COTW: Ectopics and Outside Hospitals

One of my former attendings at St. Joe's where I did my residency used to say that getting pregnant is the most dangerous thing a woman can do with her life. Basically, if you look at the statistics of maternal mortality, and even in the US dying from abortions, infections, bleeding, and the “morbidities” (or bad side effects) that come from pregnancy it's worse than women dying from, say, motor vehicle accidents. I never really appreciated that fact until I came here, because women are dying at a much higher rate than I've seen before. So far in the hospital, I think around 10 women have died from complications of their pregnancies, just in the last three months that I have been here. Contrast that to no deaths in four years at St. Joe's (although we came close a couple of times). It's tough to see, mentally and emotionally, when women that “shouldn't” be dying, are.
Sometimes I get a chance to save women that would have otherwise died. One of the biggest life-saving interventions involves ectopic pregnancies. For the non-medically initiated reading this blog, an ectopic pregnancy is when the embryo implants outside of the uterus—usually in the fallopian tube, but sometimes on the ovary, inside the abdomen, etc. It's life threatening to the mom because as the pregnancy develops, it can rupture through the tube (or wherever it's located) and cause severe bleeding. Unfortunately, there is no way to save the developing pregnancy, but quick surgical intervention by removing the pregnancy and sometimes the tube can save the mom's life. In women who come in with severe belly pain, we always try to keep this diagnosis high on the list in our minds to make sure we don't misdiagnose it. I've done about half a dozen of these surgeries here, and it's been rewarding.
My case of the week is related to this topic, sort of, and also to the fact that Tenwek gets a lot of referrals from surrounding hospitals for more severe illnesses and diagnoses. Many of these patients, however, come with little to no documentation of what has been done for them, or a note bearing a diagnosis that is not true. It's a challenging situation. Several weeks ago my intern, Elijah, called me to the delivery room to see a “critically ill” patient. She was lying on the stretcher, moaning and writhing about, while he was trying to start an IV. Although her belly was distended and extremely painful to the touch, she didn't appear obviously pregnant.
“What's going on here?” I asked. Elijah tried to explain what he knew, and handed me the referral note from the “outside hospital.” Now, medical people will know what I mean when I say the note was a SOAP note. Basically, this is our standard form of medical documentation where you first record the patient's story, then your exam, and finally your assessment/diagnosis and your plan of care. Her note was scribbled on the back of an advertising flier, and read:
S: Abdominal pain
O: Distended abdomen
A: Ruptured ectopic
P: To Tenwek for surgery
This, my friends, is a pathetic note. There is no patient history, no vital signs (blood pressure, etc), no lab tests, and no indication of why this particular physician (or whoever) thought the patient had a ruptured ectopic pregnancy, other than the fact that she was a female in her 20s. Now, the key to diagnosing an ectopic pregnancy is actually (surprise, surprise), a positive pregnancy test. If you're not pregnant, you can't have an ectopic pregnancy. We did not have a pregnancy test result for this patient. She was obviously in pain, though, and appeared to have a surgical abdomen, so I asked Elijah to put a catheter in the patient so we could get a pregnancy test documented before we wheeled her to the OR. I placed the ultrasound on her belly and saw this:

Just then, Elijah placed the catheter in...and got over TWO LITERS of urine out of her bladder. Normally, you would pee about 1/8 of that amount. The patient received immediate relief. Diagnosis: urinary retention. The pregnancy test turned out negative, and she went home happy. So some days you save lives in dramatic ways, and some days you don't really save lives at all but do provide comfort, and it's cause to laugh at the system and be glad for easy solutions that offer big relief. And it's always a lesson to never assume anything about previous care received by a patient!