Emergency medicine after Dobbs vs Jackson Health

[FemaleMD]

Would any of our colleagues in Missouri offer comments on what their current practices are to be for ectopics, septic AB etc, what are hospital attorneys advising?

Do you need to get methotrexate approval from a magistrate similar to getting approval in a catholic hospital system? Is everything admitted to OB For them to sort out with legal? Who’s legal representative are you following the advice of, the hospital or your own?

Concerns mount over ‘medical emergency’ exception in Missouri’s abortion ban

---

Members don't see this ad.

 

[futureapppsy2]

I hope this isn’t too political, but I think a huge problem with these laws is that they’re written by people with no knowledge of medicine. For example, they seem to almost presume that people have a light above their head that lights up when a medical emergency happens and all pregnancy complications are either nothing or fatal, with no in-between. The end result is that physicians dealing with pregnant patients are having to decide between treating a patient, it leading to an abortion/miscarriage, and possibly going to jail, or waiting/not acting and having the patient die or be seriously injured. The laws don’t allow for the clinical realities.

 

[PianoMedic]

Just saw this article come through from ACEP Now, for what that’s worth:

Special Edition: EMTALA Requirements Remain Fully in Effect in the Post Roe v. Wade World

The whole country is still digesting the monumental Dobbs v. Jackson Women’s Health Organization Supreme Court decision that overturned Roe v. Wade last week and trying to grasp the plethora of legal and health-related implications that the decision will have.

www.acep.org

Tldr: EMTALA will override any state laws for conditions deemed medical emergencies. Ectopic pregnancy is listed as an example. Not ruptured ectopic. Just ectopic. Take it as you will.

 

[thegenius]

Just saw this article come through from ACEP Now, for what that’s worth:

Special Edition: EMTALA Requirements Remain Fully in Effect in the Post Roe v. Wade World

The whole country is still digesting the monumental Dobbs v. Jackson Women’s Health Organization Supreme Court decision that overturned Roe v. Wade last week and trying to grasp the plethora of legal and health-related implications that the decision will have.

www.acep.org

Tldr: EMTALA will override any state laws for conditions deemed medical emergencies. Ectopic pregnancy is listed as an example. Not ruptured ectopic. Just ectopic. Take it as you will.

Yes federal statue overrides state laws...but in most cases I don't see how emergency care will change at all. It's only going to change if ER docs regularly perform abortion procedures, and I think that is very rare.

 

[Groove]

...and you might administer ceftriaxone and azithromycin but not Plan B?

she’s got to figure out where else she can go to get meds to prevent her becoming pregnant from this horror?

Correct.

 

[Rendar5]

I thought you didn't treat non-emergencies like gonorrhea and chlamydia that hasn't happened yet. You should just let her figure out where to go if she does develop an infection and treat her then. (couldn't really resist a snarky dig. That said, I wasn't making a dig at your views on Plan B. While I don't agree with them I can understand and respect your point of view based on your reply to my last post)

 

[Janders]

I must work in a different practice environment. I have no SANE team. I have no location to transfer these patients to. I have, at best, a bedside RN who’s done a couple of these and has a heart and is willing to put time into it. I’m not double covered 24/7, so I can’t just let my partner pick up every sexual assault case that may need plan B (these cases also are… often rough. We should share the burden together).

The (overwhelmingly) young women often have concomitant issues accessing care and lack a PCP / primary OB/GYN.

So for me to shrug my shoulders and say “eh, not pregnant yet, plan B isn’t an emergency” isn’t taking a NEUTRAL stance on the issue. They need to know that pregnancy is a possibility, and Plan B is a viable option (pro-active education by myself/RN staff). Assuming one does that, at least, they still need to get to somewhere that has plan B, and pay extra (would have just been lumped into the sexual assault ER-bill co-pay…). In some areas and with some patients these are low bars for them to hurdle. But in some rural areas or in certain poverty stricken areas, this is a real hurdle you are placing in front of the patient. As well, plan B has a weight limit (or recommendation) and maybe they should be counseled to take Ella, etc.

