POTD: Medical Termination of Pregnancy (LLFTP #5)

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/

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POTD: PPE + Precautions (LLFTP #4.5)

Today's POTD is going to be short but sweet. 

It's not based on a particular case from The Pitt, but rather emerged from seeing the physical comedy of poor MS4 Whitaker being soaked in various patient fluids at multiple points in the season. As we all know, patient fluids — along with their droplets, aerosolized particles, etc. — can be vectors for the transmission of disease. Recognizing that, today we'll be talking about the primary ways to protect yourself from communicable diseases in the healthcare setting: PPE and isolation precautions!

We're all trained in "standard precautions", a minimal level of common-sense practices that should be used during all patient encounters to reduce risk of infection and transmission. 

  • Hand hygiene

  • PPE used as needed

  • Cough etiquette

  • Clean and disinfect equipment

  • Clean/replace textiles/laundry

  • Safe sharps practices

When a patient is suspected to carry certain infectious diseases, "transmission-based precautions" should be added to reduce risk. These include specific recommendations as to what type of PPE one should wear. 

Contact precautions are added for pathogens tthat spread through direct contact with the patient or with contaminated materials (blankets, clothing, etc.). This includes suspected C. diff or enterococcus infection, norovirus, uncontrolled diarrhea due to other gastrointestinal infection, MRSA, Candida species, MRSA, lice and scabies, and herpesviruses. 

  • Minimize contact with other patients

  • Wear gown + gloves for all patient/environmental contact

  • Cover patient during transport, disinfect rooms/equipment during/after transport

  • Use dedicated or disposable equipment

Droplet precautions are added for pathogens that spread through respiratory droplets generated by talking, coughing, or sneezing. This includes influenza, Neisseria and HIb meningitis, other meningococcal disease, mumps, pertussis, plague, rhinovirus, rubella, group A streptococcal disease, and COVID in general. For many of these conditions, droplet precautions can be deescalated after 24 hours of appropriately antimicrobial therapy.

  • Single patient room vs dedicated isolation unit

  • Source control w/ patient masking, especially during transport

  • PPE should cover eyes, nose, and mouth, and should be discarded (or sanitized) immediately before room exit

  • Extra emphasis on "covering the eyes" — see the face shield vs goggles in the CDC graphic below. Regular eyeglasses are inadequate (I am often guilty of this, even though we have masks with integrated face shields readily available in the ED's yellow carts).

Airborne precautions are added for pathogens that can be aerosolized, i.e. carried through the air in small particles that remain airborne for an extended time and are small enough to penetrate many barriers. This includes herpes zoster that is disseminated or in immunocompromised patients, measles, SARS, smallpox, pulmonary or extrapulmonary draining tuberculosis, and COVID with aerosol-generating procedures.

  • Airborne infection isolation room (if unavailable, patient masking + private room w/ closed room) 

  • Source control w/ patient masking, especially during transport

  • Use a fit-tested N95+ respirator, which should only be removed after leaving room

  • Limited contact with susceptible healthcare workers

  • Often combined with contact precautions (add gown + glove)

Lastly, and most relevantly for Whitaker, procedures should prompt the use of appropriate barrier PPE. 

  • Gloves, always

  • Mask + eye protection for any procedure that may generate respiratory droplets or fluid splashes

  • Semipermeable (yellow woven/spun) isolation gown for procedures on patients with contact precautions, light splash risk

  • Nonpermeable (blue plastic-y) isolation gown for procedures with risk of high volume fluid exposure (bloody traumas, disimpactions) 

  • Sterile gloves, sterile gown, mask, and bouffant cap for all sterile procedures

References:
https://www.cdc.gov/infection-control/hcp/basics/standard-precautions.html
https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html
https://www.cdc.gov/infection-control/hcp/isolation-precautions/appendix-a-type-duration.html
https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/personal-protective-equipment-infection-control

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POTD: Death Determination (LLFTP #4)

Monday marks the start of a new week, and I thought I'd start us off with a more cheery and uplifting topic. 

Death!

Technically contains spoilers, but well-foreshadowed (obvious) ones.

Episode 4 concludes the story of nursing home resident Mr. Spencer, whose wishes against intubation had been ignored until now; and also trundles towards the inevitable end for Nick Bradley, whose heart is pumping but has shown no other signs of life, and is undergoing repeated rounds of brain death testing in the ED. 

