ED for abortion

[DocEspana]

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So this is becoming a recurring event and no one I work with has a clear grasp of what to do (though more or less we all say the same thing - DC to outpatient services ).

Down in Florida, so for us the rule is 6w6d or less with ultrasound to confirm gestational age and chemical abortion is allowed electively. Increasingly we've had early pregnancies come in at the 5ish week mark saying that they want to get an abortion before it's 6 weeks (they usually don't realize they have 6 additional days beyond that).

I generally confirm pregnancy and refer them to planned parenthood. But we seem to be down to just two PP sites in the county now and it's a big city. The two OBGYN groups working our system don't see new patients in anything resembling a decent time frame and the two times I've curbsided them they say to send it to PP.

I'm increasingly getting women here saying, correctly I imagine, that PP has a >1 week wait time to be seen just due to the numbers of people going to the two sites so I've been referring them a county away where I haven't heard any issues yet with being seen promptly but I'm so curious if anyone has even considered starting the drugs in the ED.

I don't hesitate at all to terminate a nonviable pregnancy. Do it all the time. I realize that terminating a viable pregnancy is theoretically now not an emergency and would be borderline outside of the scope of my specialty... But also is that the only thing stopping me? The follow up would suck but not getting the abortion by 6w6d would suck more and eventually I'm going to get someone who is 6w5d and needs action immediately to meet the time window. The instructions they'd get if there were complications would be to come back to the ER anyway.

Thoughts?

 

[TooMuchResearch]

It seems like you are functionally the only specialist available to manage the patient. We do lots of other things that other specialties definitely could do. So perhaps you do it.

 

[BigRhinoGuy]

FL has a 24-hour consent requirement that might complicate this.

 

[southerndoc]

You could always say it's not an emergency. It's not your job to solve society's problems.

Do you prescribe methotrexate for arthritis, do you prescribe hair loss medication? There are plenty of drugs from other specialties that we don't prescribe. I will still refer to OB/GYN and let them make the decision. I quite honestly am not even up on all the nuances of Georgia law (where I practice) to know at what time these medicines are allowed.

 

[Porfirio]

You do one, and you will have a waiting room full of more to do.

 

[Boatswain2PA]

I don't hesitate at all to terminate a nonviable pregnancy.

Do you hesitate to terminate a viable pregnancy?

 

[DocEspana]

Do you hesitate to terminate a viable pregnancy?

exclusively for the political/legal ramifications. You give me no heartbeat on an u/s and a patient telling me they want it out rather than repeat the u/s with obgyn later in the week? I'm rx'ing to induce.

 

[DocEspana]

FL has a 24-hour consent requirement that might complicate this.

interesting. yeah.

 

[DocEspana]

It seems like you are functionally the only specialist available to manage the patient. We do lots of other things that other specialties definitely could do. So perhaps you do it.

I think the feeling everyone is having is that for 2ish years its always been "well PP is around and OBGYNs are around and it will get done." and now PP is overwhelmed and people are getting *just* about at that point where there is eventually going to be someone who cant be seen within the legal timeframe despite being identified early enough in theory. So I've been asking people i work with when this arises and everyone is sort of vaguely alluding to the idea that the second something goes wrong with one of them (or someone's cuban mother beats their ass and makes them recant under duress) they will come for the ED doc for practicing outside their scope or not having appropriate follow up set up or whatever.

Sort of want to do the good thing but also dont want to be the person they make ane xample out of.

 

[thegenius]

So this is becoming a recurring event and no one I work with has a clear grasp of what to do (though more or less we all say the same thing - DC to outpatient services ).

Down in Florida, so for us the rule is 6w6d or less with ultrasound to confirm gestational age and chemical abortion is allowed electively. Increasingly we've had early pregnancies come in at the 5ish week mark saying that they want to get an abortion before it's 6 weeks (they usually don't realize they have 6 additional days beyond that).

