Florida showing why laws need to be carefully worded

[DocEspana]

Throughout all of 2019 one of the state politicians made it her personal crusade to be the person in florida who passed a law banning pelvic exams under anesthesia (at least without consent). Cool. I always found it very creepy that this was a thing some people did and that it could happen during non-gyn surgeries just so a student can get practice while the patient is out cold anyway.

So Florida went to make a law to ban such exams. Except.... thats not what the law says.

https://www.flmedical.org/florida/Florida_Public/Docs/Legal-update-Summary-SB-698.pdf

This goes into effect July 1st and, for those who didn't read the single page flyer, it goes WAY beyond just making sure all exams under anesthesia have consent. All pelvic exams (except court ordered ones, and the elusive emergently life-saving pelvic exam) need consent. Not just exams-under-anesthesia. And not just consent. They need written consent that cannot be included in the general consent. Digging into the actual bill; it needs to be a distinct and separate consent which lists out both who will be performing the exam and for what purpose it is being done.

As one of the only non-obgyn fields doing pelvic exams with any real frequency this is just comically poorly written for the means of an emergency department and i guarantee you this will lead to some serious lawsuits for florida EM physicians. Likely both crazy patients who will pounce on someone who overlooked the laws requirements and unfortunate cases of someone who *needed* one but didnt get one because the requirement for a written consent with customized elements is too onorous - and then had a bad outcome. I know the law's "heart" (if i may anthropomorphize a law) is in the right place, but its horrendously written.

And yet I can go and fondle all the testicles I want in the name of identifying torsions and testicular cancers.

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[Dr Mantis Toboggan]

Throughout all of 2019 one of the state politicians made it her personal crusade to be the person in florida who passed a law banning pelvic exams under anesthesia (at least without consent). Cool. I always found it very creepy that this was a thing some people did and that it could happen during non-gyn surgeries just so a student can get practice while the patient is out cold anyway.

So Florida went to make a law to ban such exams. Except.... thats not what the law says.

https://www.flmedical.org/florida/Florida_Public/Docs/Legal-update-Summary-SB-698.pdf

This goes into effect July 1st and, for those who didn't read the single page flyer, it goes WAY beyond just making sure all exams under anesthesia have consent. All pelvic exams (except court ordered ones, and the elusive emergently life-saving pelvic exam) need consent. Not just exams-under-anesthesia. And not just consent. They need written consent that cannot be included in the general consent. Digging into the actual bill; it needs to be a distinct and separate consent which lists out both who will be performing the exam and for what purpose it is being done.

As one of the only non-obgyn fields doing pelvic exams with any real frequency this is just comically poorly written for the means of an emergency department and i guarantee you this will lead to some serious lawsuits for florida EM physicians. Likely both crazy patients who will pounce on someone who overlooked the laws requirements and unfortunate cases of someone who *needed* one but didnt get one because the requirement for a written consent with customized elements is too onorous - and then had a bad outcome. I know the law's "heart" (if i may anthropomorphize a law) is in the right place, but its horrendously written.

And yet I can go and fondle all the testicles I want in the name of identifying torsions and testicular cancers.

appears to include rectal exams as well.

 

[Rendar5]

Since I’m only doing them for potential life or reproductive threatening emergencies. Won’t really affect it unless I’m having more than one person doing it (like never). Same as declaring all mvc’s as having potential medical emergencies from a laypersons perspective so insurance companies do their job and allow the patient to go to the ER and not get a massive bill

 

[deleted109597]

Guess nobody needs pelvics anymore. I wonder if pelvic US will count as needing a consent as well.

 

[Birdstrike]

Throughout all of 2019 one of the state politicians made it her personal crusade to be the person in florida who passed a law banning pelvic exams under anesthesia (at least without consent). Cool. I always found it very creepy that this was a thing some people did and that it could happen during non-gyn surgeries just so a student can get practice while the patient is out cold anyway.