So what would I do if one of our docs was working overnights, and refusing to Rx Plan B to sexual assault victims? No one else is working. There isn’t a 24/7 pharmacy in walking distance. Is just giving a paper handout that says “you can go buy plan B if you want!” Enough?

 

[turkeyjerky]

Would any of our colleagues in Missouri offer comments on what their current practices are to be for ectopics, septic AB etc, what are hospital attorneys advising?

Do you need to get methotrexate approval from a magistrate similar to getting approval in a catholic hospital system? Is everything admitted to OB For them to sort out with legal? Who’s legal representative are you following the advice of, the hospital or your own?

Concerns mount over ‘medical emergency’ exception in Missouri’s abortion ban

Seems as though I might be an outlier here, but I consult obgyn everytime I have an extopic, and honestly prefer them to come in for methotrexate (unless they're willing to see them in the ER and discharge). It seems like, ime, every case has some diagnostic uncertainty, or a relative contraindication/caution.

 

[Dr Mantis Toboggan]

Ob has to come in and order it at my hospital. I’m an ER doctor, I don’t give chemotherapy.

 

[thegenius]

Seems as though I might be an outlier here, but I consult obgyn everytime I have an extopic, and honestly prefer them to come in for methotrexate (unless they're willing to see them in the ER and discharge). It seems like, ime, every case has some diagnostic uncertainty, or a relative contraindication/caution.

As do I. Every ectopic gets a OB consult.

 

[turkeyjerky]

Okay, so say a woman w/ a severe underlying health condition such that pregnancy is expected to result in substantial risk of morbidity or mortality, say severe pulmonary arterial hypertension, gets pregnant and comes to an ER requesting an OB consult for termination. What does EMTALA mandate we do?

Not an acute emergency, however, how can the patient be deemed 'stable' for outpatient followup, if the indicated outpatient procedure (termination) cannot be offered in the jurisdiction?

I don't find that article on EMTALA useful in the least. All it does is put us between a rock and a hard place. Doubtful that hospital administrators or risk mgmt will be helpful, as malicious compliance always seems to be their MO.

 

[RoyBasch]

Seems as though I might be an outlier here, but I consult obgyn everytime I have an extopic, and honestly prefer them to come in for methotrexate (unless they're willing to see them in the ER and discharge). It seems like, ime, every case has some diagnostic uncertainty, or a relative contraindication/caution.

I’m the same.

I insist that the order for MTX actually be entered in the EMR by the consulting gynecologist. I’m not doing them any favors or solids here.

I think this new criminal legal peril only reinforces my practice.

 

[WilcoWorld]

I also consult OB on every ectopic, just like I consult surgery on every appendicitis - I'm not qualified who can me managed medically vs surgically.

Ob has to come in and order it at my hospital. I’m an ER doctor, I don’t give chemotherapy.

I'm curious - will you Rx colchicine for gout?

 

[wholeheartedly]

We didn’t have OB/GYN at my last hospital…

 

[Dr Mantis Toboggan]

I also consult OB on every ectopic, just like I consult surgery on every appendicitis - I'm not qualified who can me managed medically vs surgically.

I'm curious - will you Rx colchicine for gout?

Lol well played.

Edit: I’m not smart enough to write for any medicine that has doseage based on body surface area.

 

[FemaleMD]

I didn’t mean to imply that the ED physician is managing ectopic pregnancies exclusively. I too consult OB on every ectopic, and they (OB) are the ones who are placing the methotrexate order. Can’t say that I’ve ever sent an ectopic pregnancy home. I do send indeterminate pregnancies home after OB consultation with close follow up.

My experience with Religious affiliated hospital system after consulting the OB, the OB then has to take a request for a type of treatment (Methotrexate, surgery)through a process which includes review by the hospital staffed religious clergy for approval prior to treatment.

What I have seen discussed in other forums and news outlets is that some hospital systems are refusing to treat Hemodynamically stable ectopics. Some reports of stable etopics with hemoperitoneum being admitted and necessitating either instability or drop in hemoglobin or other evidence of “acute life-threatening issue“ before the hospital will Allow the OB to perform definitive treatment. I was wondering if anyone has seen this IRL.

