Abortion can be lifesaving

While I realize Joe Walsh lost his election bid, it is still worth emphasizing that his infamous statements about abortion are false, especially considering efforts like those in Ohio to pass a “heartbeat bill”. Abortion is sometimes necessary to save the life of the mother. Via the Irish Times we hear the sad story of a woman being allowed to get sicker and sicker, while a non-viable but “living” fetus kills her.

“The doctor told us the cervix was fully dilated, amniotic fluid was leaking and unfortunately the baby wouldn’t survive.” The doctor, he says, said it should be over in a few hours. There followed three days, he says, of the foetal heartbeat being checked several times a day.

“Savita was really in agony. She was very upset, but she accepted she was losing the baby. When the consultant came on the ward rounds on Monday morning Savita asked if they could not save the baby could they induce to end the pregnancy. The consultant said, ‘As long as there is a foetal heartbeat we can’t do anything’.

“Again on Tuesday morning, the ward rounds and the same discussion. The consultant said it was the law, that this is a Catholic country. Savita [a Hindu] said: ‘I am neither Irish nor Catholic’ but they said there was nothing they could do.

At this point the story is mostly upsetting because of the pain and distress the patient was undergoing for a nonviable fetus. But in the next sentence the story goes from describing mere horrific, dangerous medical care and patient abuse to total medical incompetence and wrongful death:

“That evening she developed shakes and shivering and she was vomiting. She went to use the toilet and she collapsed. There were big alarms and a doctor took bloods and started her on antibiotics.

If this timeline is correct, this sounds like “rigors”, a classic sign of impending sepsis. Her collapse is concerning for impending septic shock. One of the most important factors in preventing worsening sepsis after infection, per the Surviving Sepsis guidelines, is source control. That is, if there is a source for the sepsis – a foreign body, and infected wound, etc., it needs to be removed/drained so that the condition doesn’t worsen. This, in addition to being common sense, is medically imperative to prevent the worsening of symptoms.

However, for the sake of a non-viable fetus in the midst of a miscarriage, source control was ignored, and the patient proceeded to worsen and die.

At lunchtime the foetal heart had stopped and Ms Halappanavar was brought to theatre to have the womb contents removed. “When she came out she was talking okay but she was very sick. That’s the last time I spoke to her.”

At 11 pm he got a call from the hospital. “They said they were shifting her to intensive care. Her heart and pulse were low, her temperature was high. She was sedated and critical but stable. She stayed stable on Friday but by 7pm on Saturday they said her heart, kidneys and liver weren’t functioning. She was critically ill. That night, we lost her.”

This appears to be death from a critical delay in source control, in the face of septic shock. Removal of the fetus should have occurred emergently when she presented with signs and symptoms of sepsis in order to save her life. This was not done, and she almost certainly died as a result of this delay.

Maternal mortality in pregnancy is very rare thanks to modern medicine. However, when ideology trumps medically-appropriate care we turn back the clock to when women died routinely in childbirth.

Keep Akin in the race!

Everyone has heard about Akin’s comments about “legitimate rape” and the push now coming from the GOP to get him out of the race. But is this really fair or ideal? The problem with removing Akin from the race over this is that his gaffe was not just one exposing his scientific ignorance, but because it was a Kinsley gaffe. That is, it’s a gaffe because it unintentionally revealed the truth.

I’m not saying that his medieval medical hypothesis has any scientific validity, he is after all just parroting pro-life misinformation spread to attack scientific data about the frequency of pregnancy after rape. The Kinsley gaffe in this case is that he revealed the truth about what he, and other pro-life politicians who support no-exception abortion bans, believe.

Why should we punish this truth-telling with removal of Akin from the race? All that will happen is that the GOP will replace Akin with another pro-life fanatic who is simply better at hiding what he actually believes about women, reproduction, sexual assault, and their autonomy over their own bodies.

