Medical Question: Suicidal Pregnant Patient

Lisa Asks:

I just found your site and it looks great! I'm writing my first mystery novel and I have a character who attempts suicide by taking an overdose of Ambien. She is discovered in time and pumped out, but I'd like to know:

If she was unconscious when they found her, would they give her adrenaline or anything to wake her up, or just let her sleep it off? Would she be on oxygen or on an IV with some sort of drugs to counteract the sleeping drug? If her family visited her right afterward is there a chance she'd still be sleeping? Would she be in a regular ward or the ICU on the first day? Or would she be shipped right to a psych ward?

Jordyn Says:

An unconscious patient is approached in a very step-wise fashion. This is drilled into medical people from the day they start school. Are they responsive? If not, open the airway. Is there anything in the airway that needs to come out? If not, the airway is clear. Is the patient breathing? If yes, how well? What are her breath sounds? What is her oxygen level? Does she have signs of respiratory distress? If the patient is not breathing well, she'll be assisted at that point. Next, is there a heartrate? If so, is it adequate? What is the blood pressure?

Actually, this has recently been reversed by the American Heart Association. Generally, there is a quick pulse check first. If no pulse... CPR is started right away. Then after a round of compressions, the patient is assessed for breathing. The components I mentioned above still apply.

 Based on this assessment, the EMS crew would determine what interventions need to be done. There are two medications that can be given as reversal: Narcan and Flumazenil. These only work for opiates and benzodiazepines.

 Adrenaline is Epineprhine. It would depend on what her other vital signs were at the time of her discovery. We don't give epinephrine just for unconsciousness. If she doesn't have a pulse and is not breathing and she has a particular arrhythmia (v-fib, v-tach, pulseless electrical activity) then these would be an indication for epinephrine. If she requires epinephrine, she likely will need someone to breathe for her as well.

 One thing I noticed is that you say her "stomach has been pumped out". This really isn't part of emergency care for overdose anymore. Many people don't understand what it means. We basically shove a garden hose down your throat and irrigate the stomach out with saline. The issue became that the risks of the patient having complications from the procedure were not worth the risk (risk to benefit ratio). Such complications could be inhaling vomit into their lungs and developing pneumonia or creating an electrolyte imbalance from using large amounts of saline to clear the stomach.

Generally, if a patient is discovered within one hour of their ingestion, we will give activated charcoal which is essentially ground up charcoal mixed with sugar. It looks like black sludge. The patient can either voluntarily drink it or we can put a tube into their stomach and give it that way. This medication will absorb the drug from their stomach, bind it so it becomes inactive, and then they poop it out.

Heidi adds:

It's pretty tough to over dose on Ambien unless it was your intention, so I'd definitely call that a suicide attempt. We'd probably monitor her ( on the obstetrics floor) for twenty four hours, put in a psych consult and have a sitter (a suicidal patient can't be left unattended).

You can keep a baby on the monitor starting at about 24 weeks, any GA (gestational age) before that you use a Doppler. We probably wouldn't keep her on the monitor but we'd admit her so she couldn't leave. Basically scare her into staying for "the sake of the baby" if nothing else. That way if she goes AMA (against medical advice) the hospital is not liable for either her or the baby.

Most level 2 and above hospitals see 24 weeks as the cut off for viability and there lots of things we can do to keep the fetus alive in cases of PPROM (Premature Rupture of Membranes), accidents, that kind of thing and with the right staff and facility you can maintain the viability of a 17 weeker.  

As for Ambien, we'd watch her more for maternal sake then baby. L&D nurses are good at getting the real story too, better than the counselors sometimes.  Ambien in a nut shell: 24 hours observation, intermittent monitoring, sitter, and consults. To get mama back in the game we do bedside ultrasounds so she can bond with baby and turn up the monitor so she can hear the baby, make life more real for her.  Nurses little tricks.

Any other thoughts for Lisa?

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Lisa Mladinich is the author of "Be an Amazing Catechist: Inspire the Faith of Children" and the founder of AmazingCatechists.com and Catholic Writers of Long Island. Her weekly catechetical column can be found at http://www.patheos.com/About-Patheos/Lisa-Mladinich.html

Sorting though Disaster: Triage and 9/11

As a tribute to the upcoming ten year anniversary of 9/11, I thought it would be nice to have our resident ER doc write about triage.

Where were you on 9/11? Please, leave a comment today.