I generally confirm pregnancy and refer them to planned parenthood. But we seem to be down to just two PP sites in the county now and it's a big city. The two OBGYN groups working our system don't see new patients in anything resembling a decent time frame and the two times I've curbsided them they say to send it to PP.

I'm increasingly getting women here saying, correctly I imagine, that PP has a >1 week wait time to be seen just due to the numbers of people going to the two sites so I've been referring them a county away where I haven't heard any issues yet with being seen promptly but I'm so curious if anyone has even considered starting the drugs in the ED.

I don't hesitate at all to terminate a nonviable pregnancy. Do it all the time. I realize that terminating a viable pregnancy is theoretically now not an emergency and would be borderline outside of the scope of my specialty... But also is that the only thing stopping me? The follow up would suck but not getting the abortion by 6w6d would suck more and eventually I'm going to get someone who is 6w5d and needs action immediately to meet the time window. The instructions they'd get if there were complications would be to come back to the ER anyway.

Thoughts?

For me...it's simple. Elective AB's are not a medical emergency. This is the purview of Obstetrics and it will always be within their scope. I don't want the medicolegal problems associated with this responsibility. We have no formal training in this. Will the ER be responsible for following the beta on all of these patients?

Sorry patient. I can't plug every single hole in the health care system. I already have my finger in about 65 holes, and it's hard because I only hvae 10 fingers. No other speciality is plugging more than 5 holes.

There is a point where you just gotta say no!

My other point is your entire ER needs to be on the same page here. Your ER can have it as a policy not to electively abort viable pregnancies, no matter the gestational age.

BTW, I don't terminage nonviable pregnancies either without an OB directive. Never. I'll never give drugs to do that. It's not my area of expertise and if there is any harm that comes, you'll get F^#$K@D.

 

[thegenius]

You do one, and you will have a waiting room full of more to do.

That is true!

Your entire group needs to get on the same page as this.

I say NO.

 

[DocEspana]

BTW, I don't terminage nonviable pregnancies either without an OB directive. Never. I'll never give drugs to do that. It's not my area of expertise and if there is any harm that comes, you'll get F^#$K@D.

I agree with everything you said except this last part. Terminating nonviable pregnancies is super standard in like..... 75-80% of the places I have worked. And it was *baffling* to the last 25%. So I know where youre coming from. whats funny is that it was super accepted and normal and obgyn would get grumpy to even be consulted over something 'so straightforward' in NYC and Baltimore and Orlando and Miami.... but I literally got called into the principles office by my director who was aghast when I did it in rural florida and I confirmed in rural WV/Kentucky that they thought it was wild that I would do that.

The major cities where the patient could easily be seen by obgyn, it was just done in the ED and they could follow up with obgyn (or just come back to the ER) in 48 hours to recheck hcg. and in the areas where there was one group serving 2-3 counties and the wait time to be seen was damn near a trimester of pregnancy was where people were waiting for the solitary obgyn office or mother nature to get around to it eventually.

Not even saying either one is right/wrong. Just stumbled onto something I always found backwards. that "itll get handled as an outpatient" was the SoC where it really wouldnt be handled outpatient and "just start it in the ED, I know you know how to" was how the obgyns would respond in the places where they could actually see people a day or two after. Just my n=1 on that.

 

[xaelia]

Don't fight the battles, fight the war.

In such bleak times, only the accumulated weight of those who have suffered the failing system will be able to effect change.

 

[Pinner Doc]

Not surprised and yet baffled that so many of you work under these restrictions.

Glad I’m not longer practicing in EM. And a large problem for me was this - the ED will increasingly continue to hold the safety net for cuts not only to healthcare, but to social supports. We are, in fact, explicitly or implicitly, yet certainly untenably, expected to “plug every hole in the healthcare system” — to quote someone here.

 

[Groove]

Not an emergency and not my problem if they can't get in to see an OB in a timely manner. I can't think of a less desirable patient population to encourage routine presentations to the ER for elective abortion. I'd rather deal with drug seekers all day long.

