker called in with abdominal pain and was in the emergency room.  When they checked her, they found out that she was pregnant, but the embryo was in her fallopian tubes and that was causing the pain.  I believe that they had to take the baby and do a D@C. She was about 3 weeks pregnant I believe.  It is hard when that happens.  I truly hope that the patient will be OK and will be back on their feet soon.



This was about 12 years ago.  I hear she will probably be okay.  As far as I know, she did fine.  That situation you are talking about (baby outside the uterus) is called an ectopic and yeah, if the baby implants in the tube it needs to be removed either mechanically or chemically.


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## savemachine (Dec 21, 2016)

I hope that woman in her late 30's is OK and feeling well.  It is always good that EMS personnel understand the symptoms of certain conditions and start treatment early even before nurses get to see the patients.  I praise the EMS personnel very much.


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## Handsome Robb (Dec 21, 2016)

savemachine said:


> I hope that woman in her late 30's is OK and feeling well.  It is always good that EMS personnel understand the symptoms of certain conditions and start treatment early even before nurses get to see the patients.  I praise the EMS personnel very much.



Not to be a **** but do you read the responses to your posts? 

Thank you for the praise. 


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## FLMedic311 (Dec 21, 2016)

Any one have concerns with the use of Zofran during pregnancy with the recently release of some data suggesting an association of heart defects or cleft pallet??


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## ERDoc (Dec 23, 2016)

FLMedic311 said:


> Any one have concerns with the use of Zofran during pregnancy with the recently release of some data suggesting an association of heart defects or cleft pallet??



To paraphrase something I heard on OB attending say recently, "Almost every drug can cause problems in pregnancy.  We recently stopped using zofran and started using reglan again.  Sure, reglan seems to have a slightly higher risk but it's not in the news."


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## Clare (Dec 24, 2016)

I agree she does not need immediate referral or transport anywhere. She can see her GP.


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## savemachine (Jan 18, 2017)

ERDoc said:


> This.  I had a woman in her late 30s who had a tubal ligation and was on OCPs for cycle regulation come in with abd pain.  Admitted to OB for her ectopic.


 Thank you for this information.  I appreciate knowing about this and will keep an open mind about this.


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## savemachine (Feb 22, 2017)

Thank you for the information.  This is good information to know.


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## EpiEMS (Feb 22, 2017)




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## Handsome Robb (Feb 22, 2017)

We need the facebook trash pigeons on here.


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