CEMACH

Chapter 18: Emergency medicine

Summary of key findings for 2003-05

Of the women whose cases were assessed in relation to ED practice, the main diagnoses were:

Fifty-two  women who died from Direct, Indirect or Coincidental causes died in the ED. The majority of these women had either collapsed in the community and were already undergoing cardio-pulmonary resuscitation (CPR) on arrival or collapsed shortly afterwards.

Emergency care before arrival at the ED

The emergency services’ response to a 999 call about a sick pregnant woman will usually consist of an ambulance staffed by a paramedic and an ambulance technician. Untrained personnel are not permitted to work in ambulances; the minimum training for an ambulance technician is equivalent to that of a nursing auxiliary. Additionally, in some areas, there may be a rapid response vehicle which allows early interventions to be carried out if this vehicle arrives first. These are staffed by paramedics usually in a car. In addition there are emergency care practitioners (usually with an ED nursing background) whose role is to manage the patient at home according to protocols. Regardless of type of vehicle, most paramedic crews act within very specific guidelines in terms of their resuscitation algorithms. Nevertheless, unanticipated problems can still occur:

A woman being transported to the hospital with severe abdominal pain was given nalbuphine en route for pain relief. This is an opioid which has become less commonly used with the advent of morphine into paramedic protocols. She had a profound anaphylactic reaction resulting in cardiorespiratory arrest and eventual death.

In some areas a doctor will attend the patient in the community at the request of the paramedics. These doctors have undergone pre-hospital training (i.e. they are trained to manage sick patients outside a hospital environment) and most are GPs, ED doctors or anaesthetists. They provide a different set of skills for the patient out of hospital and a proportion of these patients are pregnant or peripartum women.

Women in extremis on admission

Fifty-two (18%) of women who died from Direct or Indirect maternal causes this triennium died in the ED, most of whom were brought in already undergoing cardio-pulmonary resuscitation (CPR). Several others were initially resuscitated and then moved to critical care. Overall, the level of care and the resuscitation measures were of a good or excellent standard with adherence to protocols. Even when the outcome is poor there can be a sense of satisfaction that these well researched guidelines are followed effectively.

Perimortem caesarean section 

Thirteen of the women who died in the ED were delivered by perimortem caesarean section. A number of other women had a perimortem section in the ED but survived long enough to be transferred to Critical Care. Two of the women who had the operation performed in the ED, and who died there were only 20-22 weeks pregnant and only six women were more than 34 weeks of gestation. The median gestational age was 30 weeks. The only baby who survived was born to a mother at term who suffered a cardiac arrest after admission and for whom the operation could be performed within the recommended five minutes of collapse1. None of the babies of the women who were admitted already undergoing active CPR survived.

The total number of perimortem caesarean sections performed for all mothers this triennium, 52, has almost doubled since the last Report, where only 27 cases were assessed. In this Report twenty babies survived, including one set of twins, but their chances of survival were greatly improved with advanced gestational age. These  findings indicate that with improved resuscitation techniques more babies are surviving perimortem caesarean sections particularly where the women collapsed in an already well-staffed and equipped delivery room or operating theatre. However they also highlight the very poor outcome for babies delivered in Emergency Departments, especially on women who arrive after having undergone CPR for a considerable length of time.

These findings underscore the guidelines from the Managing Obstetric Emergencies and Trauma course (MOET)1 which make it clear that perimortem caesarean section should only be carried out when the mothers cardiac arrest has been witnessed within the previous five minutes. The outcome of any other circumstance is universally poor. In addition the baby must be delivered within five minutes to facilitate resuscitation.

The care the mothers received

A large number of women who died in 2003–2005 came into contact with emergency services including paramedics and on-call physicians in addition to those working in the ED. In the cases in which ED treatment has been implicated in the death, there are three clear themes for lessons to be learned:

Clinical practice
Recognition of the sick woman

One of the core skills of being a clinician is the recognition of a patient who is unwell. This is not the same as making a diagnosis. In fact the two skills are often independent of each other. Recognition of the seriously ill woman relies on taking a complete history (listening to the cues given by her or her relatives), measurement and understanding of vital signs such as heart rate, respiratory rate and pulse oximetry. It is not dependent on complex and time-consuming tests.  Recognition of illness needs to be taught to clinicians of all grades on a regular basis. It is also important to make this teaching multi-disciplinary.