 

[Porfirio]

I just cannot imagine the headache of protesters and hospital admin for the ER docs when it becomes widespread knowledge the ER is doing elective abortions. Imagine the Press Ganey scores.

I think that would create a huge hurdle for an already hard job. I would leave the ER group.

(This statement is not meant to say abortion is right or wrong.)

 

[WhatJobDoIPick]

Not an emergency.

Never doing it. Viable or non viable.

Why this is even a question is proof positive of how bad this field is.

First we were asked to solve the opiate crisis, then COVID, now this?

Nope.

 

[DrDrummer]

Refer to any number of services that will dispense meds by mail.

 

[JacobMcCandles]

This is one of those unforced error situations. It’s only an issue because the group is letting it be one. Devise a group policy that says no elective abortions in the ED and then follow it. I didn’t do this in training and consider it outside my scope of practice. No law or other government action/in-action changes that. If your OB doctors really cared they’d set up an outpatient process through their clinic but they don’t.

 

[RustedFox]

This is one of those unforced error situations. It’s only an issue because the group is letting it be one. Devise a group policy that says no elective abortions in the ED and then follow it. I didn’t do this in training and consider it outside my scope of practice. No law or other government action/in-action changes that. If your OB doctors really cared they’d set up an outpatient process through their clinic but they don’t.

This is a genius-level post.

 

[WhatJobDoIPick]

This is one of those unforced error situations. It’s only an issue because the group is letting it be one. Devise a group policy that says no elective abortions in the ED and then follow it. I didn’t do this in training and consider it outside my scope of practice. No law or other government action/in-action changes that. If your OB doctors really cared they’d set up an outpatient process through their clinic but they don’t.

This is a genius-level post.

"Planned Parenthood has no openings."

Soooo...make them? There is no law of physics that says PP can't stay open till 8pm on weekdays and be open all day on Saturday / Sunday.

For all the political posturing surrounding this issue, if people cared to the extent they say they do, they'd find a way to make the above work.

But no, as with everything else, it's "just go to the ER."

 

[thegenius]

"Planned Parenthood has no openings."

Soooo...make them? There is no law of physics that says PP can't stay open till 8pm on weekdays and be open all day on Saturday / Sunday.

For all the political posturing surrounding this issue, if people cared to the extent they say they do, they'd find a way to make the above work.

But no, as with everything else, it's "just go to the ER."

"This is like going to Home Depot and asking for spaghetti."

in the words of a famous member of this group.

Why is it so hard for ER doctors to just say no?

 

[JacobMcCandles]

For all the political posturing surrounding this issue, if people cared to the extent they say they do, they'd find a way to make the above work.

Exactly. I’m sure at least a few of these private practice OBs have complained about their state laws and how their patient population won’t have access to the care they need yet they don’t do anything about it. Put up or shut up. The truth is they don’t want to provide that care at low or no cost.

To all the newer EM docs out there, don’t make your life harder than it already is. You can’t fix society’s issues and this isn’t your problem. Honestly, this is one of the easier social issue patients because these patients are young, can walk, and are safe at home.

 

[Pinner Doc]

This is one of those unforced error situations. It’s only an issue because the group is letting it be one. Devise a group policy that says no elective abortions in the ED and then follow it. I didn’t do this in training and consider it outside my scope of practice. No law or other government action/in-action changes that. If your OB doctors really cared they’d set up an outpatient process through their clinic but they don’t.

This is the entirely predictable consequence of laypeople making laws that drive obstetricians away from practicing in certain environments. Gee, who could’ve seen this coming?

 

[JacobMcCandles]

This is the entirely predictable consequence of laypeople making laws that drive obstetricians away from practicing in certain environments. Gee, who could’ve seen this coming?

Doesn't matter. This isn't our issue and only has as much impact on the ED as the physicians let it.

 

[TeddyBoomBoom]

Absolutely 0% chance I will be performing elective abortions in the ED. I’m very much pro choice, but that is not at all in my job description.

