Congo Epic Problem

For my coworkers in St. Louis, you will understand the title of this post. For everyone else, Epic is the computer program that we use in our hospital for orders, documentation, vitals, etc. We have a love hate relationship with the functionality. We love to say that we have an Epic problem. Yesterday, I performed a tubal ligation, several gynecologic exams, and two cesarean sections. One was for presumed eclampsia. She came to the ER in a coma, seizing, and 28 wks pregnant with elevated blood pressure and edema. They gave her phenobarbital, a bolus of magnesium in her IV, Rocephin for possible meningitis, ruled out cerebral malaria, and observed her overnight. When I heard about her in the morning, I immediately went to see her. Her uterus was tetanic (contracting constantly) and I had little hope for the fetus. But the treatment for eclampsia is delivery and often the mothers will do better after delivery. I indicated a cesarean section and we delivered a stillborn infant. After the surgeries of the day were finished (Gyn-wise), I went to see the the patient with eclampsia. She had not improved. She was still tachypnic in the 50s/min, blood pressure was rising, and she had made minimal urine output. I discussed with the resident that they should give more IV fluids and minimize the lasix as she was likely dry. She did not have any crackles in her lungs to indicate fluid overload. She had only received 1 dose of magnesium the night before, and as her blood pressure was rising, I thought she likely needed it to avoid another seizure. There was no way to intubate her in this situation as we would have done in the US. The following is the process I went through to get magnesium started. To my fellow OB residents, remember how frustrated we get when we order magnesium and it is not even going 30 min later? Read on. :S

1. Asked the resident about mag. He said, "it is very difficult" and went back to the OR for more cases. 2. Looked around, and all in the room were assistant nurses or techs and did not speak English. 3. Walked around the hospital to find Dr. Rice for a second opinion. Found Paul in the peds ward who said he was at home. Walked home to get further consultation with Dr. Rice 4. Walked back to the hospital with Dr. Rice 5. Assessed the patient. Assistants were faithfully taking blood pressures. Blood pressure was 150/110. Still in a coma. Edematous eyes, face, feet, no crackles in the lungs. Responsive to pain, pupils reactive to light. Still tachypnic. Decided we should start mag. 6. Walked to OR to get back up with the supervising doctor, Dr. Fina. He agreed, sent a different resident with us to get the mag going. 7. Walked to the lab to ask them to obtain a creatinine and sodium level. 8. Walked to the patient to order the mag on the chart. 9. Resident went to the central pharmacy to get the mag 10. Lab tech came to the patient to get blood 11. Dr. Rice walked with the lab tech to find the result 12. Resident came back with a bottle of mag. I was unsure how much mag was present in the bottle or how many mL to give. 13. Walked to the lab to tell Dr. Rice I was going to the OR. 14. Walked back to the OR. (which requires me to change into different shoes and put on my scrub hat every time) Asked Dr. Fina about the concentration. 1mL = 500mg. 15. Walked back to the lab to see if there was a result. Negative. 16. Walked back to the patient bedside. Wondered how to give 2g/h by IV after the initial bolus.  
17. Looked up on Epocrates (my handheld drug reference) that I can give magnesium 4g IM q 4 hours. Calculated 8mL = 4g. 18. Dr. Rice returned to the patient bedside without a lab result. Failed. They would try again. 19. Dr. Mpoo, another supervising doctor and the medical director, came to the patient bedside. We discussed that we needed to give the magnesium IM. He agreed. 20. Walked to the maternity to find the nurse in charge. Explained to her how to give the magnesium and to check for respiratory status and reflexes prior to giving the magnesium doses each time and the side effects. 21. Dr. Mpoo wrote the order in French. 22. We decided to minimize the number of doses due to our inability to know creatinine at this time. Changed the order on the record. 23. Nurse in charge reported that there were no reflexes. 24. Walked to the patient bedside with the nurse in charge and Dr. Mpoo. Checked reflexes. They were 1+. 25. Taught the nurse to effectively check the reflexes. She was able to do this. 26. Walked home.

  

All in all, 26 steps and 2 hours later, our patient was on mag. And in the US, I write, "mag" and it pops up in an order set.  A few mouse clicks later and this is sent to the pharmacy automatically who sends the medication in a tube system to the nurse who checks the reflexes and hooks the patient up to the mag. Sadly, our patient needed intubation with the severe tachypnea and we found out she passed away overnight. This is life and death in Congo. It is my hope that these deaths can be minimized with prevention at the level of the health centers on the front lines with prenatal care and blood pressure checks monthly.