Pregnancy ESI

[nctxil]

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Pregnant patient at 33 weeks gestation with clear radicular pain. Likely L5. No numbness, reflex changes, or weakness. No comorbidities. Would you consider an ESI (no flouro) without ordering an MRI first?

Thanks for your thoughts.

 

[Tenesma]

technically an MRI shouldn't be a big deal... other than the patient may have aorto-caval compression lying flat and that could compromise uterine/placental blood flow

what are the benefits?? and what are the risks???

would you take the risk that if anything happens to that baby because of the ESI you will be liable???

what happens if your ESI induces labor and baby is born premature?

what happens if you give her a spinal headache - how are you going to manage that?

etc...

 

[Ligament]

Pregnant patient at 33 weeks gestation with clear radicular pain. Likely L5. No numbness, reflex changes, or weakness. No comorbidities. Would you consider an ESI (no flouro) without ordering an MRI first?

Thanks for your thoughts.

You should certainly USE fluoro for this case, not avoid it. The exposure is minimal and insignificant to the fetus. Now, I still would not do it for the issues Tenesma elucidated, but if I were to do this procedure I would certainly use fluoro.

 

[Tenesma]

dude --- why use fluoro? you don't want her to be lying prone on that baby... unless you would use fluoro in the lateral decub position?

 

[Pain_doc]

Have had similar situations. An MRI is perfectly safe to obtain. I do not use fluoro however & perform the epidural "blindly" 🙂. (in my state, statute of limitations for lawsuit is 2 years for an adult, but until 18 years old in case of infant/child/fetus)

 

[lobelsteve]

Call your malpractice carrier prior to the procedure. Ask how many years of liability you incur for the patient and then for the unborn child.

Ask what literature supports performing an ESI for pain in a 33wk pregnancy.
Ask what happens if you induce her by your injection?
Call the district attorney in your area and explain the potential complications in this case and if they occur, would it justbe medical malpractice or would he want to prosecute you.

I'm going to recommend Tylenol, moist heat, gentle stretching.
I do not prescribe medications to pregnant patients. If you become pregnant while under my care, we call the Ob and begin a taper off all meds. See you in 9 months. I know the methadone literature and of its safety in pregnancy. I'm still not taking the risk. I'm glad you do. I know where to send pregnany folks.

 

[PMR 4 MSK]

Call your malpractice carrier prior to the procedure. Ask how many years of liability you incur for the patient and then for the unborn child.

Ask what literature supports performing an ESI for pain in a 33wk pregnancy.
Ask what happens if you induce her by your injection?
Call the district attorney in your area and explain the potential complications in this case and if they occur, would it justbe medical malpractice or would he want to prosecute you.

I'm going to recommend Tylenol, moist heat, gentle stretching.
I do not prescribe medications to pregnant patients. If you become pregnant while under my care, we call the Ob and begin a taper off all meds. See you in 9 months. I know the methadone literature and of its safety in pregnancy. I'm still not taking the risk. I'm glad you do. I know where to send pregnany folks.

I'm with lobelsteve on this one. Can't see that's it's worth the risk. It doesn't matter how much you warn about the risks, have her sign informed consent, etc., if there's a bad outcome with a baby,you'll be blamed. Even if you don't do it, there's a 5% or so risk of a problem in the 3rd trimester - and if you've done an ESI, you'll be blamed. Not worth it, dude.

Also, as most of the literature right now seems to indicate that ESI's are worthless (we all know they help but have failed to prove it), a jury will be told that you used a procedure on a pregnant woman that has not been proven effective even on non-pregnant women.

 

[nctxil]

Call the district attorney in your area and explain the potential complications in this case and if they occur, would it justbe medical malpractice or would he want to prosecute you.

I understand that proceeding without an MRI would be a stretch, but would it be considered malpractice to perform an ESI in a pregnant patient at 33 weeks gestation if an MRI showed clear pathology explaining the pain? I've done these with reasonable results and luckily no complications. I didn't realize I was deviating from the standard of care so blatantly.

There are no studies that I am aware of that prove the use of ESIs in this population, but the role ESIs are debated in every population.

I've never heard of a prosecution for doing an ESI in a pregnant patient. Has this really happened? Is it considered battery to the patient and fetus? Maybe I'm naive and should be practicing more defensively.