 

[Dred Pirate]

My experience with Religious affiliated hospital system after consulting the OB, the OB then has to take a request for a type of treatment (Methotrexate, surgery)through a process which includes review by the hospital staffed religious clergy for approval prior to treatment.

Gotta love that religious clergy are helping determine medical care - SMH

slightly off topic - but some what relevent to this discussion. I use to work at a small hospital with no OB- but they did minor surgeries. 25 miles down the road was a Catholic hospital that had an OB department. If a patient had a C-section at hospital B, they could not have a tubal ligation, but that same OB would then re-admit them down the road to our hospital for the procedure. Because of religion, we put these patients through the risk of two surgeries - I just don't get when religion gets in the way of doing what is best for the patient - and something that is going to likely happen anyway (and I consider myself a Christian, but I get very dismayed by those in charge of many of the religions)

 

[miacomet]

So I am pro life but will not judge other docs/people for having abortions. I disagree with it in the vast majority of cases regardless of gestation, but that is my beliefs.

So if someone comes in who has been assaulted, condom broke, or just wanted it to be safe then I ask the doctor working with me to take the case. I have been lucky for 99% of my career to be working in double coverage so never been an issue. I prob had about 3-4 people who requested this in 20 yrs so quite rare.

But if I were single coverage, I would tell them to come back when I am not working or go to the local UC.

You don't offer Plan B?
Can I not offer random services I don't believe in?
How horrible for the patient.

 

[miacomet]

It's wild how many people think the end of Roe won't affect healthcare, yet every major medical society from AMA to ACOG is deeply concerned with the impact.

 

[maxxor]

Hospitals Must Provide Abortions in Emergency Situations, Biden Administration Says

New federal guidelines aim to help doctors and hospitals reconcile state laws restricting abortions with a federal law that can require the procedure to stabilize a pregnant woman with an emergency medical condition.

www.wsj.com

Well here’s an attempt to settle the EMTALA question…

 

[thegenius]

Hospitals Must Provide Abortions in Emergency Situations, Biden Administration Says

New federal guidelines aim to help doctors and hospitals reconcile state laws restricting abortions with a federal law that can require the procedure to stabilize a pregnant woman with an emergency medical condition.

www.wsj.com

Well here’s an attempt to settle the EMTALA question…

Yea I don't think this is in dispute. The question is what the ER doctor should do when the bHCG is 4500 and she has an empty uterus and an otherwise normal OB US. Pt has no pain and no bleeding and normal vitals.

This is not an emergency but highly unlikely a viable pregnancy. I would not give anything in this case. This is up to OB. and if I didn't have OB I would put to OB as an outpatient.

Even though I'm in CA....if I were in an anti-abortion state and a patient comes in with a bleeding (or even non-bleeding but confirmed) ectopic I won't bat an eye at all.

 

[emergentmd]

You don't offer Plan B?
Can I not offer random services I don't believe in?
How horrible for the patient.

So are we to dictate how physicians should practice within standard of care?
As an ER doc, is plan B an emergency treatment? If so, can you point me to literature that states this?

Yes, you can refuse to offer services if you practice within standard of care. I bet you do this all the time.
Most OB docs do not offer abortions, well within their scope of practice.

How horrible for the pt? Nice projecting judgement. I am sure your practice would never be judged.

 

[turkeyjerky]

So are we to dictate how physicians should practice within standard of care?
As an ER doc, is plan B an emergency treatment? If so, can you point me to literature that states this?

Yes, you can refuse to offer services if you practice within standard of care. I bet you do this all the time.
Most OB docs do not offer abortions, well within their scope of practice.

How horrible for the pt? Nice projecting judgement. I am sure your practice would never be judged.

I'm good w/ declaring that offering emergency contraception to a rape victim is an emergency.

 

[Mount Asclepius]

I'm good w/ declaring that offering emergency contraception to a rape victim is an emergency.

