Do I look stupid to you?

Spontaneous rupture of membranes (aka SROM, aka water breaking) is a great reason for doctors to actively intervene in a pregnant patient’s care.  If the pregnancy is at term, it’s a good time to induce or augment labor in order to facilitate childbirth.  If it’s preterm, it’s a good time to attempt to stop or prevent labor, at least temporarily, to help prepare the mother and baby for delivery.  If, on the other hand, the water has not broken but the mother tells us it has (either because she really thinks her water broke or because she’s just tired of being pregnant), it’s important that we not promote labor and delivery, largely for the benefit of the child.  Either way, if a woman tells us her water has broken, it’s important for us to determine whether or not that’s really the case.

There are, of course, ways for the OBs to tell if a patient’s SROM is legit.  Typically, they perform three tests: speculum exam, ferning test, and nitrazine test.  The speculum exam involves using a speculum (what else?) to look for pooling of amniotic fluid the patient’s cervical vault.  The ferning test is done by putting a sample of the presumptive amniotic fluid on a microscope slide and looking for a characteristic crystallization pattern.  And the nitrazine test is done by exposing a sample of presumptive amniotic fluid to nitrazine and watching for a distinctive, characteristic color change.  If more than one of these tests are positive, it’s more likely that the patient did indeed experience SROM.

Despite modern medicine, however, some TOBPs think they can fake out their OBs.  "Hmm," they think, "I'll bet if I sit on a gurney and get the Chux pad under my butt wet, the doctors will think my water broke."  And what's the easiest way for them to get that pad wet?  Why, urinating on it, of course!

Which brings us to the patient.  She was a young woman, maybe 25 years old, who presented to the L&D deck one night while I was covering the night OB anesthesia service.  She arrived with a large water bottle in hand (really a 32 oz. mug full of water), which she was quite attached to.  She was complaining of regular, severe contractions, despite appearing to be quite comfortable.  The L&D nurses set her up in a triage room and took her vital signs, then she was seen by an OB resident.

The OB resident emerged from the patient's room several minutes later, shaking her head.  "That patient is gross," she said.

"What happened?" I asked.

"I was getting ready to do a spec exam, and I had my back turned to her, and she peed all over the Chux!" was the disgusted reply.

"Wait, what?!"

"She peed!  I had my back turned, and I was putting on gloves, and she got all excited and said, 'What was that?!  What was that?!  My water just broke!"

"OK..." I prompted.

"The Chux pad under her was wet, and her urine was really dilute from all the water she's drinking, but I could smell it and there wasn't much fluid in her vagina.  She peed on the Chux to try to make me think she SROMed."

"Wow..." I muttered, shaking my head.

"Anyway, I got what sample I could, and now I have to check nitrazine and ferning.  See you."

With that, the resident left and I returned to my reading.  I had all but forgotten about the incident when the OB resident returned and tapped my shoulder.

"OK, Matt, get this: you know how sperm makes the nitrazine test have a false positive?" she asked.

"You're asking me to cast my mind back to the dark days of med school, but yeah," I answered.

"Her nitrazine turned blue, but I could see swimmers on the slide.  So I went back in and asked her when the last time was that she had sex."

"OK..."

"And her husband said, 'Oh, it's been more than a week,' but she got really quiet and wouldn't look at me."

I looked over at the resident.  "You don't think..."

"Yes, I do think.  This lady is some piece of work.  I think I'm not the only one she's lying to this evening."

I shook my head in disbelief.  "I guess I'd rather be in your shoes than her husband's.  You think he'll put two and two together, and figure out why you asked when they had sex?"

"Maybe," she answered.

And there you have it.  Sometimes, the answers you get are a bit more than you bargained for.  And as irritating as it is when patients think their doctors are gullible fools, there are certainly worse things.

Ascending aortic dissection

No matter how much you know about medicine and anesthesiology, you’re going to come face-to-face with cases that challenge you.  Whether it’s the patient’s disease process, their overall health status, or considerations stemming from the surgical procedure itself, some cases are going to present a challenge.  And when those factors all combine with patient beliefs that prevent you from using some of your most important tools, you just set up for the case and know that you’re screwed six ways to Sunday.

My patient was a 33-year-old black woman with Marfan syndrome.  She had suffered an ascending aortic aneurysm with subsequent dissection.  Her chart showed that she had presented to an emergency room two months prior for chest pain, but a full workup had been unrevealing.  At the time of her dissection, she had become neurologically compromised, and on the day of her surgery she was in the ICU intubated but requiring no sedation.  She had also become hemodynamically unstable and her kidneys had failed; she was on CRRT.  She had anasarca with her tongue so swollen that it protruded several centimeters from her mouth; it was obvious that if we dislodged her endotracheal tube she would asphyxiate as we were unlikely to be able to replace it.  Similarly, we could see that placement of her lines was going to be very complicated.