Most people over the age of twenty probably have some memory burned into their mind of the fire consuming the World Trade Towers and their ultimate collapse and destruction.

northernlight220

I had just flown in from Chicago the night before. I remember waking up to the incessant ringing of our phone. Tired from the previous night, I was adamant about letting the machine pick it up. It became clear after about five minutes of solid ringing that perhaps it was an emergency. I answered and a good friend of mine was on the other end blubbering, crying—nonsensical. I remember fragments of her words—“planes crashed” , “New York”, “Thank God you’re back!”--“Just turn on your TV!”

I think I sat on the couch watching the tragedy unfold for the next three days.

A good friend of mine was working as a nurse at the time of the attacks. She’d just gotten off the night shift and was getting settled into sleep when the events broke. Immediately, she hustled back out of her apartment to go back to the hospital.

Upon her arrival, they were setting up for multiple victims, beginning to formulate a plan of how they would triage the patients.

Here’s triage from the ED doctor’s perspective: Dr. Edwards.

Some extraordinarily difficult decisions have to be made when you're dealing with a mass casualty situation. Unless you have unlimited resources to treat everyone, victims will have to be triaged.  Triage comes from the French verb trier--meaning to sort--and classically we think of three triage categories: 1) those victims so gravely injured they will not survive regardless of what you do; 2) those who can probably be saved if the right things are done quickly; and 3) those with lesser injuries who may be in distress but who can obviously wait (i.e., the walking wounded). 

 Battlefields have always been the crucible of innovations in trauma care, and indeed the modern concept of triage dates to the Napoleonic Wars of the late eighteenth and early nineteenth centuries.  The individual credited with inventing it (as well as field hospitals and fast-moving ambulances manned by trained individuals) was Dominique Jean Larrey, the French emperor's surgeon-in-chief. 

 Partly in response to 9/11, disaster medicine is now an actual specialty unto itself, with post-graduate fellowships and board exams.  Because of this, triage grows into more of a science each year as we evolve ever more sophisticated rating scales based upon injuries and vital signs to help providers make those fateful decisions about whom they will race to save.  

 The person assigned to triage duty must be trained to rapidly differentiate hopeless cases from those who might be saved, Typically, that individual will attach a color-coded tag alerting the rest of the team to the patient's category, and will also perform immediate life-saving maneuvers including the control of external bleeding, needle decompression of pneumothoraces (collapsed lungs), the insertion of mechanical airways, the initiation of field IV fluid resuscitation.  But more often primary triage involves deciding who must be transported to the hospital first. 

 When a mass casualty event occurs, hospitals switch into "disaster mode."  Carefully worked out plans involving the assignment of crisis team roles and the mobilization of additional staff--all practiced in regular drills, lest we become complacent--are activated.  Hallways and lounges become triage and treatment areas.  Larrey would have been impressed.

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Frank Edwards was born and raised in Western New York.  After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester.  Along the way he earned an MFA in Writing at Warren Wilson College.  He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.

Ways to Induce Labor According to the Old Wives

Have a pregnant character in your novel? What lengths might they go to to put themselves into labor? Would those methods actually work?

I'm pleased to host guest blogger Erin MacPherson today at Redwood's Medical Edge to discuss those ever popular myths (and some truths) about how to get a woman to go into labor. Erin has a wicked sense of humor so this should not only be informational but give you a chuckle as well. She hosts the equally funny Christian Mama's Guide.

If you're interested, I've started doing a twice monthly guest post over at Erin's blog giving "real life" girlfriend to girlfriend advice about pediatric issues. Ever wonder what a pediatric ER nurse thinks about things? This is the place to look. You can find my first post there that discusses if it's truly a risk taking a less than two-month old out in public. http://www.christianmamasguide.com/2011/08/31/newborns-and-the-er/

Welcome, Erin! I think her non-fiction book would be a great gift for anyone expecting a little one.

Somewhere between 36 and 41 weeks of pregnancy, you might decide to take matters into your own hands and try to induce labor at home. I fully support this. Not because I think it will work—it probably won't—but because the diversion of trying to induce labor at home will probably keep you from destroying the still-dirty baseboards in your nursery or wasting more gas on another trip to the hospital. Here are the old wives' best labor-inducing tricks:

1.        Eating spicy food. The story goes that eating a spicy burrito will get your whole digestive track moving and doing the Macarena, and your cervix will want to join the fun. The only effect I ever felt from eating spicy food was heartburn, but it's worth a try. A little Thai curry never hurt anybody.

2.        Walking. I tried this—a lot—at the end of my first pregnancy. I'd get home from work, grab a snack, lace up my tennies and start roaming the neighborhood. I didn't want to roam too far from home in case I actually went into labor, so I spent most of the time pacing in front of my house and looking psycho in front of my neighbors. It never did jump-start contractions, but it did soothe my nerves to be outside and get some fresh air.