 

[lobelsteve]

I understand that proceeding without an MRI would be a stretch, but would it be considered malpractice to perform an ESI in a pregnant patient at 33 weeks gestation if an MRI showed clear pathology explaining the pain? I've done these with reasonable results and luckily no complications. I didn't realize I was deviating from the standard of care so blatantly.

There are no studies that I am aware of that prove the use of ESIs in this population, but the role ESIs are debated in every population.

I've never heard of a prosecution for doing an ESI in a pregnant patient. Has this really happened? Is it considered battery to the patient and fetus? Maybe I'm naive and should be practicing more defensively.

Are you saving her life by performing an epidural? How do you know it is not pelvic plexitic pain from a uterus pushing on it? I would not get an MRI, I would not perform an epidural, and I would discuss her care and document the heck out of everything you discuss in the room with the patient. You should use the words like I do not know, there is not much data or literature on this, etc.

Raise your right hand and tell me everything you know about how epidural steroids may affect the 33 week gestation child. WHat if the kid gets a cold while in the hopsital (because no one bothers washing their hands) and then gets RSV and gets put on a vent/NICU/etc. Was the child immunocompromised from a dose of steroids given weeks earlier?

I'm a very defensive practioner, not one paralyzed with fear. The difference is: if she were suicidal over the pain, I'd find a way to do the procedure. if she was in horrible pain but not suicidal, then the risk outweighs the benefit.

When you treat a pregnant person, you treat the child. That puts you on the hook for 18-21 years of tail coverage. Kid doesn't get into Harvard- it's something you did.

Malicious prosecution is an unfortunate turn of events in medical decision making. The DA's offices have taken up the slack from the public outcry that medical boards are not doing enough. The AMA has several articles over the last few years where physicians were prosecuted for medical acts in criminal court.

Disclaimer: The risk is actually very low of having a complication or adverse outcome. The consequences should that actually occur would be devastating. THat is the only reason why I am so against it. DO NO HARM! Live to fight pain another day.

 

[Mister Mxyzptlk]

Share the love. I would do it w/o fluoro if it was blessed by the OB and perinatologist. Informed consent should document every possible thing you can think of.

The alternatives are analgesic meds (which has its downside as well) or no meds/just suffer. Those high levels of catechols from the pain can't be good for the baby either.

Sometimes you just have to grab the bull by the tail and face the situation.

 

[Ligament]

dude --- why use fluoro? you don't want her to be lying prone on that baby... unless you would use fluoro in the lateral decub position?

I see your point Tenesma. I like Steve Lobel's rationale on risk/benefit issues. IF by some magic the benefit outweighed the risk I'd do it under fluoro, using one of those pregnant massage table bolsters...the massage therapists can have them lay prone for tens of minutes comfortably with them...

http://www.massagewarehouse.com/itemdetail~cat~103209305~MENU~103209305~item~221+0069.asp

I'd definately get it in rasberry rather than teal for medicolegal reasons.

 

[Tenesma]

i think anybody would be a fool to lay a woman over 26 weeks in the prone position - doesn't matter about bolsters - you are screwed if something happens...

 

[Ligament]

Tenesma, I'll admit I have no experience in this case to back up my argument so I'll withdraw on my position. I cannot provide a strong argument either way.

 

[lobelsteve]

Tenesma, I'll admit I have no experience in this case to back up my argument so I'll withdraw on my position. I cannot provide a strong argument either way.

Outstanding! You see a gap in your knowledge/skills/capabilities and you walk away. This is the most important thing that I doc can come to understand, and it is not easy to come by. I applaud your honesty and integrity. It makes me feel like there is still hope for pain medicine.

Just a rough week on the trail.....

 

[NOSfan]

MRI w/o gad in pregnancy is ok (likely no teratogenic effects). ESI also are ok. I would, however, require neuroimaging of the L/S spine and including ipsilateral pelvis prior to intervention. I had a case similar to this that turned out to be pelvic abscess! Thank goodness I had the imaging prior to planned ESI.

Regards.

 

[Ligament]

Thanks Steve.

i think anybody would be a fool to lay a woman over 26 weeks in the prone position - doesn't matter about bolsters - you are screwed if something happens...

Outstanding! You see a gap in your knowledge/skills/capabilities and you walk away. This is the most important thing that I doc can come to understand, and it is not easy to come by. I applaud your honesty and integrity. It makes me feel like there is still hope for pain medicine.

Just a rough week on the trail.....