So Florida went to make a law to ban such exams. Except.... thats not what the law says.

https://www.flmedical.org/florida/Florida_Public/Docs/Legal-update-Summary-SB-698.pdf

This goes into effect July 1st and, for those who didn't read the single page flyer, it goes WAY beyond just making sure all exams under anesthesia have consent. All pelvic exams (except court ordered ones, and the elusive emergently life-saving pelvic exam) need consent. Not just exams-under-anesthesia. And not just consent. They need written consent that cannot be included in the general consent. Digging into the actual bill; it needs to be a distinct and separate consent which lists out both who will be performing the exam and for what purpose it is being done.

As one of the only non-obgyn fields doing pelvic exams with any real frequency this is just comically poorly written for the means of an emergency department and i guarantee you this will lead to some serious lawsuits for florida EM physicians. Likely both crazy patients who will pounce on someone who overlooked the laws requirements and unfortunate cases of someone who *needed* one but didnt get one because the requirement for a written consent with customized elements is too onorous - and then had a bad outcome. I know the law's "heart" (if i may anthropomorphize a law) is in the right place, but its horrendously written.

And yet I can go and fondle all the testicles I want in the name of identifying torsions and testicular cancers.

Keep this in perspective. Remember those stories your senior residents told you about all those lives they saved with pelvic and rectal exams? They were BS. It was to trick the medical students into doing them, so they didn't have to.

Have your hospital and/or EM group get an attorney to write up a special pelvic exam consent form with check boxes and fill in the blanks, then scan into your EMR. If they agree, you both sign and proceed as normal. If not, you punt to ultrasound and OB/GYN for an outpatient pelvic. No biggie.

Most of the time lawyers make doctors' lives miserable. But look on the bright side. Sometimes gifts come in strange packages. This may be one case where they accidentally make your life better. "Sorry, can't do your pelvic exam today. It would be illegal for me to do it. Only your OB/GYN can. Bye."

 

[Buckeye1992]

“or if the pelvic examination is immediately necessary to avert a serious risk of imminent substantial and irreversible physical impairment of a major bodily function of the patient”

This should cover ED exams right?

 

[Buckeye1992]

I am all for doing urine GC/Chlamydia

 

[DocEspana]

“or if the pelvic examination is immediately necessary to avert a serious risk of imminent substantial and irreversible physical impairment of a major bodily function of the patient”

This should cover ED exams right?

Our legal says no. They're reading that as not "unknown gyn diagnosis" but rather "uterus falling out and subsequent impending death by exsanguination".

They also openly state that they understand if other places read it differently.... But they think they're wrong

 

[DocEspana]

appears to include rectal exams as well.

This is the silver lining.

Also any tag team rectal exam is just *the worst* ER visit ever.

 

[DocEspana]

Keep this in perspective. Remember those stories your senior residents told you about all those lives they saved with pelvic and rectal exams? They were BS. It was to trick the medical students into doing them, so they didn't have to.

Have your hospital and/or EM group get an attorney to write up a special pelvic exam consent form with check boxes and fill in the blanks, then scan into your EMR. If they agree, you both sign and proceed as normal. If not, you punt to ultrasound and OB/GYN for an outpatient pelvic. No biggie.

Most of the time lawyers make doctors' lives miserable. But look on the bright side. Sometimes gifts come in strange packages. This may be one case where they accidentally make your life better. "Sorry, can't do your pelvic exam today. It would be illegal for me to do it. Only your OB/GYN can. Bye."

Yeah boss says they're going to add a distinct page to the mindless signatures the patients get. But, because technology is stupid, it won't be gender sensitive. I hope we just have guys signing for pelvic exams rather than getting a printed sheet I have to discuss with people.

 

[Zebra Hunter]

The amount of pelvics I have done in the last year is maybe 6 or 7. I have significantly reduced the number of pelvics I do given that it almost never changes management, and when it does change management, half the time it is leading to an inappropriate change in management.

Gonorrhea and chlamydia can be tested from the urine. Vaginal discharge and lower abdominal pain is PID regardless of what my exam shows. Might get a pelvic US or CT to eval for TOA if they look ill or pain is significant. Pregnant vaginal bleeding either get a formal or bedside US depending on gestational age and if they already have one performed. Older vaginal bleeding gets an US.

