Is Plan B and "Emergency"

[docB]

This is a seperate topic from the moral objection thread. Let's try to keep this one away from the moral objection issue and on the EMTALA realted topic.

Many of us (EPs) are now working under hospital mandated programs where we have to exclude non-emergent patients from the ED unless they can pay.

See thread:
http://forums.studentdoctor.net/showthread.php?t=167548&highlight=trouble+horizon

Now my question:

If a patient present to an ED requesting Plan B (no other complaints) do they have an "emergency medical condition" as defined by EMTALA and are they therefore entitled to care in the ED?

Before you all shout "Yes, of course!" consider that prescriptions for Plan B are available from many sources besides the ED including Planned Parenthood and in CA pharmacies. The time course usually allows for referral to a primary care source. The "bad outcome" of denying Plan B is not death or damage to a bodily part or organ (trying to recall the exact EMTALA language) but is an unwanted pregnancy.

Let's bounce this around a little then I'll tell you what my group decided.

---

Members don't see this ad.

 

[deleted87716]

Well, it is frequently referred to as "emergency contraception."

Realistically, it's more of an "urgency" than an "emergency," given the 72-hour window, but most patients aren't likely to grasp the difference.

 

[EctopicFetus]

Emergency medical condition means--

(i) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in--

(A) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

(B) Serious impairment to bodily functions; or

(C) Serious dysfunction of any bodily organ or part; or

(ii) With respect to a pregnant woman who is having contractions--

(A) That there is inadequate time to effect a safe transfer to another hospital before delivery; or

(B) That transfer may pose a threat to the health or safety of the woman or the unborn child.

I dont think Plan B fits under these rules. If anything I guess an argument could be made regarding the "health" of the mother but I dont think it would be upheld simply because there are other options and the risk clearly not immediate. Thats just my 2 cents.

 

[sdn1977]

Since this is a specific request for a drug only.....not a medical diagnosis, I feel I can chime in, particularly since this is problem with many drugs.

To be very clear: In EVERY state Plan B has OTC status for men & women over 18, so it is available in EVERY pharmacy for those over 18 in EVERY state.

Under 18, there are more limited choices - always Planned Parenthood & then you need to find out if your state allows pharmacy prescribing & find the nearest pharmacy. You can do this easily by accesinng not-2-late.com. IMO - ERs should have this list available.

So...for the under 18 crowd, time becomes of the essence, particularly when the other accessible sources are not open - weekends, holidays, etc. In addition....in this population, the issue arises of assault or abuse, which doesn't make it an emergency, just puts a twist on it.

Just curious....what do you do if you have a pt wanting a narcotic because his ran out & his doctor is not accessible & he'll go into withdrawal - this is more controversial because it involves drug diversion, but will occasionally happen with pts who have valid requirements.

But...I just had a real situation last Friday night - a pt arrived from BC, Canada & had left his Plavix behind. He was s/p 3 coronary stents x 4 weeks..so really shouldn't go without. But, in the US, we can't fill an rx from an international physician, so I couldn't transfer his rx to me. I gave him the following choices - see a physician here (we have some urgent care centers here and an medical clinic at SFO so I'm not forced to refer to an ER unless really at night) or have him get someone to overnight FedEx his rx. Both expensive, but this shipping less so. He actually chose the latter & I gave him a tablet for one day. A bit off topic, but similar - the only reason for a physician visit is the need - in this case a valid & similarly time sensitive one - for a drug.

 

[DocWagner]

Plan B does not fall under "emergency medical condition". As the condition is not a pathological process, but rather the method of acquiring the condition "alleged sexual assault" is the true complaint. Assessment of the assault is an "emergency medical condition".

For the above,
Emergency narcotic prescription is not a valid "emergency medical condition" unless acutely injured or immediately post surgical. Withdrawal is not my consideration as narcotic prescriptions are calculated and if taken correctly, anticipation of refill is pretty easy...ie count ahead. I do not prescribe alcohol to alcoholics on Election Day or on sundays in states with 'blue laws' either.

