Abortion vs Other Procedures

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Abortion vs Other Outpatient Procedures

This is going to be controversial, I know. I am careful to label personal opinion where it is expressed. Feel free to call me out on it if you have data to support your position. I don’t claim to be the ultimate authority on this subject, only an educated commentator. I expect a lot of reaction and don’t plan to respond to it much, so please don’t expect a flame war. If you have strong views, express them, but I’d ask that you respect opposing views and don’t engage other commenters directly here. Take it private or go elsewhere.

There has been a series of laws passed in several states setting requirements for facilities that perform outpatient abortions. The provisions that create the most controversy are those requiring providers who do procedures in these settings to have admitting privileges at a nearby hospital so that they can treat complications arising from the procedure.

Pro-abortion voices say that this constitutes an undue burden on the facility and will force many of them to close, thus limiting access to abortion services for large numbers of mostly poor women. It is further alleged that these laws are nothing more than an end run around constitutionally guaranteed rights and are motivated by a desire to outlaw all abortion.

I am purposely leaving aside the above arguments for now. They are both valid and firmly held convictions on the part of those who wish to maximize the availability of abortion services. I do not necessarily agree with the motivations of the lawmakers who have passed these laws, nor do I personally believe that there should be no regulation of abortion under any circumstances.

What I have attempted to do is to assess the risk of first and second trimester abortion in the outpatient setting, compare that risk to other commonly done outpatient procedures and then compare the state and local regulations that are available for review covering various types of outpatient facilities.

Unfortunately, there is surprisingly little hard data on the risks associated with outpatient abortion. Organizations such as Planned Parenthood and the American College of Obstetrics and Gynecology have issued position papers estimating the risk of ‘significant complications’ at around 0.7/1000 abortions. A review of their citations for deriving that number done through Google Scholar and Medline searches turns up only a handful of studies, most over twenty years old, to support that number. The best and most highly powered (meaning a large number of patients studied over a sufficient period of time) is from 1998 and was done through a retrospective review of 97,000 first trimester abortions over a fifteen year period. Their findings are clearly the numbers that are commonly cited: a 0.71/1000 incidence of complications requiring hospital admission. But there was also an 8.46/1000 incidence of complications requiring some sort of emergency room or urgent clinic visit. Several much smaller studies have shown similar risks, although one from Scotland cited numbers as high as 2.8/1000 hospitalizations.

Bottom line: depending on whether you are an optimist or a pessimist, outpatient first trimester abortion is a reasonably safe procedure with a low risk of major complications, but that risk is not zero. Pessimistically, a prudent provider should have contingency plans for dealing with the small number of patients who have a problem requiring hospitalization. Fair statements?

How does this compare with other outpatient procedures? For comparison, I chose outpatient colonoscopy because it is a common procedure often done in freestanding dedicated endoscopy centers, requires at least some moderate sedation to accomplish, and has potential complications that may require admission to a hospital. I also tried to look at the increasingly common office GYN practice of doing hysteroscopy and ablation as an office procedure with local or sedation anesthesia.

Colonoscopy has been much better studied. The most recent large-scale study was from New Zealand and looked at 15,000 outpatient colonoscopies over a five-year period. The urgent hospital admission rate for colonoscopy related problems (excluding cardiac or respiratory issues) was 0.85/1000 procedures. This incidence compares well with the risks cited for abortion.

Office GYN data was harder to obtain, involves smaller numbers, and was not randomized. Overall, there appears to be a 36.4/1000 incidence of ‘reported complications’. But that number includes everything from low-grade fevers to phlebitis to uterine perforation, so it is difficult to compare it to the data for abortion. Nevertheless, state and local health regulations and professional society recommendations are available for this situation.

Most professional societies recommend that the provider doing these procedures either have admitting privileges at a hospital in the area, or have a standing admission arrangement to care for patients who have complications.

