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- Thank you so much for doing this.
- Yeah. Thank you.
Thanks for having me today.
- How has the decision to limit access
to legal abortion impacted emergency physicians?
- So not only emergency physicians
but I feel like healthcare in general,
this will be a decision that will have repercussions
for primary care doctors, as well as emergency medicine
physicians and obstetrics and gynecologists as well
but specifically to our specialty emergency medicine
what we are bracing for more so is an influx
of patients who will unfortunately have
adverse repercussions based on the limitation
and access to medically safe abortions.
- And when someone first comes to the ER
and whether they know it or not, they're pregnant
what are some of the serious conditions that you encounter?
- So what we typically will see regularly
are complications related to bleeding, infection,
number of different conditions that can affect women
and pregnant patients in a host of ways.
We essentially are trained as emergency medicine providers
to plan for the worst possible outcome in patients
that we see.
And in that respect for women who are pregnant
who are having complications as such, it can be devastating
and even can be deadly to patients as well.
And so these are things that we consider whenever
we see someone who is pregnant, who is coming in
with belly pain or coming in with a fever and pregnant
and things that we'll need to continue to consider
and also to have additional considerations
in the setting of the new law change.
- Can you give some examples?
- So one of the conditions that we see, not commonly
but we will see in the emergency department every now
and then as a condition called a ruptured atopic pregnancy.
Now this is a condition in which the pregnancy will
not be in the uterus where we would normally see
a viable pregnancy, but rather in the outside area
of the uterus where they at Nexa.
So what we will typically do in those cases is
we'll do an ultrasound to confirm the location
of the pregnancy.
We'll do a whole battery of test just to make sure
that the blood count looks okay and make sure
that the pregnancy markers are exactly where
we expect them to be.
However, one of the complications of an ectopic pregnancy
as we see commonly is bleeding.
Now, one of the considerations for atopic pregnancy are one
of the things that you must understand is
that these pregnancies are not viable.
Right now in medicine we do not have the technology
or the capabilities of receding that pregnancy
in the uterus.
And so regularly during our typical standard of care
these are patients that would go to the operating room
with our partners from the gynecology divisions
to have essentially an abortion of that pregnancy
in order to save the life of the mother.
And so that's something that we want to continue to happen
because again, these are life saving therapies
but also for people to be aware who are providers
that this is still something that we are obligated
to perform.
- And is that something that is standard,
do you think for emergency room physicians across the state?
- Absolutely, so I have been very fortunate to practice
at different settings throughout the state of Wisconsin.
I currently practice in a setting in which I am
in the metropolitan areas mostly.
However, I've been in rural locations where
I've been the only doc on call in the middle of the night
for the next 20 miles or so.
And so my patient demographic is going to be similar
to patient demographics,
if I'm in one of the city facilities
that I have ample resources available to me
at all hours of the night.
And so what my concern is at this point in time is
what is going to happen to the rural doc
when she is working at two o'clock in the morning
and you have this ruptured ectopic pregnancy that comes in.
What we don't want to happen is we don't want that physician
to be on the phone with a lawyer to try to determine
what is right and what is wrong,
what could the potential repercussions be both legally
and professionally, if she does what she knows is right
for the patient and what can be life saving for the patient
- Has that happened?
- So I have read multiple reports at this point
in time by both ED docs, as well as gynecologists
already in the state and some outside the state as well
who have been on the phone with lawyers
for a number of hours in order to, again,
try to negotiate what is going to be the best way
to care for these patients.
And again, what ramifications could be felt
by that provider should they go ahead with a therapy
that they did just months ago
and what is the typical standard of care for these patients?
So it's definitely a situation now that has become
very scary to be a provider and is also a detriment
to the patients that we're treating.
- And that's for an ectopic pregnancy
which is considered to be more obvious, I guess,
but there are a number of other conditions
that are much less clear for physicians.
Is there any sort of guidance that people can go
to that they can make a quick decision?
- So as of right now, there have been a couple of
governing bodies both in obstetrics,
as well as in emergency medicine
and even at the state level, in which we have guidelines
to help support our clinical decision making.
One of the policy statements was performed
by the Centers of Medicare and Medicaid
that was most recently updated in late 2021
in which they leaned on the fact that we are covered
as providers, both in the emergency setting, as well as
in the obstetrical setting to do the best thing
for our patients in the moment in order to prevent any
morbidity or mortality as we call it
or any risk for death or bad outcomes.
At this point in time, the most recent policy statement
by our governing body and emergency medicine is
to reflect on that recommendation
and to know that as a provider, you're covered both on a
on a federal level, as well as a professional level
in order to protect the life of your patient at the time.
- And yet we're still hearing stories
of mothers that are infected or bleeding for many days.
Are you concerned as an ER physician that
will keep hearing a lot of these stories?
- Absolutely, so at this point in time
there was a recent podcast that came out.
