Obestetrical Scenario

[coffeegal]

Here is a scenario I came up with for my capstone project, tell me what you think:
TOPIC: Obstetrics
DISPATCH: MED 123 respond emergency traffic to a sick person at 123 Hawthorne Ln. Cad Notes: 20 YOF, nauseated and vomiting. Caller hung up.
BSI/PPE: Gloves
SCENE SIZE UP
Scene is safe
MOI/NOI: N/V
# of patients: 1
Additional Resources: Fire Department is on scene
C-Spine: not indicated
PRIMARY
GI: You arrive to the pt’s residence and go inside the house. Your patient, 20 YOF, is in the hallway bathroom leaning over the toilet vomiting.
LOC: Alert and oriented
CC/Life Threats: N/V
A: Patent
B: 22RR, normal, 98% on room air, L/S clear and equal.
C: Strong radial pulse, no major bleeding, skin pale, diaphoretic, cool.
HISTORY
Onset: Started about a week ago with N, just started throwing up yesterday morning, but it went away about 11, and came back this morning.
Provocation: “Nothing helps”
Quality: N/A, no pain
Radiation: N/A
Severity: N/A, no pain. Threw up three times yesterday, hasn’t stopped today
Time: Started again when I woke up this morning.
S: N/V, approx 100mL fluid loss noted in the toliet
A: Codeine, Ibuprofen
M: Multivitamin, Allergy meds, Birth Control
P: No history
L: Dinner last night
E: Just woke up
SECONDARY
-Cardiovascular: Sinus Tachycardia 124HR
-GI/GU: Last ate a chicken and rice for dinner, staying hydrated with water, urinating normally, LBM yesterday.
-Reproductive: LMP last month, supposed to start 5 days ago for this month. Just got married last month, sexually active, but takes birth control.
VITALS
110/62; 122HR; 20RR; 98% on room air; BGl 74; Sinus Tachycardia
116/64; 110HR; 18RR; 98%; Sinus Tachycardia
DIAGNOSIS: Hyperemesis Gravidarum (Morning Sickness)
INTERVENTIONS: IV, Fluids, Zofran, Oxygen
TRANSPORT: Routine to closest facility.

 

[Handsome Robb]

If she's compliant with her BC it's highly unlikely she's pregnant. If she's taken a round of antibiotics that can reduce the effectiveness. Women can be irregular with their menstrual cycles and not be pregnant.

I guess I don't really see what you're getting at. Do you have a question you need answered?


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[coffeegal]

Realistic? I know it might be hard to figure out what the problem is because it could be a lot of things from a bug to food poisoning, but I tried to make it kinda obvious.

 

[Handsome Robb]

Yea, it is but like you said there's a lot that could be wrong here. Is this a scenario you're presenting to classmates for them to answer?


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[coffeegal]

It's a scenario we are going to go through for practice.

 

[SpecialK]

From the information presented the only specific treatment I'd give her is an ondansetron wafer.

My recommendation would be she continues oral fluids and see her GP within the next few days to get a bHCG to check she is not pregnant (not usual if somebody is on OCP but I've seen it before .....). Certainly doesn't need immediate referral, nor ambulance transport, anywhere.

 

[BobBarker]

Why are we giving Oxygen to a person with a level of 98% on RA?

 

[NomadicMedic]

Yeah, she'd get (at most) a zofran ODT and a yak sak. Nothing particularly worrisome here. I'd assume, since she called 911 and is a millennial, she at this point "can't even" and "OMG" needs to be taken to the ED post haste.

Maybe a BLS call if she's not puking and I hold off on the zofran.

 

[Handsome Robb]

It's a scenario we are going to go through for practice.

If you want it to absolutely be pregnancy but not make it blatant and make your classmates think and provide a teachable moment I'd make it so she's compliant with her BC but had a respiratory infection or something that she was on abx for.

Like the others have said I'd give her a zofran ODT and a ride if she wanted it. Otherwise I'd probably just give her the ODT and recommend she makes an apt with her PCP or goes to an urgent care.


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[VentMonkey]

If you want it to absolutely be pregnancy but not make it blatant and make your classmates think and provide a teachable moment I'd make it so she's compliant with her BC but had a respiratory infection or something that she was on abx for.

And instead of calling it BC, give it a name brand like Depo™, or Marena™. Instead of the obvious "morning sickness" angle, perhaps she's tachypneic, and dyspneic.

If they go further into their assessment they find that she'd recently completed a long road trip as well...see where I am going here?

Either way, again like the others said, you gotta blind side people. This is what helps develop a strong clinical base, index for suspicion, and critical thinking capabilities.

Side note: this was a scenario question I would give to my cockier paramedic interns as part of their internship; many stop at Marena™, as they had no clue what that was. My answer to them was almost always "look it up".