I’m thankful for Akin’s honesty, because he has dropped the facade that the radical right cares about women, respects their autonomy, understands sexual assault or has any place in this century. He has pulled back the curtain and shown what they really believe. Other examples of this attitude abound, from the abusive ultrasound bills, to this comment from Idaho Republican Chuck Winder in March wondering if women even know what rape is, to American Vision’s comparison of the blowback against Akin as “like gang-rape”. He has only further exposed the misogyny of the pro-life movement and brought some of their more despicable lies front and center for all to see. We should be thanking him for his honesty.

Transvaginal ultrasound now being legislated in Idaho

In the continual spread of assaults on women’s reproductive freedom in the wake of the 2010 tea party movement, another state, Idaho, is legislating women receive unnecessary and invasive medical procedures prior to obtaining abortion.

This is part of an unprecedented effort at the state level to restrict reproductive rights, and in 2011 a record number of these measures have passed.

And it won’t stop here, as we’ve seen in Georgia, they are trying to pass a law to force women to carry all 20 week gestations to term, even if the fetus is dead. And if you think that’s creepy, Georgia isn’t the first to do it, such laws have succeeded in Nebraska, Idaho, Indiana, Kansas, Oklahoma,Alabama and Utah.

John Scalzi has a guest post from a physician asking “where’s the outrage?”. Well it’s right here. Scalzi’s poster is suggesting that civil disobedience should follow, but I’m worried that that might be the excuse these states are looking for to shut down clinics and effectively ban all abortion within a state. While I agree the situation is untenable, and is requiring physicians to engage in unethical practice I worry that violating the law is just what the zealots are waiting for. But maybe this needs to happen. We need a test case in front of the courts that asks the question, “can legislatures dictate medical practice in conflict with medical ethics, and without medical justification?” I think the answer would be no, and should be no. Physicians shouldn’t be taking orders from the state on what they do in the examining room. Physician autonomy, ethical practice, reproductive freedoms, and the whole doctor-patient relationship are on the line here. Physicians are here to treat patients, not to serve as tools of the state, against our patients’ interests, to score political points for zealots.

Demanding women deliver dead babies is unethical and unsafe

In a debate on the floor of the Georgia State house over a bill to force women to bring all pregnancies after 20 weeks to term, even in cases of dead or non-viable fetus, this Georgia representative reaches a new low. State Rep Terry England seems to be suggesting pigs and cows do it, why can’t humans?

Rep. Terry England compares women to cows, pigs and chickens. from Bryan Long on Vimeo.

Aside from this genius on-the-farm reasoning of Mr England, the failures of reasoning and misrepresentations of scientific knowledge engaged in to pursue this legislation are many.

The legislation is justified ostensibly because of the ability of the fetus to feel pain after 20 weeks, but there is no data or a legitimate scientific basis for this claim. Our knowledge of neurological development would suggest that conscious perception of pain may not be possible for a fetus at any point and the neural framework for transmission of pain is not even mature before 29-34 weeks.

Second is the issue that concern for the pain for a nonviable or dead fetus should not outweigh medical risk to the mother. The American College of Obstetricians and Gynecologists recommend dilation and extraction or induction of labor once the diagnosis of stillbirth has been made. The risks of carrying a non-viable fetus are the higher complication rate of delivery versus dilation and extraction, as well as a very high risk to the mother of complications like disseminated intravascular coagulation (DIC) if the amniotic sac is ruptured and she is exposed to the dying tissue. For stillbirth or nonviable pregnancies, dilation and extraction is far safer and more effective with 24% of patients undergoing labor experiencing complications compared to 3% for D&E.

It has been under-reported that since the 2010 election, the rate of anti-contraception, anti-abortion, and frankly anti-woman legislation has shot through the roof. In 2011 state legislatures have enacted a record number of laws restricting reproductive rights:

In the 50 states combined, legislators introduced more than 1,100 reproductive health and rights-related provisions, a sharp increase from the 950 introduced in 2010. By year’s end, 135 of these provisions had been enacted in 36 states, an increase from the 89 enacted in 2010 and the 77 enacted in 2009.

