OB case for the Orals.

[sevoflurane]

I elected to do mine in October... but here is a case for those of you taking them in the next couple of weeks.

30 yo AA G1p0 at 30 weeks gestation, with Sickle cell ds, with splenic infarction, BP 70/40, HR 120, hgb 7, FHT 60-70-loss of variability. Jehovah's witness, refused Blood. 20g IV right hand.

Wacha gonna do?

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[bullard]

Volume resuscitate. Try to make sure one of the senior residents is operating, not the $%$ing intern. Etomidate/sux/tube assuming otherwise no medical problems and easy airway. Uterotonics. Before she goes to sleep, make sure she understands she may die if she doesn't accept a necessary blood transfusion. Cellsaver might be a little controversial in the C-section room, but I'd go ahead and get it hooked up. Expect the worst, hope for the best. ICU postop.

 

[rsgillmd]

Volume resuscitate. Try to make sure one of the senior residents is operating, not the $%$ing intern. Etomidate/sux/tube assuming otherwise no medical problems and easy airway. Uterotonics. Before she goes to sleep, make sure she understands she may die if she doesn't accept a necessary blood transfusion. Cellsaver might be a little controversial in the C-section room, but I'd go ahead and get it hooked up. Expect the worst, hope for the best. ICU postop.

Not as controversial these days as a couple of years ago. I've used it. Have a separate suction for when they puncture membranes to be on the safe side.

However, you've got to ask the patient if she is agreeable to it. Most of the ones I've met have been agreeable, but a few have not.

There are other unknowns here about the mother and the baby obviously, including whether the baby is low enough to be pulled out vaginally with forceps. However, in general, I agree that you should not kill the mother to save the baby. In this situation if you fix the mother, odds are you'll fix the baby.

 

[Intrathecal]

If OB residents haven't already done so, administer O2 via non-rebreather mask, place patient in left uterine displacement position, fluid bolus, and see if things improve. Place a larger peripheral IV. Check platelet count before neuraxial techniques. If they call for C-section and neuraxial out of the question, prop/pentathol, sux, tube. Call NICU and be ready to intubate the baby when it comes out.

 

[pgg]

History and exam. Sounds like she's bleeding - do we have a diagnosis re: where the bleeding is from? Ie, previa vs uterine rupture vs GSW vs leeches from her holistic internet-trained midwife ... That degree of hypotension & tachycardia is a lot worse than what I'd expect from someone who isn't bleeding. Hb of 7 isn't too far out there for a pregnant sickler, chronic anemia alone doesn't explain those vitals, and acute blood loss won't be reliably reflected in that number anyway.

Other concerns -
1) As with all JWs, determine what products they will accept. If no RBCs, then what about FFP, platelets, cryo, albumin, 7A, etc. Some will surprise you with what they'll take. Cell saver? Maybe.
2) Sickler - do the usual things to reduce the risk of sickling (avoid hypoxia, hypothermia, etc) but you're probably somewhat screwed there as she's already vasoconstricted, peripherally cold, and likely in need of pressors.

LUD, oxygen. Phenylephrine followed by crystalloid resuscitation and better access. If by chance these maneuvers result in a normotensive mom and FHR >120, reassess. I'd have a heavy bias against regional even if she appears stable now. Otherwise GA - etomidate/succ RSI/delivery. Continued resuscitation / bleeding control.

 

[Planktonmd]

Great answer PGG!
If were the examiner I would let you pass!
I took the orals long time ago but I always tell people to think of the case as they would think of a chess game, try to anticipate where the examiner is going to lead you next, and tailor your answers accordingly.
The issues here are:
1- Acute bleeding in a patient that refuses blood transfusion.
2- Urgency: the baby is not doing too well
3- most likely difficult airway: the examiner is going to steer you there so be prepared.
4- IV access
You need to be prepared for their next move and no matter what your plan is you need to be able to defend it and show a reasonable thought process.

History and exam. Sounds like she's bleeding - do we have a diagnosis re: where the bleeding is from? Ie, previa vs uterine rupture vs GSW vs leeches from her holistic internet-trained midwife ... That degree of hypotension & tachycardia is a lot worse than what I'd expect from someone who isn't bleeding. Hb of 7 isn't too far out there for a pregnant sickler, chronic anemia alone doesn't explain those vitals, and acute blood loss won't be reliably reflected in that number anyway.

Other concerns -
1) As with all JWs, determine what products they will accept. If no RBCs, then what about FFP, platelets, cryo, albumin, 7A, etc. Some will surprise you with what they'll take. Cell saver? Maybe.
2) Sickler - do the usual things to reduce the risk of sickling (avoid hypoxia, hypothermia, etc) but you're probably somewhat screwed there as she's already vasoconstricted, peripherally cold, and likely in need of pressors.

LUD, oxygen. Phenylephrine followed by crystalloid resuscitation and better access. If by chance these maneuvers result in a normotensive mom and FHR >120, reassess. I'd have a heavy bias against regional even if she appears stable now. Otherwise GA - etomidate/succ RSI/delivery. Continued resuscitation / bleeding control.

 

[IN2B8R]

Great answer PGG!
If were the examiner I would let you pass!
I took the orals long time ago but I always tell people to think of the case as they would think of a chess game, try to anticipate where the examiner is going to lead you next, and tailor your answers accordingly.
The issues here are:
1- Acute bleeding in a patient that refuses blood transfusion.
2- Urgency: the baby is not doing too well
3- most likely difficult airway: the examiner is going to steer you there so be prepared.
4- IV access
You need to be prepared for their next move and no matter what your plan is you need to be able to defend it and show a reasonable thought process.

