Two difficult OB cases

May 13th, 2015 by Garrett Hooker

I’ve been going in every morning to see that patient of mine who’s in respiratory failure.  The tap seemed to help somewhat and she’s breathing a bit more comfortably, but it’s sort of a temporary fix and she’s needing Valium intermittently to stay relaxed.  I don’t think she has much longer.  I got her labs back today.  Unfortunately, what we’re able to do at our facility is so simplistic it almost wasn’t even worth sending them.  Basically they were inconclusive, but there were a few signs that the effusion is secondary to some sort of malignancy.

 

Clinic was busy yesterday, as are most Mondays.  My patients were as follows:

– 14 month old male with viral gastroenteritis.

– 22 month old male with possible viral gastroenteritis.  He was recently treated for Giardia but couldn’t leave a stool sample at the moment, so I don’t really know.

– 6 month old male with chronic cough…probably just GERD, but could be pertussis around here.

– 19 year old male with patellofemoral syndrome.

– 4 year old male with viral URI and a chalazion.

– 38 year old male with GERD and a headache.

– 1 year old male with one episode of hematochezia.

– 47 year old female with constipation and a lumbar back strain.

– 13 year old female with recent Chikungunya who came in for a follow up on her myalgias.  She had a white count of 27,000 about 4 days ago.

– 44 year old male with constipation

– 55 year old female with atypical chest pain, probably caused by a combination of trapezius spasm and anxiety.  Of note, she was also wearing a Yoda shirt that said “size matters not” and probably had not idea what the translation was.

– 53 year old male with newly diagnosed COPD and hypertension. Started him up on some inhalers and Norvasc.

 

I was invited over to Mark and Heidi Merritt’s house for supper.  They’re both from Virginia and have been here for about 10 years.  Mark is a family doc who’s been working with me on that lady in respiratory failure.  A home cooked meal was appreciated since I’ve pretty much been eating like a bachelor for the last week.  Here they have an interesting version of Neopolitan ice cream that contains strawberry and vanilla, but lime instead of chocolate.  At the moment though, anything cold is nice.

 

This morning our ob/gyn, Vance, had to run to La Ceiba.  So, the plan was for us to turn any OB patients away who weren’t imminently about to deliver since we didn’t really have coverage for c-sections.  I’ve done a number of them in the past, but apparently they don’t just hand the reigns over to people they just meet…probably a good policy I suppose.  Anyway, at no more than 12 minutes into the day, and 15 year old G1P0 at 37 weeks rolls in dilated to about 6 cm.  The nurse comes to let me know we have someone here, so I went and checked her.  She was actually more like 7 cm and her cervix was really thin, so I didn’t think there would be any way she’d be able to make it to another hospital.  I went back to clinic and tried to see people between visits back to check her.  After doing this for a couple of hours, she was complete and ready to start pushing.  She actually did a really nice job and got the baby out in about 45 minutes, which is pretty good if it’s your first rodeo.  Her pelvic outlet was pretty small, so she had a second degree perineal lac that I started sewing up…but blood just kept gushing down into my field of view and it was hard to get anything done.  I eventually gave her a dose of Methergine in addition to the Pit which she was already receiving in the IV.  This still didn’t stop the bleeding.  The girl weighed in at probably about 100 pounds, and knowing her reserve probably wasn’t as high as some of our fluffier ladies, I decided to subject her to a bimanual exam.  This is especially uncomfortable for somebody without an epidural.  I was able to retrieve a couple handfuls of clots, along with what appeared to be some retained tissue…likely the source of the bleeding.  After I got all that out, the bleeding stopped and I was able to go back to clinic.  I was a little concerned for a few minutes though.

 

The patients I saw in clinic today included the following:

– 53 year old female her for an ER follow up from the other night.  She came in with hip pain that I thought was probably just due to a strain.  Turns out it was.

– 73 year old female here for a follow up on COPD and CHF

– 66 yo F with diabetes and osteoarthritis in multiple places

– 59 yo M with newly diagnosed hypertriglyceridemia

– 63 yo F with constipation

– 48 yo F with something I can’t recall

– 12 yo M with an elbow abnormality that’s been worsening over the past 3 years.  Whenever he extends his elbow, the olecranon slides laterally over the humerus rather than into the olecranon fossa.  I took an x-ray of it and will be sending him to one of our surgeons.  I’m concerned it could be an osteosarcoma and he’ll need to have his arm amputated.  Here’s a picture of it:

169.possible osteosarcoma

 

 

Right as I was finishing up with clinic, Peter came to tell me there was a 20 year old G1P0 at approximately 20.5 weeks with a threatened abortion in the ER.  She’d been bleeding for about 2-3 days.  Apparently yesterday she had an ultrasound done at another facility and everything looked normal.  I got out the ultrasound and was able to find fetal heart tones, but it looked like the baby was breech and some of its contents were already outside the uterus.  I moved her to the OB room and did a sterile speculum exam on her.  Right away I could see her amniotic sac at the introitus and knew delivery was pretty much imminent.  So I explained in broken Spanish to these people that basically the baby was about to deliver and would die within a few minutes of being outside mom.  They of course were upset, but took the news surprisingly well.  I’m thinking down here maybe people are just more accustomed to having a poor pregnancy outcome now and then.  I ended up delivering that baby a little while later.  Just to add to the excitement, it was breech.  I’ll spare the details, but suffice it to say that didn’t help matters.