The surgical plan was, of course, for median sternotomy, cardiopulmonary bypass, and repair of her dissected aneurysm.  Bypass causes notable dilution of the patient's blood, and transfusion of red blood cells and other blood products is very common in such cases.  This patient, starting with her hemoglobin a very anemic 7.3 gm/dL, would certainly require transfusion.

Except that she was a Jehovah's Witness.

It's not much fun to walk into a case knowing that your patient will die if she doesn't have surgery, but that she'll probably die because of the surgery.  The only solace you can take is from the knowledge that no matter what you do, it's going to be very difficult for you to make her any worse.  Some consolation.

The procedure and anesthetic management had been discussed at length with the patient's family, and their wishes had been made extremely clear.  We documented everything imaginable, partly so we could honor the patient's and the family's wishes and partly so we would know what fluids we would be able to administer.  The patient could receive no red blood cells, platelets, or plasma, but she could receive albumin, recombinant factor VII, and Cell Saver.

My attending and I made the best of it and prepared for the procedure.  He handled transport since my mobility is still limited by my tibial fracture.  The anesthesia techs helped with positioning and monitoring the patient, and I scrubbed and gowned for the placement of lines.

This patient already had a triple-lumen central line in her left IJ and it was simple to swap it over a wire for one of the double-lumen lines preferred at this particular hospital.  Placement of a MAC in her right IJ was a bit more complicated due to her extreme edema.  With virtually no neck mobility and great difficulty in retracting her edematous folds of skin, a two-handed procedure became a four-handed one as my attending and I each retracted skin in opposite directions, he handled the ultrasound, and I drove the needle.  We ultimately prevailed, though, and the case was soon underway.

Transesophageal echocardiography is a very useful tool in assessing the anatomy and function of the heart and the great vessels.  This young lady's TEE was wretched.  It showed a functional heart pumping blood into a badly traumatized aorta, a massive communication evident whereby blood could move from the true lumen to the pseudolumen.  The pseudolumen had grown in size until it dwarfed the true lumen; I thought it miraculous that the patient still had peripheral pulses.  The surgeons and my attending, for whom cardiac surgery and cardiac anesthesia are daily aspects of life, seemed impressed by the extent of her dissection.

For several hours, the surgeons worked, opening the young woman's chest and repairing her aorta.  All along, there were indications of how sick this young woman truly was.  Her BIS was constantly low, starting in the mid-20s when we rolled into the room and actually going to 00 with a flat EEG on 0.3 MAC of isoflurane, indicating the probable extent of her neurological devastation.  We drew no unnecessary lab work, regarding every milliliter of her blood as a precious commodity that should not be wasted.  An ABG drawn shortly after initiation of bypass showed that she was severely anemic, with a hemoglobin concentration of about 6 gm/dL.  Instead of waiting until the end of the case to administer Cell Saver blood, we asked the perfusionist to start making whole and half units as soon as he was able.

And still the surgeons worked.  They were ultimately successful in repairing her aorta, and we all breathed sighs of relief as the patient tolerated the weaning of cardiopulmonary bypass with only two vasoactive infusions.  The sternotomy was closed and the attending surgeon scrubbed out to dictate the case as his assistant continued with skin closure.

But as he closed, the patient began to deteriorate.  Her pressures worsened, her heart rate accelerated, and her BIS, already tenuous, dropped.  Fearing what we would see, my attending and I looked at the TEE and found the diagnosis: cardiac tamponade.  The patient was bleeding into her pericardial sac, and the blood looked like it was already clotting.

We showed the junior surgeon what we had seen and he immediately began cutting the sutures holding the patient's chest closed.  The attending surgeon hastily scrubbed back into the case and within a minute the patient's sternotomy had been reopened.  My attending and I watched the surgeons scoop clotted blood from the patient's pericardium, knowing that every red blood cell lost to that clot was a cell she needed desperately.

 As the surgeons closed the patient's chest again, we very cautiously administered albumin to maintain a reasonable blood volume without hemodiluting the patient too much.  By the end of the case, the patient's total fluid input was just one liter of albumin and 300 ml of lactated Ringers.  And still her final hemoglobin was just 4.4 gm/dL.  My attending and I traded dire prophecies with one another after we dropped our patient off in the ICU.  Neither of us thought she would live out the night.

Nearly a week later, she remains alive.  But all is not well.  Her neurological exam remains remarkably poor, and each day further dims the hope that she will experience any sort of meaningful recovery.

To me, that is one of the most difficult parts of medicine: knowing you've done your best, knowing you've done as well as anyone anywhere could do, and still feeling that you've been beaten.  All you can do is say a prayer for your patient and hope that you can help the next one.