 

[EctopicFetus]

Plan B does not fall under "emergency medical condition". As the condition is not a pathological process, but rather the method of acquiring the condition "alleged sexual assault" is the true complaint. Assessment of the assault is an "emergency medical condition".

For the above,
Emergency narcotic prescription is not a valid "emergency medical condition" unless acutely injured or immediately post surgical. Withdrawal is not my consideration as narcotic prescriptions are calculated and if taken correctly, anticipation of refill is pretty easy...ie count ahead. I do not prescribe alcohol to alcoholics on Election Day or on sundays in states with 'blue laws' either.

I think alleged sexual assault is one thing. But I imagine the majority of people seeking plan b are NOT those who were assualted but rather those who had consensual sex and either made a bad decision (unprotected sex) or perhaps their contraception failed (broken condom).

I agree with above.

 

[quinsy]

To be very clear: In EVERY state Plan B has OTC status for men & women over 18, so it is available in EVERY pharmacy for those over 18 in EVERY state.

The second part does not necessarily follow from the first - remember that there are many pharmacists who will not fill a prescription for Plan B, notably at Wal-Mart pharmacies. In some rural areas, Wal-Mart may be the only pharmacy because it has driven all the smaller operations out of business.

So I would think it might be somewhat location dependent what the situation is.

Also, I would be wary of trying to decide whether the patient's need for plan B is 'their own fault for making a bad decision' and that type of thing. The stakes are high for a lot of people, and birth control is not 100% effective. Can't we just try to help them out if they need it regardless of how we may feel about whatever sexual choices they made? Then we are getting into morality issues. It doesn't sound like providing plan B would take up much time & resources in areas where it would be difficult to get it otherwise. I can understand turning them away in a busy ED or anyplace where it's readily available OTC.

 

[sdn1977]

The second part does not necessarily follow from the first - remember that there are many pharmacists who will not fill a prescription for Plan B, notably at Wal-Mart pharmacies. In some rural areas, Wal-Mart may be the only pharmacy because it has driven all the smaller operations out of business.

So I would think it might be somewhat location dependent what the situation is.

Also, I would be wary of trying to decide whether the patient's need for plan B is 'their own fault for making a bad decision' and that type of thing. The stakes are high for a lot of people, and birth control is not 100% effective. Can't we just try to help them out if they need it regardless of how we may feel about whatever sexual choices they made? Then we are getting into morality issues. It doesn't sound like providing plan B would take up much time & resources in areas where it would be difficult to get it otherwise. I can understand turning them away in a busy ED or anyplace where it's readily available OTC.

You are going on old information. As of March 3, 2006 - Walmart stocks Plan B in all its pharmacies.

 

[Seaglass]

With any emergency contraception the efficacy is clearly a matter of time. The relative urgency for prescribing it depends on the availability of other sources. Teenagers may not know how to contact their regular doctor if they even have one, and if they fill it through their insurance their parents are likely to find out. So separate from the moral issues, I would say that at non-office hours or for those without a PCP it is an emergency. There are many complications of pregnancy some of which threaten life and limb and few complications of emergency contraception. There are also significant social costs and medical costs regarding unwanted pregnancies. You could argue the merits of emergency contraception solely on that basis if you wanted too - you think it's rough treating this one girl for 5 minutes, think about treating her unwanted kid for 20 years.

 

[Miami_med]

Unless one defines pregnancy as "Serious impairment to bodily functions; or
Serious dysfunction of any bodily organ or part," it wouldn't be an emergency. If the patient doesn't get this pill, the worst that happens is the patient becomes pregnant. Thus, it would have to be defined whether pregnancy meets this condition. If you said that pregnancy implied this to my wife, she might punch you.

