PIH - What is it?
By Ann Wiseman, RN, CLNC

There are an awful lot of obstetrical acronyms, but this is one of the more dangerous that you will undoubtedly see in the course of your casework.

A few years ago, I taught a brown-bag lunch seminar for the Maryland Trial Lawyers Association on How to Interpret a Medical Chart. Let's face it, there are a lot of acronyms or some might call it medicalese in the medical world. But here, I'd like to hone in on one of the more serious obstetrical acronyms.

A little history first, though. OB, of course, would refer to obstetrics and GYN to gynecology. Most physicians practice both areas. In a history of an OB patient, you might see something like this G4P3AB1. The G means gravida or the number of pregnancies. The P means Para or the number of live births. The AB means abortion or the number of spontaneous abortions (miscarriages) or induced or therapeutic abortion (surgical or chemical). So the above acronym says that this woman was pregnant four times, gave birth to 3 live babies, and had one miscarriage or abortion. Sometimes the AB is preceded by an "S" or a "T" to signify the type of abortion.

When looking at an ill obstetrical patient, the main disease you will hear about is PIH or Pregnancy Induced Hypertension. This occurs when, due to the pregnancy, the patient acquires high blood pressure. It is manifested by a blood pressure greater than 140/90, protein in her urine, hyperactive reflexes, swelling (edema), blurred vision, headache, and epigastric pain. It is a dangerous disease in pregnant women because it not only has the potential to kill the mother, but also the infant.

Another term for PIH is preeclampsia. When you see "pre" in front of a word it should alert you to the fact that there is a pre-, peri-, and post- condition. So preeclampsia is the same as PIH. Eclampsia, however, is what it would lead to and this is manifested by all of the above symptoms with seizures.

There is no known cause. When diagnosing PIH, the physical signs are as listed above. She may have one or two of the symptoms or all of them. As severity of preeclampsia increases, patients may experience more symptoms. These symptoms are usually first seen in the physician's office during routine checks and, if not treated, will lead to more serious complications. This is why it is extremely important to get all of the prenatal records, as well as the pre-pregnancy records. Looking at those records, you will get a better idea of the patient's health prior to pregnancy and delivery.

Treatment of PIH would include bed rest, admission to the hospital, and diet, but the hypertension diet has not been proven to help as yet. The patient would be placed on medications to bring the blood pressure down. They may be oral medications or intravenous medications depending on the severity of the PIH. The only real cure for PIH is delivery of the infant. PIH can present itself postpartum anytime from delivery to two to three weeks after delivery.

Case Study. A 23-year-old, gravida 1, para 0, 34-5/7 weeks pregnant, arrived to L&D with complaints of headache, blurred vision and abdominal pain. A fetal monitor was placed and vital signs were taken. BP 192/103 (on her back), 171/98 (on her left side), pulse 94, respirations 24, temperature 98.9. The fetal monitor showed a baseline heart rate of 145-150 beats/minute with minimal long-term variability.

They continued to watch her for another three hours. BPs ran 170/90s to 190/110s. Her abdominal pain kept getting worse, but nothing showed on the monitor. About three hours after arrival, she complained of a severe headache and increasing abdominal pain. She was given Tylenol 2 tablets. At the fifth hour, she couldn't stand the pain in her abdomen and she requested something stronger for pain. The nurse told her she wasn't in labor and couldn't have pain medication. She was just being watched as an outpatient and when she went home, she could take something stronger if she had anything.

The patient got up to go to the bathroom and became very dizzy. Her abdominal pain increased, and she started bleeding vaginally. Her husband helped her back to bed and called the nurse. The nurse came in and placed her back on the fetal monitor, but couldn't pick up the fetal heart rate very well. When she did pick it up, the rate was in the 60s. The nurse did some resuscitative measures, turned the patient to her left side, applied oxygen and did a vaginal exam to place a scalp electrode so she could see what the heart rate was as she thought it was the mother's pulse that was being picked up on the monitor. The fetal scalp electrode picked up the heart rate in the 40s.

The patient was taken for a "crash" cesarean section, and the baby was born with Apgars of 0, 1, 4 at 1,5, and 10 minutes (normal Apgars being 8-10). After surgery, the mother had a seizure in the recovery room and magnesium sulfate was started. She was in the intensive care unit for three weeks and was finally discharged home after four and a half weeks. The baby was diagnosed with severe cerebral palsy and is in a wheelchair today. The case settled pretrial for $1.3 million.

The question now is how can a CLNC help you on a PIH case such as this? We can prepare interrogatories and requests for production. We can find experts such as obstetrician, perinatologist, labor and delivery registered nurse, neonatologist, pediatric neurologist, and life care planner. We can also conduct medical and nursing literature research, prepare depositions and prepare trial exhibits.

