Inter-Hospital Transfer of the Pregnant Woman: 2/2

July 4, 2012July 21, 2016 / Jordyn Redwood / Leave a comment

Dr. Tanya Goodwin concludes her two-part series on NICU designations and transfer of the OB patient. Excellent information for any author writing this scenario. You can find Part I here.

Welcome back, Tanya!

Prior to any transfer, the woman’s pre-term labor must be assessed. The OB performs a history and physical examination while the nurses attach a fetal Doppler and a Tocometer to record fetal heart beat and uterine contractions respectively, start an IV, and they or a lab tech draw blood.

MPR News

Typical blood work would include a complete blood count (for evidence of infection, anemia, or clotting problem) electrolytes (blood chemistry), type and screen (in case blood transfusion necessary or injection for blood type – Rhogam). If the woman is contracting then medications to stall labor are started (Magnesium Sulfate IV, Procardia orally).

Before the OB or labor nurse performs a vaginal exam to assess cervical dilation, a sterile speculum is inserted into the vagina and a special swab called fetal fibronectin is done (a positive result increases the risk that the woman will deliver pre-term). If ruptured membranes are suspected then a sample of fluid is evaluated for amniotic fluid. If the water hasn’t broken pre-term, then the OB does an internal exam to check for cervical dilation.

Antibiotics may be given to decrease the risk of neonatal Group B Streptococcal sepsis (severe and life threatening bacterial infection) Also a corticosteroid injection may be given to the woman between 26 – 32 weeks gestation to help accelerate fetal lung maturation.

Once the woman is assessed for labor, the OB must make a decision as to the probability that his/her patient will make it to another facility without giving birth en route or encounter a medical complication. The OB’s first obligation is to the mother, and then fetus. Stabilizing the pregnant woman is paramount. The fetus depends on the health of the mother.

A U.S./governmental code called EMTALA or Emergency Medical Treatment and Active Labor Act forbids rejection of care and transfer of an unstable patient to another facility. This applies to all hospitals that participate (or receive payment) from Medicare/Medicaid, which is virtually every U.S. hospital. Its original intention was to prevent hospitals from “dumping” indigent patients into “charity hospitals”.

The OB explains the situation to the woman and any family she consents to relay medical information to. This is typically the father of the baby. Risks and benefits of transfer are discussed with the woman and “family” and the woman must give consent to be transferred.

The OB then calls a “transfer center” relaying information regarding the woman’s status and the necessity for transfer to a higher level of care. The transfer center finds the nearest suitable facility and connects the admitting OB to the receiving/accepting OB. Medical information is exchanged. Once the patient is accepted, then depending on distance or urgency, the woman is transported via helicopter (weather permitting) or ambulance. If this is a neonate, then the pediatrician is in charge of obtaining appropriate transport. Nurses also give nurse-to-nurse report. Medical records generated are copied and go with the patient. Everyone involved keeps one another updated as to the outcome, hopefully a happy ending but unfortunately not always that way.

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Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com

Inter-Hospital Transfer of the Pregnant Woman: 1/2

July 2, 2012July 21, 2016 / Jordyn Redwood / Leave a comment

I’m pleased to host Dr. Tanya Goodwin as she discusses the difference between NICU’s and their designation. This will be Part I of her post. Part II covering transfer specifics will be on Wednesday.

One thing I want to point out is the Trauma Center designations run opposite of NICU’s. A Level I Trauma Center is where the most critical patients are taken if possible. Level II and Level III can always stabilize but may need to transfer the patient out.

Welcome back, Tanya!

Most pregnant woman will happily deliver their babies in a comfy hospital maternity unit. But for a few, their labor and delivery may need to be at a more specialized facility, or their infants may need to be transferred to an appropriate NICU or Neonatal Intensive Care Unit.

So how does this all happen?

Aside from a rare, life threatening maternal illness or a pregnant woman involved in a traumatic accident, transfer of the pregnant woman is usually based on the neonatal need.

A woman between 36 and 40+ weeks gestation (last month of pregnancy) can stay at a level I facility. Their babies will do quite well in a regular newborn nursery. Occasionally, a full-term baby may not adjust well to extrauterine life or have breathing problems or unforeseen medical or surgical issues that requires prompt transport to level II or III NICU (usually level III).

