Trainwreck #5

[usalsfyre]

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.

 

[Aidey]

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?

 

[abckidsmom]

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.

 

[usalsfyre]

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"

Vitals?

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

Any labs? Maybe a urine dip?

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

Any non OB medical history?

Substance abuse, and multiple STIs

Vaginal deliveries or c-sections?

All vaginal

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.

What drugs does she have a history of abusing?

Cocaine, alcohol, heroin and occasionally methamphetamine

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.

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.

What about reflexes? Edema?

+1 edema, normal reflexes.

Fetal movement?

Minimal fetal activity, but good FHTs by doppler.

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

 

[Sam Adams]

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?

 

[usalsfyre]

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)

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.

 

[abckidsmom]

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.


Substance abuse, and multiple STIs


All vaginal

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


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


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


+1 edema, normal reflexes.


Minimal fetal activity, but good FHTs by doppler.

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.

 

[fast65]

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


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[Sam Adams]

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)

 

[firetender]

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

 

[abckidsmom]

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.

 

[Farmer2DO]

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.

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.

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.

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.

 

[Aidey]

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.

 

[abckidsmom]

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?




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.



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.

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????

 

[usalsfyre]

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...

 

[abckidsmom]

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.

 

[usalsfyre]

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".

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.

 

[abckidsmom]

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.

 

[Farmer2DO]

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.

 

[usalsfyre]

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...