These include everything from preventing physicians from using telemedicine to prescribe medication to requiring ultrasounds prior to abortion despite the fact no association of OB/Gyns supports universal ultrasound prior to abortion. In an effort to legislate their control of women’s reproductive systems, they are interfering more and more with the physician-patient relationship. It has become so extreme that in 11 states they have legislation requiring physicians to perform unnecessary invasive procedures, basically forcing physicians to engage in unethical medical practices. There is no legitimate medical reason for these measures. These exist to shame women, and increase the expense and difficulty of constitutionally-protected medical procedures and medical decisions like birth control and abortion.

These efforts to ban abortion after 20 weeks, which have succeeded in several states including Nebraska, Idaho, Indiana, Kansas, Oklahoma,Alabama and Utah, are a highly intrusive attack on women’s reproductive freedom. It is once again, an attempt to insert politics in the doctor-patient relationship. Finally it is medically unethical, dangerous, and morally bankrupt to expose women to greater risk by preventing them from having the option of safe termination of pregnancy all for the sake of a dead fetus.

Via Jezebel

Pennsylvania next in line to require transvaginal U/S prior to abortion

Pennsylvania is poised to enact a ultrasound bill even more stringent than Virginia’s failed bill.

Even as the transvaginal ultrasound bill in Virginia was causing national outrage, Pennsylvania conservatives were quietly pushing a even more restrictive abortion bill. The legislation is designed with so many difficult and differing restrictions that long-time abortion policy analyst Elizabeth Nash at the Guttmacher Institute told Raw Story, “I’ve never seen anything like it.”

In addition to mandating the much-maligned transvaginal ultrasound requirements since rejected by the state of Virginia, Pennsylvania legislators proposed strongly encouraging women to view and listen to the ultrasounds, forcing technicians to give the women personalized copies of the results and mandating how long before any abortion the ultrasound much be preformed — and that’s just for starters.

That last requirement has already been passed and struck down in Louisiana, partially over concerns of patients’ privacy and potential risks for women in abusive relationships, Nash said.

“This bill definitely suffers the legislators-playing-doctor problem. … There are a number of requirements in this bill that are medically unnecessary,” Nash said, pointing out that so many requirements packed into the 22-page bill could make it logistically difficult for abortion providers to comply with them. “This bill is something that would be unacceptable to most women seeking an abortion.”

You know how I feel about this. Legislating unnecessary medical procedures is unethical and unlawful, and real Republicans don’t believe government should legislate medical decisions. Hopefully this bill will suffer a similar fate.

Rick Santorum: usually wrong, never in doubt

There is a joke expression about surgeons, “sometimes wrong, never in doubt.” Depending on how you feel about surgeons I’ve heard it begin “sometimes right” and “even when wrong.” Applied to Rick Santorum, I think it has to be “usually wrong” if not “always wrong” given the serious of ridiculous distortions, lies, and made up statistics in the last week.

Starting with his claim that 62% of people that go to college religious graduate without their faith. It seems plausible. College expands peoples experiences and exposes them to new ideas, and such experiences are not going to always mesh with fundamentalist writings of long dead priests. Well, while counterintuitive it actually turns out to be the opposite case. Those who do not attend college may be at higher risk of losing their religion.

“There is no statistical difference in the dropout rate among those who attended college and those that did not attend college,” said Thom Rainer, president of the Southern Baptists’ LifeWay Christian Resources research firm. “Going to college doesn’t make you a religious dropout.”

A 2007 LifeWay survey did find seven in 10 Protestants ages 18 to 30 who went to church regularly in high school said they quit attending by age 23.

The real causes: lack of “a robust faith,” strongly committed parents and an essential church connection, Rainer said.

