Emergency medicine after Dobbs vs Jackson Health

[Dr Mantis Toboggan]

Leaving personal views on abortion out of it (as that would not belong in this forum), how is our specialty going to be impacted by this decision? I practice in a state where in 30 days or so terminating a pregnancy will be against the law. Obviously we don’t provide elective pregnancy termination but what about our patients with non-ruptured ectopics, who need D&C for failed miscarriage, etc? I do not envy my ob/gyn colleagues, that is for sure.

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[PianoMedic]

Leaving personal views on abortion out of it (as that would not belong in this forum), how is our specialty going to be impacted by this decision? I practice in a state where in 30 days or so terminating a pregnancy will be against the law. Obviously we don’t provide elective pregnancy termination but what about our patients with non-ruptured ectopics, who need D&C for failed miscarriage, etc? I do not envy my ob/gyn colleagues, that is for sure.

This sounds like it is going to be a legal quagmire in a lot of states. I have had OB/GYN ask me to write the methotrexate for the patient. That could be a concern depending on how these laws have been written. Admittedly, I live in a state where this won’t be an issue so I haven’t reviewed these laws in significant detail. I don’t envy OB/GYN, nor my colleagues in those states who have to navigate this. Hopefully ACEP and the state equivalents prove useful and can provide guidance for EM docs in affected states.

 

[Boatswain2PA]

Are there any states that don't plan on having exceptions for ectopic or other real risks to mom?

 

[Boatswain2PA]

I've heard a lot about the OK law, just googled it. Allows for abortion to save life of woman in a medical emergency, or cases of rape/incest reported to PD within 6 weeks

 

[CoolDoc1729]

Leaving personal views on abortion out of it (as that would not belong in this forum), how is our specialty going to be impacted by this decision? I practice in a state where in 30 days or so terminating a pregnancy will be against the law. Obviously we don’t provide elective pregnancy termination but what about our patients with non-ruptured ectopics, who need D&C for failed miscarriage, etc? I do not envy my ob/gyn colleagues, that is for sure.

My state has a trigger law. There had already been messaging from the AGs office that they will not be enforcing it, and also this am the state medical board sent out an email that there will be no licensure actions related to this.

 

[Dred Pirate]

Are there any states that don't plan on having exceptions for ectopic or other real risks to mom?

I swear I heard there was some states, but a quick google search I cannot find specific confirmation.

Many just say "if needed to prevent a severe complication to the mother's health" or some wording like that.

made me think - if a patient is suicidal because of said pregnancy, would that qualify? Obviously that is a huge can of worms, but I could see it being a case to try to challenge the laws at some point in the future, One caveat, most of the states that have the bans, wouldn't have a facility capable of performing a "traditional abortion" for lack of a better term - so not sure sure how that would play out since I am sure as hell not a lawyer

 

[Mbekweni]

Before Roe v Wade psychiatrists played a big part in legal abortions with mental health attestations relating to the pregnancy.


Opinion | The ‘Open Secret’ on Getting a Safe Abortion Before Roe v. Wade

 

[Dr Mantis Toboggan]

I swear I heard there was some states, but a quick google search I cannot find specific confirmation.

Many just say "if needed to prevent a severe complication to the mother's health" or some wording like that.

made me think - if a patient is suicidal because of said pregnancy, would that qualify? Obviously that is a huge can of worms, but I could see it being a case to try to challenge the laws at some point in the future, One caveat, most of the states that have the bans, wouldn't have a facility capable of performing a "traditional abortion" for lack of a better term - so not sure sure how that would play out since I am sure as hell not a lawyer

In my state at least mental health issues will not be allowed as reasons to permit abortion. It is explicitly stated as such.

 

[Groove]

An ectopic is not viable pregnancy where the fetus can survive and obviously the mother's life is at risk. I fail to see the legal or clinical landmines that people seem to paint in these hypotheticals. Just do what's right for the patient and don't kill them.

About the only scenario I can think of where I might have to stop and think a bit more would be in having an OB tell you to administer MTX for whatever reason. I think you'd have to have certainty on your diagnosis.

If you find yourself taking care of a pt who obtained an illegal abortion and is experiencing complications...I "think" adherence to reporting requirements to the state or CDC is the responsibility of the hospital and not the provider but I'm not 100% certain. It might be worth reaching out to risk management or hospital attorneys regarding this topic if you practice in a state with trigger laws.