3.        Sex. The gist of this method—which I'm sure was "discovered" by a man—is that sperm on the cervix can help spur it into dilating. Sounds a bit fishy to me, but my husband thought this sounded like a great idea, so I agreed to give it a try. It did not work out as well as my hubby or I had hoped. Not only did I not go into labor, but it was a bit tricky navigating around a really, really huge pregnant belly. But, you can rest assured, the same "professionals" who suggest this method, also assure you that it will in no way hurt your baby, so if you're wanting to give it a try, feel free.

4.        Castor oil. Castor oil makes your bowels move. The theory here is that —aside from giving you a really bad case of diarrhea— your moving bowels will somehow trigger a chain-reaction and the rest of your body will start moving as well. I have yet to know anyone that got anything other than diarrhea and some abdominal cramping from taking castor oil, but if you're a glutton for punishment—and ready to spend the day in the bathroom—then drink up.

5.        Nipple stimulation. I want to go on record as telling you not to try this one at home. I have a girlfriend whose doctor assisted her with nipple stimulation using a breast pump in the doctor's office with access to medical help, but most doctors don't recommend this method at all. Why? Because it actually works. Something about how nipple stimulation mimics a baby's suckling and causes your body to start contracting. The problem is that the contractions are often super-close together and super-unproductive, so it can pose a danger to you and your baby. So, if you absolutely must try this, I suggest that you talk to your doctor or midwife very candidly about it first and stay close to the hospital (say, in the parking lot) when you actually do it.

6.        Acupressure. Tell your hubby you want a foot rub—he groans and moans. Tell your hubby you need him to perform some acupressure to induce labor and suddenly he puts on his superhero glasses and gets focused on the task at hand. The general idea here is that by putting pressure on certain pressure points around your body, you can stimulate your uterus into contracting. Look up the pressure points online and ask your doctor if you're at all nervous. At the very least, you'll get a nice foot rub.

7.      Raspberry leaf tea. Raspberry leaf is on the pregnancy no-no list because it has a tendency to produce contractions. But if producing contractions is your aim, raspberry leaf tea can move off of the ix-nay list and onto the A-OK list. My doctor said it was safe after thirty-eight weeks, but before you go making yourself a big pitcher of raspberry iced tea, you might want to call your doctor just to be uber-certain that it's okay. It's always better safe than sorry.

8.      Begging and pleading with God for mercy. I guarantee that God will eventually hear your pleas and put you out of your misery.

QUESTION: What did you (or WOULD you) do to induce labor? Have you written a scene with a pregnant woman in labor?

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Religious Objection to Medical Care

Some religions object to medical care. Some believe in faith-healing. Other's will accept some medical treatment but object to some procedures such as blood transfusions.

When I worked in the pediatric intensive care unit, one of these instances arose. The child was on a breathing machine and not doing very well. The patient's hemoglobin level was low. You may know this as anemia. However, that's just one type of anemia. What's hemoglobin? It's the part of your red blood cell that carries oxygen. When you don't have enough hemoglobin to carry oxygen, your cells begin to starve and die. This leads to shock and death. It doesn't matter how much oxygen we deliver, if there's nothing to carry it to those individual cells, the patient can still die.

This problem is easy to solve. We give the child a blood transfusion. The parents, based on their religious beliefs, refused. This child's levels were so low, he was at risk for complications and he's already critically ill. It won't take much to tip him over the edge. What are the options?

In pediatrics, often tests can be run with a lot less blood so we do micro-sampling and keep track of every drop of blood we take. Micro-containers generally fill with about a 1/2ml of blood whereas adult tubes take up to 3ml's. Generally, patients in the ICU get labs every day to track their progress. The physician may choose to decrease the amount of labs done on a daily basis to conserve blood.

We ended up getting a court order to transfuse blood. The ICU docs were willing to respect the parent's position up to a point, but they were not willing to let the child die.

Imagine being the nurse at the bedside in the morning, trying as best as you can to only take a small amount of blood. Then getting the results back and wondering if you'll have to be the one to transfuse this patient.

The child survived and ended up not getting a blood transfusion and actually did really well. The nursing staff met with the family and a member of their church to discuss the issues that surrounded their child's care. A nurse asked the mother, "What would it have been like for you if we did give your child blood?" The mother responds, "It would have been like you raped my baby."

Those are strong, powerful words. I remember them to this day. Enough conflict? I think so and I definitely felt it at the time.