I oddly agree. Odd in that I'm the first person to argue that most conditions really aren't emergent. This isn't a great argument though for this debate. It feels like an easy cop out. We don't deal with only emergent conditions. We primarily do acute care medicine. I think that in this scenario many of these patients present to us for care and don’t easily have access to information or medical education regarding alternative locations of care or the resources to always seek out those alternatives. I personally feel that it is incumbent on a physician to put any personal feelings aside and do what is in the best interest for the patient in front of them. I recognize this is easier for me to do, where as others might have moral objections. Despite those objections, I think physicians should offer the medical intervention of plan B that I believe to be standard of care for these situations allowing the patient to make an informed decision. Withholding treatment just adds a barrier to care further stigmatizing and alienating patients in already difficult situations.

 

[Mount Asclepius]

I'm not too worried that this decision will significantly affect us directly as EPs. It will more so affect obstetricians, and will dramatically affect patients. I don't anticipate my practice patterns regarding OB care in the ED changing.

I'll continued to provide plan B in situations where it's indicated. I do this extremely rarely anyways. I think the majority view plan B as contraception and not abortion (without getting into the semantics of the argument). I also don't see 'emergent' plan B as a high priority target for the vast majority of states including those that fall into the classification of anti-abortion. Granted they might try to move the goal posts with time if more and more restrictions pass in these states.

When we take care of ectopic pregnancies, OB is essentially always consulted and involved in the care of these patients determining both the timing of management as well as medical versus surgical management. The management of the stable ectopic pregnancy in some states may become more challenging, but OB will be the primary one navigating these issues. This isn't something we as EPs are going to really struggle with managing.

 

[emergentmd]

If Plan B is deemed an emergency condition, then as an ER doc I will see the pt/prescribe it if there is no other doc avail to do it.

But this is a slippery slope I don't think any doc would want to go down and I would be against this for this fact. Yes, We all treat non Emergencies all the time but it is the freedom of the doc to offer something or not.

Some docs I know NEVER would order an MRI from the ER for knee pain. I have ordered it prob 3 times due to some sympathetic cases.

Again, if some feel that all ER docs should prescribe plan B, then wouldn't the corollary be that all OB doc should offer abortions? I am sure there are a good amount of OB docs who does not offer Plan B.

If specialists whose primary field is pregnancies take the first step and mandate they all offer Plan B/abortions, then I would be reluctantly fine with non pregnancy specialists mandate Plan B.

 

[VA Hopeful Dr]

If Plan B is deemed an emergency condition, then as an ER doc I will see the pt/prescribe it if there is no other doc avail to do it.

But this is a slippery slope I don't think any doc would want to go down and I would be against this for this fact. Yes, We all treat non Emergencies all the time but it is the freedom of the doc to offer something or not.

Some docs I know NEVER would order an MRI from the ER for knee pain. I have ordered it prob 3 times due to some sympathetic cases.

Again, if some feel that all ER docs should prescribe plan B, then wouldn't the corollary be that all OB doc should offer abortions? I am sure there are a good amount of OB docs who does not offer Plan B.

If specialists whose primary field is pregnancies take the first step and mandate they all offer Plan B/abortions, then I would be reluctantly fine with non pregnancy specialists mandate Plan B.

I'll take that bet

 

[emergentmd]

I'll take that bet

Ok, let me rephrase that there are some OB docs who does not prescribe Plan B. I will accept mandates on prescribing it as an ER doc, once OB is required too.

 

[miacomet]

If Plan B is deemed an emergency condition, then as an ER doc I will see the pt/prescribe it if there is no other doc avail to do it.

But this is a slippery slope I don't think any doc would want to go down and I would be against this for this fact. Yes, We all treat non Emergencies all the time but it is the freedom of the doc to offer something or not.

Some docs I know NEVER would order an MRI from the ER for knee pain. I have ordered it prob 3 times due to some sympathetic cases.

Again, if some feel that all ER docs should prescribe plan B, then wouldn't the corollary be that all OB doc should offer abortions? I am sure there are a good amount of OB docs who does not offer Plan B.

If specialists whose primary field is pregnancies take the first step and mandate they all offer Plan B/abortions, then I would be reluctantly fine with non pregnancy specialists mandate Plan B.