In an act of (delayed) mercy, Mr. Spencer is extubated in line with his original advanced directives and allowed to progress to circulatory death. This form of death is the oldest and most "obvious" type, with it fundamentally boiling down to "the heart stopped" (and in today's high-tech world, we can add verbiage like "cardiac standstill or no organized cardiac activity on echo"). For the purposes of medical documentation, there must be another cause of death listed — saying a patient died of "cardiopulmonary arrest" is akin to saying "they died because they died". In Mr. Spencer's case, we could perhaps list "septic shock", "acute hypoxic respiratory failure", "pneumonia", and "advanced age" as his causes of death. Circulatory death is sometimes reversible with cardiopulmonary resuscitation, which creates an interesting ethical conflict with regard to the "Dead Donor Rule" in organ donation. The 1981 Uniform Determination of Death Act, which has been adopted by most states in the USA, requires "irreversible cessation of circulatory and respiratory functions" in order to declare death; meanwhile, the ethical norm of the DDR requires all donors be dead — so is your potential donor really dead if CPR has a chance of resurrecting them? The current widespread practice is to respect the pillar of autonomy, i.e. if ceasing or withdrawing care according to the wishes of the patient or decision-maker would lead to death, then that would be functionally "irreversible". (I also invite everyone with more of an interest in ethical debates to consider the classical Trolley Problem)

On the other side, the brain death testing for Nick Bradley continues. He's a young man who suffered anoxic brain injury after an unintentional opioid overdose (from contaminated alprazolam). His neurological exam was dire, with dilated and fixed pupils, no corneal reflex, no gag reflex, no oculocephalic reflex (eye movements with head turning) or oculovestibular reflex (eye movements with ice water in ear). The UDDA also creates the standard that the entire brain (including the brain stem) must lose function in order to declare brain death. There is no unifying federal guideline for how testing for brain death can be done. Protocols are based on state regulations and institutional policies, and two states (NJ and NY, as I'm sure many of you have seen) have provisions for the restriction of brain death testing. In Nick's case, as the brain stem controls respirations, an apnea test was performed in a prior episode to evaluate his respiratory drive. He is part of the population that the test is valid for: otherwise without prior respiratory disease, and with no hypoxemia, acidosis, hypotension, or hypothermia. An ABG is obtained first to check baseline PaCO2, then the vent is adjusted to provide oxygen without ventilation (e.g. CPAP mode with no backup rate). This state should be continued for 10 minutes, and aborted if the patient shows any signs of spontaneous breathing or decompensation; at which point another ABG should be taken. If the pH < 7.30 and PaCO2  > 60 (or >20 above patient's prior baseline, if abnormal), there is no respiratory drive. 

In this episode, Nick is being prepared for a confirmatory study, which is usually only indicated if prior studies are inadequate or if mimics like locked-in syndrome are suspected. The study of choice is cerebral scintigraphy, what Dr. Robby refers to as a "cerebral perfusion study": radiolabeled dye (technetium) is injected, and uptake into the brain tissue is evaluated based on presence of dye. In brain death, there is no uptake into brain tissue. As Dr. Robby warns the parents, this is the final test. 

For NY specifically, the NYS Department of Health uses the 2023 consensus guidelines by the American Academy of Neurology. They include an excellent flowchart that can be used to guide one down the pathway of brain death testing. In short, the first considerations are whether a disease process causing brain damage has occurred, if other reversible causes have been excluded or corrected, if sufficient time has passed to establish permanency (recommending 48 hours for < 2 months of age, 24 hours for > 2 months of age), and if there are no signs of brain function at or above the level of the brainstem based on exam. Following an exam indicative of total loss of such brain function, the next step is apnea testing vs ancillary tests (EEG, 4-vessel catheter angiography, radionuclide perfusion scintigraphy, transcranial doppler if adult). One definitive apnea test or ancillary test in adults is enough to declare brain death; for pediatric patients, the recommendation is for a 2nd round of testing after a 12-hour observation period. 

I want to also briefly mention a third "type" of death that isn't so much medical as philosophical. One could use the phrase ego death, or personality death — the loss of one's identity and personhood. The human experience encompasses more than what our meat alone would indicate, and defining "death" based solely on the activity of said meat can sometimes feel crude. The concept of ego/personality death is one approach to the question of "at what point of dysfunction do I stop being myself?" I.e., as your mind loses function, at what point would you consider yourself to be gone? This can be useful to consider when determining your own goals of care.

Other little lessons from episode 4:

  • Dr. Robby teaches us about Ho’oponopono, a Hawaiian prayer of healing and reconciliation. He specifies 4 phrases "that matter most": “I love you. Thank you. I forgive you. Please forgive me.” 

  • Lower abdominal pain (that may be cyclical) in a "premenarchal" young female should prompt consideration of imperforate hymen. Please handle the conversation more delicately than Dr. King.

  • Starting BiPAP on a patient with a pneumothorax will lead to tension pneumothorax. I'm convinced that Dr. Santos did it maliciously, so as to create a need for a chest tube, a procedure that she had been itching to perform. More broadly, as a trainee, please update your supervisors about interventions you want to perform, especially on your first day

  • Betting on ambulance chases should not be done in view of patient care areas.

References:
https://pmc.ncbi.nlm.nih.gov/articles/PMC3372912/
https://www.uptodate.com/contents/diagnosis-of-brain-death
https://www.uptodate.com/contents/evaluation-of-the-potential-deceased-organ-donor-adult
https://emcrit.org/ibcc/brain-death/
https://jnm.snmjournals.org/content/44/5/846
https://www.health.ny.gov/professionals/hospital_administrator/determining_brain_death/docs/aan_brain_death_guidelines.pdf

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