 

[dpmd]

On the one hand, any adult should be able to get Plan B without having to resort to getting it by going to the ER (as mentioned before, it is OTC and you just have to go to a pharmacy-or if you can't afford it you can got to planned parenthood). On the other hand, what if it is possible to get the person that comes to the ER this drug without taking more time than that required for triage. Perhaps having an algorithm where a person could get a scrip (even though you don't really need one) from the triage nurse would work. I have no idea if this is allowed, but it would let the ER get rid of these people without them feeling like they weren't helped (then maybe they won't try making up complaints in the hopes that will get them the drug).

I don't think it should qualify as an emergency.

 

[Febrifuge]

See, where I work, the docs don't need to see the woman. She goes to Triage, says she needs Plan B, and the RN sends her to the pharmacy. I do not think it's free, but we do take every insurance plan known to humankind, plus a few others.

 

[deleted77919]

I do not think it's free, but we do take every insurance plan known to humankind, plus a few others.

I always wondered what Martians used instead of Blue Cross/Blue Shield . . .

I think we need a new fellowship for treating offworlders.

Or perhaps these patients are from earth, just not human . . . maybe we need more vets in the ED!

 

[FoughtFyr]

I dont think Plan B fits under these rules. If anything I guess an argument could be made regarding the "health" of the mother but I dont think it would be upheld simply because there are other options and the risk clearly not immediate. Thats just my 2 cents.

In the "real world" sense, I agree with you. But, the gist of Roe v. Wade was the (mental) health of the mother. So, without getting into a discussion of the morality, the courts have held that an unwanted pregnancy is a risk to the mental health of the mother.

- H

 

[EctopicFetus]

In the "real world" sense, I agree with you. But, the gist of Roe v. Wade was the (mental) health of the mother. So, without getting into a discussion of the morality, the courts have held that an unwanted pregnancy is a risk to the mental health of the mother.

- H

Yeah but I dont know if this qualifies. I spoke to an attorney who happens to specialize in health law and their opinion was similar to mine. It doesnt qualify.

Fought, I think that the real issue is that they could then go somewhere else and have this "mental health" issue resolved. It is Urgent perhaps but clearly not emergent. I think the 5 mins to see this person is one thing, but then there are issues of increasing magnitude if this person is 14 or so. Do you tell the parents? can they then sue you for treating their kid without permission. Of course even if she had insurance the bill would eventually go to the parents and questions would arise at that point. There are more "real world" issues. Sadly, I dont know that there is a simple answer.

Bottom line though is I think this qualifies at best as Urgent.

 

[docB]

Interesting points. My group debated this for weeks. We eventually decided that the liability of denying Plan B was too high aned that we would prescribe it. We never could agree on what EMTALA would want but we were intimidated by the litigation system.

 

[GeneralVeers]

What is the down side to prescribing plan B?

 

[DocWagner]

It is difficult to argue "mental anguish" considering SOOO many things could fall under this and there ARE ALTERNATIVES (ie abortion if pregnancy is confirmed).

Plan B remains an elective medication, is not the standard of care, and will remain under debate.

 

[GeneralVeers]

It is difficult to argue "mental anguish" considering SOOO many things could fall under this and there ARE ALTERNATIVES (ie abortion if pregnancy is confirmed).

Plan B remains an elective medication, is not the standard of care, and will remain under debate.

But why not give it? We do a lot of things that are not necessarily "standard of care".

 

[EctopicFetus]

But why not give it? We do a lot of things that are not necessarily "standard of care".

Just to be the devils advocate what if they claimed ignorance and that they didnt understand what this medicine was for etc. basically a HA for nothing. I could think of other reasons as well but i need to shower so i can go to work.

 

[DocWagner]

Because this presents a choice in treatment while not deviating from the standard of care. The debate is "to give or not to give", my statement is do either, but realize this is not the standard of care, therefore it is not an academic argument or legal argument, but rather an argument of personal choice.

 

[docB]

What is the down side to prescribing plan B?

In our case we operate under a hospital policy that "non-emergent" patients, ie. those without an EMTALA qualifying emergency medical condition are required to pay before they receive ED care. The debate really happened because we were trying to figure out if this really qualifies as an emergent condition.