All Ob doctors should be trained in, competent in, and supportive of abortion care. Should a doctor who has chosen to specialize in endometriosis surgery and who no longer practices general ob/pregnancy care be compelled to perform abortions? No, of course not. But in EM, Plan B is part of our scope of practice. If you stopped practicing EM and went into Pain, no you would not obligated to provide any kind of pregnancy care.

But people should not be practicing clinical medicine who do not respect consent and bodily autonomy. Providing Plan B and supporting abortion care are necessary to support bodily autonomy. WHO, ACOG, and the AMA all recognize abortion care as fundamental to pregnancy care. If someone doesn't, they certainly shouldn't be involved in the care of pregnant patients.

 

[WilcoWorld]

Plan B can prevent a pregnancy from occurring, but only if given soon enough.
If Plan B is withheld to a rape victim, and they get pregnant, that person may very well feel compelled to abort the pregnancy.
If you believe life begins at conception, then withholding Plan B has led to an otherwise preventable death.

If you believe life begins at conception, and you think preventing death is an emergency, then Plan B is an emergency in rape victims presenting to the ED.

 

[emergentmd]

All Ob doctors should be trained in, competent in, and supportive of abortion care. Should a doctor who has chosen to specialize in endometriosis surgery and who no longer practices general ob/pregnancy care be compelled to perform abortions? No, of course not. But in EM, Plan B is part of our scope of practice. If you stopped practicing EM and went into Pain, no you would not obligated to provide any kind of pregnancy care.

But people should not be practicing clinical medicine who do not respect consent and bodily autonomy. Providing Plan B and supporting abortion care are necessary to support bodily autonomy. WHO, ACOG, and the AMA all recognize abortion care as fundamental to pregnancy care. If someone doesn't, they certainly shouldn't be involved in the care of pregnant patients.

This is just where we just have to disagree one. I do not think that someone should have forced to do anything that is standard of care and not in an emergency situation.

What you are saying is anyone doing Obstetrics should be forced to do abortions? Are you really saying this?

So I assume all FM, IM, Pedi, EM, UC docs should be forced to do Plan B?

All cake makers should be forced to make same sex marriage cakes?

All trial lawyers should be forced to represents murderers?

Just b/c you are trained, then you should be forced to do something you do not believe in when there a viable options?

If I were an OB, and someone was going to die if I did not abort, then hell yes I would do it. But I for sure would not do elective abortions and I would have no problems telling a pt this with referrals to clinics that will abort babies.

 

[emergentmd]

Plan B can prevent a pregnancy from occurring, but only if given soon enough.
If Plan B is withheld to a rape victim, and they get pregnant, that person may very well feel compelled to abort the pregnancy.
If you believe life begins at conception, then withholding Plan B has led to an otherwise preventable death.

If you believe life begins at conception, and you think preventing death is an emergency, then Plan B is an emergency in rape victims presenting to the ED.

Truthfully, if someone came in b/c they were raped, I would give Plan B if I had NO partners working who could give Plan B.

But No, I am not giving plan B just b/c someone came in and the condom broke or they just couldn't wait to put one on. Again, I am reasonable and sympathetic to individual cases.

 

[miacomet]

This is just where we just have to disagree one. I do not think that someone should have forced to do anything that is standard of care and not in an emergency situation.

What you are saying is anyone doing Obstetrics should be forced to do abortions? Are you really saying this?

So I assume all FM, IM, Pedi, EM, UC docs should be forced to do Plan B?

All cake makers should be forced to make same sex marriage cakes?

All trial lawyers should be forced to represents murderers?

Just b/c you are trained, then you should be forced to do something you do not believe in when there a viable options?

If I were an OB, and someone was going to die if I did not abort, then hell yes I would do it. But I for sure would not do elective abortions and I would have no problems telling a pt this with referrals to clinics that will abort babies.

Yes, Plan B is medical care. It's part of the standard of care for rape victims and others who need post coital birth control. If you can't respect patient autonomy (and also don't understand how Plan B works) you should certainly not be practicing in any field where someone might need Plan B.

