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

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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Medical Question: Drugging a Pregnant Woman

Sheila asks: In my WIP, I have the good guy (a doctor) trying to get the pregnant heroine away from a dangerous situation. She resists so I thought he might give her an injection to knock her out. Is any drug available to put a pregnant woman into a deep sleep that is not harmful to the fetus?
Jordyn says: First thing to know is that every drug has a pregnancy classification given by the FDA based on its potential harm to a growing baby. You can find an example of this at this web site: 

http://www.safefetus.com/fda_category.asp

Based on this, you can look up certain drugs and get a hint about their potential harm to the baby.
I looked up several drugs that could be injected to knock a woman out.
Benzodiazepines are all injectable… this would be Valium, Versed and Ativan. Given rapidly IV, they could knock the woman out but also depress her ability to breath. This could harm the baby. They are all category D on the scale which denotes that there is evidence of potential harm. However, how far along is the woman in her pregnancy? Is she near term? Drugs will have different effects given the term of pregnancy and also how long the drug is used for. For instance, a single injection of Valium given late in pregnancy probably will have little effect on the baby as far as causing a birth defect. Also, this doesn’t mean you can’t pick this drug. It would increase the internal conflict of your character, knowing he is giving a potentially harmful drug to this woman.
Benadryl, which is an antihistamine, can also be given IV. It may make the character sleepy but not totally knock her out. Benadryl’s effects aren’t at all predictable. It’s drug category is B.
Then, I thought of Ketamine. We use this in the ER all the time to sedate patients for reductions of fracture and other painful procedures. It has a very predictable effect and can be given IV or into the muscle (IM– intramuscularly). The IV duration is typically shorter than the IM duration.
Here’s some info regarding Ketamine’s use during pregnancy:
Ketamine Pregnancy Warnings
“Ketamine has not been formally assigned to a pregnancy category by the FDA. Animal studies at higher than human doses failed to reveal evidence of teratogenicity or impairment of fertility. There are no controlled data in human pregnancy. Since the safe use in pregnancy and delivery has not been established, the manufacturer recommends that ketamine be considered contraindicated in pregnant women. Ketamine has been assigned to pregnancy Risk Factor B by Briggs et al. as probably compatible.” http://www.drugs.com/pregnancy/ketamine.html.

Heidi offers this perspective:  It would be highly unusual for a doctor to get involved with a patient’s decision to return to an abusive relationship (or prevent it). The intervening party is usually the nurse. In the case you are describing, if the nurse was trying to keep a pregnant patient out of harm’s way, she/he could do many things but the standard is to get a good reactive strip, then give 2mg Stadol and 25 of Phenergan, this combo will generate a nonreactive strip (put both mom and baby to sleep), the doc cannot release the patient with a non-reassuring strip.

Benadryl can also be used to put a pregnant person to sleep, Tylenol pm is highly used but it does not usually affect the strip. But for all intensive purposes, the drug of choice to stop a pregnant person from going anywhere would be phenergan because it is easily accessed, you do not need a witness to remove from the automated drug delivery system, and it is prescribed regularly for nausea and vomiting which are common in pregnancy. Also, pregnant patients are familiar with it and don’t usually question it if the doctor orders it.
Any other thoughts for Sheila?

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A retired middle-grade science teacher and proud grandmother to three, Sheila Hollinghead lives in south Alabama with her husband of thirty years. She has written three books and is seeking publication. She also writes two blogs, one for Christian writers called Rise, Write, Shine!: http://sheilahollinghead.blogspot.com/ and a devotional blog, Eternal Springs:  http://sheilaodomhollinghead.wordpress.com/.