Would that save you a lot of time and money? Of course it would. So, the next time you have an obstetrical case...take a Nurse with you to Court & and WIN!!!

The BUGS!
By Ann Wiseman, RN, CLNC

BUGS! YUK! Yes, they are everywhere on your shoes, on your clothes, on your hands, in your mouth, on your hair and, yes, even on your eyelashes.

Have you ever heard of a nosocomial infection? Many of you probably have heard of this. It is a hospital acquired infection. In other words, indeed we can become infected in the hospital if we're not careful or if THEY are not careful. These infections are caused by bugs or germs that are rampant in society, but especially so in hospitals.

Think for a minute how many really ill people are in the hospital. You'd think that there would be even more of these types of infections. However, there aren't.

Back in the 1800s, a physician in France was finding that many of his new mothers were dying of massive infections. He knew there was a reason, but wasn't quite sure what it was. So, he started experimenting. At that time, if a woman was to go into the hospital to give birth, she was subjected to a physician who did not wear gloves, did not wash his hands between deliveries, and did not change from his street clothes. In other words, he was pretty filthy. Of course, many women bleed when giving birth, allowing all of these wonderful germs the physician carried with him to jump from him directly into their bloodstream causing massive infections and death.

This physician discovered this and began washing his hands between deliveries and found fewer deaths were occurring with his patients. Then, when he donned a gown in addition to washing, he had even fewer deaths. And then, of course, he began washing, donning a clean gown, AND wearing gloves and deaths were few and far between. The other physicians saw this and finally adopted his practice and they, too, had much fewer deaths in childbirth.

Then, in the 1940s, penicillin was discovered to treat infections that got by the physicians. This was a wonderful new wonder drug, but unfortunately, these bugs are smart and began to mutate causing new drugs to be discovered.

One of the largest problems with people taking antibiotics is that they tend to begin feeling so much better by the 4th or 5th day of a 10-day treatment regimen. They then stop their antibiotics to save for the next time they get ill. The bug that is still in the system and not completely dead, begins to mutate to the point where that stockpile just does not work the next time you get sick.

You must be prescribed another antibiotic and the same thing happens. You start feeling better, you stockpile for the next illness  and so on and so on.

Case Study - Sepsis. Mr. W is a 31-year-old body builder who presented to the neurosurgeon with complaints of pain and weakness to his right arm and hand. His ultrasound showed a herniated disc (C6-7). He was scheduled for an anterior cervical diskectomy on 2/22 as a short-stay patient. His fiance, his parents and her parents were there with him.

Postoperatively, he was very uncomfortable. While in PACU, his BP remained elevated and his pain did not go below an 8. He was medicated with Versed, morphine and Valium. The neurosurgeon did not respond to the nurses' calls regarding uncontrolled pain until the patient was being transferred to a room on the short-stay unit. At that time he was started on PCA morphine. In addition to the PCA, the neurosurgeon ordered scheduled Valium, Flexeril, Ambien and Toradol (all pain and psychotropic medications).

During the night, Mr. W's pain was still unrelieved. By morning, the neurosurgeon ordered Percocet and changed his status to in-patient without assessing him. His neurological status was changing and there was no response to the unrelieved pain.

The following night, Mr. W went into respiratory arrest and finally a code was called. The team attempted to intubate him, but was unable to. An incision was made through his operative site, and a #6 Shiley was passed into his trachea. He was then taken to the operating room for exploration, where he was found to have a large tracheal hematoma. At 9:00 am on 2/24 his WBC was 30.6.

Eight days later he died from respiratory, kidney and cardiac failure and sepsis.

What does all of this mean to you? Did Mr. W die because of the hematoma? No. He died because the physician in this case did not bother to personally assess the patient's complaints of unrelieved pain, but continued to prescribe medication. He died because the physician did not take the time to look at the incision site and assess why Mr. W was having the pain. He died because by the time he was taken to surgery, he already had an infection going, which got into his blood stream (sepsis). He died because of gross negligence on the part of the physician and the hospital staff for not following through.

There may very well have been deviations in care, as to hand washing, and using gloves, but it is a CLNC who has the knowledge and experience to review a chart and become the medical detective you need to see where the breakdown occurred. She would be able to assist in finding testimony experts for you, look at orientation schedules, a list of instructors and qualifications, as well as sign-in sheets for mandatory in-services that would instruct the hospital staff. The CLNC would also be able to help with interrogatories, requests for production, depositions, and trial exhibits.

So the next time you get a case that has a question of untreated infection, make sure you Take a Nurse with you to Court ... and WIN!!!