Scoring systems such as the modified early obstetric warning system (MEOWS) described in Chapter 19 - Critical care, and included as one of the overarching recommendations of this Report, can be used to elucidate the level of “unwellness”. Essentially this adds together a score for heart rate, respiratory rate, blood pressure, GCS and temperature and gives an overall score. However early warning systems are only useful if they are regularly repeated and acted upon.

Shortness of breath and the diagnosis of pulmonary embolism

Pulmonary embolism (PE) continues to be a difficult diagnosis which is often made too late. Whilst some of the women who died from PE could not have been saved no matter when the diagnosis was made, a small number went unrecognised, mainly because PE was not considered early enough. The diagnosis of PE is already challenging in the non-pregnant patient but in pregnancy it becomes even more difficult. Of those women who died from a potentially salvageable PE many had felt breathless prior to admission. Traditional teaching allows clinicians to assume that isolated breathlessness is a normal feature of pregnancy and this can often reduce the awareness of its severity. It is unusual to be breathless at rest in pregnancy or in the postpartum period, especially in the presence of tachycardia:

A woman presented to her GP with breathlessness, pyrexia and hypotension. She was referred to the medical registrar who saw her on the ambulatory medical unit (AMU) and made a diagnosis of pneumonia with a differential of PE. Intravenous antibiotics were commenced and a raft of tests done, all of which were abnormal. Although she was patently unwell she was transferred to a gynaecology ward where she suffered an arrest from which she could not be resuscitated. A postmortem diagnosis of PE was made.
The importance of tachycardia

Tachycardia is without doubt the most significant clinical feature of an unwell patient and is regularly ignored or misunderstood. Measurements of respiratory rate and heart rate are infinitely more important than measurements of blood pressure. A normotensive patient may all too often be unwell and compensating.  A tachycardic patient is hypovolaemic until proved otherwise. A patient with tachypnoea has a cardiorespiratory cause until proved otherwise. Attributing tachycardia and tachypnoea to anxiety is naïve and dangerous. For example:

A woman was seen three times in the ED with abdominal pain and diarrhoea. She was discharged on the first two occasions with a diagnosis of gastroenteritis, even though she had a history of collapse and measured heart rates of 130 and 144 beats per minute. She arrested and died on her third presentation. At postmortem she was found to have had an ectopic pregnancy.
Ectopic pregnancy

Mismanaging ectopic pregnancies has always been easier than making the correct diagnosis, partly because cases present infrequently (1 in 100 pregnancies) but mainly because their presentation may not be classical. The triad of symptoms described in textbooks of emergency medicine is bleeding, abdominal pain and amenorrhoea, but many of the women who died, as well as some who survive, have a variety of non-specific symptoms including diarrhoea, vomiting and collapse.  Many of the women who come into the ED with symptoms from ectopic pregnancy do not know or volunteer that they are pregnant. It is disappointing that occasionally these women do not have a pregnancy test done as a routine.  Without a pregnancy test it is hard to include ectopic pregnancy in the differential diagnosis.  It is crucial that the risk factors for ectopic pregnancy are taught and recognised. The following case is an example of the consequences of misdiagnosis:

A woman collapsed at home following an episode of diarrhoea. On admission to the ED she was tachycardic, hypotensive and IV access was difficult. No pregnancy test was carried out. She arrested and was resuscitated after a very prolonged period of CPR. On the return of spontaneous circulation she was noted to have a haemoglobin of 8 dl. An ultrasound scan was carried out, which led to further delays, and free fluid was noted . At her eventual laparotomy a ruptured ectopic pregnancy was revealed but she suffered a further, fatal, cardiac arrest.   

Box 18.1

ED learning points: ectopic pregnancy

ED clinicians need to be aware of atypical clinical presentations of ectopic pregnancy and especially of the way in which it is often associated with diarrhoea and vomiting and may mimic gastrointestinal disease. Fainting in early pregnancy may also indicate an ectopic pregnancy.

There must be a low threshold for β hCG testing in women of reproductive age attending the ED with abdominal symptoms.

Pregnant women with abdominal pain should be reviewed by staff from the Obstetrics & Gynaecology department.