Really the only time I do one is vaginal bleeding with report of trauma (in non-SA cases), severe cramping/bleeding from miscarriage (usually PoC are stuck in cervix), severe vaginal bleeding, or toxic appearing with either lower abdominal pain or vaginal discharge with no clear etiology on imaging or UA.

 

[Groove]

Pretty similar practice pattern to @Zebra Hunter. I rarely do pelvics anymore unless it's removing a FB. It hardly ever changes my management. It's also beyond frustrating to get culture results from our charge nurse from "providers" that sent off for GC/Chlam cultures days back and I'm the one having to dig through the chart to see if the pt got the obligatory rocephin/azithro and/or whether they need to get called back. I can't remember the last time I sent off for a GC/Chlam culture. If you're thinking about culturing them, just dose them already. Leave all the culture shenanigans for their OB/GYN/PCP. What a worthless test for an EM doc.

Breaking News: Why Are You Still Performing Pelvic Exams? : Emergency Medicine News

An abstract is unavailable.

journals.lww.com

 

[BoardingDoc]

Pretty similar practice pattern to @Zebra Hunter. I rarely do pelvics anymore unless it's removing a FB. It hardly ever changes my management. It's also beyond frustrating to get culture results from our charge nurse from "providers" that sent off for GC/Chlam cultures days back and I'm the one having to dig through the chart to see if the pt got the obligatory rocephin/azithro and/or whether they need to get called back. I can't remember the last time I sent off for a GC/Chlam culture. If you're thinking about culturing them, just dose them already. Leave all the culture shenanigans for their OB/GYN/PCP. What a worthless test for an EM doc.

Breaking News: Why Are You Still Performing Pelvic Exams? : Emergency Medicine News

An abstract is unavailable.

journals.lww.com

Why isn't the charge nurse or a mid-level handling these gc/ch results? I've never worked in a system where the doc was expected to followup on pending tests unless there was a clinical question from the QA team. Even then it's basically "the patient was sent home on x but culture says it's resistant. Here's the resistance list. What do you want me to rx?"

Having the MD do this is an idiotic use of resources.

 

[Groove]

Why isn't the charge nurse or a mid-level handling these gc/ch results? I've never worked in a system where the doc was expected to followup on pending tests unless there was a clinical question from the QA team. Even then it's basically "the patient was sent home on x but culture says it's resistant. Here's the resistance list. What do you want me to rx?"

Having the MD do this is an idiotic use of resources.

Who knows. I've been doing it for 7 years at this gig and am numb to it. If I'm the early a.m. doc, they also hand me a list of XR "positives" from the night before and it's my job to look up each chart and see if the ordering doc/APC correctly interpreted it and/or call the pt back to the ER. We also have to call any "COVID +" results for the day back to the pt personally, regardless of whether we saw them or not. Insane, no?

 

[GeneralVeers]

Who knows. I've been doing it for 7 years at this gig and am numb to it. If I'm the early a.m. doc, they also hand me a list of XR "positives" from the night before and it's my job to look up each chart and see if the ordering doc/APC correctly interpreted it and/or call the pt back to the ER. We also have to call any "COVID +" results for the day back to the pt personally, regardless of whether we saw them or not. Insane, no?

That all sounds miserable. I wouldn't do any job where I was required to call a bunch of patients back personally. How do you even have time to see the new patients in the ED with all that nonsense?

 

[Birdstrike]

Yeah boss says they're going to add a distinct page to the mindless signatures the patients get. But, because technology is stupid, it won't be gender sensitive...have guys signing for pelvic exams...

This is totally off subject, but the next time you read one of those articles claiming computers (AI) are going to someday "be smarter than humans" and "take over the world," think back to this moment.

 

[DocEspana]

This is totally off subject, but the next time you read one of those articles claiming computers (AI) are going to someday "be smarter than humans" and "take over the world," think back to this moment.

To be fair, I never expect goog.... Skynet.... To enslave us and make some better society. I expect them to just kill us all after some chain of logic decides thats just the simplest way to the goal.

The only thing that gives me solace is that, if EMRs are any indication, it will take skynet 1,200 clicks per human it wants to kill to pull the task off.

 

[Birdstrike]

To be fair, I never expect goog.... Skynet.... To enslave us and make some better society. I expect them to just kill us all after some chain of logic decides thats just the simplest way to the goal.

