We emergency physicians are generally a confident bunch. But in the time it takes to slip on a peel and hit the pavement (a bananosecond), some of us ratchet up adrenaline output when we pick up a chart and notice a history like 22 yo F, minor MVC, c/o headache and back pain, 32 weeks pregnant.

From whence comes this anxiety? A bit may stem from reading about those seven-figure lawsuit verdicts for pregnancy-related malpractice cases. However, tied to this are those questions and comments I often hear from residents seeking assurance, even when they know the answers.

• Can I get this x-ray?
• Is it OK to give her morphine IV? Should I start with 1 mg? (Sure, if it’s in the right acupuncture point.)
• Wow, I’m so used to not treating asymptomatic elevated BP that I almost forgot to address it for this pregnant patient.

Getting answers from specialists can often be frustrating. The OB doc may be uncomfortable with the non-OB aspects of the case, while the other consulting specialists may be uncomfortable applying their expertise in the context of pregnancy.

I recall asking a surgeon to look at a third-trimester patient with likely appendicitis and an equivocal ultrasound. His plan related to me was, “We’ll sit on it overnight.” After making some remark about his own application of procto-tocin, I suggested an MRI. He was a bit leery, but with some education and pressure on our radiologist to do our hospital’s first MRI to rule out appendicitis (accomplished without procedural sedation on that radiologist), we identified an acute appy.

As with many aspects of EM, it may be up to the EP to coordinate optimal care in these situations. In 1981, Dr. Arnold Greensher and I, along with a panel of well-regarded academic specialists, including a group of perinatologists, developed a system called Prenatal Care – A Systems Approach© to help OBs and primary care physicians integrate prenatal care within a comprehensive risk management system. It includes frequently updated information on managing nonobstetric illness and injury in this population.

The track record for the system has been quite surprising to us, as well as to the medical malpractice insurers who purchased the system for their docs: There were more than 1.5 million deliveries during this time period with only 8 malpractice claims. The expected number of claims would be 400-700. For a large number of users, premium rates went down dramatically during a time when national rates were going in the opposite direction.