 

[Kwijibo]

You CAN do an epidural on a pregnant female, especially at 33 weeks, obviously with the risks and benefits weighed. Remember, this patient is not likely going to present with a 5/10, intermittant pain. She is going to have to suck it up unless it is incapacitating, debilitating pain, and those whose see alot of fresh radic's know what that is like.

I think a lot of the fear of doing an epidural steoid injection in a pregnant female has to do with a lack of understanding of the physiologic effects of pregnancy. Not saying I am an expert, but having an anesthesia backround forces you to have to know this stuff.

In medicine, you can always be viewed as wrong for what you did if S@#t hits the fan, but it is your responsibility to provide your patient with what you feel is the best medical care available. PMR4MSK, the arguements you use for not doing an epidural are weak. You basically state that epidurals aren't proven to work so why would you do one. If thats the case why do any at all? Steve, I see no medically justifiable reason to not offer this patient an epidural if she is in severe pain. Have her see her OB or an MFM and get their okay with the procedure documented. Steroids are not likely going to induce labor. Severe constant pain is probably more likely to. And opiods are okay to use in pregnancy.
My wife is an OB and she agrees. Also, my sister in law is an anesthesiologist and she had an epidural while pregnant for a severe radiculopathy.

I believe in practicing defensive medicine. I practice pain in Manhattan, and I would say that 50% of my patients are actively involved in litigation. I have 2 patients that are actively suing their previous pain docs!! And none of them get treated differently than the 70 year old lady with spinal stenosis (although she probably has a case against someone too). I believe I am giving them the best medical care that can be provided, and this lets me sleep at night.

 

[Tenesma]

uh... you are providing the best medical care possible but that doesn't really matter in court... i am glad you can sleep - but what about standard of care.

if ANYTHING happens to the pregnancy and ANYTHING happens to the fetus/neonate - then you bet your butt you are going to end up in court - regardless of whether you made a decision that you thought was best medical care...

and informed consents mean nothing when it comes to babies and malpractice lawyers --- i mean OBs have been successfully sued for being too "rough" during an exam that precipitated early labor...

i don't care if it has been done - i mean in India the standard of care for C-sections is General Anesthesia... and maybe the standard of care in the Netherlands are ESIs during pregnancy...

there are many other options to treating radiculitis - she doesn't even have any radiculopathy according to the OP.

not to mention that there are a myriad of other things that can cause pain into the leg...

i agree that an MRI without gad should be fine if the tech allows the patient to lie a bit slanted - should be okay --- but I wouldn't even order the MRI unless there were more significant neurologic findings.

 

[nctxil]

I won't proceed without an MRI. It appears so straight forward and she's so uncomfortable that I thought I could get away without one. Obviously, that's a bad idea. I don't want to miss something.

As far as the medicolegal aspects, I'm willing to take the risk. I don't see the point in letting her suffer if there is something safe that I can offer. Of course, I wouldn't do anything without informed consent. Whatever that is worth.
Am I missing something or has anybody actually seen or heard of labor being induced by an ESI or is this just a theoretical risk? Is there definitive literature on this subject? Does a lumbar ESI during pregnancy have a higher complication rate than a cervical ESI in a healthy 40y/o M? A complication could be devastating in either case, but we do cervical ESIs everyday.
Anytime you come within 10 feet of a pregnant patient, you're subject to litigation. The only way to absolutely eliminate the risk is to not accept the consult. By the time a patient is referred to a pain management specialist, they're way past Tylenol, moist heat, and gentle stretching. There are cases brought against physicians for failure to treat pain aggressively enough.
The patient becomes bedridden, depressed, loses her appetite, stops taking her prenatal vitamins, and the child is born with a neural tube defect (I understand this is not possible at 33wks, but jurors may not understand this). "You're willing to prescribe acetominophen, a Preg. Cat. B medication, but not oxycodone, another Preg. Cat. B medication. Isn't oxycodone for severe pain doctor? You could have done more, doctor." Lawyers are much more creative than I am. If there is a lawsuit brought by a patient that you treated during pregnancy, and you offered any recs at all, you're going to be roped in. The most concerning part is that it appears that there are many physicians (expert witnesses) that would testify that an ESI during pregnancy is a breach of the standard of care. Some may even consider this a criminal act - I'm not sure of the crime, but fetal battery perhaps?

 

[paindefender]

I won't proceed without an MRI. It appears so straight forward and she's so uncomfortable that I thought I could get away without one. Obviously, that's a bad idea. I don't want to miss something.

