We emergency physicians are generally a confident bunch. But in the time it takes to slip on a peel and hit the pavement (a bananosecond), some of us ratchet up adrenaline output when we pick up a chart and notice a history like 22 yo F, minor MVC, c/o headache and back pain, 32 weeks pregnant.
From whence comes this anxiety? A bit may stem from reading about those seven-figure lawsuit verdicts for pregnancy-related malpractice cases. However, tied to this are those questions and comments I often hear from residents seeking assurance, even when they know the answers.
Can I get this x-ray?
Is it OK to give her morphine IV? Should I start with 1 mg? (Sure, if it’s in the right acupuncture point.)
Wow, I’m so used to not treating asymptomatic elevated BP that I almost forgot to address it for this pregnant patient.
Getting answers from specialists can often be frustrating. The OB doc may be uncomfortable with the non-OB aspects of the case, while the other consulting specialists may be uncomfortable applying their expertise in the context of pregnancy.
I recall asking a surgeon to look at a third-trimester patient with likely appendicitis and an equivocal ultrasound. His plan related to me was, "We’ll sit on it overnight." After making some remark about his own application of procto-tocin, I suggested an MRI. He was a bit leery, but with some education and pressure on our radiologist to do our hospital’s first MRI to rule out appendicitis (accomplished without procedural sedation on that radiologist), we identified an acute appy.
As with many aspects of EM, it may be up to the EP to coordinate optimal care in these situations. In 1981, Dr. Arnold Greensher and I developed a system called Prenatal Care – A Systems Approach to help OBs and primary care physicians integrate prenatal care within a comprehensive risk management system. It includes frequently updated information on managing nonobstetric illness and injury in this population. The system’s development was coordinated with a panel of well-regarded academic specialists, including a group of perinatologists.
The track record for the system has been quite surprising to us, as well as to the medical malpractice insurers who purchased the system for their docs: There were more than 1.5 million deliveries during this time period with only 8 malpractice claims. The expected number of claims would be 400-700. For a large number of users, premium rates went down dramatically during a time when national rates were going in the opposite direction.
Over the past year, I’ve contributed two well-received articles for the Focus On series in ACEP News: Trauma in the Obstetric Patient in July 2010 and Perinatal Disaster Management in September 2011 (both can be found at www.acep.org/focuson). I was honored to be invited by the publication’s editorial panel to provide a quarterly column that focuses on unique aspects of emergency care of the pregnant patient. The goal of this column will be to provide practical recommendations for the EP on common presenting problems in this population. I will often have coauthors, including specialists in that topic, as well as perinatologist input. One of our residents will be an integral part of this group. Our column is not intended to be a standard of care, but rather a sound, easy-to-use package of recommendations that would be considered one avenue for providing optimal care.
Each article will have a clinical tool – a summary that can stand alone for easy reference. In fact, our Trauma Table is posted in a number of EDs that I have visited. As ACEP News technology progresses, we hope to have these as a library with the tables hyperlinked to the specific didactic parts of the articles.
In this issue, we debut our first article, Stroke in Pregnancy (pp. XX-XX). This will provide a nice supplement to any stroke protocols at your hospital. Later in 2012, we plan to have one on sepsis and another on cardiac emergencies, including acute coronary syndromes.
I look forward to sharing this column with you.
Dr. Roemer is an Associate Professor in the Department of Emergency Medicine, Oklahoma University School of Community Medicine, Tulsa.