Monday, May 20, 2013

A pregnant conundrum?

20yoF ~9mo pregnant (aka due any minute) called us for labor in progress... pt is a G3P1011 (this indicates 3 pregnancies, with 1 term births, 0 preterm births, 1 induced abortion or miscarriage, and 1 living kids).

Pt indicates that she is having strong contractions every 2-3mins apart lasting ~30sec ever since her water broke ~30min prior... she delayed calling 911 or having anyone take her because she wanted to "check" with her OB/GYN as to what she should do... who told her to come in to the hospital immediately as the pt is status post 1 C-section already, and has been scheduled for another one 1wk from now.... per her doctor the pt absolutely CANNOT have a VBAC (Vaginal Birth After C-section) because of some unknown complication that occurred with her first birth putting her at higher risk for uterine rupture... and most certain maternal & fetal death.

The problem.... her doctor's hospital is 25mins away Lights & Sirens or 45mins through rush hour traffic non-emergent... vs. the closest Obstetric Hospital which is 5mins away. The pt absolutely refuses to go to any other hospital other than the one where her physician is...

For anyone that knows me, if there is any chance of a delivery... I get off the scene quicker than if this was a trauma... aka... I'm on scene 5mins or less usually... so approximately 5mins into on scene time, and despite exhaustive efforts at convincing pt (visibly uncomfortable from her contractions) that it would be the safest to take her to the closest facility, the pt gets off the stretcher starting to walk back out of my ambulance & indicates that she will REFUSE if I take her anywhere other than her hospital. My partner offers to have our supervisor meet us on scene (eta ~15min) to see if he can remedy this situation.

So my question to YOU is...
1) Do you take her to her hospital of choice, knowing that you may be risking a vaginal delivery in the truck on the way there? And/or the possibility of uterine rupture?
2) Do you wait for your supervisor to show up & settle this?
3) Do you get her family involved, and try convincing her further to go to the closest hospital?

Any other suggestions?


First off, I must say that this may have been one of the most commented on posts (on EMSDoc911 Facebook page) that I've had in a while... which is great, because my intention for posting these cases is to stimulate a flow of ideas between the many professions that are within the realm of EMS and medicine.  It is always very interesting to see the variety of approaches to the same issue at hand... because how a paramedic may handle this may not be the same as a nurse or another professional... there were even a multitude of different/contradictory responses by paramedics that are of the same certification level.

This case was NOT clear cut... EMS rarely is... so the way I approached it, you may disagree with, and that is OK.  The last thing any of us need is a medic that second guesses you or me from the comfort of his couch.  Learn, don't second guess.

But to the case...

The one thing that I will never be able to adequately describe to you is the true feel of the scene, the gut feeling while in it, and the chaos of the real world.  Even though my call may be very similar to yours, every scene is dynamic, and never exactly the same.  My patient was in pain... but not too much pain... she looked like she was going to deliver... but not right now... she needed to be taken to the hospital... but the closest one? Not yet. Did I feel comfortable risking a 25min drive in rush hour traffic?

I was.

The most important point out of this is the fact that taking her to the closest facility AGAINST her will... is kidnapping, plain and simple.  Several of you suggested doing this... this is against the law.  It is NEVER ok to drag somebody to a facility without their explicit consent (unless implied consent of course)... this would be an ambulance chaser lawyer's dream.

Air transport from the scene is RARELY (if ever) utilized when intra-city, particularly when there are more hospitals scattered in the city than the local 711s, hence risks of flight/landing itself outweigh any benefits of expedited transport by this mode.  Any time you consider AIR transport, ask yourself this, what is the benefit that this patient will be receiving?  If you are 20-30mins away by ground from the facility of choice, is it really quicker?  If not, then what would this patient be gaining by flying?

Let's take our case, if I was to activate a helicopter:
2min from my call to activation of the flight crew
3min for warming of heli & crew readying
5min flight to scene (we assume heli is close... not always)
5min for scene time: pt packaging, take-off, etc
5min flight to hospital
5min from safe landing on the roof, pt extrication out of heli, elevator to ED or L&D

Total time:  25min!  And this is on the LOW end!!!

