It’s a bitterly cold winter morning, and rush hour has just ended when the mobile intensive care unit (MICU) 78 was dispatched for a syncope call. The MICU responds immediately, saying that a young and eager new paramedic student will also be on board. Pre-arrival information states that the patient is a 32-year-old female with abdominal pain who had a syncopal episode just before the 9-1-1 call. The local volunteer fire department’s quick response unit was also dispatched and had arrived on scene prior to the MICU.
The initial impression reveals an approximately 30-year-old female who is sitting upright on the porch of a nice, modern residence. The patient is covered up with a blanket and is accompanied by her husband, toddler son, and an EMT from the QRS. Although the patient appears to be in a moderate amount of discomfort, she seems to be in no apparent distress. The EMT from the QRS reports that he found the patient as she currently is when he arrived. He also reports that the patient was on the way to her car when she suddenly passed out, most likely from the abdominal pain.
The patient was immediately loaded into the ambulance, as the patient was visibly shivering, and secured to the litter. During the initial assessment, she states that she had a sudden onset of severe abdominal pain this morning. Her husband decided to take her to the local hospital for evaluation, and while they were on the way to the car, she had a sudden surge of pain, which dropped her to her knees. The patient’s husband then activated 9-1-1. However, the patient denies syncope or loss of consciousness.
While the patient and her husband are in the back of the ambulance, you allow your paramedic student to interview the patient for further details while you simultaneously conduct an assessment. The patient states in Spanish that she is a gravida 4 para 1 and is currently 9 weeks pregnant after medical fertility treatments. She also admits that she suffers from fairly complicated polycystic ovary disease.
Additionally, she states that while she was preparing breakfast, she developed right-sided abdominal pain at the level of the umbilicus and reports that it radiated from her right to left in all abdominal quadrants. Finally, she states that she is nauseated, and has never felt anything like this before. She also states that the pain is so excruciating she can’t even describe it.
Her physical assessment is unremarkable, and her skin color was initially pale while she was outside. Now, her color has improved to appear normal while she’s in the ambulance. Her hands are still somewhat cool to the touch, and she has a weak radial pulse but a strong brachial pulse. She has normal lung and heart sounds. Her abdomen is exquisitely tender on palpation and is slightly distended with a minimally palpable uterine fundus. The rest of the exam is benign, and there are no abnormal findings.
The patient’s vital signs reveal a weak pulse rate of 82 BPM; blood pressure of 100/70, and respiratory rate of 30 with an O2 saturation of 100% without supplemental oxygen. Oxygen at 2 LPM was administered via capnography nasal cannula and reveals normal waveform with an EtCO2 of 18.
The patient is coached to slow her breathing, and the EtCO2 steadily improves and finally reaches the low 30s during transport. Her blood sugar was obtained and was 117 mg/dL. Her ECG rhythm was normal sinus without ectopy.
After the patient history and clear distress from pain, the paramedic and student discuss the many possible treatment options available. As the patient continues to moan and wail from the pain, the student advises that he’s going to start an IV and administer normal saline at a wide-open rate for treatment of the patient’s hypotension. The paramedic agrees with the treatment plan, and the paramedic student also states that he’d like to call medical command for orders for the administration of Zofran 4 mg SL.
The student calls command and is ordered to give the Zofran and continue the IV fluids wide open and titrate them based on the patient’s blood pressure. Throughout the remainder of the transport, the patient continues to complain of severe abdominal pain and states that the pain is so bad that she feels as though she could pass out. However, despite the patient’s complaints, she seems to calm down while en route to the hospital and no longer screams of the pain. Her vital signs improve and are now within normal limits; she had received a total of 500 mL of normal saline solution (NSS).
On arrival at the emergency department (ED), the patient suddenly began to scream again in pain as she was being wheeled to her room. Care was transferred to the RN, and the paramedic student gave his patient hand-off report. Just before leaving, the paramedic and RN discuss the possibility of this patient’s demonstration of pain and discomfort being false. The providers also discussed how the display of extreme emotion wasn’t congruent with the distress the patient was actually having. This was obvious by her screaming episodes and then calmness as she was transferred into the ED room. As the paramedic and the student leave, the paramedic says that he wonders whether the patient was fooling them by overreacting to abdominal cramping.
Shortly after arriving at the ED, the patient complains to the RN that “something is wrong with me.” The patient then suddenly becomes grossly pale and diaphoretic. The patient was found to be significantly bradycardic at 35 BPM and hypotensive at 64/32. She was immediately placed into the trendelenberg position, prepared for pacing, and Atropine 1mg was administered via IVP intravenous push. The patient responded appropriately to the Atropine with a heart rate at 65 BPM. During some additional questioning, the patient reported she had an ultrasound confirming that she had a properly placed and normally developing pregnancy.
The ED staff continues supportive care and while doing so, the patient has a repeat episode of hypotension and bradycardia. The patient was then subsequently administered 4 liters of normal saline at a wide-open rate as well as multiple blood products. The attending physician conducts a rapid abdominal ultrasound, commonly used in trauma patients, and it reveals a small amount of free fluid in the abdominal cavity as well as an appropriate intrauterine pregnancy. Initial blood laboratory studies were within normal limits, and additional studies, 3 hours later, reveal a significantly low blood count of 6g/dl (normal range 12-16g/dl).
The patient’s fertility specialist arrived in the ED and immediately ordered the patient to be taken to the operating room. She was found to have approximately 2 liters of blood in her abdominal cavity from a large ruptured ovarian cyst. She required major surgical interventions and was later discharged.
Despite this patient’s normal vital signs and generally normal appearance, her abdominal pain as well as previous medical and fertility history should lead you to be highly suspicious for several life-threatening emergencies. Your top differential diagnosis of any female of child-bearing age that presents with severe abdominal pain should be a ruptured ectopic pregnancy.
The patient, having had a fetal ultrasound sometime prior to the onset of these symptoms, which rules out an ectopic pregnancy, would then lead you to consider the next diagnosis of a large ovarian cyst vs. ruptured ovarian cyst. Ovarian cysts and their rupture are fairly common disease processes in women of child-bearing age; however, this patient’s life-threatening and emergent presentation with such profound shock and intra-abdominal hemorrhage is extremely rare, but it should always be kept in the back of one’s mind when evaluating patients with similar complaints.
Rapid transport and fluid resuscitation is paramount in the care of any patient presenting with these symptoms, as this case is a true surgical emergency.