“Higher education is not the villain,” said Catholic University sociologist William D’Antonio. Since 1986, D’Antonio’s surveys of American Catholics have asked about Mass attendance, the importance of religion in people’s lives and whether they have considered leaving Catholicism.

The percentage of Catholics who scored low on all three points hovers between 18 percent in 1993 and 14 percent in 2011. But the percentage of people who are highly committed fell from 27 percent to 19 percent.

“Blame mortality,” D’Antonio said, “The most highly committed Catholics are seniors, and they’re dying out.”

Do colleges indoctrinate the young to turn on their parents and reject religion? Salon argues they do a little bit, but the indoctrination that tends to be found on college campuses is on pretty universally accepted issues like rejecting racism and homophobia, both of which a majority of Americans now believe are repellent. But to politicians like Santorum, teaching tolerance is a major drawback to college attendance. The claim that colleges engage in indoctrination against religion is bogus, however, unless one is referring to religious beliefs in discrimination against other races and homosexuals.

If anything the opposite is the case as studies have shown higher rates of religious “drop out” among the less-educated. Politifact also challenges his statement that Obama wants everyone to go to college cause he’s a snob.

And how about all his other wacky claims? That prenatal screening causes abortion? Or that JFK believed religious people shouldn’t serve in government?
Continue reading “Rick Santorum: usually wrong, never in doubt”

Forcing Doctors to Perform Unnecessary Medical Procedures is Unethical and Unlawful

Many bloggers and commentators have expressed outrage over the decision by Virginia to require ultrasound examination, possibly transvaginal ultrasound, prior to women obtaining an abortion. From Bill Maher to Dahlia Lithwick people are outraged and have even suggested that it should be considered rape to force women to undergo vaginal examination by ultrasound prior to receiving abortion. Worse, it’s clear from statements like this one by delegate Todd Gilbert, that there isn’t a medical concern related to this intervention. It’s simply designed to humiliate women and interfere with the doctor patient relationship with exclusively anti-abortion motivations:

“the vast majority of these cases [abortion] are matters of lifestyle convenience.” And, 

”We think in matters of lifestyle convenience and in other matters that it is right and proper for a woman to be fully informed about what she is doing.

This just reflects how stupid these guys are, because anyone with half a brain could come up superficially plausible defense of the statute from grounds of medical safety. They’re just too brainless to do so and clearly are just trying to interfere with women and their doctors as they try to make a difficult decision.

There are some indications for ultrasound prior to abortion. Many physicians performing the procedure or especially offering medical abortion might perform a transvaginal ultrasound prior to proceeding. It can serve a few useful purposes. It can help confirm intrauterine pregnancy as well as uterine location. It may be needed to assess patients in their postoperative exam or medical follow up visits to rule out retained products of conception. In cases of uncertain dates, it can give you gestational age of the fetus, which may be critical in determining the appropriateness of the subsequent procedure used. After all, medical abortion is typically limited to the first 9 weeks and uncertainty about gestational age should result in ultrasound prior to use of medical abortifacients.

However, neither the FDA nor any professional organization of obstetricians and gynecologists indicate ultrasound should be a required component prior to medical or surgical abortion. The procedure is often unnecessary. So, what Virginia has done has legislated a requirement for an unnecessary medical procedure, unsupported by any professional medical association, on a specific subpopulation of women. Given the history of forced sterilization in Virginia, you’d think they’d be more sensitive on this issue. This is the state where Buck v Bell brought the issue of forced medical procedures to light.

This statute cannot, therefore, stand on either medical ethical or constitutional grounds. The state legislature can not force me or any other physician to perform an unnecessary, and therefore unethical, medical procedure. The state legislature can not pick on a subpopulation of citizens and force them to receive an unnecessary medical procedure.

I don’t think this law will stand, but it once again will require a legal fight, waste of time and resources, and all of this once again in a effort by governmental busybodies to interfere in women’s health decisions in a punitive fashion. The Republicans need to watch out. This is just another indication of a the size of the assault on women’s reproductive rights, and if they keep pushing, they’re going to see what a mistake it is to piss off 51% of the population.