Exact same time that it would have taken me to transport this pt emergent to the EXACT same hospital... WITHOUT the extra utilization of fire/ems units for landing site prep, shutting down traffic, dangers of flight itself... and the exponentially higher bill for the air transport... for what?  Benefit?

Some indicated that it looked like she had "a while before delivery" as her contractions were still far apart... remember, the BEST place for a delivery to take place is in the comfort of a L&D dept, and not our MRSA infested trucks.  When was the last time you honestly deconed your ENTIRE truck after EVERY patient?  Furthermore, when deliveries go bad, they go REALLY bad... there is no in between.  Err on the side of caution, particularly with higher risk deliveries, and not the complacency of her "contractions are still far apart," we have NO fetal monitoring equipment in EMS... and by the point WE realize fetal distress, it is usually too late.

Others of you wanted to involve the patient's OB/GYN physician... a wise choice at first glance, but impractical when you have limited time.  Calling AND getting a hold of a physician that will ALSO give you a time a day can be worse than getting a customer service representative from a cell phone company.  In my opinion, it is time wasted when time counts... however, a wise choice when you have the luxury to play with time.

Calling med control.  Even though you will get an ER doc much quicker on the phone, don't forget that you may be on hold for a while as well... they may be busy doing a procedure, in with a patient... all too often I have been asked to call back OR have been on hold for up to 10-15mins waiting to get an attending to pick up... again time wasted, when you don't have much to spare.  Furthermore, unless the physician you are calling has a decent professional relationship with you, trusts you, I would bet that they would be hard pressed to offer you any other advice other than TAKE HER TO THE CLOSEST HOSPITAL.  A sentiment you already knew, and your patient rejected.  By the looks of my patient, some random ER doc telling her the same thing I did, would not have cut it.

Remember, that in that moment, you are attempting to relinquish the responsibility for making the tough, "life & death" decision by calling the ED doc... but this goes both ways... it would take a LOT for me as the doctor to take on that liability from you, if I was on the receiving end.  If this is the first time that I have ever spoken to you, and you ask me whether you should/should not take this pt to the closest facility AND/OR getting me to talk to the patient... yea, I will be erring on the side of caution, I'm not there on scene with you, I don't have the full picture... and will tell you the SAFEST thing to do... which may NOT be the BEST thing to do.  Makes sense?

My patient was determined to go to her doc, and I was NOT going to stand in her way OR waste time.  For those of you that frequent the inner city populace as your patients, do know that heated scenes can explode in seconds.  This was one of those times.  Everyone was outside, everyone was yelling, everyone was putting in their two cents, and everyone wanted to get in my truck.... ummm no.  Family help has its merits, this wasn't one of those cases.

Waiting for the sup?  As you can probably already tell, that would be an incredible waste of precious time... I will let you fill in the blanks as to why I think that is a bad idea.

After unsuccessfully attempting to reason with my determined patient, I agreed to take her to her hospital 25mins away under the following conditions:

1) If there was ANY worsening (sudden bleeding, imminent delivery, significant vital sign deterioration), I would divert to a closer OB capable facility, there were going to be TWO that we were passing on the way, ~10mins apart, giving me ample buffer in case I needed to divert.
2) I would be the judge of her deterioration if any, and my decision would be final.
3) She would be signing a refusal acknowledging the fact that she disregarded my medical advice at the potential risk of harming her unborn fetus AND herself.

The patient agreed to all terms.  The transport was uneventful, and she delivered a healthy baby boy later that afternoon by her doctor.

Moral of this long, dragged out post, if you made it this far reading it... sometimes what you feel is the best for the patient, is in reality what is actually best for you, and not necessarily for your patient.  Our job is not easy... our patients are not always reasonable with what YOU want (even though sometimes it may be what is best for them)... but a compromise can usually be obtained if YOU are reasonable to their demands.  We are here to serve THEM... even though the patients sometimes may not want to serve themselves.

Her actions could.... key word COULD... could have been disastrous.  But they were HER actions, and we must respect that... to a degree.  My rule of thumb is:

The more UNSTABLE a pt is, the LESS bargaining power THEY have.

The more STABLE a pt is, the LESS bargaining power I have.


Stay safe!


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