As far as the medicolegal aspects, I'm willing to take the risk. I don't see the point in letting her suffer if there is something safe that I can offer. Of course, I wouldn't do anything without informed consent. Whatever that is worth.
Am I missing something or has anybody actually seen or heard of labor being induced by an ESI or is this just a theoretical risk? Is there definitive literature on this subject? Does a lumbar ESI during pregnancy have a higher complication rate than a cervical ESI in a healthy 40y/o M? A complication could be devastating in either case, but we do cervical ESIs everyday.
Anytime you come within 10 feet of a pregnant patient, you're subject to litigation. The only way to absolutely eliminate the risk is to not accept the consult. By the time a patient is referred to a pain management specialist, they're way past Tylenol, moist heat, and gentle stretching. There are cases brought against physicians for failure to treat pain aggressively enough.
The patient becomes bedridden, depressed, loses her appetite, stops taking her prenatal vitamins, and the child is born with a neural tube defect (I understand this is not possible at 33wks, but jurors may not understand this). "You're willing to prescribe acetominophen, a Preg. Cat. B medication, but not oxycodone, another Preg. Cat. B medication. Isn't oxycodone for severe pain doctor? You could have done more, doctor." Lawyers are much more creative than I am. If there is a lawsuit brought by a patient that you treated during pregnancy, and you offered any recs at all, you're going to be roped in. The most concerning part is that it appears that there are many physicians (expert witnesses) that would testify that an ESI during pregnancy is a breach of the standard of care. Some may even consider this a criminal act - I'm not sure of the crime, but fetal battery perhaps?

My consult would read: Epidural injections have not been proven to be safe and effective in gestating women. Suggest Vicodin PRN and MRI of the LS spine after delivery.

 

[Kwijibo]

Every one practices in their own way, especially in the field of pain management. And I don't think there is a standard of care, that's the problem with pain. Or if there is, docs aren't following it.

You have to remember, no matter how you got there, if there is a bad outcome, there is essentially nothing you can do in the majority of cases. There is some bloodsucking 'expert witness' out there that will testify against you. Why do you think neurosurgeon and OB insurances are so high? Do they all practice that badly? Informed consent or not. Docs fault or not. Obviously if you are outside the standard of care you will go down in a blaze, but everytime you put a needle in someone, bad things can potentially happen.

Not that I'm a cavalier, but you can't just stick your head in the ground when there is risk. What do you do when you get a patient referred for severe trigeminal neuralgia? What about a celiac plexus neurolysis? There are plenty more that the thought of makes me nervous...

Again, I am only talking about a patient with severe, incapacitating, and unresponsive to other treatment pain.

 

[nctxil]

My consult would read: Epidural injections have not been proven to be safe and effective in gestating women. Suggest Vicodin PRN and MRI of the LS spine after delivery.

Why Vicodin (Cat. C) vs. Oxycodone (Cat.B)? I know it's used but, Vicodin has not been proven safe and effective in gestating women.
A 4y/o is diagnosed with autism. The mother remembers that Vicodin was prescribed during pregnancy. Would the boy have autism if she was given oxycodone instead? Her lawyers know the pregnancy drug categories and told her it's clear that oxycodone is safer than hydrocodone. The jury sees the chart also - looks pretty clear-cut to them and the doctor didn't even bother to find out what pathology they were treating with this dangerous narcotic. Lawyers will find a reason to sue you no matter how "safe" you try to play it.

I've conceeded that I shouldn't do an ESI without an MRI, so why no diagnostics now? What if I'm missing that pelvic abscess or tumor? We can give 2 months of Vicodin to a pregnant patient without an MRI, but not do an ESI without one?

 

[lobelsteve]

Why Vicodin (Cat. C) vs. Oxycodone (Cat.B)? I know it's used but, Vicodin has not been proven safe and effective in gestating women.
A 4y/o is diagnosed with autism. The mother remembers that Vicodin was prescribed during pregnancy. Would the boy have autism if she was given oxycodone instead? Her lawyers know the pregnancy drug categories and told her it's clear that oxycodone is safer than hydrocodone. The jury sees the chart also - looks pretty clear-cut to them and the doctor didn't even bother to find out what pathology they were treating with this dangerous narcotic. Lawyers will find a reason to sue you no matter how "safe" you try to play it.

I've conceeded that I shouldn't do an ESI without an MRI, so why no diagnostics now? What if I'm missing that pelvic abscess or tumor? We can give 2 months of Vicodin to a pregnant patient without an MRI, but not do an ESI without one?