**Update: I also noticed from Lithwick’s article Virginia has enacted a personhood law saying life begins at conception. More idiocy. This is like Indiana legislating the value of pi = 3. It is unscientific and illogical. Life does not begin. It is continuous. There is no dead state between parents and offspring. Sperm are alive, eggs are alive, the fusion of the two is alive. Instead they are legislating what constitutes life that is important, or more likely “ensouled”. As a fundamentally philosophic/religious and ultimately arbitrary point, government has no business legislating such a thing. But legislating that life has a “beginning” is biologically ignorant.

What Illegal Abortion Looks Like

Many are linking to this story around the blogosphere and I encourage everyone to read it. In it, a Ob/Gyn describes her emergency care of a woman who arrived in her ED in hemorrhagic shock from a botched illegal abortion. Though clearly it was touch and go and there was some panicky action, our heroine thought fast and saved a life. My mother once worked in a labor and delivery ward to put herself through medschool in the days before Roe v Wade and this type of situation was common.

This is a great story because it illustrates two points. One, the war on abortion by the right wing is futile. We know abortion is more common where it is illegal and cases like these are more common. Banning abortion does not save lives. It results in more abortions, and more lives lost. Worse, in countries with strict bans even treatment of ectopic pregnancy is forbidden where there is still a beating heart detected by ultrasound. Doctors in these countries can literally go to jail for saving a woman’s life, all for the sake of a non-viable embryo that will kill the mother. The hypocrisy of calling this position pro-life is demonstrated by cold hard data. More women die. More fetuses are aborted.

Second, it shows how a well-trained doctor can save a life with some quick thinking. Hemorrhagic shock is something I’m pretty familiar with after my second year rotation in Shock Trauma, and in a few spectacular cases of bleeding on the wards. There are many times when as a doctor you think you’ve probably saved a life. Every case of appendicitis, dropped lung, or kid with a gastroschisis technically is a save but situations like those don’t have quite the same visceral terror and immediacy of someone who is bleeding to death right in front of you. It’s hard to keep a cool head when you’re elbow deep in a pool of blood. One case in particular that sticks out in my mind was during a nice calm Saturday in the fall. I had just finished assisting in an open appendectomy and was doing my usual neurotic repetitive rounds through the ICU I always did when I was on call. At this particular hospital, when on call I was responsible for all ED surgical consults, all the surgical floor patients, as well as the surgical ICU (I had to carry 4 pagers). So since I’d been in this case for the last hour or so I decided to check in with the ICU folks. It wasn’t the sickest ICU I’ve ever worked, nothing like the U Maryland Surgical ICU or Cardiac Surgery ICU, but, like the ocean, it’s never a good idea to turn your back on the ICU patients. So, I was passing by one patient’s room and I seen on the monitor a blood pressure of 60/40…
Continue reading “What Illegal Abortion Looks Like”

A global warming conspiracy theorist has won 4 states, should we be worried?

The states in Green have gone for Rick Santorum, who besides having a a Google problem also believes in one of the wackiest conspiracy theories there is – the climate change hoax. That is, the belief that there is a shady group of Illuminati that have power over thousands of climate scientists from all over the world, and in their greed for sweet sweet grant money scientists uniformly falsify all their data to serve this power-hungry cabal. Is that an exaggeration? Nope, that’s what people who believe in the “hoax” ascribe to (see skeptical science’s thorough debunking of Evans here). This is a more severe form of the denial by Newt or Romney, who claim “insufficient evidence”, the more basic goalpost moving of half-hearted global warming denialism.

But now we have a full-blown global warming hoax-promoting conspiracy theorist picking up momentum to become a candidate for president. Should we be worried?

Continue reading “A global warming conspiracy theorist has won 4 states, should we be worried?”