Ruptured Uterus vs Fractured judgment. Implicit Bias Leads to Life-Threatening Misdiagnosis: A Case Report (1 Class A CE with 1 Pharm)

The unconscious biases we hold may blind our ability to recognize clear and distinct clinical signs and symptoms, or even lead us to make errant choices in treatment. Maternal mortality is rapidly rising in our country and implicit bias may be a contributing factor. We present a case report, detailing the missed diagnosis of Cocaine-induced uterine rupture in a parturient with known Substance Use Disorder (SUD). This multifaceted case highlights the anesthesia risks associated with SUD in pregnancy, and details the risks associated with “Crack” Cocaine use, specifically. Black Maternal Health disparity, differential diagnosis associated with Kehr’s sign, best practices in obstetric anesthesia, emergency hysterectomy under regional anesthesia, "Microaggression" among healthcare professionals, and the role of the CRNA in critical decision making are identified / discussed. Additionally, we bear the question: Does implicit bias influence a Surgeon’s perception of a CRNAs ability to make emergent, critical, anesthetic decisions? Training all health care providers to recognize and overcome bias is one step in reducing maternal mortality rates.