This idea that bc we are legally obligated to evaluate every person for life threatening emergencies, that we just fill the role of every other specialty when the other specialty in unavailable, astounds me.

I’m sympathetic but it’s not my role.

 

[allantois]

Legislative issue

 

[Pinner Doc]

From a systems standpoint, this IS becoming an emergency medicine issue in many states, whether we like it or not. Restrictive laws have turned time into the limiting reagent, and the only 24/7 entry point left for these patients is the ED.

Saying “that’s outpatient/for OB” assumes those services exist and can act fast enough — which, in many places, they no longer do (see my earlier point). Ignoring that doesn’t protect our scope; it just transfers the human and social consequences back to us down the line - as miscarriage complications, psych crises, child neglect/NAT, or overwhelmed parents in crisis.

I’m not saying we need to start dispensing mife/miso from the Pyxis tomorrow, but we can’t keep pretending this isn’t our problem. The policy changes made it our problem. If we stay hands-off on the front end, we’re guaranteeing we’ll see the fallout on the back end — just under different ICD codes.

 

[TeddyBoomBoom]

From a systems standpoint, this IS becoming an emergency medicine issue in many states, whether we like it or not. Restrictive laws have turned time into the limiting reagent, and the only 24/7 entry point left for these patients is the ED.

Saying “that’s outpatient/for OB” assumes those services exist and can act fast enough — which, in many places, they no longer do (see my earlier point). Ignoring that doesn’t protect our scope; it just transfers the human and social consequences back to us down the line - as miscarriage complications, psych crises, child neglect/NAT, or overwhelmed parents in crisis.

I’m not saying we need to start dispensing mife/miso from the Pyxis tomorrow, but we can’t keep pretending this isn’t our problem. The policy changes made it our problem. If we stay hands-off on the front end, we’re guaranteeing we’ll see the fallout on the back end — just under different ICD codes.

Respectfully disagree. “Emergency” does not equate to “unable to schedule elective procedure.”

I acknowledge the societal problems and logistical failure of the system, but I can only play my role as en ER doc. Practicing way outside my scope won’t be my answer to the problem.

Just my two cents. Though I don’t agree, your argument is a reasonable one.

 

[WhatJobDoIPick]

From a systems standpoint, this IS becoming an emergency medicine issue in many states, whether we like it or not. Restrictive laws have turned time into the limiting reagent, and the only 24/7 entry point left for these patients is the ED.

Saying “that’s outpatient/for OB” assumes those services exist and can act fast enough — which, in many places, they no longer do (see my earlier point). Ignoring that doesn’t protect our scope; it just transfers the human and social consequences back to us down the line - as miscarriage complications, psych crises, child neglect/NAT, or overwhelmed parents in crisis.

I’m not saying we need to start dispensing mife/miso from the Pyxis tomorrow, but we can’t keep pretending this isn’t our problem. The policy changes made it our problem. If we stay hands-off on the front end, we’re guaranteeing we’ll see the fallout on the back end — just under different ICD codes.

Respectfully disagree. “Emergency” does not equate to “unable to schedule elective procedure.”

I acknowledge the societal problems and logistical failure of the system, but I can only play my role as en ER doc. Practicing way outside my scope won’t be my answer to the problem.

Just my two cents. Though I don’t agree, your argument is a reasonable one.

Nah. Let it be primary care's problem. Don't have a primary care provider? Welp notch another one under column of personal responsibility.

Cash upfront and absolution of all med mal risk is the only way I'd consider doing this.

 

[JacobMcCandles]

From a systems standpoint, this IS becoming an emergency medicine issue in many states, whether we like it or not. Restrictive laws have turned time into the limiting reagent, and the only 24/7 entry point left for these patients is the ED.

Saying “that’s outpatient/for OB” assumes those services exist and can act fast enough — which, in many places, they no longer do (see my earlier point). Ignoring that doesn’t protect our scope; it just transfers the human and social consequences back to us down the line - as miscarriage complications, psych crises, child neglect/NAT, or overwhelmed parents in crisis.