If you are set on the ESI, what is the need for an MRI? Are you looking for root compression, HNP, or looking to see if there is something else going on that would make you decide against doing the ESI?

I'm glad there are docs willing to take the risk for these patients, but what else has been done to allay her pain thus far?

 

[spondy14]

Bottom line is, some are willing to take the risk, while others are not (for many different reasons). What about this scenario..a 10-15 week pregnant female with radic (nurse in your surgical center) is willing to take the risks you discuss, but you (pain doc) still are unwilling to give an injection. Two weeks after your consultation she has a miscarriage.....and how happy are you NOW that you decided against giving that injection. You would have to live with that for a long time even though the injection had nothing to do with it....that was a true story.

 

[lobelsteve]

Bottom line is, some are willing to take the risk, while others are not (for many different reasons). What about this scenario..a 10-15 week pregnant female with radic (nurse in your surgical center) is willing to take the risks you discuss, but you (pain doc) still are unwilling to give an injection. Two weeks after your consultation she has a miscarriage.....and how happy are you NOW that you decided against giving that injection. You would have to live with that for a long time even though the injection had nothing to do with it....that was a true story.

Are you saying that radiculopathy led to miscarriage?
Are you saying that her pain led to miscarriage?

Suppose you gave the injection and 2 weeks later she had a miscarriage.
Then what?

 

[nctxil]

Bottom line is, some are willing to take the risk, while others are not (for many different reasons). What about this scenario..a 10-15 week pregnant female with radic (nurse in your surgical center) is willing to take the risks you discuss, but you (pain doc) still are unwilling to give an injection. Two weeks after your consultation she has a miscarriage.....and how happy are you NOW that you decided against giving that injection. You would have to live with that for a long time even though the injection had nothing to do with it....that was a true story.

OK, same creative lawyer files a lawsuit 1.5 years after this incident because the patient is having difficulty conceiving again. The patient wonders if there was any malpractice committed in her previous pregnancy because that may have been her only chance to have a child. He notices that in your office her BP and HR were higher than normal as was the case a week later in her OBs office. Could it be argued that her excruciating pain and subsequent increased sympathetic tone for 2 weeks led to her spontaneous abortion? Could an ESI or more aggressive treatment of her pain (if conservative measures failed) have actually saved her pregnancy? Is that any less plausible than a spontaneous abortion caused by an ESI performed 2 weeks prior?
I'm not questioning your clinical judgement, just playing Devil's Advocate.
I still contend that once you consult with a pregnant patient and make ANY recs or no recs, you have accepted the risk. If there is any bad outcome and lawsuit, your care will be subject to scrutiny - whether it it ultraconservative or aggressive.

 

[nctxil]

If you are set on the ESI, what is the need for an MRI? Are you looking for root compression, HNP, or looking to see if there is something else going on that would make you decide against doing the ESI?

I'm glad there are docs willing to take the risk for these patients, but what else has been done to allay her pain thus far?

My original question was whether or not to do an MRI. I figured I would have a lot of opposition to proceeding without an MRI. I typically would not do this and I really didn't have a good reason not to get one - just that an MRI is uncomfortable for a gravid patient, it's expensive, would delay care, and it is unlikely to show any pathology that would change my treatment plan. Now I am afraid of abscesses, tumors, conversion disorder, criminal prosecution.... so, I will be getting an MRI.
I did not expect so much opposition to doing an ESI in a pregnant patient. I feel like I have a knowledge gap here, what is the risk? When we are discussing risk, is it risk of a lawsuit (I can accept this) or actual procedural risk? Is it riskier than some of the other procedures we do on a daily basis?

Not to stir the pot but, I'm just curious. I wonder what the split is among anesthesiologists vs. PM&R on this issue. Here's and informal, non-scientific poll:

I would consider an ESI in a 33 y/o pregnant patient with an MRI confirmed L4-5 HNP compressing Rt. L5. She has resultant Rt. L5 radicular pain . + SLR on the right. No weakness numbness, or reflex changes. No comorbitities. HR, RR, and BP slightly above normal. She has been referred to you by the OB after failing 4-6 weeks of conservative care (anything you can think of) and consulted with a neurosurgeon. She is miserable, not suicidal. The procedure has been blessed by her OB, neonatologist, neurosurgeon, The Pope, Oprah,.... I'm sure I have missed some qualifiers here, but you get the point.