 

[emergentmd]

But bottom line is Physicians have the right to practice within standard of care. If you can find a somewhere that states that ER docs are required to prescribe Plan B in all circumstances, then I would be happy to change my practice. But otherwise, you are just judging someone's practice and I am sure you would not like someone telling you how to practice when you are within standard of care.

 

[emergentmd]

Yes, Plan B is medical care. It's part of the standard of care for rape victims and others who need post coital birth control. If you can't respect patient autonomy (and also don't understand how Plan B works) you should certainly not be practicing in any field where someone might need Plan B.

I never said Plan B is not medical care, if you can show me I am happy to retract. If medical care is a giant pie, standard of care is a part of that pie. If you can show me something from CMS, ACEP, or similar that states that EM docs are required to prescribe Plan B then I will be happy to change.

Also, this has nothing about respecting a patient's autonomy. So if a pt comes in demanding dilaudid, then will you just send them with a script no questions asked, otherwise "Who are you to judge how traumatic pain is for a person?" B/c by your definition, you are not respecting their autonomy. But maybe you would like to turn Medicine into Mcdonalds.

 

[WilcoWorld]

Judge, lest you be judged would make for a better country.

I agree that this would improve the US.
I fail to see how taking maternal health care decisions out of the clinic and into the statehouse is consistent with non-judgement.

 

[miacomet]

I never said Plan B is not medical care, if you can show me I am happy to retract. If medical care is a giant pie, standard of care is a part of that pie. If you can show me something from CMS, ACEP, or similar that states that EM docs are required to prescribe Plan B then I will be happy to change.

Also, this has nothing about respecting a patient's autonomy. So if a pt comes in demanding dilaudid, then will you just send them with a script no questions asked, otherwise "Who are you to judge how traumatic pain is for a person?" B/c by your definition, you are not respecting their autonomy. But maybe you would like to turn Medicine into Mcdonalds.

Unlike Dilaudid, you are actually giving a medication with almost no side effects. Pregnancy is 15x more dangerous than abortion; you are potentially committing your patient to a 15x higher chance of death.

You really think it is your role to literally force someone to bear a child? Like, that should be your decision? Not theirs?

 

[emergentmd]

Unlike Dilaudid, you are actually giving a medication with almost no side effects. Pregnancy is 15x more dangerous than abortion; you are potentially committing your patient to a 15x higher chance of death.

You really think it is your role to literally force someone to bear a child? Like, that should be your decision? Not theirs?

Let me say that I respect your stance, and you should be able to practice within standard of care without being judged. Once you start to question someone's care that is well within standard of care, then you open a can of worms that will destroy medicine. All of the EM metrics already is taking a large bite out of the practice of medicine and put it into the hands of administrators who never touched the pt.

With this said, I will really do not want to debate abortion anymore bc it always end up in painting prolifers as being cold, disrespecting women rights, heartless, etc. Believe me I am none of this, and have done gone beyond what many physicians would do for their patients.

Bottom line is if I am practicing within standard of care, then who are you to judge if my practice is appropriate. There is a reason we have standard of care and all are judged if we practice inside/outside of this.

I believe I practice within standard of care. If not, please show me where EM standard of care is to prescribe Plan B. That is all I ask, otherwise its ok to respect how someone practices within standard of care.

 

[emergentmd]

I agree that this would improve the US.
I fail to see how taking maternal health care decisions out of the clinic and into the statehouse is consistent with non-judgement.

I never want healthcare to be taken from providers. Although I am prolife and happy how SCOTUS ruled, I am against taking away provider's autonomy.

 

[WilcoWorld]

This is just where we just have to disagree one. I do not think that someone should have forced to do anything that is standard of care and not in an emergency situation.

What you are saying is anyone doing Obstetrics should be forced to do abortions? Are you really saying this?

So I assume all FM, IM, Pedi, EM, UC docs should be forced to do Plan B?

All cake makers should be forced to make same sex marriage cakes?

All trial lawyers should be forced to represents murderers?

Just b/c you are trained, then you should be forced to do something you do not believe in when there a viable options?

If I were an OB, and someone was going to die if I did not abort, then hell yes I would do it. But I for sure would not do elective abortions and I would have no problems telling a pt this with referrals to clinics that will abort babies.