I’m not saying we need to start dispensing mife/miso from the Pyxis tomorrow, but we can’t keep pretending this isn’t our problem. The policy changes made it our problem. If we stay hands-off on the front end, we’re guaranteeing we’ll see the fallout on the back end — just under different ICD codes.

Wrong. You could say the same thing about pretty much any social issue you encounter outside of work. It’s only our issue as much as we let it be. Nobody can force me to do something that’s out of my scope of practice. If OBs care as much as they say then they’d help with the problem. If EM docs wanted to help then they’d could get involved with Planned Parenthood and volunteer there or even try to open a more local Planned Parenthood if there isn’t one so they can do elective abortions in an appropriate setting.

If the ED wanted to go above and beyond then they can create a complete resource list to give to these patients so they can look at their options.

 

[RustedFox]

From a systems standpoint, this IS becoming an emergency medicine issue in many states, whether we like it or not. Restrictive laws have turned time into the limiting reagent, and the only 24/7 entry point left for these patients is the ED.

Saying “that’s outpatient/for OB” assumes those services exist and can act fast enough — which, in many places, they no longer do (see my earlier point). Ignoring that doesn’t protect our scope; it just transfers the human and social consequences back to us down the line - as miscarriage complications, psych crises, child neglect/NAT, or overwhelmed parents in crisis.

I’m not saying we need to start dispensing mife/miso from the Pyxis tomorrow, but we can’t keep pretending this isn’t our problem. The policy changes made it our problem. If we stay hands-off on the front end, we’re guaranteeing we’ll see the fallout on the back end — just under different ICD codes.

Show me the apparent threat to life or limb with a normal pregnancy.

 

[allantois]

The affected individuals should call their representatives, and maybe if one of the relatives of these politicians is affected - then they will consider changing the laws. By sort of solving the issue at the ER level, you are just letting the system stay in its present equilibrium, which is certainly not a sustainable long-term solution.

 

[southerndoc]

From a systems standpoint, this IS becoming an emergency medicine issue in many states, whether we like it or not. Restrictive laws have turned time into the limiting reagent, and the only 24/7 entry point left for these patients is the ED.

Saying “that’s outpatient/for OB” assumes those services exist and can act fast enough — which, in many places, they no longer do (see my earlier point). Ignoring that doesn’t protect our scope; it just transfers the human and social consequences back to us down the line - as miscarriage complications, psych crises, child neglect/NAT, or overwhelmed parents in crisis.

I’m not saying we need to start dispensing mife/miso from the Pyxis tomorrow, but we can’t keep pretending this isn’t our problem. The policy changes made it our problem. If we stay hands-off on the front end, we’re guaranteeing we’ll see the fallout on the back end — just under different ICD codes.

Sorry. Not changing my practice on this. MSE done, discharge. EMTALA complied.

 

[WhatJobDoIPick]

Sorry. Not changing my practice on this. MSE done, discharge. EMTALA complied.

I think the overarching idea that people here are pushing back against is this concept that patients are entitled to our labor simply for existing.

Nurse "the patient wants..."
-Their IUD removed
-levofloxacin instead of doxycycline
-both their ears disimpacted
-a neurology consult
-admission
-Insert mostly anything else

Its shocking to some patients, and even nurses and maybe a few physicians too, that we DON'T actually have to do any of this.

Someone asked above why EPs tolerate this. To get a sense of the mentality of many EPs, go to the reddit emergency medicine forum. People there all riled up to go to war against ICE agents and provide elective terminations, etc, in their ERs, instead of quitting their atrocious Team Health job and standing up for themselves as physicians.

Most EPs are pretty dumb, in my unsolicited opinion. Most have a passive sheep like employee mindset which they self selected into.

 

[JacobMcCandles]

Someone asked above why EPs tolerate this. To get a sense of the mentality of many EPs, go to the reddit emergency medicine forum. People there all riled up to go to war against ICE agents and provide elective terminations, etc, in their ERs, instead of quitting their atrocious Team Health job and standing up for themselves as physicians.