We have a continuing medical education podcast
that's called emergency medicine reviews and perspectives.
And they did a piece right around the time
that this decision came out.
And what they reflected on was the two different categories
of abortions that we see on a global standpoint.
And it was based on the World Health Organization's
definitions of such.
One is considered a safe abortion.
So of course if you think about it,
it's an abortion that's performed in a medical setting,
hopefully, by practitioners that are well educated
on the complications and have done the research on
different methods to perform the procedure.
Now, unsafe abortions are kinda the opposite of that, right?
And so these are procedures that are performed
by people who aren't traditionally trained
by methods that aren't up to the standard of care
that we're normally seen in a developed nation
in which this is legal.
Now, what we have seen on a global perspective is
when there are strict restrictions against abortions
in a safe manner, it doesn't stop the practice.
And so what we worry about in emergency medicine,
and of course, we're about a month out from the decision,
but what we worry about at this point in time
is are we going to start to see that number creep up
for women that are seeking care from people who
aren't licensed professionals and may have bad outcomes
related to an unsafe abortion.
Now, with that being said, we see a stark difference
in the complications from safe abortions versus unsafe.
So if you think about complications in the form
of bleeding, infections, these are less than 1%
morbidity mortality.
Death is less than 1% in safe abortions.
However, if you look at the unsafe abortions
we're seeing numbers up to 4.5 to 13%
for mortality alone.
About a third of those patients will have
adverse outcomes or have some complication.
And so this is something that not only are we planning for
and kind of keeps us awake at night
but it's something that we have to continue
to expect in our emergency departments coming soon.
- Along those lines, are you at all concerned
that the medications used to induce abortions
will become more limited or or even banned out of
more policies put in place?
- And so it's tough to determine
what will come down the pike for our patients
who are seeking treatments in this fashion.
One of the things that the Centers of Medicare,
and Medicaid really touch on,
as well as in that EMTALA article of reference,
it's more so the different techniques
and the different modalities of abortion.
And so definitely included in that are medications
like misoprostol that are used typically
to induce medicinal abortions.
And so with the way the abolition of the law is structured
now that technically is covered under
what has been removed from the treatment modalities.
- And those are frequently used for miscarriages
- Exactly, for miscarriages
as well as for intended abortions as well.
- And have you seen or heard of any complications
with miscarriages since the decision came down?
- So that is essentially the situation in where
we have people who have been on the phones
for a number of hours now, in order to try to determine
if they can give that medication.
What would be the liability based on that?
We've had a couple of articles that have been
written recently about people who have been seeking
unsafe abortions as well.
And what are the ramifications of transferring
that patient to a facility in which they can safely
perform a lifesaving procedure and in a state
much like our own, where that may not be legal.
And so fortunately we have clear guidelines
from a federal standpoint.
However, the statewide standpoint is a little bit more
of a gray area.
- How does that make you feel as a physician
because your job is to do everything you can
for your patient?
- Anyone in medicine, the primary purpose of medicine
is to do no harm.
We've all trained very long time and have put forth
a lot of effort to do what's best for our patients.
And it gets frustrating at times when you attempt to do that
and what the next step is
and you can't do it because of certain parameters in place.
However, that won't stop us from doing what we need to do
in the moment.
And I hope that a lot of other physicians
in the state share that same model, essentially.
We need to continue to protect our patients
and continue to do what's safe for them.
- Are patients of childbearing years expressing fears
and concerns.
- Absolutely, I've had a number of patients
who have come in who either got the pregnancy diagnosis here
in the emergency department when I saw them
versus if they got a home test and had a positive test
and in sort of counseling them for next steps
if they wish to seek an abortion
they're devastated because they know
the recent changes in laws.
And so for those patients, it's a very scary moment.
For us it's a scary moment because we as providers
don't know what the next steps are for that patient,
at least if they remain in the state.
- And there are patients who do want children
and the fear is still if complications happen.
- Yeah, absolutely.
And so that the other side of the coin.
And so if there are complications associated with it,
if let's say this is an unviable pregnancy
for whatever reason,
will there be potential damage or even death
associated with adverse outcomes,
if we aren't able to perform
a medically indicated procedure.
And so for that demographic as well on a whole,
for our patients, it can be something that is
very very unsettling.
- If you had a crystal ball and and kind of thought about
what was gonna happen next,
what do you think would be kind of the best outcome?
- So fortunately I am on the medical aspect of things
and I never want to perceive the future or think about
what politicians are gonna do next this summer part.
But what I will say is what I would want for
our medical institution in general to do
is to continue to plan and ahead
for potential adverse events to continue to do
what's right for our patients, as well as to continue
to fight for our patients, because this as well as other
indications that we've been doing since
the advent of medicine we're gonna continue to do
what's right and we're gonna continue to fight
for those who can't fight for themselves.
- All right, Dr. Chris Ford, thanks very much.
- Thank you so much.