Handling a maternal cardiac arrest situation-rural EMS

[Riblett]

So I propose the following question regarding a sudden cardiac arrest of a pregnant female in the rural setting. Pt is anywhere from 24-40 weeks gestation in a witnessed cardiac arrest. You obviously do not spend anytime on scene working it, so it is time to make the hospital choice.

You have three options:

1. Take her to the local community hospital ED that is less than ten minutes away. They have no OB capability, no NICU/PICU.

2. Take her to the hospital in the border county to the north, about 20-25 min drive hauling ass. Their ED is nothing special, they don't have a NICU/PICU, but they have full OB capabilities.

3. Take her to the hospital in the border county to the south, about a 25-30 min drive hauling ass. They are a level one trauma center, pediatric specialty ED, full OB capabilities, full NICU/PICU.

Which hospital would you choose and why? How would your decision change if the arrest was traumatic in nature? Is use of a helicopter appropriate?

[Arctickat]

The best chance of survival for mother and baby is for me to stay on scene and work her. The time my patient loses by running BLS to out local hospital will be wasted. The nearest facility capable of a c-section is over an hour from me and the nearest NICU is over 2 hours. There is no helicopter service available at all.

More than likely, they are both dead.

[fiznat]

What do you mean by "OB capabilities?"

There are a lot of OB code situations for which the only real treatment is emergency delivery of the baby. A coded, expectant mother needs an ED capable of treating this patient, not epi + atropine from the paramedic on scene. I'm confused though what the real difference is between the 1st and 2nd (by distance) option hospitals. What can #2 offer that #1 cannot? If they both have doctors and an emergency room that's really all you need *right now.*

[Riblett]

Good question Fiz,

The local community hospital is a very small ED with 14 beds and 1 MD. THey have always thrown a fit if you bring anything OB to them. There are no OB/GYN docs or dedicated facilities. They also transfer any and all pediatric patients if they have more than a simply stitchable lac, simple fracture, or the sniffles. They rarely if ever give any blood or blood products in the ED. Any remotely significant trauma gets transferred out.

It seem to me that all they really need for an emergency c-section is a scalpel and an MD.

[JPINFV]

Ok, color me naive since the county I worked in required all ERs to be able to handle peds and OB (at least stabilize before transfer to a hospital with a specialty service), but shouldn't all ERs be able to stabilize and treat peds and OB, at least till a transfer is arraigned?

[fiznat]

It seem to me that all they really need for an emergency c-section is a scalpel and an MD.

I agree. These patient(s) - assuming they survive initially - are going to get shipped to the 3rd hospital at some point anyways. What they need immediately, in minutes not hours, is a physician capable of stabilizing the situation for the interm. That doesn't necessarily mean a specialty OB doc - an Emergency Physican should be able to handle it. He'll probably shit his pants haha, but he *should* be able to handle it.

Still, a quick call to medical control as you start moving might not be a bad idea. Driving 30 mins to the large hospital in my opinion would not be an option.

[Riblett]

Option 1, the community hospital ED has basic neonatal resuscitaton capabilities. They don't have any more equipment than you have in your peds bag, except for Lab capabilities. Technically, since they are and ED they should be able to stabilize all patients while transport is being arranged. But what is stabilization for this patient? Can and will they do it.

There is no apparent cause for the arrest when you are making your decision to transport. Which hospital is the best choice? This is nt a trick question...I really don't know.

[Arctickat]

Good question Fiz,

The local community hospital is a very small ED with 14 beds and 1 MD. THey have always thrown a fit if you bring anything OB to them. There are no OB/GYN docs or dedicated facilities. They also transfer any and all pediatric patients if they have more than a simply stitchable lac, simple fracture, or the sniffles. They rarely if ever give any blood or blood products in the ED. Any remotely significant trauma gets transferred out.

It seem to me that all they really need for an emergency c-section is a scalpel and an MD.

Congratulations, you just described every hospital emerg within a 60 mile drive for me. I stick by my answer because anything we do will be done at the hospital, we will just be able to have it done sooner and arrive at the hospital in time for them to consider alternatives.

[fiznat]

Don't guess. If we can't figure it out between us there is no reason you should be expected to make the correct choice while sweating through this patient's code. Just call medical control, that's what they're there for. Even if they confirm what you were going to do anyways, at least now the liability for that choice is off of your shoulders and you can focus on doing the rest of your job enroute to the hospital.

[ERDoc]

Congratulations, you just described every hospital emerg within a 60 mile drive for me. I stick by my answer because anything we do will be done at the hospital, we will just be able to have it done sooner and arrive at the hospital in time for them to consider alternatives.

This patient needs a midline incision from xyphoid to pubis. Are you prepared to do that? If not, DO NOT wait on the scene, you will sentence the baby to death. The c-section needs to be done within 5-10 minutes of maternal arrest for the best possible outcome (though literature is lacking due to the inability to enroll many patients in a double-blinded study). Get your IV in and start running like hell. Push meds on the way.