State regulations covering outpatient surgical and endoscopy facilities require a written plan to deal with emergency complications that occur on site. These vary but almost always include a designated hospital to which patients will be transferred and many require written agreements for admission should that become necessary. Note, though, these are regulations or recommendations, not statutes, so they are subject to reinterpretation and revision by the regulating agency without involvement of the legislature.

The statutes, which have been proposed or passed regarding abortion clinics, reflect many of these recommendations but escalate those recommendations to the level of statutory law. This singles out these clinics for special consideration and to that extent, the critics of these laws are correct. On the other hand, in many states, these clinics are exempt from the regulations governing outpatient surgery or endoscopy facilities. That is a different kind of special treatment that may be just as invalid. These clinics generally do only one or two types of procedures, often under local anesthetic only. But the incidence of complications with this technique is not zero and is comparable to endoscopy. Endoscopic facilities, at least in AZ and surrounding states, must meet more stringent regulations than facilities that provide abortion services.

In summary, the laws requiring admission privileges are not overly outrageous in concept, but do constitute a special escalation of statutory requirement aimed at abortion centers alone. For this reason they are not valid unless they include ALL centers that perform any type of invasive procedure.

Personal position: ALL facilities that do invasive outpatient procedures should be governed by the same set of regulations and requirements. No increased requirements unless there is documented increased risk that needs to be addressed. No laxity of requirements for procedures that are covered under the umbrella of ‘reproductive rights’. At a minimum, abortions clinics should have written policies and procedure for dealing with complications at the facility and should have transfer arrangements made in advance for patients who require hospitalization. Outpatient surgery and endoscopy centers have these provisions. Abortion clinics should too.

Philosophical statement: As a surgeon, I find it irresponsible at best for a provider to do a procedure with a low but inherent risk of a major complication and not have the ability to take care of that patient in the event that the complication occurs. I am not proposing that this position be made law, but I am tired of cleaning up other people’s messes. Here I am not referring to abortion, but to the plastic and cosmetic surgeons who do outpatient operations and have no admitting privileges to take care of their breast augmentation or tummy tuck patients who bleed or get infected after release form their private surgicenters. I extrapolate this to providers who do D&C, vacuum curettage, or other invasive abortions and who cannot admit the very few patients who have a problem. The fact that something is rare is not an excuse.

Crying Wolf

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Crying Wolf

Anyone who has spent time on the Internet has seen those annoying pop-up ads that contaminate commercial websites. Now, thanks to the Electronic Medical Record, physicians can enjoy the same type of interference as they are trying to negotiate patient charts.

One of the features of most EMR systems are pop-up alerts that trigger for any number of reasons and interrupt the flow of charting to inform you of some problem or demand some action. Some of these are useful, such as a pop-up warning that the patient is allergic to the antibiotic that you just tried to order. Others are merely annoying, such as the Medicare two midnight certification you have to attest to before you can make your over-65 patient an inpatient admission. But the net effect of all of these pop-ups is alert fatigue. They happen so often, and are so often for trivial reasons, that you tend to ignore them and click the boxes until the alert goes away and you can get on with your work.

I recently had six Priority Alerts (oh my!) trigger on one patient in the course of a routine 23hr postoperative observation period following an uncomplicated hernia repair. The patient was doing fine and none of the ‘Priority Alerts’ was valid, or in my opinion a priority. Two were completely off base and had I just ‘clicked boxes’ would have resulted in unnecessary imaging and testing with some potential morbidity.

How did we get here? I wish I knew. I tried to research some of the alerts through my department committee and went down a rabbit hole of diffused responsibility, well-intentioned effort and contradictory responsibility. These alerts can be placed in the system by just about anyone. The hospital administration places them to try to comply with CMS admission guidelines. Various departmental committees place them to improve compliance with best practice guidelines. The pharmacy is sometimes the worst offender, placing not only allergy alerts but drug interaction alerts that range from important, such as warning that two drugs have potentially fatal interactions, to the stupid, such as warning me that hypertonic solutions may cause phlebitis. Each of these may seem like a good idea, but they are given equal weight in the EMR (IT people and the computer can’t tell if something is important or trivial) so that the fatal interaction alert looks the same as the warning that ibuprofen should be given with food.