You can still find some occasional good things on Reddit but, as a whole, Redditors live in a made up fantasy world and largely can’t function in a normal society.

 

[RustedFox]

You can still find some occasional good things on Reddit but, as a whole, Redditors live in a made up fantasy world and largely can’t function in a normal society.

It amazes me every time I wander over to r/emergencymedixine how absolutely obtuse they are.

 

[Jabbed]

Elective termination of pregnancy is obviously not an emergency, but neither is the other 50-75% of my day/paycheck. We should just rebrand as Acute Care Medicine and be done with it.

I wouldn’t be opposed to providing the meds if there was healthcare system buy-in and clear departmental guidance as it’s obviously an un-met need, but I’m not going to become the lone wolf ED doc providing abortion care that gets doxxed and targeted by pro-life terrorists.

 

[thegenius]

Elective termination of pregnancy is obviously not an emergency, but neither is the other 50-75% of my day/paycheck. We should just rebrand as Acute Care Medicine and be done with it.

I wouldn’t be opposed to providing the meds if there was healthcare system buy-in and clear departmental guidance as it’s obviously an un-met need, but I’m not going to become the lone wolf ED doc providing abortion care that gets doxxed and targeted by pro-life terrorists.

It’s not even acute care. It’s urgent care of immediate care. Immediate care has too many syllables though.

 

[DocEspana]

From a systems standpoint, this IS becoming an emergency medicine issue in many states, whether we like it or not. Restrictive laws have turned time into the limiting reagent, and the only 24/7 entry point left for these patients is the ED.

Saying “that’s outpatient/for OB” assumes those services exist and can act fast enough — which, in many places, they no longer do (see my earlier point). Ignoring that doesn’t protect our scope; it just transfers the human and social consequences back to us down the line - as miscarriage complications, psych crises, child neglect/NAT, or overwhelmed parents in crisis.

I’m not saying we need to start dispensing mife/miso from the Pyxis tomorrow, but we can’t keep pretending this isn’t our problem. The policy changes made it our problem. If we stay hands-off on the front end, we’re guaranteeing we’ll see the fallout on the back end — just under different ICD codes.

side note @Emapp20177 be careful with the inappropriate response. It can get the post flagged for mods and the poster in trouble. Which is likely not what you intended.

 

[DocEspana]

I think the overarching idea that people here are pushing back against is this concept that patients are entitled to our labor simply for existing.

Nurse "the patient wants..."
-Their IUD removed
-levofloxacin instead of doxycycline
-both their ears disimpacted
-a neurology consult
-admission
-Insert mostly anything else

Its shocking to some patients, and even nurses and maybe a few physicians too, that we DON'T actually have to do any of this.

Someone asked above why EPs tolerate this. To get a sense of the mentality of many EPs, go to the reddit emergency medicine forum. People there all riled up to go to war against ICE agents and provide elective terminations, etc, in their ERs, instead of quitting their atrocious Team Health job and standing up for themselves as physicians.

Most EPs are pretty dumb, in my unsolicited opinion. Most have a passive sheep like employee mindset which they self selected into.

double ear disimpaction drives me nuts. not even 'found out thats what caused it'. When they come in knowing thats the problem and want you to scoopy scoopy for them.

Rx: debrox kit and reinforce that they have to irrigate their ear after usage.

 

[BoardingDoc]

double ear disimpaction drives me nuts. not even 'found out thats what caused it'. When they come in knowing thats the problem and want you to scoopy scoopy for them.

Rx: debrox kit and reinforce that they have to irrigate their ear after usage.

Yeah, I remember previously doing cerumen disimpactions with quite some frequency. Then one day several years ago our ER just started saying no. Here's an Rx like you said and off you go. We certainly wouldn't be Rxing meds for elective abortions. Hell, even unilaterally terminating non-viable pregnancies like @DocEspana mentioned seems wild to me. I live in a quite liberal area and that's still something that I've literally never done. SAB = OB referral.