Terb and Tremors

Very interesting day today. I have to say that after over a decade in Labor and Delivery, it's not everyday that I encounter a real challenge that actually hurts my head. I did today and loved it. This type of challenge kind of reminded me of the intricacies and complexities of medicine. It gives me a little nudge to remember why I started here in the first place.

The patient presented a couple of days ago at 30 weeks gestation, complaining of early contractions. As she changed in a gown and got into bed, the nurse noted that the patient was so weak that she could barely hold herself up. She was contracting significantly, the nurse gave her a shot of Terbutaline to stop the contractions, then went to gather the equipment to start an IV. It's been rediculously hot in our area and it's not unusual for us to get a number of women, contracting because of dehydration. As the nurse walked in the door and the patient realized she was going to get an IV, she immediately began feeling nauseated and sweating profusely. We see this fairly often - a patient's blood pressure can drop as a response to pain or nerves - we say the patient "vagalled." Sure enough this is what happened. The fetus quickly reacted to the drop in blood pressure and it's heart rate dropped. The nurses took all the appropriate actions and even called in the anesthesiologist who was nearby. He gave some ephedrine to bring up the blood pressure and quickly the baby's heart rate recovered and Mom felt much better.

The preterm contractions continued, and although the Fetal Fibronectin Test was negative, Magnesium Sulfate was ordered so slow the contractions. As the Mag was running the patient got two doses of Betamethasone, a medication to help mature the baby's lungs in case of a preterm delivery. Twenty-four hours later, as per the usual protocol the Magnesium was stopped. "Give her a chance to recover, the Doctor instructed, the you can send her home."

Two hours later, the nurse went to send the patient home and found that she was so intensely weak that she couldn't even sit up in bed by herself. There was no way we could send her home. So we talked to the Doctor and order a million tests, trying to find out what was going on. When everything came back fairly normal, the Obstetrician decided to consult with Internal Medicine. The IM guy came by, disregarded everything we had to say and ordered asthma treatments. I'm not sure why he just didn't write "I don't know what the hell I'm doing here" in the progress notes.

This is where I enter. Oh, I thought this morning, I'm going to fix her! Right.....

The day begins with the patient wanting to use the bedpan. Oh, no, I think to myself, we're not using a bedpan. She will walk to the toilet like the normal, healthy young woman that she is! I break this news to her and she looks a little startled, but begins struggling to sit up. All the while, in my great wisdom, I am extolling the virtue and importance of activity and ambulation. She manages to get to the side of the bed. She is shaking uncontrollably - a deep inner shaking that could clearly not be faked. I'm starting to think I'm in over my head. I call for help. Together with the help of another staff member and an IV pole, we head for the bathroom. I swear to God I might as well have been assisting an 95 year old woman with a hip replacement to get up for the first time! The process took over half and hour and I'm not sure who was more exhausted by the end of it - the patient or us staff members!

Guess she wasn't faking. Back to the drawing board.

More consults, Internal Medicine, Neurology, Physio Therapy, Respiratory Therapy, a battery of lab tests.... the funny part is how we ended it today: they decided to stop everything. "Let's just let everything get out of her system," they decided. Ya think?! I'm curious to see what happens when I get back to work in a few days.