It was another day of craziness, this time of the OB variety. A patient I saw in triage a few days ago returned. She is about 39 weeks pregnant with mild preeclampsia, being followed very carefully in clinic. Well, today she flipped her mild preeclampsia right on its head and came in seizing. It was frightening. She seized twice (once in the field, one in the hospital), had a brief post ictal state, then became extremely combative, taking 5 people to hold her down to medicate her, get and IV line in, and draw labs. She stabilized enough to be sent eventually to Anchorage, thankfully. Paradoxically some times patients are too sick to be sent to Anchorage. Recently there was a similar patient who was sent, seized in the air, got pulmonary edema, and coded in the medevac. Both she and her baby did not make it.
But it was a different fate for this patient, thankfully. She made it to Anchorage and delivered there safely. Right around the time this patient was being stabilized, I got an interesting call from a PA in one of the subregional clinics. The subregional clinics are slightly better equipped than the village clinics, meaning they have some limited lab capabilities, occasionally have the option of xrays, and are mostly staffed by PAs.
This PA announced, "I have a 34 week pregnant woman who is ruptured." Hmmm. Not my favorite. And this particular village is quite remote (on the scale of bumble to more and more bumble, meaning 1.5 hours away by flight). The PA said she hadn't done a speculum exam on the patient but when she went to do so, "cups of clear fluid came pouring out". The PA approximated her cervix at 3-4 cm dilated. I ran this by the high risk OB on call doc who kindly told me that this particular PA is a lovely person who is completely incapable of making correct clinical judgements when it comes to OB. It seems this PA has had a few similar claims with resultant medevacs for women not ruptured, not dilated, not in labor. Regardless, I had to activate the medevac. The real question was to send a doc along or not. If a preterm ruptured woman is not in labor (no contractions at all) then a doctor does not have to accompany the medic team. However, if she is contracting, the doc must go. That means me (eeek) or the high risk OB (yes, please).
I called the PA back to assess contractions (bearing in mind the reliability of the assessor). Her response: No contractions at all but she has an urge to push. Well, gosh. That just doesn't make any sense at all. And this was not this woman's first baby. Another rock paper scissors moment... and the high risk OB doc decided to go along for the ride. Whew. I was glad not to have to leave the floor. That creates all sorts of havoc.
While the team was in flight I received 2 ALL CAPS PAGES that A DELIVERY IS IMMINENT in the village of question. I call the PA back who was certain the baby was about to deliver (meanwhile the medic team was about 40 min away). I talked her through a few things that I could and sent her on her merry way. Did the baby deliver? No. Was she having contractions? No. Was she ruptured? Yes. But the team made it back to Bethel safely with the fetus in question still in utero. The patient was kicking into labor just as I signed off to the night doc. And she turned out to be 35 weeks which made everyone breathe a little easier.
Work in between all that hair-raising two discharges, a new psychiatric admission, a million other RMT calls, a women presenting in active labor, and another woman presenting with term rupture of membranes, not quite in labor, and that brings us up to 6 pm.
I scooted out of there ready to collapse and inhale some instant soup. Another day awaits. And then another. And another. And then I go back home (but who's counting?!).
so my friend from growing up, Brenda, is the OB case manager...she said she's going to try to find you.
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