If you run into a clinical scenario where you're not sure how to proceed, just call risk management and make it their problem. That's what I intend to do.

Interesting times... Just remember HIPAA will not protect reproductive health data going forward and all your notes may be discoverable so document well...especially in those cases where you may feel the need to distinct between "abortion" vs "miscarriage at home".

 

[AMEHigh]

Are there any states that don't plan on having exceptions for ectopic or other real risks to mom?

Since SB8 was in effect in TX, there had already been patients who had to jump through hoops to get care for ectopic pregnancies and abortions for things like their water breaking at 17 weeks but there still being a fetal heart beat (same has often been true at Catholic hospitals for many years). So even with these "exceptions" care is delayed and people are facing ever increasing legal hurdles to get healthcare. It’s really sad. Medicine is not black and white and these laws are really messing with people’s lives and well being.

Even if they aren’t going to imminently die, waiting around for hours or days to get care just because you live in a certain zip code with idiotic politicians is not mentally healthy.

 

[wholeheartedly]

An ectopic is not viable pregnancy where the fetus can survive and obviously the mother's life is at risk. I fail to see the legal or clinical landmines that people seem to paint in these hypotheticals. Just do what's right for the patient and don't kill them.

About the only scenario I can think of where I might have to stop and think a bit more would be in having an OB tell you to administer MTX for whatever reason. I think you'd have to have certainty on your diagnosis.

If you find yourself taking care of a pt who obtained an illegal abortion and is experiencing complications...I "think" adherence to reporting requirements to the state or CDC is the responsibility of the hospital and not the provider but I'm not 100% certain. It might be worth reaching out to risk management or hospital attorneys regarding this topic if you practice in a state with trigger laws.

If you run into a clinical scenario where you're not sure how to proceed, just call risk management and make it their problem. That's what I intend to do.

Interesting times... Just remember HIPAA will not protect reproductive health data going forward and all your notes may be discoverable so document well...especially in those cases where you may feel the need to distinct between "abortion" vs "miscarriage at home".

I think the issue is you are a physician and it’s straightforward to you, but it’s politicians running the show and they’re doing dumb stuff like trying to pass laws that say that docs have to reimplant ectopics (in two different states).

Then some pharmacists are reporting that they got notice from cooperate not to give out certain meds that can be used for abortion even if the indication is something other than abortion.

 

[Groove]

I think the issue is you are a physician and it’s straightforward to you, but it’s politicians running the show and they’re doing dumb stuff like trying to pass laws that say that docs have to reimplant ectopics (in two different states).

Then some pharmacists are reporting that they got notice from cooperate not to give out certain meds that can be used for abortion even if the indication is something other than abortion.

You're referring to the Ohio bill where the lawmakers have already admitted they didn't research it adequately. These things will work themselves out and there no doubt will be some growing pains. I once had a doc tell me not to focus so much on hyper analyzing all the minutia of hypothetical situations and just focus on the patient. If you're legitimately trying to do the best thing for the patient in front of you with limited available information, then chances are that no jury is going to send you to jail.

I do agree that the certain lack of clarity over the next few months will no doubt prove to be frustrating to physicians but I doubt anyone is going to find themselves inadvertently sending themselves to jail or exposed to a clinical situation where they find themselves unable to care for their patient.

These are laws that have been in place since 1973 and are now gone. What do people expect? Just give it time. I'm sure there will be some confusing and contradictory laws introduced in certain states that will no doubt go through multiple revisions.

 

[thegenius]

Luckily in CA I won't have to deal with this. In fact...they are trying to put into the CA constitution the right for an abortion (it's already solidly in law.)

 

[WilcoWorld]

If you're legitimately trying to do the best thing for the patient in front of you with limited available information, then chances are that no jury is going to send you to jail.

I generally agree with this principle. However this is an emerging issue where people's idea of "the best thing for the patient" can vary quite widely and the laws around it have yet to be tested. With respect to this issue, I cannot share your confidence.

 

[AMEHigh]

Also, don’t report your patients to the police. Most people who have previously been jailed and criminalized for their pregnancy outcomes is because healthcare professionals called the police on them. We should not be acting as agents of the state. Take care of your patients and don’t call the police.

