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Trial & Error

Trial & Error

Think Outside of the Box (and Policy)

Mouw, Michael MD

doi: 10.1097/01.EEM.0000695628.79862.ef

    ‘Doc, we need you in room nine stat!”

    I dropped the phone at my workstation at this suburban freestanding ED (FSED) and hustled down the hall. The teenage girl I had just seen, whose transfer I had been arranging when I was interrupted, was lying unconscious on the floor in a growing pool of blood. On the floor near her right hand was an empty urine specimen cup.

    On first contact in room nine a few minutes earlier, I had found her alone, sitting up on the stretcher, pale and diaphoretic, with a blood pressure of 70 mm Hg displayed on the monitor and a lot of blood in the bed. No nurse, no IV access. A brief history revealed she had started bleeding just a couple of hours before and had been having some moderate pelvic pain. She had missed a period, but had had no sexual activity. I went to the doorway and asked her nurse sitting at the desk to start IVs and get a pregnancy test. “I'm going to have to transfer her out since she's obviously in shock. If we don't get her pressure up with a liter bolus, we'll need to give her the O negative blood we have on hand. I'm going to enter her orders for you and get on the phone to arrange the transfer.”

    His look was one of surprised alarm. He had clearly mistriaged the severity of her situation. “OK, doc, but I can't get the saline out of the Pyxis until you put the order in.”

    This FSED had its own lab that performed urine hCGs (but not quants), as well as most other basic labs. I returned to my desk and ordered two IVs, a CBC, a type and screen, and a urine pregnancy test. I then got on the phone to the mother ship and asked to speak to an EP to arrange transfer. That's when I dropped the phone to return to room nine.

    Apparently, the first thing her nurse did was give her a urine cup and instruct her to go across the hall to collect a sample! Once we got her back in bed, he called another nurse to help. While he started the IV, I went for the portable ultrasound. I returned to find them trying unsuccessfully to catheterize her bladder. I remembered a trick I had learned somewhere, so we dipped an hCG stick into the vaginal blood. It was positive. Her bedside ultrasound was positive for intraperitoneal blood.

    The receiving EP accepted the transfer without a fuss. That FSED had a policy that required us to use their internal EMS for transfers, but they wouldn't be there for an hour, so I called 911. A county crew arrived 10 minutes later to take her. Total time in our department: about an hour (30 minutes of that before I saw her). They removed 3 L of blood from her abdomen and a ruptured ectopic. The next day, I was emailed by the medical director asking why I hadn't waited for their own ambulance!

    Case Lessons

    • You don't have to wait for a urine specimen to get an hCG. It can be done on venous or vaginal blood.
    • If facility administrative policies are in obvious conflict with patient safety, do what's best for the patient.

    Read the Trial & Error Blog

    Dr. Mouw's blog is a collegial forum for emergency physicians to share lessons they learned from mistakes in practice. Submit your case, and we will publish it there with a brief analysis by Dr. Mouw. All cases will be published anonymously unless you choose to use your name, as Dr. Mouw has done. Submit cases to [email protected].

    A few rules:

    • No names (patients or otherwise) or identifying characteristics.
    • Don't exceed 500 words. Cases will be edited for grammar, length, and clarity.
    • Photographs, clinical images, and lab reports are welcome, and should be 300 dpi and in jpg, tif, or gif format.
    • Authors are responsible for obtaining consent from patients, family members, and health care professionals depicted in images, and must attest to EMN that consent was obtained.
    • Authors should provide their full name and contact information for verification purposes. This will not be published without permission.
    • Only post cases outside the statute of limitations. Pertinent references are helpful.
    • Comments about the cases are welcome. Submit yours to [email protected]. Limit: 200 words.

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    Dr. Mouwtrained in emergency medicine at Charity Hospital in New Orleans and entered practice at Brackenridge Hospital in Austin, TX, in 1987. He was an associate medical director, emergency medicine residency faculty member, and active in medical staff affairs there until 2017. He also served as a quality/peer reviewer for the Texas State Board of Medical Examiners. He now works locums at community hospitals and freestanding EDs, and writes the EMN blog Trial & Error at Follow him on Twitter@mouwser.

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