 

[EpiEMS]

Yeah, she'd get (at most) a zofran ODT and a yak sak. Nothing particularly worrisome here. I'd assume, since she called 911 and is a millennial, she at this point "can't even" and "OMG" needs to be taken to the ED post haste.

Maybe a BLS call if she's not puking and I hold off on the zofran.

Wouldn't bother me to take it BLS if the transport time is <30 minutes or so. I only have so many emesis bags, you see

I feel like this scenario could use some fleshing out, story-wise, but I'm not strictly sure what. I think Robb and VentMonkey had some good thoughts on this one.

 

[VentMonkey]

Wouldn't bother me to take it BLS if the transport time is <30 minutes or so. I only have so many emesis bags, you see

I feel like this scenario could use some fleshing out, story-wise, but I'm not strictly sure what. I think Robb and VentMonkey had some good thoughts on this one.

In all seriousness, true hyperemesis gravidum can be at least something worth IVF, Zofran IVP, and some D50 if they had been in fact vomiting for days on end (it can happen), but as others mentioned this would start as a Zofran ODT, simply cardiac monitor, and a BGL-type of call; there's not much else to do.

Op, perhaps brush up on your critical thinking skills a bit? Good luck.

 

[coffeegal]

Thanks for the replies. I wound up changing up the scenario to a preeclampsia that goes to eclampsia call. This way it is cut and clear on ALS, and also will required meds if they don't assess correctly, as she will start seizing again.

It's hard to paint the picture I was going for in the scenario above. I was thinking along the lines of been throwing up so much for days and haven't been able to keep much down, so she is dehydrated from hyperemesis gravidarum. Maybe I needed to paint that picture a little better in the scenario. Thanks for the feedback, showed me I needed something a little better.

 

[VentMonkey]

I wound up changing up the scenario to a preeclampsia that goes to eclampsia call. This way it is cut and clear on ALS, and also will required meds if they don't assess correctly, as she will start seizing again.

Fair enough, just remember as others pointed out clear cut scenarios sometimes make foe "cut and dry paramedics", which also does nothing for their critical thinking abilities.

I understand perhaps at this phase, you may not want to confuse their moldable brains too much, but perhaps even throw some differentials at them once you wrap your scenario up.

Also, let us know how it goes.

 

[Handsome Robb]

In all seriousness, true hyperemesis gravidum can be at least something worth Zofran IVP and some D10 if they had been in fact vomiting for days on end (it can happen), but as others mentioned this would start as a Zofran ODT, simply cardiac monitor, and a BGL-type of call; there's not much else to do.

Op, perhaps brush up on your critical thinking skills a bit? Good luck.

Fixed that for ya.


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[VentMonkey]

just failed the Nremt -b for the 3rd time , what now?

Wrong thread.

http://emtlife.com/threads/having-trouble-passing-nremt-b-suggestions.8740/

 

[CALEMT]

yeah sorry bout that just frustrated and feel like i'm losing hope with becoming a FF.

Totally not related to this thread but this is a pet peeve of mine. Not the grammar, but becoming a EMT or paramedic just to get on with a FD. You should become a EMT or paramedic because you want to, not because you have to.

Anyway, carry on with the OB scenarios.

 

[Alan L Serve]

Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat again: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test.

"I can't be preggers! It's IMPOSSIBLE! I'm on b-control, he uses condoms, and I'm a lesbian who has never had sex with a man, and I live in seclusion on the top of a mountain with not a single human being around doing yoga 24/7/365!" Turned out she was preggers and they did an abdominal CT scan for her abd pain while believing her story that she couldn't possibly be preggers. The baby waved and gave the middle finger to the CT tech for the unnecessary high dose of radiation and for believing the mom.

Say it again with me, ok?: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test.

Once get those confirmed laboratory results back which show negatives for pregnancy then you can consider others items on your differential such as food poisoning, viral GI, etc.

 

[gotbeerz001]

Sometimes an AMA can reveal more about a medic than a call with a definitive answer


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[gotbeerz001]

Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test. I repeat again: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test.

"I can't be preggers! It's IMPOSSIBLE! I'm on b-control, he uses condoms, and I'm a lesbian who has never had sex with a man, and I live in seclusion on the top of a mountain with not a single human being around doing yoga 24/7/365!" Turned out she was preggers and they did an abdominal CT scan for her abd pain while believing her story that she couldn't possibly be preggers. The baby waved and gave the middle finger to the CT tech for the unnecessary high dose of radiation and for believing the mom.

Say it again with me, ok?: Every female of child bearing age is considered pregnant until proven otherwise by a confirmed laboratory test.

Once get those confirmed laboratory results back which show negatives for pregnancy then you can consider others items on your differential such as food poisoning, viral GI, etc.

OP, this advice will get you past the OB section of the registry...


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