Once the debate was going additional issues arose such as side effects of hormone pills such as blood clots, cancer, etc. As most of us (and EPs generally) would balk at starting a woman on BCPs we were uneasy with this as well. We also encountered difference of opinion about what work up (blood, pelvic, HCG) is needed before we could safely prescribe Plan B. We also were concerned about the possible ill effects and future liability if you gave Plan B to someone who was already pregnant but didn't know it.

Now I know most of these issues have been worked out in the lit but once you guys get into practice you'll learn about the dinosaurs.

Of note the morality issue never came up even once.

 

[Febrifuge]

I just had a weird thought... what about those patients who might not be entirely honest about how long they've been pregnant? What if, say, a woman who's 9 weeks along decides to come in and say she needs Plan B... here's where I play my not-in-school-yet ignorance card and ask what, pharmacologically, happens to that fetus?

I mention this because it might be a good argument in favor of a more thorough exam prior to writing for the stuff. Doesn't mean it's an "emergency" or not, but it might be a good reason to decide on a more thorough screening.

 

[DocWagner]

Well...yeah. Who orders Plan B without getting a pregnancy test first...who would do that? Plan B is the "morning after pill", ie, a positive pregnancy test would be a bit more than the "morning after".

If the patient wants to buy the stuff OTC that is her issue.

 

[sdn1977]

What is the down side to prescribing plan B?

Not too much - hence its long overdue otc status! (yeah, yeah, yeah...there's what's written in the warning section of the pt pkg insert. But, you could find many of those same warnings in asa, apap, ibuprofen, pseudoephedrine pt pkg inserts.)

 

[joeG]

What would you want for yourself (if female) or your girlfriend (or not)?

 

[FoughtFyr]

Yeah but I dont know if this qualifies. I spoke to an attorney who happens to specialize in health law and their opinion was similar to mine. It doesnt qualify.

Fought, I think that the real issue is that they could then go somewhere else and have this "mental health" issue resolved. It is Urgent perhaps but clearly not emergent. I think the 5 mins to see this person is one thing, but then there are issues of increasing magnitude if this person is 14 or so. Do you tell the parents? can they then sue you for treating their kid without permission. Of course even if she had insurance the bill would eventually go to the parents and questions would arise at that point. There are more "real world" issues. Sadly, I dont know that there is a simple answer.

Bottom line though is I think this qualifies at best as Urgent.

I'm not sure. Lots of the MH issues we see in the ED would best be handled on an outpatient basis. Look, lawyers are the devil and the courts are their playground. There is no way I would risk being that "out there" on an issue this fraught with public discord. Remember what happened to Wal*Mart when they, as a private company, didn't want to carry "Plan B"? My face on the evening news? No thanks, I'm not that photogenic!

- H

 

[sdn1977]

What would you want for yourself (if female) or your girlfriend (or not)?

I am female & I was glad it became otc. When it became available on pharmacist prescribing access here in CA - about 10 yrs ago - I made sure my daughter & her friends all knew how to find a pharmacist who could give it to them. The burden of getting thru an ER is not an easy task - particularly when you're not sick - at least where I live.

But....I'm also in favor of Gardisil vaccines too!

 

[EctopicFetus]

I'm not sure. Lots of the MH issues we see in the ED would best be handled on an outpatient basis. Look, lawyers are the devil and the courts are their playground. There is no way I would risk being that "out there" on an issue this fraught with public discord. Remember what happened to Wal*Mart when they, as a private company, didn't want to carry "Plan B"? My face on the evening news? No thanks, I'm not that photogenic!

- H

Right but now it looks like we are talking about less of an EMTALA issue and are talking more about fear of being sued (not necessarily successfully) and having out face thrown all over the news. I agree with you that no one wants this.

On another note dont you think we create mental anguish and affect the mental health of people when we "force" them out of the ED? Also, even if we impact their mental health I would argue that if a person is not DTS/DTO then their "psych condition" is not emergent. So by me not giving this medication I might cause them increased stress or mental anguish but I doubt they would try to kill themselves to it. If they did, then pysch admit it is.