I'll take this bait.

I assert that YES, by working in an Emergency Department you DO accept an obligation to provide certain care AND ALSO you are not obligated to provide just any care the patient wants.

If you are a Jehova's Witness, you may not decide to withhold a blood transfusion to someone in hemorrhagic shock. You may decide not to prescribe dilaudid for chronic back pain. This is not a contradiction. What's the distinction? In one case you are deciding what's best for the patient on ethical or metaphysical grounds (which isn't the MD's purview) on the other you are deciding what's in the patient's best interest on physiologic grounds (which is in the MD's purview).

In the case of denying plan B you are deciding not to do something on the basis of your personal ethics. In the case of denying dilaudid you are deciding not to do something on the basis of physiology.

 

[Arcan57]

Let me say that I respect your stance, and you should be able to practice within standard of care without being judged. Once you start to question someone's care that is well within standard of care, then you open a can of worms that will destroy medicine. All of the EM metrics already is taking a large bite out of the practice of medicine and put it into the hands of administrators who never touched the pt.

With this said, I will really do not want to debate abortion anymore bc it always end up in painting prolifers as being cold, disrespecting women rights, heartless, etc. Believe me I am none of this, and have done gone beyond what many physicians would do for their patients.

Bottom line is if I am practicing within standard of care, then who are you to judge if my practice is appropriate. There is a reason we have standard of care and all are judged if we practice inside/outside of this.

I believe I practice within standard of care. If not, please show me where EM standard of care is to prescribe Plan B. That is all I ask, otherwise its ok to respect how someone practices within standard of care.

Standard of care is a nebulous term but I have seen physicians sanctioned by health care systems for not prescribing Plan B and I've seen lawsuits filed over lack of prescription. And these occurred in a geographically close proximity to you.

 

[BoardingDoc]

Reminder to all: refrain from personal attacks.

I just gave a warning about this to someone. Given the uniquely incendiary potential that this thread has, post bans from this point on will be handed out very liberally.

 

[miacomet]

I'll take this bait.

I assert that YES, by working in an Emergency Department you DO accept an obligation to provide certain care AND ALSO you are not obligated to provide just any care the patient wants.

If you are a Jehova's Witness, you may not decide to withhold a blood transfusion to someone in hemorrhagic shock. You may decide not to prescribe dilaudid for chronic back pain. This is not a contradiction. What's the distinction? In one case you are deciding what's best for the patient on ethical or metaphysical grounds (which isn't the MD's purview) on the other you are deciding what's in the patient's best interest on physiologic grounds (which is in the MD's purview).

In the case of denying plan B you are deciding not to do something on the basis of your personal ethics. In the case of denying dilaudid you are deciding not to do something on the basis of physiology.

Really well put.
In the case of Dilaudid, you can argue there is a reasonable risk to the patient.
There is much less risk to the patient (the patient is the person requesting the Plan B, not a theoretical fertilized egg that may or may not exist) from giving Plan B than from not giving Plan B. Pregnancy is dangerous. Plan B is well within the standard of care; to not give it means you are refusing to give a medication with few side effects and many benefits to a patient for no medical reason whatsoever, simply because you don't want to.
You are in the position of power here, not the patient; you can't conscientiously object from a position of power.

 

[miacomet]

Inte

I never want healthcare to be taken from providers. Although I am prolife and happy how SCOTUS ruled, I am against taking away provider's autonomy.

But SCOTUS's ruling did take away autonomy from 50% of the population, many of whom are providers. If you can't trust pregnant/potentially people to make the right decisions about their bodies, how can you allow them to practice medicine?

Autonomy has also been taken away from doctors in that many not only have no control over their own bodies, but they also can't provide medically necessary care in many states.

 

[miacomet]

I think, as a matter of decency, courtesy, and in understanding of the complicated logistics of accessing medical care in the setting of a recent sexual assault, we do a lot of things for these patients that we wouldn't do for those who've engaged in normal behavior.

Eg, if someone comes in after a sketchy hookup, I'm not offering them prophylaxis against STIs, etc.