 

[turkeyjerky]

You're referring to the Ohio bill where the lawmakers have already admitted they didn't research it adequately. These things will work themselves out and there no doubt will be some growing pains. I once had a doc tell me not to focus so much on hyper analyzing all the minutia of hypothetical situations and just focus on the patient. If you're legitimately trying to do the best thing for the patient in front of you with limited available information, then chances are that no jury is going to send you to jail.

I do agree that the certain lack of clarity over the next few months will no doubt prove to be frustrating to physicians but I doubt anyone is going to find themselves inadvertently sending themselves to jail or exposed to a clinical situation where they find themselves unable to care for their patient.

These are laws that have been in place since 1973 and are now gone. What do people expect? Just give it time. I'm sure there will be some confusing and contradictory laws introduced in certain states that will no doubt go through multiple revisions.

I wonder if hospital administration at Mt Carmel and the District Attorney of Franklin county share your interpretation…

 

[Kryptocoin]

Pre-1973, many doctors did what was right for their patients and were autonomous in their capacity and decision-making.

We are now under the direction of corporate medicine . Days of physician autonomy are over. You do as you're told. Or find yourself another job or in cuffs.

 

[Franzd'Epinay]

You're referring to the Ohio bill where the lawmakers have already admitted they didn't research it adequately. These things will work themselves out and there no doubt will be some growing pains. I once had a doc tell me not to focus so much on hyper analyzing all the minutia of hypothetical situations and just focus on the patient. If you're legitimately trying to do the best thing for the patient in front of you with limited available information, then chances are that no jury is going to send you to jail.

I do agree that the certain lack of clarity over the next few months will no doubt prove to be frustrating to physicians but I doubt anyone is going to find themselves inadvertently sending themselves to jail or exposed to a clinical situation where they find themselves unable to care for their patient.

These are laws that have been in place since 1973 and are now gone. What do people expect? Just give it time. I'm sure there will be some confusing and contradictory laws introduced in certain states that will no doubt go through multiple revisions.

This is almost certainly the most optimistic/charitable opinion on politicians that I've seen in this entire forum.

 

[southerndoc]

In my state at least mental health issues will not be allowed as reasons to permit abortion. It is explicitly stated as such.

That may have been the cause of this:

Mother charged with murder after 3 children killed at Paulding home

Three children died and two others were hospitalized after a domestic disturbance led to a house fire Friday night in Paulding County, police and fire officials confirmed.

www.ajc.com

 

[Apollyon]

Also, don’t report your patients to the police. Most people who have previously been jailed and criminalized for their pregnancy outcomes is because healthcare professionals called the police on them. We should not be acting as agents of the state. Take care of your patients and don’t call the police.

Wasn't that more than 50 years ago? I mean, I know for what I'm a certified reporter. This isn't one, not even close. That makes your post insulting. I'm guessing people "jailed and criminalized for their pregnancy outcomes" were 1. a long time ago and 2. mostly (although not all) in the US south. Your post is like "don't beat your kids". I'm not champing at the bit to drop a dime on a pregnant lady. Also, that might get me thrown in "HIPAA jail".

 

[Dr Mantis Toboggan]

Wasn't that more than 50 years ago? I mean, I know for what I'm a certified reporter. This isn't one, not even close. That makes your post insulting. I'm guessing people "jailed and criminalized for their pregnancy outcomes" were 1. a long time ago and 2. mostly (although not all) in the US south. Your post is like "don't beat your kids". I'm not champing at the bit to drop a dime on a pregnant lady. Also, that might get me thrown in "HIPAA jail".

I believe most deep red states will pass laws making healthcare providers mandatory reporters.

 

[Apollyon]

I believe most deep red states will pass laws making healthcare providers mandatory reporters.

Not THAT'S scary. But, we ain't there, yet.

 

[WilcoWorld]

Wasn't that more than 50 years ago? I mean, I know for what I'm a certified reporter. This isn't one, not even close. That makes your post insulting. I'm guessing people "jailed and criminalized for their pregnancy outcomes" were 1. a long time ago and 2. mostly (although not all) in the US south. Your post is like "don't beat your kids". I'm not champing at the bit to drop a dime on a pregnant lady. Also, that might get me thrown in "HIPAA jail".