I asked some of my hospitalist friends what they do to handle these alerts and most of them have gotten to the point where they ignore them. So if most doctors are ignoring the alerts, what good are they?

There are a few good studies of specific types of alerts such as severe drug interaction warnings or allergy warnings that seem like a good idea but failed to show significant improvement in the incidence of these types of errors. Why? I suspect because we were already pretty good at looking for this type of stuff with multiple layers of check by the physician, the pharmacy and the nursing staff.

Other alerts, such as the sepsis alert that triggers for certain combinations of abnormal vital signs, seem to show better results at the institutions where they were tested, but no one has looked at the numbers of patients for whom the interventions triggered were not necessary. And a careful look at the data shows that many of these institutions had poorer than average results BEFORE the alert was instituted. It isn’t as hard to make a poor outcome look better as it is to make a good outcome look stellar.

The only solution I can see is to create yet another layer of bureaucracy to oversee the inclusion of automatic alerts into the record. That sort of solution grates on me, though. We have too many committees and advisory groups telling us how to practice medicine as it is. Creating some physician oversight of these alerts would return some measure of control to the practicing doctor, but only at the cost of more time spent in a meeting room and less time at the bedside.

It ain’t the model year . . .

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It ain’t the model year . . .

He was 94 years old and was in my office because his gallstones were becoming a problem. They had been diagnosed two years earlier when he had an ultrasound for an unrelated problem. At that time they were asymptomatic and he was correctly advised to do nothing unless they started to cause problems.

Three months before he came to see me, he started having intermittent pain in his right upper abdomen and some occasional nausea after eating ice cream. Two months later the episodes of pain had become worse and more frequent, almost daily. He went to the Emergency Room with one particularly bad episode. At that visit his labs (blood counts and chemistries) were normal and his pain subsided after some medication. He was given the name of a different surgeon and was discharged.

The surgeon he originally saw told him he was ‘too old’ for an operation and started him on a drug called Actigall to try to dissolve the stones.

Drug therapy for gallstones is a hit or miss proposition. Under the best of circumstances, the drug is 60% effective, takes six to eighteen months to work, does nothing to prevent or relieve the attacks of pain, and over 75% of those patients who successfully dissolve their stones will develop gallstones again within five years of stopping the drug. It may make sense in asymptomatic stones, but isn’t good therapy if the stones are causing trouble.

The man dutifully took the medication until it caused such severe diarrhea (a known side effect) that he became dehydrated and required admission to the hospital for IV fluids.

His family brought him to me because one of them sees the PA in the Primary Care practice where my wife works. The PA asked her advice and Michele gave them my name.

For 94, the man was in great shape. He took some low level antihypertensive medication and a baby aspirin daily, had no history of heart or lung disease, was thin and active, walking for exercise every day and managing his own affairs. He had family close by that could help him during his recovery. After meeting him, examining him and going over his medical records, I told him he needed an operation to remove his gallbladder. His response was “That’s why I’m here, Doc. When can we do it?”

There’s no absolute age limit for surgery. My oldest elective gallbladder surgery patient was 103 years old. Age contributes to surgical risk in a very real way. Physiologic reserves diminish with age and even minor insults may tip a patient over what my wife calls ‘The Ledge”.

Some people live on the edge of a steep physiologic ledge. They’re fine day to day, but fall hard when something challenges their reserves. There are usually some clues to this, though. Body habitus (too fat or too thin), the ability to climb a flight of stairs or walk over 100ft on level ground, engagement with current events or family activities, etc, all give you some clues as to how well a patient will tolerate surgery.

This gentleman had all good indicators. He had few medical problems, was engaged in the community and with his family, had great exercise tolerance and most important, had symptoms that significantly interfered with the activity he liked to pursue. We scheduled his surgery for the following week.