And that, my friend, is what makes some pass and others fail

 

[Gern Blansten]

There is the ethical issue of witholding blood if the mom's life is in danger, with a viable fetus at risk at the same time. Most places will get a court order if it is a kid having surgery and the parents refuse blood on behalf of the child. When the child is in utero, it is a bit cloudier. Do we, as providers, owe the child a fighting chance? Do they deserve the right to grow up with a mom?

Are any aware that the "no blood transfusion" rule was nearly abandoned by the JW church about a decade ago. It was to the point that literature was printed, but pulled just before distribution. I have seen one of the supposed documents (that was leaked out) online previously. There is an entire faction of the church who are vocal and against the "no transfusion" policy. How would it feel to have a loved one die in surgery from a preventable cause, such as refusal of transfusion, only to have the church repeal that rule. Maybe worse still would be not changing their policy. The crux of it is that their policy has changed so much over the years(some blood fractions okay now; factor therapy for hemophiliacs originally forbidden, then approved as a one time therapy, then approved for multiple uses, all of this occurring over several years time) that the policy does not even make sense any longer. How is it that someone will willingly receive a heart, liver, or kidney transplant, but will refuse blood?

Some interesting reading on the topic:

http://www.ajwrb.org/Watchtower_Leadership_and_Blood.pdf

http://www.ajwrb.org/

The author goes by the pseudonym Lee Elder, since his stance would lead to being "disfellowshipped" by his church.

Wikipedia actually has a pretty thorough discussion on the topic. I predict that, in our lifetime, we will see the abandonment of this policy.

Sorry to sidetrack, but ethical issues come up on the oral boards as well.

 

[IN2B8R]

I elected to do mine in October... but here is a case for those of you taking them in the next couple of weeks.

30 yo AA G1p0 at 30 weeks gestation, with Sickle cell ds, with splenic infarction, BP 70/40, HR 120, hgb 7, FHT 60-70-loss of variability. Jehovah's witness, refused Blood. 20g IV right hand.

Wacha gonna do?

Sevo: since we came from the same house, I feel the obligation to impart the below wisdom onto thee (for free !). Worked well for me when I took it years back and passed on first try:

1) Look sharp on exam day.
2) You will always know less than your examiners: their body language will telegraph that to you.
3) Always answer what is asked--no dancing around with an answer, otherwise you have just f*cked yourself for the remainder of your exam. If you do not know, just say "I do not know," but that line should not be coming out of your mouth too many times.
3) Even when they are tired and wrong with their questioning, you are still beneath them: do not try to correct your examiner through your answers or with further questioning (the other examiner in the room will usually pick up on the mistakes of the one who is wrongfully quizzing you).
4) Give answers that relate to what you do daily in your practice and what you have done in your training. Don't give masturbation answers: if it is propofol, sux, then tube, then that's your answer. It does not become Ketamine "because I want to maintain spontaneous breathing in a term gravid fat ass..."
5)Try to catch a good night sleep and a light breakfast before your exam. If you have not slept well, then you will literally blow every point above because you could not process what the examiners were asking you (and btw, they do not care if you didn't sleep the night before).


Good luck!

 

[Gern Blansten]

for clarification, I am not suggesting that you have the above discussion with an oral board examiner, unless they specifically lead you there. DO NOT lead yourself into ethically controversial areas on the oral board exam.

 

[sevoflurane]

Thanks for the words Home-E. Gonna have a couple of sit downs with the silver back at the ol' house (MCQ). That should also help.

Sevo: since we came from the same house, I feel the obligation to impart the below wisdom onto thee (for free !). Worked well for me when I took it years back and passed on first try:

1) Look sharp on exam day.
2) You will always know less than your examiners: their body language will telegraph that to you.
3) Always answer what is asked--no dancing around with an answer, otherwise you have just f*cked yourself for the remainder of your exam. If you do not know, just say "I do not know," but that line should not be coming out of your mouth too many times.
3) Even when they are tired and wrong with their questioning, you are still beneath them: do not try to correct your examiner through your answers or with further questioning (the other examiner in the room will usually pick up on the mistakes of the one who is wrongfully quizzing you).
4) Give answers that relate to what you do daily in your practice and what you have done in your training. Don't give masturbation answers: if it is propofol, sux, then tube, then that's your answer. It does not become Ketamine "because I want to maintain spontaneous breathing in a term gravid fat ass..."
5)Try to catch a good night sleep and a light breakfast before your exam. If you have not slept well, then you will literally blow every point above because you could not process what the examiners were asking you (and btw, they do not care if you didn't sleep the night before).


Good luck!

 

[IN2B8R]

Thanks for the words Home-E. Gonna have a couple of sit downs with the silver back at the ol' house (MCQ). That should also help.

G'luck. Let me know if you need any help. I'm sure you are dying to know my true identity

 

[sevoflurane]

G'luck. Let me know if you need any help. I'm sure you are dying to know my true identity

I will uncover your identity IN2B8R....

http://piratevitamins.files.wordpress.com/2009/03/******_ninja.jpg







....

 

[IN2B8R]

I will uncover your identity IN2B8R....

http://piratevitamins.files.wordpress.com/2009/03/******_ninja.jpg







....

Hahaha, love that pic