A level II nursery or special care nursery can accommodate those infants between 32 and 35 weeks. A 35 “weeker”, if doing well can stay at a level I /newborn nursery. Infants in a Level II are mainly there to feed and grow or receive a course of antibiotics.

Level III NICU’s are for babies that need long term care such as assistance with respirations via ventilators, medical or surgical issues. They may need to be fed through special nutritional intravenous fluids. These are the NICUs you usually see on TV.

A newer level, IV, has been touted as the place for extreme pre-term babies, between 22-25 weeks. Level III/IV are in urban centers (tertiary centers or teaching hospitals) where there are 24 hr neonatologists/sub-specialty neonatologists, physicians, surgeons, anesthesiologists, fellows, residents, and medical student. A very busy place!

Two of the most common scenarios requiring maternal transfer are pre-term labor (labor before completed 36 weeks pregnancy) and premature rupture of membranes (water breaking before 36 weeks). These conditions frequently co-exist, but not necessarily. If the OB is in a level I unit, then transfer of the woman is considered. If the OB is in a level II unit then depending on the gestation, the woman may stay or may be transported. No problem if already in a tertiary hospital.

Dissociative Fugue: Tanya Goodwin

May 11, 2012July 21, 2016 / Jordyn Redwood / Leave a comment

I’m so pleased to have Dr. Goodwin back. She is a lot like me in that the rare and unusual fascinate her. I thoroughly enjoyed this post and I think it makes for a good character disease/developemnt.

Welcome back, Tanya!

In case you missed my last month’s guest post on necrotizing fasciitis, rare or unusual medical conditions fascinate me. Today’s weird condition is dissociative fugue, the basis of my debut novel, If Memory Serves, in which my protagonist, Dr. Tara Ross experiences this disorder.

The Merck Manual defines dissociative fugue as one or more episodes of amnesia resulting in the inability to recall one’s past and the loss of one’s identity accompanied by the formation of a new identity with sudden and unexpected travel from home; a traumatic nature that isn’t explained by normal forgetfulness.

The DSM IV (a diagnostic manual of psychiatric disorders) characterizes dissociative fugue by 1) sudden and unplanned travel from home 2) inability to recall past events or important information from the person’s life 3) confusion or loss of memory 4) significant distress or impairment.

Fugue is temporary and there isn’t a physical or organic cause (ie brain injury or stroke). Although it’s rare (2% of population), it can happen to those that are chronically stressed, often with a major inciting event noxious enough to catapult them into a fugue state. It’s the brain’s defense mechanism, and eventually resolves within days, weeks, or months, leaving them unaware of occurrences during their amnesic state. They are fully functional but may not recall their identity or parts of their identity. They are often called travelers since they wander or travel away from home. Their nomadic adventure generally occurs after a stressful event.

Physiologically, the hippocampus of the brain is bathed in cortisol, the stress hormone secreted by the adrenal glands, those glands that sit on top of the kidneys. Normally cortisol is ushered away from the brain by calming hormones that bind or pick up cortisol and send it to the kidneys for excretion. The chronic wearing of the nervous system leads to the decrease of important neuropeptides and neurotransmitters necessary for memory creation, processing, and storage. The brain is like a computer and if pressed with too many requests in too short of time freezes from the overload.

So what’s the treatment? Dissociative fugue is temporary and will eventually resolve, but psychotherapy and cognitive therapy can be very helpful. If the person is very anxious or clinically depressed, pharmacologic remedies are considered. And of course, other organic sources of memory loss should be ruled out by blood work and radiologic tests such as CAT scans.

Because the disorder is self-limiting, the prognosis is good. Attention to the underlying emotional issues decreases the likelihood that dissociative fugue may reoccur.

So how did I get interested in dissociative fugue? When I was an OB/GYN resident (doctor in training) I often left the hospital exhausted and stressed. One day, I couldn’t remember how I had made it home, waking up in my bed completely disorganized. It was a frightening experience, at least for a minute or two. That prompted me to think of dissociative fugue and what it must feel like to be totally lost.