This was quite recent.

 

[NITRAS]

I believe most deep red states will pass laws making healthcare providers mandatory reporters.

I mean we already deal with rampant patients breaking the law with drug use and “undocumented” migrants. Barring patients being violent, I’ve never seen or heard any calling the police.

 

[AMEHigh]

Wasn't that more than 50 years ago? I mean, I know for what I'm a certified reporter. This isn't one, not even close. That makes your post insulting. I'm guessing people "jailed and criminalized for their pregnancy outcomes" were 1. a long time ago and 2. mostly (although not all) in the US south. Your post is like "don't beat your kids". I'm not champing at the bit to drop a dime on a pregnant lady. Also, that might get me thrown in "HIPAA jail".

No, people have been jailed for pregnancy outcomes this year, last year, etc. I will post some information and resources shortly.

 

[Apollyon]

This was quite recent.

It's the idea that the doc in the ED is calling 911 on these patients (which doesn't seem to be the case in that one you posted). I'm not "the white devil", looking to throw hapless pregnant women to the wolves. We didn't do that in SC when I worked there, and I'm not doing it now, and an admonition to not do it is insulting. That implies that docs are hoping they get the chance.

 

[AMEHigh]

It's the idea that the doc in the ED is calling 911 on these patients (which doesn't seem to be the case in that one you posted). I'm not "the white devil", looking to throw hapless pregnant women to the wolves. We didn't do that in SC when I worked there, and I'm not doing it now, and an admonition to not do it is insulting. That implies that docs are hoping they get the chance.

I’m not going to go in to detail about specific cases, and I don’t think most healthcare workers (this includes nurses, social workers, etc, so no it’s not always the doc calling 911) are malicious but there is a lot of confusion about the law and that leads to healthcare workers reporting pregnant and postpartum people to the police. I mean there are healthcare providers who think you have to drug test patients and report them to CPS, which isn’t the case.

Anyway, here is some info about some specific cases and then some general information.

https://www.nationaladvocatesforpregnantwomen.org/arrests-and-prosecutions-of-pregnant-women-1973-2020/

https://www.brennancenter.org/our-work/analysis-opinion/miscarriage-justice-danger-laws-criminalizing-pregnancy-outcomes

She was jailed for losing a pregnancy. Her nightmare could become more common

Opinion | How this Texas woman's arrest highlights a dangerous anti-abortion phenomenon

And this is definitely a problem enough that an organization has created a bail fund and funding for lawyers for people who have been criminalized. I know they’re helping with a very recent case.
If/When/How's Repro Legal Defense Fund

 

[Groove]

That may have been the cause of this:

Mother charged with murder after 3 children killed at Paulding home

Three children died and two others were hospitalized after a domestic disturbance led to a house fire Friday night in Paulding County, police and fire officials confirmed.

www.ajc.com

Eh, what's the point here exactly? Are you implying that all her kids should have been aborted because mom's unstable? You do realize there were 7 kids in the house and 4 of those kids survived, right?

 

[southerndoc]

I believe most deep red states will pass laws making healthcare providers mandatory reporters.

You have no basis for that statement.

 

[southerndoc]

Eh, what's the point here exactly? Are you implying that all her kids should have been aborted because mom's unstable? You do realize there were 7 kids in the house and 4 of those kids survived, right?

My point was that she had a mental health condition before her kids were born. I really don't think abortions would change anything with mental health issues. Even if she had an abortion for kids 3 and 5, she likely would've snapped anyhow.

In this case, the children who survived smelled like gasoline.

 

[Mr. Vandemar]

You have no basis for that statement.

This is going to age like milk.

 

[Dred Pirate]

Look at the maps of sates that already have or likely will ban abortions - Cairo Illinois is going to be the location for "travel abortions"

 

[turkeyjerky]

Look at the maps of sates that already have or likely will ban abortions - Cairo Illinois is going to be the location for "travel abortions"

PE has entered the chat

 

[southerndoc]

This is going to age like milk.

and if it turns into a political discussion, TOS will be enforced.

 

[Dr Mantis Toboggan]

You have no basis for that statement.

Agreed. Pure speculation/fear/worry on my part. It’s what I do.