A) Anesthesiologist - Yes
B) Anesthesiologist - No
C) PM&R - Yes
D) PM&R - No

 

[lobelsteve]

My original question was whether or not to do an MRI. I figured I would have a lot of opposition to proceeding without an MRI. I typically would not do this and I really didn't have a good reason not to get one - just that an MRI is uncomfortable for a gravid patient, it's expensive, would delay care, and it is unlikely to show any pathology that would change my treatment plan. Now I am afraid of abscesses, tumors, conversion disorder, criminal prosecution.... so, I will be getting an MRI.
I did not expect so much opposition to doing an ESI in a pregnant patient. I feel like I have a knowledge gap here, what is the risk? When we are discussing risk, is it risk of a lawsuit (I can accept this) or actual procedural risk? Is it riskier than some of the other procedures we do on a daily basis?

Not to stir the pot but, I'm just curious. I wonder what the split is among anesthesiologists vs. PM&R on this issue. Here's and informal, non-scientific poll:

I would consider an ESI in a 33 y/o pregnant patient with an MRI confirmed L4-5 HNP compressing Rt. L5. She has resultant Rt. L5 radicular pain . + SLR on the right. No weakness numbness, or reflex changes. No comorbitities. HR, RR, and BP slightly above normal. She has been referred to you by the OB after failing 4-6 weeks of conservative care (anything you can think of) and consulted with a neurosurgeon. She is miserable, not suicidal. The procedure has been blessed by her OB, neonatologist, neurosurgeon, The Pope, Oprah,.... I'm sure I have missed some qualifiers here, but you get the point.

A) Anesthesiologist - Yes
B) Anesthesiologist - No
C) PM&R - Yes
D) PM&R - No

You know my answer, and i can send her to you.
The risk is legal, not procedural. She has pain without neurologic deficit. Do you really need an MRI, would you get an EMG. If you feel the ESI is needed, why delay in getting diagnostic tests?

The premise for the poll is flawed. It is clear you feel anesthesia will be more aggressive in treating this patient.

The question on the stand would be: " Just how many epidurals on pregnant women have you done?" You say thousands. Next question, " And how many of these patients were 6+ weeks away from being in labor?"😎

 

[spondy14]

Are you saying that radiculopathy led to miscarriage?
Are you saying that her pain led to miscarriage?

Suppose you gave the injection and 2 weeks later she had a miscarriage.
Then what?

I said neither. The girl had a miscarriage (which a certain percentage will, for no apparent reason) and if she would of had the injection, then the injection certainly would have been discussed as a possible cause.

I have never heard of pain nor radiculopathy causing a miscarriage

 

[spondy14]

OK, same creative lawyer files a lawsuit 1.5 years after this incident because the patient is having difficulty conceiving again. The patient wonders if there was any malpractice committed in her previous pregnancy because that may have been her only chance to have a child. He notices that in your office her BP and HR were higher than normal as was the case a week later in her OBs office. Could it be argued that her excruciating pain and subsequent increased sympathetic tone for 2 weeks led to her spontaneous abortion? Could an ESI or more aggressive treatment of her pain (if conservative measures failed) have actually saved her pregnancy? Is that any less plausible than a spontaneous abortion caused by an ESI performed 2 weeks prior?
I'm not questioning your clinical judgement, just playing Devil's Advocate.
I still contend that once you consult with a pregnant patient and make ANY recs or no recs, you have accepted the risk. If there is any bad outcome and lawsuit, your care will be subject to scrutiny - whether it it ultraconservative or aggressive.

I agree completely

 

[nctxil]

You know my answer, and i can send her to you.

The question on the stand would be: " Just how many epidurals on pregnant women have you done?" You say thousands. Next question, " And how many of these patients were 6+ weeks away from being in labor?"😎

I don't mind seeing pregnant patients or other less than straightforward cases. Why would you refer a patient to me for a procedure that you have suggested is almost certainly malpractice and may be criminal? It's one thing if you agree that it is a legimate treatment option, but don't feel comfortable doing it. It's another if you think that because it is unproven, it is malpractice.