AGAIN, I want to be clear, I would treat these people personally, but I dont think not treating is a violation of EMTALA and as DocWagner mentioned this is not standard of care nor is there a legal obligation to treat.

 

[EctopicFetus]

I am female & I was glad it became otc. When it became available on pharmacist prescribing access here in CA - about 10 yrs ago - I made sure my daughter & her friends all knew how to find a pharmacist who could give it to them. The burden of getting thru an ER is not an easy task - particularly when you're not sick - at least where I live.

But....I'm also in favor of Gardisil vaccines too!

I agree these are very low priority and you might wait 10+ hours to be seen, longer if you are unlucky.

I am also for Gardasil as long as parents who wish to can opt out. Assuming no serious negative info comes out when/if I have a little daughter she will be getting this vaccine.

 

[DocWagner]

You aren't going to get sued.
This is an optional treatment effective in the first hours of pregnancy. There are other methods and it is EXCEEDINGLY difficult to prove mental anguish for unwanted pregnancy...in fact I would imagine a legal precedent to sue a physician an win for anything remotely similar.
You guys can't be forced into this. Look , I write the prescription AFTER PATIENT GIVES CONSENT...consent is a bigger issue here.

 

[The White Coat Investor]

What would you want for yourself (if female) or your girlfriend (or not)?

What if I'm neither female nor have a girlfriend?

I might be a married male, a gay male, a single male etc etc etc?

 

[The White Coat Investor]

I just had a weird thought... what about those patients who might not be entirely honest about how long they've been pregnant? What if, say, a woman who's 9 weeks along decides to come in and say she needs Plan B... here's where I play my not-in-school-yet ignorance card and ask what, pharmacologically, happens to that fetus?

I mention this because it might be a good argument in favor of a more thorough exam prior to writing for the stuff. Doesn't mean it's an "emergency" or not, but it might be a good reason to decide on a more thorough screening.

It seems to me that lots of people get pregnant on oral contraceptives without harm to the fetus. I don't know why taking a double dose would somehow wipe out a 9 week gestation. This is estrogen/progesterone not methotrexate we're talking about here.

 

[sdn1977]

I just had a weird thought... what about those patients who might not be entirely honest about how long they've been pregnant? What if, say, a woman who's 9 weeks along decides to come in and say she needs Plan B... here's where I play my not-in-school-yet ignorance card and ask what, pharmacologically, happens to that fetus?

I mention this because it might be a good argument in favor of a more thorough exam prior to writing for the stuff. Doesn't mean it's an "emergency" or not, but it might be a good reason to decide on a more thorough screening.

Nothing happens to the fetus. It neither harms the fetus nor does it disrupt the pregnancy.

Again....all this info is available online easily & is also in easy to read format within the product packaging designed at the 7th grade reading level.

 

[FoughtFyr]

You aren't going to get sued.
This is an optional treatment effective in the first hours of pregnancy. There are other methods and it is EXCEEDINGLY difficult to prove mental anguish for unwanted pregnancy...in fact I would imagine a legal precedent to sue a physician an win for anything remotely similar.
You guys can't be forced into this. Look , I write the prescription AFTER PATIENT GIVES CONSENT...consent is a bigger issue here.

Yep, I agree. But imagine the press when the middle-american, blond-haired, petite, girl-next-door ends up all over the news saying someone from your group wouldn't give her plan B after her rape.

- H

 

[quinsy]

You are going on old information. As of March 3, 2006 - Walmart stocks Plan B in all its pharmacies.