Was the other surgeon wrong to refuse to operate on this man? I can’t say. I don’t know his skill level or, more important, his experience with older patients. All surgeons have different tolerances for risk. Some of us are very safe surgeons because our risk tolerance is very low. These surgeons won’t take on difficult or higher risk patients. Perhaps they fear complications, or perhaps they just recognize their own limitations. I never criticize someone for declining a non-emergent operation on the grounds of unacceptable risk.

My own risk tolerance has its limits. I have refused to operate on people whose risk profile exceeded what I consider a reasonable level. But usually that is based on physiology rather than age alone. In most cases, age is not the sole limiting factor. One must take into account the disease process, the prognosis with and without surgery, and the patient’s own understanding of risks and benefits.

Many of my patients are over 90 years old. Our trauma unit regularly treats older patients. There is a 60+ initiative in the hospital system that tries to devise protocols for patients in the Medicare age range. We have recently begun to look at an 80+ initiative to recognize the different needs and risks of that increasingly common demographic.

My patient’s surgery went well. I kept him overnight in the hospital for safety sake, but found him walking on the ward the next morning when I made rounds. He went home that day and has done well since.

As my mentor and Chief, Dr. Ray Fletcher once told me, “It ain’t the model year, but the mileage that counts.”

A Suicide in the Heartland

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Suicide
A friend on Facebook recently forwarded a news article and a link to a physician blog about the media response to a physician’s suicide. (http://www.idealmedicalcare.org/blog/doctors-death-an-inconvenience-for-patients/) A lot of the concern centered on the lack of compassion for the physician who took his own life and the seemingly self-centered comments of several ‘patients’ at the hospital. Lost in the coverage was any exploration of the problem of physician suicide or suicide in general.
Any one who works in trauma or emergency medicine is acutely aware of both sides of this issue. We are the first line of treatment for these patients and must deal with the immediate repercussions on the families and loved ones left behind. Our profession also has a higher than average rate of suicide among the doctors, nurses, and other providers who work in this environment.
Many of the comments regarding this particular incident focused on the lack of help for residents who are struggling with the demands of training. It doesn’t get much better after one leaves the nest of the residency and goes into practice. Doctors are expected to remain cool and objective, to be able to deal with adversity and come through unscathed and secure in their daily lives. We all know it’s BS, but we all tacitly buy into the myth because it preserves our standing as ‘professionals’. Displays of emotion, except under tightly circumscribed control, are seen as weakness and as ‘unprofessional’. So we cover up pain and uncertainty, limit our responses to well rehearsed bromides, and box up our regrets like toxic waste to be buried or locked away never to be seen again.
This is not limited to medical workers. Police, firefighters, soldiers; anyone who must deal with stress or chaos and continue to do a job knows what I am talking about. Expectations for physicians in this regard are high, but I would argue that they are even higher for first responders such as police officers or firefighters. And guess what? All of those jobs carry a higher risk of suicide.
I must admit to some ambivalence about suicide and patients who attempt it. I have myself circled that pit of despair but was able to pull back. As the child of a suicide, I have seen the devastation that the act brings to a family left behind. Part of me wants to blame suicidal patients for their own self-centered actions. But I know, both emotionally and intellectually, that it is unfair to do so. Another part of me coldly acknowledges that the ultimate freedom we possess in having free will is the freedom to decide to die. There are times when it makes sense to end ones life. It can even be a noble act. Most often, though, it is an act of despair, done impulsively. The individual just wants to end their pain, right now, and has no other thought.
Solutions? I have none. This is not a plea for understanding or a call for action. The problem is too complex for such simplistic responses and the needs of each suicide are so individual that all-encompassing solutions are unrealistic. Calls for better ‘balance’ between work and life are sensible, but for many of us the line between work and what is really a WAY of life is indistinct and variable. We need the sense of purpose and commitment that comes from a life in service in order to find meaning and fulfillment. I am often unhappy with my profession, but I would be even unhappier working in a job that was simply a means of paying for the things I really enjoyed doing rather than getting paid to do something that I love. The price for that is high, but to me is still worth it.