To answer your question, I would say I've probaly done less than 5 epidurals on patients greater than 6 weeks from being in labor. I have done plently of labor epidurals, but those patients are already in labor. An ESI is technically easier than a labor epidural. I'm not sure what point this line of questioning would prove.
I didn't bring up the question about anes. vs. PM&R on this issue because of labor epidurals or technical skills. I think there may be a difference in risk tolerence. As an anesthesiologist, I have dealt with far riskier situations than this, especially in pregnant patients. Risk is constantly present. I know it is there, but I have become somewhat numb to it. I just do what I have to do the best way I know how.
I don't think one approach is right and the other is wrong. I'm just trying to put the responses in context.

 

[Tenesma]

riskier situations - i think the key here is when anesthesiologists get involved with risky situations it is usually because the injury has already occured...

do i feel comfortable with a rapidly decompensating patient - sure - thanks to my anesthesia background... but that bravado doesn't apply to any situation where I could potentially INDUCE injury

here is a similar comparison that may make you think about it differently - would you do an ESI on a patient that is 1 week out of a drug-eluting stent on Plavix??? so if the answer is no, then how would you treat the radiculitis in that patient population? and why can't you apply some of those aspects to the pregnant patient...

remember always First Do No Harm - and by the way just because the neonatologist, the OB, the pediatrician, the spine surgeon say that you should/could do it doesn't mean SQUAT... because in court you are held to the standard of care of your profession... and you are not a technician, you are a clinician who has to make his own decision based on your expertise/training.

so my answer to you is B.

 

[nctxil]

riskier situations - i think the key here is when anesthesiologists get involved with risky situations it is usually because the injury has already occured...

do i feel comfortable with a rapidly decompensating patient - sure - thanks to my anesthesia background... but that bravado doesn't apply to any situation where I could potentially INDUCE injury

I think the potential to induce injury is greater when doing a rapid sequence induction on an obese patient for an elective gastric bypass.

here is a similar comparison that may make you think about it differently - would you do an ESI on a patient that is 1 week out of a drug-eluting stent on Plavix??? so if the answer is no, then how would you treat the radiculitis in that patient population? and why can't you apply some of those aspects to the pregnant patient...

I wouldn't do the procedure until the cardiologist cleared the patient to hold Plavix. You could apply some of the same principles to treating radiculitis in the pregnant patient, but they still come with risk.

remember always First Do No Harm - and by the way just because the neonatologist, the OB, the pediatrician, the spine surgeon say that you should/could do it doesn't mean SQUAT... because in court you are held to the standard of care of your profession... and you are not a technician, you are a clinician who has to make his own decision based on your expertise/training.

so my answer to you is B.

I think clearance by the OB and neonatologist are appropriate. In no way should you let another specialist dictate your practice, but consulting with your colleagues and weighing the risks would be looked upon favorably by a jury. It would not clear you of malpractice. The decision to proceed is your own.
I don't know the standard of care in my profession for this situation.

 

[Tenesma]

the standard of care is based on your community - so talk to 3-5 pain docs in your surrounding areas and poll them informally - if they all would do it and testify in court that it is reasonable then you have your standard of care

 

[Mister Mxyzptlk]

I think it's obvious from this discussion that there is no clear standard of care. Some would, some wouldn't. The objections are based on "what if something bad happened", not "it is well known that if you do this something bad could happen." Hard to argue for breaching a standard that doesn't exist.

Let's look at the 4 elements that a plaintiff must demonstrate:

# Duty of care

You must possess the medical knowledge and skills required of a reasonably competent medical practictioner engaged in the same specialty, and apply that knowledge and skill - and exercise judgment - in the same way as a reasonably competent practitioner in the same specialty.

# Breach of duty

Proving that a health care professional breached the duty of care involves showing what a reasonably competent professional would have done in a similar situation. This is where expert witnesses come into play and I think this would basically be a battle of the expert witnesses.

A physician must disclose risks and hazards of proposed medical procedure. This must be evaluated in terms of what the physician knew or should have known at the time he recommended the treatment to patient. IMHO this is a weakness for the plaintiff here because there is nothing to know since there is no information available at all about ESIs during pregnancy.

# Injury

There has to be one - economic, loss of consortium, pain and suffering, etc.

# Proximate cause

The plaintiff has to connect the dots. Usually you need an expert witness to do this. Once again, there are no data that say ESIs are dangerous during pregnancy. An expert has to testify based on the science, which is totally absent in this case.

Here's my reading:

Duty of care - I think if you discuss this with your specialists - OB, perinatologist, etc, and have done a literature search you have discharged this obligation.

