Sunday, October 07, 2007

Why Pregnant Women Frighten Me

I had spent the first half of my shift in the "Fast Track" section of the Emergency Department. Cases that are a level 4 and 5 on the 5-point triage scale are sent to Fast Track in order to make room for the more acute cases in the main ER. Cases that rate a 4 or 5 are cuts, sprains, bumps, bruises, series antibiotics, migraines, the mother who brings her six kids in because the ER is her family clinic, and such.

(I am a fervent proponent of "Fast Track." It keeps the patients suffering from non life-threatening ailments from having to wait too long to be seen, and it keeps the really sick people from having to wait for a bed.)

But this night was tough. Every patient I had was a pregnant woman. One had a headache (she was dehydrated, and needed to drink enough water for two instead of only one). Another woman had abdominal cramping but no spotting. (fetal heart tones were reassuring, she was not spotting, and she turned out to have gastroenteritis.) Others were there for coughs, colds, fevers,and so on. In all cases, FHTs were obtained and the 'passengers' were all just fine. But I was ready to be done with pregnant women.

Don't get me wrong. I think that pregnancy is, in itself, an amazing process. But at the same time, even a "normal" pregnancy is fraught with danger to both child and mother. Pregnant women are like the X-planes of the 1950s: awesome things happen inside them, but they can self-destruct in spectacular fashion without warning and without the slightest provocation. Pregnant women scare the crap out of me.

Fast Track closed at Midnight, and I was assigned the Float RN position until 0300.

At about 0100, the medic call came, signified over the intercom system by a soft,sweetly-intoned, bong-bong-bong that belied its urgency. The MD picked up the phone to receive the report. As he took notes, his brow furrowed and he rubbed his forehead with his free hand. He hung up the phone and handed me the Medic Call sheet.

A pregnant 25-tear-old woman had an on-scene BP of 226/116. Heart rate was 52. She complained of severe headache and numbness to her left arm. ETA was 10 minutes. I groaned.

We had taken care of pre-eclamptic patients before. Magnesium is the weapon of choice because it reduces the risk of seizures associated with eclampsia. Lopressor (a beta blocker) is also favored because it protects the heart and lowers blood pressure. But since this woman's heart rate was less than 60, we could not give Lopressor and thus intended to use magnesium as aggressively as possible. She was really rummy from the Mag; her speech was slurred, her limbs were floppy. But her vital signs were great. So we sent her to CT. Since I was the 'float' RN at the time, I went with the patient. She was on a portable monitor so I could continue to see what her body was doing.

She made it through CT like a champ. No evidence of a brain injury was found. As we were exiting the CT control room I said to the CT tech with a sigh, "Taking care of pregnant women scares the crap out of me. It's like being a demolitions expert." The CT tech said a heartfelt "Amen!" We carefully transferred the woman from the CT table to the stretcher for the trip back to her room. I looked up to reach for the oxygen tubing, and then looked down at her.

At that moment, she seized.

I rolled her onto her left side and barked to the CT tech, "Get the doctor NOW!" The other tech in the room frantically stuck a Yankauer wand onto the end of some suction tubing and handed the wand to me. I suctioned the secretions out of her mouth to keep her airway clear and waited the thousand years it seemed to take for the MD to get there. He finally arrived, breathless, and asked, "How long has she been seizing?"

"About a minute," I replied. The seizure was just beginning to abate.

"Let's get her back to the room now."

We pushed her back into the exam room (which was only thirty feet away from CT) while keeping her on her left side. The seizure had stopped by the time we got her back on the full monitor. She then entered the post-ictal phase and became combative. She swung, punched, kicked, and screamed gibberish.

"Give her 1mg of Ativan. Ramp up the Magnesium to 4 grams per hour. Keep her in soft restraints. I don't want to lose that IV, and I don't want to intubate her. Get her back on the fetal monitor," the MD said as he left the room.

We followed the orders. The patient was hemodynamically stable soon thereafter, and the Ativan helped settle her down. But the problem was not solved yet. Her passenger was in grave danger, and she was not out of the woods yet, either.

The on-call OB-GYN came in the room and said, "Get her ready to transfer to the University. I've already signed the orders." I set about getting the paperwork ready while the patient's primary nurse continued direct care. Within the hour, the patient was on her way to the other hospital.

We heard the next day that the patient underwent an emergency cesarean section. The baby was in very bad shape and not likely to make it. The mom had a massive stroke during the procedure and was also not likely to survive. It was her first pregnancy.