Summary Notes Jane Doe
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Summary of Jane Doe
Executive Summary Part I
Jane Doe presented to University Hospitals MacDonaldWomen’s Center for prenatal care on12/9/10afterlearning thatshe had a positivepregnancy test.
She initially hadbeen seenin the ErinBuilding officeby a PHCNM. After learning of Ms.Doe’s previous history with high blood pressureand then
observing that Ms.Doe’s blood pressure remained elevated evenafter obtaining a doctor’s order for Aldomet 500mg twice a day and thenon 12/16/10the
nighttimedoseofAldometwas increased to1000mg. PH feltit would bein Ms.Doe’s bestinterest on12/16/10that sheonly beseenby a physicianfor
her prenatal care due to“having uncontrolled hypertension” on her firsttwo prenatal visits.
On 12/21/10,Dr. TMassumedcare of Ms.Doe. Dr. Mcontinued tocarefor Ms. Doe until the date ofher incidenton 6/15/11. During Ms.Doe’s prenatal
visits her blood pressurewas checked regularly. Ms.Doe’s bloodpressurecontinued tobe elevated throughout her prenatalcare,with no further change
in blood pressuremedication ordosage. Also,during Ms.Doe’s prenatalvisits, especially after thetwentieth week,her urinewas checked mosteveryvisit
for the presenceofAlbumin (protein) andGlucose(sugar). Ms. Doenever showedanyproblems with sugar. However, beginning on 4/5/11, Ms. Doe
started to an elevated urineproteinby dipstick. The urineprotein dipstick readings remained elevated for the remainderof Ms.Doe’s pregnancy, with the
highest reading obtainedon 6/15/11. In addition, on5/31/11, Ms. Doehad a urinetotalproteinof123mg/Landa urine protein/creatinineratio of
397mg/g. Both ofwhich areabnormally high. Again,Dr. M didnotattemptto treattheseabnormalfindings.
A third problem thatappeared trivial at first,was Ms.Doe’s complaints oftightness orswelling. Initially on 4/5/11 Ms.Doecomplainedofher wrists
feeling sore andshedescribed this as being carpal tunnel. However, according to Jane’s initialhistoryandphysicalshedid nothavecarpaltunnel listed.
Ms. Doe again complained on5/4/11 ofmissing work theprevious day due toher“wrists really hurting her”. Dr. M’s notes consistently reflected the
concern ofcarpaltunnel andtheusageofwristsplints torelievethesymptoms ofcarpal tunnel. However,Dr. Mnever questioned Jane as to whether or
not she could behaving the firstsigns ofswelling. Likewise, on 5/24/11 Ms. Doe complained ofswelling in her feet and hadrequested a doctor’s excuse
for missedworkbetween5/18/11and 5/24/11. On 6/7/11 Dr.Mhad signedFamily Medical Leavepaperwork for Ms.Doeand on 6/10/11, Dr.Mnoted
that patient “has not worked since5/31/11 due toswollen feet and pregnancyrelated uncomfortableness”. Once again,therewas notreatment ordered
to try to alleviatetheswelling.
Finally,Rural MetroEMT AW deviated fromtheACLS Algorithmby notproviding an advanced airway or attempting tostart an IV in order to administer
certainmedications that couldhavehelped bring Janeout ofthe PEAarrest. In addition, thereis no mention of AW attempting to provideoxygen toJane
with a non-rebreathermaskata flowrate of15liters per minute.
Sequence of Events On Date of Incident
June 15, 2011
PrenatalVisit Jane Doe, 40-year-oldfemale presents toherOB visit withcomplaints ofshortness ofbreath,elevatedbloodpressureof192/102,
and positive GroupB Streptestfrom 6/7/11.
Summary Notes Jane Doe
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3:52PM Rural MetroAmbulance called Rural MetroAmbulance totransport Ms. DoetoUH ER to ruleoutPreeclampsia.
4:18PM Rural MetroAmbulance arrives at Dr. M’s officeand finds Janesitting onexamtable.
4:30PM Rural MetroAmbulance leaves Dr. M’s officefor UH ER. Jane’s bloodpressureremains elevated.
4:36PM Jane has seizure, thenwent intofullcardiopulmonary arrest aftercomplaining ofshortness ofbreathx 2 and her systolic blood
pressure remained inthe220’s-240’s. Jane’s oxygen level kept dropping prior toseizure even when oxygen was applied initially at
6L per nasal cannula.
3-lead EKG showedPEA. AW was theprimary EMTat thetime andasked for assistance fromhis partner KS.
After performing a coupleofrounds ofCPR per ACLS Algorithm, AW was ableto placean oral pharyngeal airway. However, after
calling the Rural Metrodispatchandrequesting assistance,AW optedto have KS returnto driving the ambulancewhilehe
administeredCPR. At this point,AW alsodecided notto try to start an IV or placean advancedairwayas per ACLS Algorithm, rather
he just wantedKS to driveto the nearest ER.
4:51PM Rural MetroAmbulance arrives at UHER.
It is important to treat high bloodpressurein pregnancy because ofthe riskofpreeclampsia. It is important to know the signs andsymptoms of preeclampsia. It also
important toadhereto standards ofcare set forthby theAmerican Heart Associationwithregards to preventing a seizureand providing CPRduring pregnancy.
There are 2 types of Preeclampsia:
1. Mild preeclampsia is diagnosedwhen: pregnancy is greater than20 weeks; blood pressure is greater than 140 systolic and 90 diastolic; 0.3g ofprotein is
collectedin a 24-hoururine sampleor persistent 1+proteinmeasurementon urinedipstick; andthereareno signs ofproblems with the motheror thebaby.
2. Severe preeclampsia is diagnosed when there areadditionalproblems witheither motheror baby: signs ofcentral nervous systemproblems (severe
headache, blurry vision,altered mental status); signs ofliver problems (nausea and/or vomiting withabdominal pain); atleasttwicethenormal
measurements ofcertain liver enzymes on bloodtest;veryhigh blood pressure(greaterthan 160systolic or110 diastolic); thrombocytopenia (low
plateletcount); greater than5g ofprotein ina 24-hour sample; verylowurine output (less than 500mlin 24-hour); signs ofrespiratory problems
(pulmonary edema,bluish tintto the skin). (Craig Weber, High BloodPressure, 2007)
To treat thecritically ill pregnant patient:
1. Place the patientin theleft lateralposition
2. Give 100% oxygen
3. Establishintravenous (IV) access and givea fluidbolus
Summary Notes Jane Doe
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CardiacArrestAssociatedWith Pregnancy: Modifications for Pregnant Women (Primary)
1. No modification for airway
2. No modification for breathing
3. Circulation-placethewoman on her left side withherback angled15-30 degrees back fromtheleftlateral position. Thenstart chestcompressions.
Secondary Modifications for PregnantWomen
1. Insert anadvancedairway earlyin resuscitationto reducetherisk ofregurgitationand aspiration
2. Airway edema and swelling may reduce the diameter ofthetrachea. Be preparedto usea tracheal tubethat is slightly smaller than theoneyou
would use for a nonpregnant woman ofsimilarsize
3. Monitor for excessivebleeding following insertion ofanytubeinto theoropharynx or nasopharynx
4. Effective preoxygenationis criticalbecausehypoxia (lack ofoxygen to the brain) candevelopquickly (AmericanHeart Association, 2005).
Summary Notes Jane Doe
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