Victoria Fitz, MD
University of North Carolina, Chapel Hill, NC
EMR: What is the most effective way to present an OB/GYN consult over the phone?
CC: The goal should be to concisely present the information and clinical question in a way that allows the consulting provider to triage the urgency of the consult and advise any immediate intervention. Key points to convey vary depending on the clinical scenario. In general, this should include age, whether the patient is pregnant, presenting complaint, hemodynamic status, and the SPECIFIC clinical question.
For example: “This is a consult for possible ectopic pregnancy with hemodynamic instability. JR is a 26-year-old female approximately 6 weeks pregnant with a history of two prior ectopic pregnancies who presents with acute onset RLQ pain, tachycardia, and hypotension. She has a positive FAST scan.” That clearly communicates the emergent nature of the consult and the need for immediate evaluation and intervention.
Another example: “This is a consult for pregnancy of undetermined location. LM is a 37-year-old female approximately 6 weeks pregnant by LMP with a history of two prior miscarriages who presents with light vaginal bleeding for 2 days. She has normal vital signs and minimal bleeding on pelvic exam. Her cervical os is closed. Her hematocrit is 39% and she is Rh positive. Her serum beta hCG is 1500 mIU/mL. Her ultrasound shows no definitive intrauterine pregnancy. Her adnexa appear normal. We would like for you to confirm the findings and assist her with close follow-up.”
(Please note that while Gs and Ps are important, I do not consider them an absolutely crucial part of the initial consult, particularly because the numbers can be confusing. Others may feel differently.)
EMR: What basic workup do you prefer to be completed prior to seeing a consult?
CC: A pelvic exam and a urine pregnancy test are generally a must. If the patient is pregnant and has vaginal bleeding, a type and screen, Rh, and complete blood count are necessary. If the patient is stable, is presenting with a newly diagnosed pregnancy without a prior ultrasound, and is complaining of abdominal pain or vaginal bleeding, an ultrasound should be completed prior to consultation.
EMR: What do you consider to be urgent or emergent consultations?
CC: Emergent consultations include ruptured ectopic pregnancy and ovarian torsion. If you have a suspicion for either of these, the gynecology team should be contacted immediately; proceeding expediently to the operating room is paramount.
Urgent consults include concern for ectopic pregnancy in a hemodynamically stable patient, heavy (>1 pad per hour) vaginal bleeding, and sepsis.
EMR: What are some common OB/GYN complaints or procedures an EM resident should feel comfortable managing in the community setting?
CC: EM residents should feel comfortable managing uncomplicated pelvic inflammatory disease, particularly those who are afebrile, not in severe pain, tolerating fluids, have no evidence of tubo-ovarian abscess, and are able to follow up as an outpatient. You should also feel comfortable counseling a stable patient regarding expectant management of an uncomplicated first-trimester miscarriage.
Common procedures that an EM resident should feel comfortable performing include pelvic examination and basic ultrasound to confirm viability and location of pregnancy, as well as incision and drainage of a Bartholin's cyst/abscess.
EMR: Top 3 ED pet peeves?
- Calling a consult before performing a pelvic exam. Even though we will likely repeat the exam, your initial impression with regard to amount of bleeding or any abnormal findings is important for triage and initial stabilization. Often, patients with minimal to moderate bleeding can be evaluated as an outpatient.
- Not ordering a type and screen on a pregnant patient with vaginal bleeding.
- Not having an up-to-date set of vital signs available on a patient at the time of consultation.
EMR: Other pearls for emergency medicine residents?
CC: Providers in the community may not have immediate access to an obstetrician and will encounter many presentations of incomplete or missed abortions. Familiarity with how to counsel a patient for medical management (eg, cytotec) when appropriate are important in this setting. We are always happy to have an EM resident come with us to counsel a patient on management options.