Yes, if the EMRs are any indication, I'd say we're safe from computers taking over the world, for about 7 trillion years.

 

[hundreddaysoff]

How do y'all resolve the matter of yeast infection vs BV w/o a pelvic exam and wet prep?

Our wet prep takes about 4 hours to come back, so just long enough not to want pt to wait for it. My personal accuracy given mild crampy abdominal pain w/ copious white discharge but no vaginal edema/erythema and normal cervix is ~50%, ie just a coin flip.

Seems counterproductive to dose these ladies w/ both fluconazole and Flagyl empirically. "F/u gyn and don't overthink this" is a reasonable answer but I'm all about the style points, dammit.

 

[Brigade4Radiant]

How do y'all resolve the matter of yeast infection vs BV w/o a pelvic exam and wet prep?

Our wet prep takes about 4 hours to come back, so just long enough not to want pt to wait for it. My personal accuracy given mild crampy abdominal pain w/ copious white discharge but no vaginal edema/erythema and normal cervix is ~50%, ie just a coin flip.

Seems counterproductive to dose these ladies w/ both fluconazole and Flagyl empirically. "F/u gyn and don't overthink this" is a reasonable answer but I'm all about the style points, dammit.

Flagyl is just one tab as the half life is 72 hours.

Also a lot of women get yeast infections due to the antibiotics anyway so given them together prevents it

 

[Zebra Hunter]

I still don’t know why we care about BV if the patient isn’t complaining of odor. It’s not like untreated BV leads to any significant complications.

 

[hundreddaysoff]

I still don’t know why we care about BV if the patient isn’t complaining of odor. It’s not like untreated BV leads to any significant complications.

Style points mostly. Eg, preventing ER bouncebacks in women who don't have insurance for a gyn and really can't afford a bounceback.

Given all my wet prep correlations, I am half-convinced that BV does cause significant abdominal pain in quite a few women. But it's obviously not a real emergency.

 

[Groove]

I still don’t know why we care about BV if the patient isn’t complaining of odor. It’s not like untreated BV leads to any significant complications.

It would most definitely complicate...date night.

 

[Groove]

That all sounds miserable. I wouldn't do any job where I was required to call a bunch of patients back personally. How do you even have time to see the new patients in the ED with all that nonsense?

Well, it's gotten slightly better the past couple of weeks. The APCs (who weren't doing anything with our low volumes, yet have been kept on the payroll at 100% pay; funded by our paycut I might add...7K subtracted from my paycheck last month entitled "APC Adjustment") have been given duties to assume the COVID calls, so that's a plus. It is still pretty miserable though. I'm actually looking for a new job now so maybe I can find a gig with more logic and common sense.

 

[DocEspana]

How do y'all resolve the matter of yeast infection vs BV w/o a pelvic exam and wet prep?

Our wet prep takes about 4 hours to come back, so just long enough not to want pt to wait for it. My personal accuracy given mild crampy abdominal pain w/ copious white discharge but no vaginal edema/erythema and normal cervix is ~50%, ie just a coin flip.

Seems counterproductive to dose these ladies w/ both fluconazole and Flagyl empirically. "F/u gyn and don't overthink this" is a reasonable answer but I'm all about the style points, dammit.

sticky mucus discharge vs "its basically cottage cheese, doc."

I fully concur that I dont trust patient enough and would pelvic (often external exam is sufficient). But wet prep? Its a visual diagnosis, wet prep is redundant and poor resource use (imho. maybe ive not seen the mystical cottage cheese BV. <shudders>)

I say this as someone who often does double cover just on principle on many of these women for the same reasons @Brigade4Radiant mentioned.

 

[Birdstrike]

I feel like I've wandered into the "Name this discharge," Gyn sub-forum.

 

[RustedFox]

What's all the fuss?

Treat. (Rocephin. Zithromax. Flagyl.)
Street. (Rx for 2 doses of diflucan.)

 

[Apollyon]

What's all the fuss?

Treat. (Rocephin. Zithromax. Flagyl.)
Street. (Rx for 2 doses of diflucan.)

