Medical Question: Suicidal Pregnant Patient

Lisa Asks:

I just found your site and it looks great! I'm writing my first mystery novel and I have a character who attempts suicide by taking an overdose of Ambien. She is discovered in time and pumped out, but I'd like to know:

If she was unconscious when they found her, would they give her adrenaline or anything to wake her up, or just let her sleep it off? Would she be on oxygen or on an IV with some sort of drugs to counteract the sleeping drug? If her family visited her right afterward is there a chance she'd still be sleeping? Would she be in a regular ward or the ICU on the first day? Or would she be shipped right to a psych ward?

Jordyn Says:

An unconscious patient is approached in a very step-wise fashion. This is drilled into medical people from the day they start school. Are they responsive? If not, open the airway. Is there anything in the airway that needs to come out? If not, the airway is clear. Is the patient breathing? If yes, how well? What are her breath sounds? What is her oxygen level? Does she have signs of respiratory distress? If the patient is not breathing well, she'll be assisted at that point. Next, is there a heartrate? If so, is it adequate? What is the blood pressure?

Actually, this has recently been reversed by the American Heart Association. Generally, there is a quick pulse check first. If no pulse... CPR is started right away. Then after a round of compressions, the patient is assessed for breathing. The components I mentioned above still apply.

 Based on this assessment, the EMS crew would determine what interventions need to be done. There are two medications that can be given as reversal: Narcan and Flumazenil. These only work for opiates and benzodiazepines.

 Adrenaline is Epineprhine. It would depend on what her other vital signs were at the time of her discovery. We don't give epinephrine just for unconsciousness. If she doesn't have a pulse and is not breathing and she has a particular arrhythmia (v-fib, v-tach, pulseless electrical activity) then these would be an indication for epinephrine. If she requires epinephrine, she likely will need someone to breathe for her as well.

 One thing I noticed is that you say her "stomach has been pumped out". This really isn't part of emergency care for overdose anymore. Many people don't understand what it means. We basically shove a garden hose down your throat and irrigate the stomach out with saline. The issue became that the risks of the patient having complications from the procedure were not worth the risk (risk to benefit ratio). Such complications could be inhaling vomit into their lungs and developing pneumonia or creating an electrolyte imbalance from using large amounts of saline to clear the stomach.

Generally, if a patient is discovered within one hour of their ingestion, we will give activated charcoal which is essentially ground up charcoal mixed with sugar. It looks like black sludge. The patient can either voluntarily drink it or we can put a tube into their stomach and give it that way. This medication will absorb the drug from their stomach, bind it so it becomes inactive, and then they poop it out.

Heidi adds:

It's pretty tough to over dose on Ambien unless it was your intention, so I'd definitely call that a suicide attempt. We'd probably monitor her ( on the obstetrics floor) for twenty four hours, put in a psych consult and have a sitter (a suicidal patient can't be left unattended).

You can keep a baby on the monitor starting at about 24 weeks, any GA (gestational age) before that you use a Doppler. We probably wouldn't keep her on the monitor but we'd admit her so she couldn't leave. Basically scare her into staying for "the sake of the baby" if nothing else. That way if she goes AMA (against medical advice) the hospital is not liable for either her or the baby.

Most level 2 and above hospitals see 24 weeks as the cut off for viability and there lots of things we can do to keep the fetus alive in cases of PPROM (Premature Rupture of Membranes), accidents, that kind of thing and with the right staff and facility you can maintain the viability of a 17 weeker.  

As for Ambien, we'd watch her more for maternal sake then baby. L&D nurses are good at getting the real story too, better than the counselors sometimes.  Ambien in a nut shell: 24 hours observation, intermittent monitoring, sitter, and consults. To get mama back in the game we do bedside ultrasounds so she can bond with baby and turn up the monitor so she can hear the baby, make life more real for her.  Nurses little tricks.

Any other thoughts for Lisa?

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Lisa Mladinich is the author of "Be an Amazing Catechist: Inspire the Faith of Children" and the founder of AmazingCatechists.com and Catholic Writers of Long Island. Her weekly catechetical column can be found at http://www.patheos.com/About-Patheos/Lisa-Mladinich.html