Today we'll be looking at a case from episode 5 from "The Pitt", which was actually briefly mentioned in the signout from Dr. Abbott during episode 1.
Spoilers!
Ms. Wheeler is 17 years old and pregnant and returns for elective pharmacological termination of pregnancy. She was evaluated by Dr. Abbott yesterday, with pelvic ultrasound showing a fetus with EGA 10 weeks and 5 days. EGA measurements in early pregnancy can be based on gestational sac size, crown-rump length, or biparietal diameter, with can be plugged into an exponential formula (use a calculator or a table for this). As per Dr. Abbott, she was supposed to come back in the morning for mifepristone — I'll discuss the reason for this delay later. Dr. Collins repeats the ultrasound and finds an EGA of 11 weeks and 2 days, which is problematic. Mifepristone (in combination with misoprostol chaser) is approved by the FDA for medical termination of pregnancy up to 10 weeks, with off-label use (and decreasing efficacy) through up to 12 weeks. Guidelines from both the Pennsylvania and NY Departments of Health allow the use of mifepristone + misoprostol at up to 11 weeks. Beyond that timeframe, the next step is a procedural/surgical abortion (subject to their own guidelines, which we won't cover today).
Dr. Robby mentions that a +/- 5 day differential on EGA can be seen due to inter-operator variability (and other patient factors), but heavily implies that Dr. Abbott lowballed the measurement so that Ms. Wheeler could qualify for mifepristone — following that up by suggesting that Dr. Collins should either use Dr. Abbott's or obtain new measurements that show EGA < 11 weeks. As Dr. Collins points out, this is medical record fraud, and so Dr. Robby takes over the case and tells his resident to delete her documentation and images. I cannot emphasize enough that once something is saved to the electronic medical record, it can never be fully erased — we're past the days when you could theoretically shred/burn/"lose" a page on a chart and print a new one.
After meeting Ms. Wheeler, Dr. Robby's "measurements" result in an EGA of 10 weeks and 6 days. Near the end of the episode, Dr. Collins returns to the room to give Ms. Wheeler and accompanying family member the medication and follow-up instructions. In the FDA-approved regimen, a single oral dose of 200mg mifepristone is given in the clinic, followed at 24-48 hours by 4x200μg misoprostol pouched within the cheeks for 30 minutes. In the off-label extended-EGA regimen that Dr. Collins explains, two doses of mifepristone are given — once in the clinic, then the 2nd dose at the 24-hour mark; followed another 24 hours later by two doses of misoprostol spaced 6 hours apart. Cramping and bleeding are expected, but patients should return for severe pain or heavy bleeding (as well as for symptoms of hypovolemia, infection, etc.).
But before Ms. Wheeler can take the first dose of mifepristone, someone runs into the room screaming her name and beginning perhaps the second-most-dramatic conflict of the season thus far. Turns out the woman who was allegedly Ms. Wheeler's mother is actually her aunt, and the new woman is the real mom. Why does that matter? Because under Pennsylvania state law, except in the case of medical emergency (or other specific extenuating circumstances), a parent/guardian of an unemancipated minor must provide consent for a termination of pregnancy.
On the other hand, in New York (and New Jersey) a minor may access termination of pregnancy services and other reproductive health services without consent from (or notification of) a parent/guardian.
Stepping back and looking at another aspect of women's health, all 50 states (and DC) allow minors to consent to their own STI testing and treatment; however, further details vary (including confidentiality, vaccinations etc.). New York is very protective of minors' rights and privacy, and has measures in place to protect their confidentiality (including ways to avoid the situation of charges appearing on family insurance statements), with the exception of HPV vaccination needing to be reported to the Immunization Registry (which can be queried by a parent).
Other little lessons from episode 5:
If you don't have a tourniquet, you can substitute an inflated BP cuff as a workaround.
I've never debrided a hematoma in the ED, but you could probably throw a Doppler or US probe on it to see if there's pulsatile flow before cutting into it.
When considering disposition for a patient with elevated care needs (e.g. just broke an arm), discuss with family what capabilities/services are available at home and if they would be amenable to evaluation for placement in a facility (e.g. nursing home vs acute rehab).
EMTALA obligates the hospital to evaluate and stabilize; consultants cannot refuse to evaluate a potential surgical emergency on the basis of "we weren't the ones who did the patient's procedure".
The DuCanto catheter is a large-bore (28 Fr) suction catheter that, if available, could have been used as part of SALAD technique (2016) to intubate the post-tonsillectomy hemorrhage patient. It is larger than the Yankauer tip (18 Fr, "large" bore), and can accommodate a bougie for said technique.
Retrograde intubation is an older method for addressing difficult airways, and involves passing a wire superiorly through a cricothyroidotomy.
References:
https://portal.311.nyc.gov/article/?kanumber=KA-02538
https://www.legis.state.pa.us/cfdocs/legis/LI/consCheck.cfm
txtType=HTM&ttl=18&div=0&chpt=32&sctn=6&subsctn=0
https://www.plannedparenthood.org/learn/abortion/the-abortion-pill
https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information|
about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation
https://ag.ny.gov/sites/default/files/abortion-laws-english.pdf
https://www.cdc.gov/std/treatment-guidelines/adolescents.htm
https://www.hivguidelines.org/guideline/adolescent-consent/