Hey:

What I was saying was that some pharmacists will not fill prescriptions for Plan B due to religious objections. That can still happen regardless of whether the pharmacy stocks the drug or not. So in a small town scenario, when none of the pharmacists in your town will fill your prescription due to conscientous objections... I guess these are more the people I was thinking of. Wal-Mart does stock Plan B but not by choice, and I think they are likely to employ many objectors. I have to admit, Wal-Mart just makes me mad. But I'm sure this scenario can happen at any pharmacy. I very much doubt that everyone who needs Plan B can easily get it at this point in time, though I hope it will be the case someday.

also for those who are arguing about liability, it seems that some are arguing about the liability of Plan B not working and then causing mental anguish of an unwanted pregnancy, and some are worried about the liability of it causing side effects or birth defects. I think an argument based on risk of cancer or blood clots is very silly - those risks are based on taking the pills every day, not one day in your life. As for birth defects, their incidence is extremely rare even for women taking hormones through pregnancy, so again, this is quite a small dose to worry about that kind of effect. Even from the other side of the argument, the unwanted pregnancy, Plan B is not close to 100%, rather it is 89% effective at best. So how can you be sued if it doesn't work? The longer it takes to get it, the less likely it is to work, so I think you're more likely to get in trouble for not providing it than the other way around.

 

[quinsy]

just as I was typing my reply, I noticed this timely news item.

this is what we're talking about!

http://www.ohio.com/mld/ohio/news/state/16469999.htm

Couple accuses pharmacy of denying pills

COLUMBUS - A woman has complained to the governor and an abortion-rights group about Wal-Mart workers who wouldn't give her morning-after contraceptive pills that don't require a prescription.

Tashina Byrd, 23, of Springfield, said the pharmacist ``shook his head and laughed'' when a pharmacy attendant asked this month about giving the woman and her boyfriend Plan B. The hormone pills can help prevent pregnancy if taken within 72 hours of unprotected sex.

The attendant told Byrd and her boyfriend, Brian O'Neill, 37, of Columbus, that the store stocked Plan B but nobody would give it to them, the couple told the Columbus Dispatch for a story Monday.

 

[Miami_med]

just as I was typing my reply, I noticed this timely news item.

this is what we're talking about!

http://www.ohio.com/mld/ohio/news/state/16469999.htm

Couple accuses pharmacy of denying pills

COLUMBUS - A woman has complained to the governor and an abortion-rights group about Wal-Mart workers who wouldn't give her morning-after contraceptive pills that don't require a prescription.

Tashina Byrd, 23, of Springfield, said the pharmacist ``shook his head and laughed'' when a pharmacy attendant asked this month about giving the woman and her boyfriend Plan B. The hormone pills can help prevent pregnancy if taken within 72 hours of unprotected sex.

The attendant told Byrd and her boyfriend, Brian O'Neill, 37, of Columbus, that the store stocked Plan B but nobody would give it to them, the couple told the Columbus Dispatch for a story Monday.

I wasn't aware that Walmart was the only pharmacy in Columbus. Maybe this proves that it's not an emergency. Generally, people try to solve the problem in case of an emergency BEFORE they try to set themselves up for a settlement.

 

[EctopicFetus]

Hey:

What I was saying was that some pharmacists will not fill prescriptions for Plan B due to religious objections. That can still happen regardless of whether the pharmacy stocks the drug or not. So in a small town scenario, when none of the pharmacists in your town will fill your prescription due to conscientous objections... I guess these are more the people I was thinking of. Wal-Mart does stock Plan B but not by choice, and I think they are likely to employ many objectors. I have to admit, Wal-Mart just makes me mad. But I'm sure this scenario can happen at any pharmacy. I very much doubt that everyone who needs Plan B can easily get it at this point in time, though I hope it will be the case someday.

Really then why do they stock it? Perhaps I am missing something here. I dont quite understand why everyone hates walmart. I know they put little poor mom and pop stores out of business but if they cant compete then maybe this is for the best. Stats show walmart save people who shop there a bunch of money a yr.

 

[EctopicFetus]

I wasn't aware that Walmart was the only pharmacy in Columbus. Maybe this proves that it's not an emergency. Generally, people try to solve the problem in case of an emergency BEFORE they try to set themselves up for a settlement.