One of Our Own

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One of Our Own

Even though Phoenix is a big city (sixth largest in the U.S.) the surgical community is a relatively small. We all know most of the other general surgeons in the Valley, if not personally, then by reputation or at one degree of separation. We know who is the best at a particular procedure, who responds quickly to calls, who you can trust in a pinch and who you can’t.
One gets closer to surgeons who are in the same immediate circle as you; the ones you see week in and week out in the locker room or the doctors lounge or waiting in the OR to start their own cases. Many of them you may have worked with directly on the same team, especially in trauma. Others you know only by sight and name, but they are still definitely part of the surgical ‘family’.
Wider associations are formed with the nurses who work in your operating room or in the trauma rooms; with the technicians who draw the labs and manage the ventilators, and scrub your cases; with the representatives from the equipment companies and the surgical device manufacturers who seem to be a ubiquitous as scrub techs. They all are included in the wide circle of those whom you know and regard as part of your world.
When you work trauma long enough, it’s inevitable that someone you know will appear in your trauma unit. The rules for family members are clear: hands off and call your back-up. But friends and acquaintances are not covered by any rules. You do what you have to and try to maintain some objectivity.
It has happened to me a few times. Some were fortunately minor traumas. Recently, though, an acquaintance showed up with a devastating injury after being hit by a car. His head and face were so traumatized that I didn’t recognize him at first. Even when the paramedics gave us his name, I did a double take. Couldn’t be, I thought. That location is nowhere near his home. He wasn’t exactly a friend, but I knew his name and where he lived. I had seen him and his wife at various social functions and knew he had teenage children.
He’d been riding his bicycle when the car hit him. He was an avid cyclist and often had his bike in the back of his truck and would ride after work wherever he happened to be.
He was in bad shape. His brain was severely injured and his facial bones were so broken that we had to do an emergency tracheostomy to help him breath. He wasn’t responsive to any stimulation and the CT showed diffuse brain injury that wasn’t fixable with surgery.
I called the neurosurgeon personally and insisted he come in, explaining that this was one of our own. He came and was as thorough and careful as always. It really didn’t matter that this was a member of our wider community. The neurosurgeon I called is always careful and thorough. That’s why I use him. But in this case, it was important to me to be able to say I’d gotten the best people I knew.
We went over his scans and his exam together. I asked the necessary questions and my neurosurgical colleague confirmed my impression that there was nothing we could do to help, nothing to change the inevitable end.
It didn’t help all that much when I talked to his wife and children and outlined as gently as I could the extent of the injury and the grim prognosis. In the end I was left with the same platitudes we use for all these situations. He’s not in pain. He may be able to hear you, so go ahead and talk to him. Everything possible is being done for him. All true, but not very helpful, and even less satisfying somehow when the patient is also someone you know. His wife thanked me and told me she was glad that it was me who was taking care of him; someone who cared about him.
Sometimes this job really sucks.

