The One with the Rule Out Ectopic

I’d never seen a patient in that much pain.  Not even in labor and delivery.

And though I’m a little ashamed to admit it, my initial reaction was to hug the wall, allowing the fully trained physicians and nurses attend her needs while I watched the shaking, the sweating, the whimpering from the periphery, the typical home of a clueless third year medical student.

I guess I need to recap a little.

I wasn’t there when she initially came in to the emergency department with lower abdominal pain and a positive pregnancy test, the kind of patient considered  an ectopic pregnancy until proven otherwise, solely because the danger of leaving a pregnancy in the Fallopian tube is so incredibly high. Unfortunately, at just a few weeks along, it was too early to observe any signs of pregnancy in her uterus on ultrasound, but there are a few other methods for diagnosis. One sounds a little bit bizarre: in women with unwanted pregnancies, one option is to carry out a dilation and curettage, the procedure used for surgical terminations. The pathologists examine the collected tissue, and if they can find the products of conception, the tissue from the fetus, then you can rest assured the pregnancy was not ectopic.

Ultimately, at that time, it was decided that this was the best option for her, and she was scheduled to come back in the morning.

The next morning, she was having doubts. One of the residents and I trekked up to the procedure unit to chat, my resident reminding me that if there is any doubt about wanting the pregnancy, then we should not do the procedure.

We explained the risks of an ectopic pregnancy. We explained the concept of the D&C and how it was absolutely NOT the only option. We re-explained everything to her worried husband. We left the room while they tearfully discussed their options.

When we re-entered, he spoke first: “She wants the procedure.”

Eyes locked on him, she nodded slowly, tentatively, assuring us she was 100% sure when prompted. I wasn’t convinced, but the consents were signed.

Later, at her scheduled procedure, her little discomfort had blossomed into full blown pain attacks. The doctors tried once more to locate the pregnancy on ultrasound; she wailed and writhed in pain, begging for medication. By this time, I’ve jumped in to grab her hand and encourage her to take deep breaths

They gave her the usual sedation for the procedure. Anesthesia’s a funny thing sometimes, and this time, it opened the floodgates.  She started bawling, telling me how she’s so upset that her husband talked her into this procedure and she’s going to be such a terrible mother because she couldn’t even risk her own life to try and save the child. Tears and words and sobs poured out, and I tried desperately to console her, completely ignoring the procedure happening toward the other end of the bed.

At one point, I even stopped and asked the attending if it was okay to proceed with everything when she so clearly didn’t want to, but unfortunately, informed consent does not extend to patients under sedation, so we had to follow her previously stated wishes.

However, her pain intensified to the point we were concerned for rupture, so we rushed to the emergency room for exploratory surgery, where we inserted the laparoscopic camera to find… nothing. No rupture. No inflamed tube. No blood. Nothing.

I figured that was it; I was a little taken aback when they then proceeded with the D&C anyway. She had been coherent in the interim between procedures; I’d had extensive conversation with her to calm her down and encourage her not to let this horrible experience ruin her whole summer. I didn’t quite understand why no one had double-checked that she still wanted the procedure if we didn’t find clear evidence of ectopic, but again, the physicians proceeded with previously stated wishes.

She woke up asking for her baby, over and over. It was easily the most heartbreaking moment I have ever seen in my entire life.

*************

The intern on this case with me actually went and told the clerkship director she was impressed with the way I stepped in to be the patient’s support. That she didn’t think she could have done that as a third year medical student. That it was exactly what the patient needed, and I did it without hesitation.

While I’m incredibly grateful for the recognition and assurance that I’m doing my job well, it’s a little unsettling to me that this isn’t the norm.

Why is it commendable to see a patient on the worst day of her life and hold her hand and listen to her? I don’t think it even crossed my mind to do anything otherwise… it just makes me a little uneasy that it was such a big deal, that perhaps others wouldn’t do the same.

I guess the oath tells us to “do no harm.” Maybe we all just need a reminder that we should also strive to be there for our patients, and to do good.

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