Just when I begin to believe I have seen everything, something new appears. This is one of the things I have always enjoyed about the practice of medicine, it is rarely boring. However, one of the things I hate is the unknown. Uncharted territory is rather routine when dealing with patients who don't know their medical history. For those of you who worry about electronic medical records and an invasion of your privacy, let me assure you, odds are some day you will be unable to speak for yourself. At that moment, you will want someone to know all the medical history you now believe you would like to hide.
Take for instance the case of Jane. She is a teenager who was found on the street immediately following what must have been a grand mal seizure. A grand mal seizure is where the patient looses consciousness, arms and legs fail, often bowel and bladder control is lost. If Jane had been at home, or even in her hometown, someone may have been found who could give a medical history. This was not the case, since Jane had run away from home.
Living on the streets of a major metropolitan area, Jane was going to a local clinic for prenatal care. No one around her seemed to know which clinic she had been attending. No one even knew if this was her first pregnancy, let alone any prenatal problems, history of illnesses, family history of diseases, or blood type. The father of the baby was not involved in the pregnancy.
I met Jane in the middle of her third seizure as the emergency medical technicians (EMTs) were transporting her into the labor and delivery area. According to the EMT who had ridden with her in the ambulance, she was incoherent the entire time, probably because she had a seizure just before they arrived. She had another seizure in route and despite medication a third seizure had just begun.
I did not know of any drug allergies, so I pick the drug most often used for seizures in pregnant women, Magnesium sulfate, ordering first a hefty loading dose to stop this seizure, and then a continuous drip to prevent other ones. Disheveled, with tangled black hair hanging in her face, and her clothes wet from sweat and urine, Jane became quiet within a few minutes of starting the drug.
She was receiving oxygen through pronged tubing in her nose and her breathing was regular. My next task was to assess the baby. Fetal heart tones were easily heard in the right lower quadrant of her abdomen. They were normal in the range of 150 beats per minute with moderate beat to beat variability. An acceleration in the baby's heart rate with not decelerations visible in the three minutes I had watched the monitor strip reassured me and my breathing became a bit more regular also.
I listened to Jane's lungs, which sounded clear. Feeling even better I decided not only were she and baby stable but she probably had not aspirated, drawing stomach contents down into her airway and lungs. This is one of the greatest dangers to the mother since pregnancy slows the emptying time of the stomach and there is almost always undigested material there. I again looked at the monitor. Baby's heart rate was steady. Another answered prayer.
I was able to hold Jane's forearm, which was warm and dry, while the nurse drew several vials of blood. I realized I was ordering tests for pregnancy induced eclampsia, along with those to determine if there might be an abruption (bleeding behind the placenta), blood type, and testing for syphilis, hepatitis, and HIV. Another nurse was placing a catheter in Jane's bladder to get urine for a drug screen. The blood pressure cuff on her arm revealed two blood pressures in the five minutes all of this was done. Both were mildly elevated. A quick urine dipstick showed 4+ protein. Regardless of what the rest of the tests would reveal this was almost surely eclampsia or a seizure due to pregnancy.
With a better working diagnosis for the cause of this young woman's seizures and a stable baby, I began to relax. Now I could focus on completing the physical exam, a sonogram to further evaluate the baby, and getting the laboratory studies back. A bonus, with seizures controlled, Jane was beginning to wake up. She still could not answer any of my questions about the pregnancy, her past medical history, or that of her family, but she did know her name, the year, and what city she was in. A runaway, after the events of the morning, she was more than willing to give me her mother's phone number.
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