But, but, but - someone is beyond dogmatic that Rocephin does nothing. NOTHING!

 

[Buckeye1992]

Our lab won’t run urine Gc/chlamydia for females but will for males for whatever reason. Our vaginitis/vaginitis swabs do come back in like 45 minutes and Gc/chlymdia in like 1-1.5hr. So at least they are pretty quick. I have had lots of patients present with severe pelvic pain and dysuria but deny discharge. Negative Hcg negative UA negative pelvic US. At that point typically do pelvic and usually find tons of discharge that ends up being positive for something.

 

[Groove]

Our lab won’t run urine Gc/chlamydia for females but will for males for whatever reason. Our vaginitis/vaginitis swabs do come back in like 45 minutes and Gc/chlymdia in like 1-1.5hr. So at least they are pretty quick. I have had lots of patients present with severe pelvic pain and dysuria but deny discharge. Negative Hcg negative UA negative pelvic US. At that point typically do pelvic and usually find tons of discharge that ends up being positive for something.

Yeah, but what are you going to do with that pelvic pain that has a neg HCG and neg US on a sexually active female? Presumptively treat for PID of course. The pelvic did not change your management. Even if you had equivocal discharge and your wet prep/cx came back negative, you'd still probably suspect a false negative and empirically treat them anyway. Rarely have I found any clinical finding on a routine pelvic exam that served as a "Aha!" moment that altered my initial formulated plan. Do I over treat some pelvics? Probably. Does it bother me? No. I'm really tired of pt's abusing the ED as a routine GYN clinic. 99% of mine haven't even attempted to make an appt with their gynecologist.

 

[Jabbed]

I've been trying to push for patients self-swabbing the STI/vaginitis panels, but haven't gotten any buy-in from nursing. Is anyone doing this?

 

[thegenius]

I've been trying to push for patients self-swabbing the STI/vaginitis panels, but haven't gotten any buy-in from nursing. Is anyone doing this?

A couple of my ER colleagues do this. I'm going to start doing it if I can remember.

@Groove I hear ya and I like your logic. Besides pulling out FB's and the once every 5 years vag laceration, pelvics are not all that helpful in the ED.

 

[southerndoc]

I've been trying to push for patients self-swabbing the STI/vaginitis panels, but haven't gotten any buy-in from nursing. Is anyone doing this?

Yes we do it. Urine GC and self-swab for wet prep.

 

[turkeyjerky]

I've been trying to push for patients self-swabbing the STI/vaginitis panels, but haven't gotten any buy-in from nursing. Is anyone doing this?

Yeah, I do this all the time for the people who just want their d/c checked out. I'm still of the belief that true PID (at least of the acute variety, subacute/chronic PID is a different matter) needs a pelvic exam to risk-stratify for TOA.

What buy-in from nursing do you need?

 

[Zebra Hunter]

Yeah, I do this all the time for the people who just want their d/c checked out. I'm still of the belief that true PID (at least of the acute variety, subacute/chronic PID is a different matter) needs a pelvic exam to risk-stratify for TOA.

What buy-in from nursing do you need?

I'm curious how you think a pelvic risk stratifies for a TOA. If you are doing a pelvic because you are worried they have a TOA, then you have already risk stratified them. Get the ultrasound.

 

[turkeyjerky]

I'm curious how you think a pelvic risk stratifies for a TOA. If you are doing a pelvic because you are worried they have a TOA, then you have already risk stratified them. Get the ultrasound.

If the tenderness lateralizes, I'm more concerned over a TOA and I'll get an US. Or sometimes it's just a feeling.

I dunno man, I doubt my usage of pelvics is any higher than most here. But some places have a long wait for US, or it's not available afterhours.

 

[SamtheWise]

Everyone hates pelvic exams, patients, nurses, physicians. They're a terrible unreliable test, and only really useful when removing foreign bodies or POC in SABs. Think about what you or your family member would want. And it's not some doctor you've met for 5 minutes digging around in your pelvis.

 

[thegenius]

If the tenderness lateralizes, I'm more concerned over a TOA and I'll get an US. Or sometimes it's just a feeling.

A feeling while your hand is on the cervix?