Honesty

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How Honest Should We Be?
A reader of my blog post in Physician’s Weekly recently took me to task for being ‘judgmental’ with respect to my trauma patients. He used the word pejoratively after saying “what a terrible, disrespectful thing to say about your patients”.
The comment that had earned his condemnation of me was a statement of fact – somewhere between seven and nine out of ten trauma patients are in the trauma bay as a result of their own stupid decision. It may have been driving while intoxicated or failing to take into account the effect of pavement on an unprotected head when riding a motorcycle or picking a fight with a stranger over a minor insult, especially while intoxicated, or some variation on similar themes. Only ten to twenty percent of patients on the trauma service on any given day are regular working folk who were blindsided by circumstances or bad luck. Perhaps my comment that trauma surgeons had become the “lifeguards at the shallow end of the gene pool” was a bit over the top, but I stand by the statistics.
So am I heartless and rude when I tell you that your skull fracture could have been a voided if you’d been wearing a helmet while riding your new Harley? Am I ‘blaming the victim’ if I take you to task for trying to drive with a blood alcohol level of 0.350 when legally intoxicated is 0.08? Or inform you forcefully that your chronic narcotic habit does not mix well with half a bottle of Jim Beam?
I don’t say these things because I think the patients are bad people. Hanlon’s razor says, “Never attribute to malice that which can be adequately explained by stupidity.” They are not evil people, only people who made stupid choices.. (I also see how the same statement could be used to refer to myself. Interesting observation, that.)
The care I try to deliver in the trauma bay is not dependent on my assessment of the patient’s choices. It’s all about the integrity of the work. That demands that I bring the same focus, the same attention, and the same respect to everyone. I may judge your action, but that isn’t to be confused with a bias against doing my best for you. I don’t care about your race, religion, sexual orientation, employment, job or any of the other criteria on which we divide ourselves.
I guess my tolerance for stupidity is waning, as I get older. Calling your decision stupid is different than calling you stupid. One is an action; the other is a character trait.
We are so afraid of being thought insensitive or uncaring or worst of all, prejudiced, that we can’t even be honest in our assessment of our patients. Honesty may offend someone. They might complain to the hospital administration. Our patient satisfaction scores will suffer.
Are we perhaps doing patients a greater disservice by scrupulously avoiding any criticism of their actions and thereby giving them our tacit approval?

Hello Darkness My Old Friend

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Hello Darkness My Old Friend

My friend Nick, the ER doctor, called me the other day to tell me that one of my patients had died under his care. He didn’t have to do that, but he knew I had followed this woman for several years and knew her family well. She had nearly died under my own care a few years ago, but through outstanding work by the ICU and other nurses, had survived and gone home to her grandchildren and had seen the birth of her first great-grandchild. She had thanked me for saving her life, when in truth, I had been largely responsible for her getting in trouble in the first place.
I hung up after the call and was suddenly overwhelmed by a rush of shame, despair and a feeling of loss so powerful that I had to stop the car and cry. Images of dead and dying patients flooded my head for reasons that I still don’t understand. I felt as if I had wasted most of my life pursuing an illusion and that the cost to my family and myself had been too high for too small a gain.
I have been shedding a lot of tears lately. Those who have read these posts or who have read my novels know that I am at heart a hopeless romantic. Even my cynical, curmudgeonly rants are based in a vision of how things should be rather than the pragmatist’s view of how things actually are. I have always been sentimental, but as I have aged, I have found my control slipping. I tear up at trivial things. I’m liable to cry at the movies or over a piece of music. I’ve been known to get choked up over Hallmark commercials.
My chosen profession makes a science of the study of mayhem. We see awful things every day; unexpected death and destruction salted with heavy doses of sadness and futility. Yet our training and our ideal of professionalism forces those of us who chose this life to view those events through the artificial lens of detached objectivity. How can we analyze this patient’s course in order to learn from it? What could we do differently? We remain in control and dispassionate to the end. But that is a lie. Those events affect us no matter what sort of outward calm we display.
We all have regrets about our life choices, even the good ones. I know that. But my reaction to the regret I felt and the flood of memories of all the times I failed to save a patient was completely over the top and frightening. Somehow my worth as a person has gotten all mixed up with my worth as a surgeon. There seems no separation or balance anymore. I still haven’t recovered my equilibrium.
I have never placed much credence in PTSD as a disabling condition. I know it is a real response to traumatic events and that people may be profoundly affected by those experiences, but I always felt that one recovered by soldiering on and drawing on ones strength to learn from the traumatic event. I have often felt helpless and inadequate when faced with a patient who was so ill or injured that I could do nothing to help. You learn to deal with it, to put it in a box and do what you can and move on. Sometimes, though, the box is too full, or the walls are thinned by fatigue or age or by assaults from several sides at once and the whole thing opens up and dumps a load of pain on you. In those times, you need a safe place to cry, or to scream at the sky, until you can recover your self-control and resume the work. But the darkness never really goes away.