Education and training
Teaching of ED staff

All departments have formal teaching for medical and nursing staff in addition to the shop floor teaching to which EDs particularly lend themselves. EDs see a huge range of patients including children, surgical emergencies, patients with mental health needs, medical emergencies and major and minor trauma. Thus pregnancy-related complications form a small but important component of the daily workload. The ability to organise a teaching programme which encompasses all eventualities is crucial. In addition the teaching has to be delivered early in the clinician’s post, repeated to those who are unavailable, and competency tested. This challenge is made more complex by the changing nature of job applicant experience and length of post in the ED.

“Red flag” teaching is usually carried out early on in the post or on induction days. This highlights conditions not to be missed, their recognition and management. The red flag signs and symptoms are those which call out for early attention due to their importance and reflection of life-threatening illness. Early teaching about the pregnant woman must include recognition of the sick mother, PE and ectopic pregnancy.

Locums/Agency staff

There is little point in having perfect systems in place if they fall apart when locum or agency staff are working. Many Trusts have a policy whereby locums cannot get paid until they go through an e-learning exercise which should contain important departmental protocols. At the very least new clinicians should be closely monitored.

Service provision
Availability of senior help

In most EDs the majority of medical staff are in the SHO-equivalent grade (F2) and therefore most patients are seen in the first instance by a relatively inexperienced clinician. If the patient is collapsed, however, or otherwise unwell the middle grade doctor or consultant should  be involved from the outset, as will senior nurses. Thus, in addition to teaching trainees how to pick up subtle clinical signs there must be a clear chain of command which is easy to access and is understood. The importance of being able to access senior help cannot be over-emphasised.

Usually if the diagnosis is clear the specialist team is sought; and if the diagnosis is unclear a more senior ED opinion is requested.  All EDs have a 24/7 senior on-call rota; many (especially the larger departments) have 24/7 resident middle grade cover and a few have consultant availability on site.  Most labour wards have a consultant obstetrician present during the day as well as one being on call during the night. Often, however, the labour ward is in another hospital and this can cause logistical challenges.  From an ED perspective it is most efficient if all services are on one site.

Protocols for referral to specialist teams

In some centres specific groups of patients are not seen by ED clinicians unless they require resuscitation. Instead they are seen directly by specialist in-patient teams.  Such groups include children under one, who are seen by paediatricians, and pregnant women, who are seen by the obstetric team. Clearly there are some groups, for example those in active labour, those with second or third-trimester bleeding, those who are unwell who should always be see by an in-patient team.

Transfer of women

In general the safest place for someone who needs resuscitation is the resuscitation room of an ED, whether or not they are pregnant.  The best place to give birth, however, when there are obstetric complications, is in a delivery suite with trained clinicians on hand. Cardiac arrest in pregnancy generally does not have a good outcome for mother or baby and optimal management is needed to avoid it.

Thus there should be clear and agreed pathways of care for where collapsed mothers go. First, a pre-emptive call should be made from the pre-hospital team to alert the hospital team of her imminent arrival. Senior staff should be on hand to meet the collapsed woman. Taking an unwell woman straight to a busy ward is rarely helpful, and it is usually a mistake to transfer a sick mother to another hospital which is smaller and less well staffed just “because it is the maternity hospital”. If necessary the team can come to the patient.  Local knowledge is essential in knowing where to take the patient to access the best care.

Conclusions

A wide variety of underlying factors may have contributed to the deaths reviewed in this Chapter. Nevertheless when misdiagnosis occurred there was often a failure to understand the altered physiology of pregnancy and a failure to ask for senior and/or specialised help.

Emergency Departments are getting busier all the time and the expectations of the general public are quite rightly getting higher. More interventions are being carried out in the ED by more senior staff but this must never preclude requesting opinion from obstetric colleagues. It is important that Emergency Departments know whom to call in an obstetric emergency and how to call them.

Not all the deaths reviewed for this chapter could have been avoided, even with better training, but there were a significant few which resulted from a poor understanding of basic clinical signs. There is a great need to ensure that teaching, training and retraining in the recognition of the sick pregnant woman should be mandatory in all medical and nursing training programmes, at induction and throughout their careers. This applies to junior and senior doctors and nurses working in the ED as it does to other clinical staff and to locum staff.

Excellent training is available in many centres, and in others the introduction and routine use of an obstetric early warning score card, a key recommendation of this Report, will be of great benefit.  There should be watertight procedures in place for ensuring all staff are aware of the importance of basic clinical signs and symptoms.

References

  1. The Advanced Life Support Group. The Managing Obstetric Emergencies and Trauma course. www.alsg.org