Columbus is a very small place and since Walmart put every single other pharmacy out of business within 200 miles of columbus this was their only option. Of course my cynical side says.. Walmart has deep pockets and perhaps Tashina and BF want some money.

 

[EctopicFetus]

Oh there is more.. Love the net..

http://news.enquirer.com/apps/pbcs.dll/article?AID=/20070116/NEWS01/701160368/1056/COL02


Brent Beams, the pharmacist, told the Dispatch that he denied the couple's request for the contraceptive pills because he believes in preserving life, and I do not believe in ending life, and life begins at conception."

After the pharmacist turned them down, O'Neill and Byrd asked for a store manager who "came over and said, 'The pharmacist has the law on his side,'" O'Neill said.

The winning couple

 

[docB]

When we get into the pharmacist refusing to dispense issue we're talking more about morality than if this constitutes an emergent condition. Let's let the morality stuff linger on the other thread.

No if we want to ask about the person who couldn't afford Plan B so the pharmacy wouldn't fill the script then we're in the right place.

 

[EctopicFetus]

Good point. Sorry I stray again!

 

[Febrifuge]

My take is largely in line with what DocB said in the first post; there are lots of good reasons to say that no way is an unplanned pregnancy a true medical emergency, and therefore Plan B is not emergency treatment. From there, we've got morality issues that go in the other thread, and we've got practical considerations, some of which have to do with the fact that the stuff is referred to as "Emergency Contraception."

Yes, it's a semantic argument, but in the liberal arts we like to say that language influences thought. And anyway, as one look at the board of any of our EDs will show, the idea of what constitutes an "emergency" in the mind of your typical is obviously very fluid, for lots of reasons. Some have to do with the hideously messed-up reality of the healthcare system, and some have to do with what people believe.

So if people believe there's an emergency, and behave as if it is, to some extent we're stuck. Our hand is forced a little; we need to either demonstrate there is no emergency, or else treat the perceived problem with a percieved solution.

I do not feel great about this. I happen to endorse Plan B heartily and believe... a bunch of stuff that goes in the other thread. But I don't feel great about having too much of the old "the customer is always right" spirit in medicine. Patients are customers... if you're an HMO. Otherwise, they're patients.

This is not to say the discussion isn't important, it's just... whatever we might decide, the reality will be that we don't get to decide.

 

[EctopicFetus]

My take is largely in line with what DocB said in the first post; there are lots of good reasons to say that no way is an unplanned pregnancy a true medical emergency, and therefore Plan B is not emergency treatment. From there, we've got morality issues that go in the other thread, and we've got practical considerations, some of which have to do with the fact that the stuff is referred to as "Emergency Contraception."

Yes, it's a semantic argument, but in the liberal arts we like to say that language influences thought. And anyway, as one look at the board of any of our EDs will show, the idea of what constitutes an "emergency" in the mind of your typical is obviously very fluid, for lots of reasons. Some have to do with the hideously messed-up reality of the healthcare system, and some have to do with what people believe.

So if people believe there's an emergency, and behave as if it is, to some extent we're stuck. Our hand is forced a little; we need to either demonstrate there is no emergency, or else treat the perceived problem with a percieved solution.

I do not feel great about this. I happen to endorse Plan B heartily and believe... a bunch of stuff that goes in the other thread. But I don't feel great about having too much of the old "the customer is always right" spirit in medicine. Patients are customers... if you're an HMO. Otherwise, they're patients.

This is not to say the discussion isn't important, it's just... whatever we might decide, the reality will be that we don't get to decide.

Im not gonna adress every point but I will say what is an "emergency" to a patient is not necessarily an emergency to us. The customer is NOT always right in the ED. You want narcs? and your pain is an emergency.. I think you are FOS and hence get none. You want to be admitted for an MRI cause otherwise it will take 1 month. We do get to decide. If you insert Oxycontin or Dilaudid or even antibiotics for plan B then I dont think too many of us would think we should just give the patients whatever they want if we dont feel it is necessary.