Breach of duty - Obviously there will be a lot of discussion with the parents. The rest of the consideration of breach of duty will hinge on whether a "reasonably competent professional" would have done the same thing in a similar situation. This is where your expert witness comes in.

Injury - If there is a bad baby you can't help that. Nothing you can do here.

Proximate cause - your lawyer is going to have to drive home the point that one cannot blame the ESI because ESIs have never been shown to produce birth defects. An expert testifying otherwise has no scientific basis for the conclusion. There are also lots of other things that cause birth defects, many falling under "we have no idea".

 

[lobelsteve]

I think it's obvious from this discussion that there is no clear standard of care. Some would, some wouldn't. The objections are based on "what if something bad happened", not "it is well known that if you do this something bad could happen." Hard to argue for breaching a standard that doesn't exist.

Let's look at the 4 elements that a plaintiff must demonstrate:

# Duty of care

You must possess the medical knowledge and skills required of a reasonably competent medical practictioner engaged in the same specialty, and apply that knowledge and skill - and exercise judgment - in the same way as a reasonably competent practitioner in the same specialty.

# Breach of duty

Proving that a health care professional breached the duty of care involves showing what a reasonably competent professional would have done in a similar situation. This is where expert witnesses come into play and I think this would basically be a battle of the expert witnesses.

A physician must disclose risks and hazards of proposed medical procedure. This must be evaluated in terms of what the physician knew or should have known at the time he recommended the treatment to patient. IMHO this is a weakness for the plaintiff here because there is nothing to know since there is no information available at all about ESIs during pregnancy.

# Injury

There has to be one - economic, loss of consortium, pain and suffering, etc.

# Proximate cause

The plaintiff has to connect the dots. Usually you need an expert witness to do this. Once again, there are no data that say ESIs are dangerous during pregnancy. An expert has to testify based on the science, which is totally absent in this case.

Here's my reading:

Duty of care - I think if you discuss this with your specialists - OB, perinatologist, etc, and have done a literature search you have discharged this obligation.

Breach of duty - Obviously there will be a lot of discussion with the parents. The rest of the consideration of breach of duty will hinge on whether a "reasonably competent professional" would have done the same thing in a similar situation. This is where your expert witness comes in.

Injury - If there is a bad baby you can't help that. Nothing you can do here.

Proximate cause - your lawyer is going to have to drive home the point that one cannot blame the ESI because ESIs have never been shown to produce birth defects. An expert testifying otherwise has no scientific basis for the conclusion. There are also lots of other things that cause birth defects, many falling under "we have no idea".

For the 1 in a million chance that something bad happens to the child in the next 21 years, the discussion will not be whether you lose the case (another 1 in a bunch), but that yes, you will get sued.

Shouldn't her radic have resolved by now anyways....

 

[Mister Mxyzptlk]

For the 1 in a million chance that something bad happens to the child in the next 21 years, the discussion will not be whether you lose the case (another 1 in a bunch), but that yes, you will get sued.

The procedures we do on a daily basis are fraught with potential complications and those complications can produce devastating results. I think a certain amount of prudence is reasonable when it comes to protecting against malpractice but if you paralyze yourself with worry you won't get anything done. If you don't want complications that could lead to lawsuits, don't treat patients. That's the only 100% protection.

 

[Tenesma]

ncxtil - if the cardiologist says the patient needs to stay on plavix for 6 months for his drug-eluting stent and the patient has a clear radiculitis - and you can't do an ESI - how would you manage the pain? and why can't you apply a similar philosophy to the pregnant woman? curious...

 

[nctxil]

ncxtil - if the cardiologist says the patient needs to stay on plavix for 6 months for his drug-eluting stent and the patient has a clear radiculitis - and you can't do an ESI - how would you manage the pain? and why can't you apply a similar philosophy to the pregnant woman? curious...

You can apply the same philosophy. You just have to weigh the risks vs. benefits of any treatment offered. You have to move on once conservative care has failed.
The difference with the Plavix pt. is that there are clear guidelines addressing that situation.

 

[lobelsteve]

So did you do the ESI yet?

Post VAS pre and post.
Post APGARs at 1 and 5
Post SAT's in 16 years.

😀

 

[Tenesma]

please let us know the outcome - and it may be worth publishing because it appears our literature is lacking when it comes to this.

this is pretty all that we really have and it is french (so it must be good)
Timsit MA. [Pregnancy, low-back pain and pelvic girdle pain]
Gynecol Obstet Fertil. 2004 May;32(5):420-6.