That said, I'd be fine w/ giving out EC after intercourse. (Weirdly, I've never actually had a patient come in requesting it. Surprising, considering I used to practice at a spot where ambo rides followed by 12 hr waits for motrin prescriptions were common---plan B aint cheap!)

Why not? What's the contraindication to testing for STDs? Why wouldn't you offer this if they were concerned?

 

[emergentmd]

I'll take this bait.

I assert that YES, by working in an Emergency Department you DO accept an obligation to provide certain care AND ALSO you are not obligated to provide just any care the patient wants.

If you are a Jehova's Witness, you may not decide to withhold a blood transfusion to someone in hemorrhagic shock. You may decide not to prescribe dilaudid for chronic back pain. This is not a contradiction. What's the distinction? In one case you are deciding what's best for the patient on ethical or metaphysical grounds (which isn't the MD's purview) on the other you are deciding what's in the patient's best interest on physiologic grounds (which is in the MD's purview).

In the case of denying plan B you are deciding not to do something on the basis of your personal ethics. In the case of denying dilaudid you are deciding not to do something on the basis of physiology.

I get your point, and even if I disagree can respect your opinion. Again, not want to argue someone's opinions or believe.

So are you saying that docs are not allowed to practice based on their beliefs? So should all docs before entering med school pledge to give up their personal beliefs?

As an extension, should all OB docs be required to perform abortions on anyone who wants one even if they are against abortion? Or is this different?

 

[emergentmd]

Why not? What's the contraindication to testing for STDs? Why wouldn't you offer this if they were concerned?

Doc miacomet, I just had sex with a hook up. Can you test me for HIV, STD, herpes, syphillis, mono, Hepatitis. Throw in Some plan B, Rocephin, azithromycin too? Can you start me on that HIV med cocktail while you are at it. Oh, throw in some diflucan b/c I get yeast on abx.

Can I come back in 6 wks to get retested just to make sure everything is still good? I mean, my body my decision right?

 

[WilcoWorld]

I get your point, and even if I disagree can respect your opinion. Again, not want to argue someone's opinions or believe.

So are you saying that docs are not allowed to practice based on their beliefs? So should all docs before entering med school pledge to give up their personal beliefs?

As an extension, should all OB docs be required to perform abortions on anyone who wants one even if they are against abortion? Or is this different?

I think that the ED (and the ICU) presents a special environment where patients do not have the freedom of choice of their doctors, so the issue is particularly acute in that setting. Thus, if you CHOOSE to practice in an ED, you CHOOSE to take on certain obligations. If you want to be free of those obligations, you can work in a different environment.
I find it ethically untenable to provide bad care in the name of patient satisfaction, so I work in a center where I don't get fired for declining to provide bad care in the name of satisfaction (and this comes at a significant financial cost to me). Similarly, a doctor who doesn't want to prescribe contraceptives shouldn't work at Planned Parenthood.

 

[Arcan57]

Doc miacomet, I just had sex with a hook up. Can you test me for HIV, STD, herpes, syphillis, mono, Hepatitis. Throw in Some plan B, Rocephin, azithromycin too? Can you start me on that HIV med cocktail while you are at it. Oh, throw in some diflucan b/c I get yeast on abx.

Can I come back in 6 wks to get retested just to make sure everything is still good? I mean, my body my decision right?

I guess I'm confused on the point you're making.

If you're implying that we're going to be flooded with a continuous stream of patients requesting STI evaluation after consensual hook-ups, that seems unlikely verging on strawman.

If you're arguing that people shouldn't be able to seek treatment for a disease because of the circumstances under which they contracted the disease, that seems like a bad take.

If you're describing what should happen during one of these encounters, I'd largely agree with you minus the very last sentence which I'd either delete or at least remove the question mark.

 

[turkeyjerky]

I never want healthcare to be taken from providers. Although I am prolife and happy how SCOTUS ruled, I am against taking away provider's autonomy.

You do understand that is exactly what the recent decision did, right? Open the door to the state restricting physicians' autonomy in preventing them from providing abortion? Why is the right so insistent upon legislating medical practice?