 

[WilcoWorld]

and if it turns into a political discussion, TOS will be enforced.

Honestly, that's inevitable. Even saying "I don't think these laws will affect me" is a political statement. Perhaps we should just close the thread now.

 

[BoardingDoc]

Honestly, that's inevitable. Even saying "I don't think these laws will affect me" is a political statement. Perhaps we should just close the thread now.

I agree it's a distinct possibility, but I don't think it's a guarantee. When this thread was first posted I literally saw the title and assumed I was going to simply be deleting the thread. So far things have been reasonable, and I'm generally a proponent of reactionary moderation as opposed to proactive moderation as the former assumes good intent on everyone's end. That said, there are obviously exceptions for people with proven track records of poor behavior, etc.

Will see where this thread goes.

 

[AMEHigh]

A health system has stopped providing plan B (which is NOT an abortion pill, please educate your colleagues about this, so many medical professionals get this wrong). So yes believe people who are saying that miscarriage and ectopic management is getting harder and harder to obtain. Our ED colleagues are important in this fight so I def think if you have the capacity to get involved with your administration that would be much much appreciated.

https://www.kansascity.com/news/politics-government/article262988028.html

 

[Boatswain2PA]

plan B (which is NOT an abortion pill, please educate your colleagues about this, so many medical professionals get this wrong)

I still have a 2010 pharmacology tomb, and a 2010 Currents (CMDT), that says otherwise.

Wonder what changed....

 

[Dred Pirate]

I still have a 2010 pharmacology tomb, and a 2010 Currents (CMDT), that says otherwise.

Wonder what changed....

depends on when you say a pregnancy starts
Plan B works by
1. preventing ovulation and/or fertilization
2. also can prevent a fertilized egg from implanting.

In your mind - do ether of these things cause an abortion?


also- an easy away around this is "regular" BC and just take enough tablets to equal the same strength (although you get added estradiol usually)

 

[VA Hopeful Dr]

depends on when you say a pregnancy starts
Plan B works by
1. preventing ovulation and/or fertilization
2. also can prevent a fertilized egg from implanting.

In your mind - do ether of these things cause an abortion?


also- an easy away around this is "regular" BC and just take enough tablets to equal the same strength (although you get added estradiol usually)

By that logic every method of BC other than barrier and spermicide is abortion.

 

[Dred Pirate]

By that logic every method of BC other than barrier and spermicide is abortion.

Agreed -specifically says it won’t terminate a pregnancy

This isn’t RU 486 (or whatever number it is- too tired to look it up)

 

[RustedFox]

I still have a 2010 pharmacology tomb, and a 2010 Currents (CMDT), that says otherwise.

Wonder what changed....

P-ph-pharmacology t-tomb?

(Thinks)

 

[WilcoWorld]

P-ph-pharmacology t-tomb?

(Thinks)

I think he meant "tome"

Tome: a book, especially a large, heavy, scholarly one.

 

[xaelia]

PE has entered the chat

Love it.

While everyone else is fussing over the ethical and legal ramifications, someone out there is already scheming to make $$$ off it.

 

[Dred Pirate]

Love it.

While everyone else is fussing over the ethical and legal ramifications, someone out there is already scheming to make $$$ off it.

you know somebody out there was thinking about this long ago....
There is always somebody to make $$ out of any situation

 

[Apollyon]

I think he meant "tome"

Tome: a book, especially a large, heavy, scholarly one.

I instantly think of "Diablo" whenever a "tome" is mentioned!

 

[Apollyon]

Agreed -specifically says it won’t terminate a pregnancy

This isn’t RU 486 (or whatever number it is- too tired to look it up)

Yes, RU-486. The "RU" stands for "Roussel-Uclaf", a French company. Thierry Roussel was heir to the RU fortune, and squandered it. I don't know if he's even still alive.

What is it, mifepristone?

 

[Dred Pirate]

Yes, RU-486. The "RU" stands for "Roussel-Uclaf", a French company. Thierry Roussel was heir to the RU fortune, and squandered it. I don't know if he's even still alive.

What is it, mifepristone?

yes mifepristone

 

[RustedFox]

I think he meant "tome"

Tome: a book, especially a large, heavy, scholarly one.

I know, amigo - I just couldn't help myself.