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Rare Disorders – Flesh Eating Disease

March 28, 2012July 21, 2016 / Jordyn Redwood / Leave a comment

I’m so pleased to host Tanya Goodwin, OB/GYN extraordinaire. She’ll be stopping by on a monthly basis to offer her insight into all things medical.

Welcome, Tanya!

http://www.medicinenet.com/necrotizing_fasciitis/article.htm

As a medical student I was taught about a barrage of diseases, acute and chronic, common and rare. One of the rare was necrotizing fasciitis.

Thinking I’d never encounter this deadly disease, I forgot about it until one night as a second year OB/GYN resident (4 year specialty training after medical school) when I was called to evaluate a woman who was transferred from a community hospital to our large teaching institution with possible necrotizing fasciitis.

I briefly reviewed this disease before I took the elevator, along with my intern (aka 1^st year resident) to the ninth floor, ready to evaluate this young woman.

It was midnight when we entered her room. My attending (supervising physician) had accepted her transfer as a direct admission, bypassing her need to enter via the emergency department.

She laid in the bed, covered with a white hospital sheet, her husband holding her hand. He darted his eyes towards us. Why would he trust us? His wife’s condition had worsened despite being hospitalized for the last three days.

During that time, she’d received intravenous antibiotics upon the recommendation of a doctor who specialized in infectious diseases. The consult was requested by her obstetrician who had admitted her to the hospital one week after she had given birth vaginally to a healthy baby boy.

Diagnosis? Necrotizing fasciitis.

Necrotizing means dying or death and fasciitis refers to inflammation of the fascia, a tough connective tissue overlying muscle. Rare, the incidence of NF is approximately 1 in 450,000 or 600 people per year.

Otherwise known by the moniker, Flesh Eating Disease.

During childbirth, the obstetrician performed an episiotomy, a surgical incision of the perineum, that skin between the vagina and anus to afford a wider opening to deliver the baby. After the delivery, the episiotomy was sutured closed. The woman went home with her baby, but had called the OB’s office several times with complaints of episiotomy pain, a common occurrence.

Instructed, as usual, to apply anesthetic foam and to take an oral pain medicine, she did so but with no improvement. After multiple phone calls, she now complained of not only refractory episiotomy pain, but fever and chills, malaise, and reddening of her genitals and inner thighs. She was told to come to the doctor’s office.

Diagnosed with an episiotomy infection, her OB admitted her to the hospital for intravenous antibiotics. The redness spread, her fever continued, she was now nauseated, and her blood work showed a significantly elevated white blood cell count consistent with a severe infection. An infectious disease consult was then made by her OB.

Necrotizing fasciitis is caused by invasion of bacteria into the fascia after a break in the skin. Many bacteria or a single offender are the culprits. Typical bacteria are of the streptococci family such as Group A streptococcus or a staphylococcus, both found on our skin. The disease really is not “flesh eating” as the toxins from the bacteria do the damage.

Some have contracted NF by swimming in water containing Vibrio vulnificans. These victims of NF had a portal of entry: a skin scrape or laceration. Those at risk for necrotizing fasciitis are people with lowered immunity from chronic diseases such as autoimmune disorders, diabetes, and liver disease, but it is also seen in healthy people or those that have had surgery or an incision. Symptoms are pain, swelling, redness, feeling poorly, nausea, vomiting, and fever.

What I saw that night still sticks in my memory 20 years later. The woman’s thighs down to just above her knees looked like the worst sunburn I’d seen. At this point, she felt nothing in the affected area as numbness had set in.

My attending physician had examined her as well. After explaining the gravity of the situation, the woman was taken to the operating room to debride, or cut out, the dead tissue. In two surgeries, the first taking all night, she had her vaginal tissues and thighs removed.

She died the second day in the intensive care unit. The bacteria had spread to all her deep tissues. She became septic and died of multiple organ failure, leaving a grieving husband and a newborn son.

NF has a mortality rate greater than 70%. If diagnosed early and treated promptly with surgical debridement, some literature suggests a mortality rate of 33%. Unfortunately for this woman, the diagnosis was correct, but the initial and critical treatment was not.

Hopefully as more providers are aware of this deadly disease, more cases of necrotizing fasciitis will be correctly diagnosed and promptly treated, saving lives.

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