Crash Cart: Required burials of miscarriages, stress echoes, and ex-inmates in the ED

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This week: The ethics of requiring women to bury the remains of miscarriages and abortions. Plus, which is better for chest pain: stress echocardiography or coronary CT angiography? Join in as our editors discuss the week’s headlines.


Texas passes new laws that would require women who have miscarriages or abortions to bury or cremate their fetal and embryonic tissue

“Abortion clinics, hospitals, and other healthcare providers would no longer be permitted to dispose of fetal remains in sanitary landfills, irrespective of the gestation period. The proposed law would take effect on Dec. 19.” Original Article by Quartz.

E. Paul DeKoning, MD, MS: So, I take issue with this article on multiple levels–it is an attempted political hack-job. The author mistakenly assumes that all readers hold the same position on abortion that she holds. I do not. First of all, I am unapologetically pro-life. If that offends your sensibilities, then you should stop reading. Actually, no. Keep reading. I want to address this article specifically, but to understand my response, I need to give my response a context: 1.) I believe life begins at conception. All life has value. I won’t bend on that. Every other criterion can be shifted (and indeed has) based on this or that–it’s a slippery slope that I’m unwilling to accept. 2.) You can judge the moral character of a nation by how it treats those most vulnerable–for example the poor, the hungry, the ex-inmates referenced in the third article this week. And it includes the unborn. Many of them will be our patients at some point in their lives. As EMPs we pride ourselves on caring for those who have nowhere else to go. Again, every life has value. I won’t apologize for that, either. A horrifying double-standard exists in this nation: if a pregnant woman is a victim of domestic violence and she miscarries, in addition to the unacceptable crimes against the woman, the perpetrator can (and I feel should) be tried for murder of the unborn. But, if the pregnancy is unexpected, inconvenient, or in any other way undesired (enter fetal abnormalities), then abortion is perfectly legal. I understand that these situations are frequently complicated and my response will undoubtedly anger some. But, we should be able to talk about it even (and especially) when we disagree. As EMPs, we routinely hold suicidal patients against their will when they are deemed to be a danger to themselves–even when the desire to end their lives seems rational. So when does the developing baby get a voice?? In order for me to be 100% pro-women’s rights (which I am), I must simultaneously be 100% pro-unborn rights (which I am). To not be a voice for the rights of the unborn (who cannot speak for themselves) actually diminishes the rights and God-given uniqueness of women. After the author arrogantly assumes I agree with her position, her next attempt is to vilify and deligitimize an elected official’s administration before it takes office. Regardless of how you voted, let’s be clear: Trump had nothing to do with this. The law was first proposed in July, before any vote was cast or counted, at a time when certainly very few in the media (or elsewhere, for that matter) thought Trump would win. Hillary had it in the bag, right? I agree wholeheartedly with the following quote: “fetal remains should not be ‘treated like medical waste and disposed of in landfills’…’for too long, Texas has allowed the most innocent among us to be thrown out with the daily waste.’ ” It is not criminal for the duly elected officials of Texas to hold this view…at least not yet. I patiently await the hate mail.

Nicholas Genes, MD, PhD: Looks like the Mainstream Media has concluded any headline that mentions Trump is going to get more clicks, and so he’s interjected into things that were awful enough without his involvement. Regardless of when you believe life begins, forcing funerals for miscarried products of conception is clearly anti-life. You’re putting a collection of tissue on the same level as the death of a parent, a spouse, a child. It’s absurd. How many times have we, in the ED, informed a patient with heavy bleeding that, in fact, there had been a pregnancy, and it’s ending in miscarriage? Can you imagine following that up with questions about a casket vs. cremation? Compared to the times we have to tell family members about the death of a loved one, this feels like a bizarre joke. What’s next – will Texas mandate the last menstrual period appear on the headstone? Or require newspapers to run an obituary? Paul, there is a horrifying double standard in the US – but not the one you point out. Rather, it’s the extreme lengths some will go to champion the unborn, while making life brutally difficult for the poor. It’s always special when we get a new law that does both at once. Does the Texas legislature want women bleeding to death at home, or suffering septic abortions? Because their life-affirming “funeral fee” creates a powerful disincentive for women to seek medical care. It’s a lot like the recent Texas law to force abortion providers to operate as ambulatory surgery centers and have admitting privileges – in that case, the high-minded notion was “patient safety.” This time it’s about respect for fetal remains. Meanwhile Texas consistently ranks among the worst states for childhood poverty, children without insurance, and other social supports. Forgive me for thinking the Texas legislature doesn’t really care about the vulnerable, and there’s no principled argument here other than “we’re dedicated to restricting womens’ rights in a bunch of underhanded ways.”

Seth Trueger, MD, MPH: Whatever your views on abortion, it is absurd to punish women for having miscarriages.

Jaime Hope, MD: Abortion is a hot button issue, to be sure!  And no one is going to change a deeply-held belief about it based on an article or argument. In fact, the principles of behavior change demonstrate that arguing for something actually strengthens and solidifies your own position internally rather than helping you see the perspective from the other side. I respect the views of both sides and the intensity of feelings. It is hard to separate the passion from the facts once the word abortion is mentioned.  This article is not an article about abortion. It is about a law that may or may not pass that will mandate the handling (and cost of handling) of remains from a pregnancy that is terminated spontaneously or electively. Regardless of your feelings of how the remains got there, they do need to be handled in a safe manner. The article states the cost of burial is the same as other forms of medical disposal. Whether this part is true or not seems to be an important part of the article that we should focus on; if the costs are increased and create a financial burden to healthcare facilities, it should be evaluated in that light.


EDs see fewer admissions when stress echoes are used for chest pain

“Hospital admission is lower when patients with chest pain in the emergency department are assessed with stress echocardiography than when they are assessed with coronary CT angiography.” Original Article by Medscape.

E. Paul DeKoning, MD, MS: Seems to make sense. My institution doesn’t even utilize Coronary CT. It isn’t part of my work-flow. But I do utilize stress ECHO virtually every day, especially when we admit patients to our clinical decision unit. Agree that the study is under-powered and very few adverse events. But intuitively, I’ve always preferred functional studies.

Nicholas Genes, MD, PhD: I did a double-take when this writeup said the study excluded patients with very low, low, and intermediate risk – in fact, that was the inclusion criteria. Still, I wonder how they were risk-stratifying, as I think most shops (certainly ours) will refer low-risk chest pain patients for outpatient workup (after negative EKG, troponins and a period of monitoring) – why were they admitting? Also I have no idea how their median ED length of stay was so short (and how a stress echo somehow took less time than a CT coronary!).


NPR discusses ways to keep ex-inmates out of the ED

“If there is any one single thing in the literature that is compelling, it’s that there’s a significantly higher risk of dying in the first two weeks following release from a correctional facility.” Original Article by NPR.

E. Paul DeKoning, MD, MS: As I said above, these are vulnerable members of our society and I think the greatest successes come from those who forge bonds and serve as advocates, essentially as sponsors. The article seems to support that: “…He’ll go with patients to their appointments, check in with some of them regularly on the phone, and he’ll even take frantic calls at 2 a.m. about whether they should go to the emergency room or not.” Would that we all had someone like this in our lives.

Nicholas Genes, MD, PhD: Note to EPMonthly editors: “Helping [blank]Stay Out of the ER Brings Multiple Benefits” is an endlessly adaptable headline.


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  1. I lean heavily to the Right on this issue, but Dr. Hope does make a good point. As for the Left, I have never understood the things they say to justify elective abortions. We are castigated because we won’t open our eyes and see that fetuses are just “a collection of tissue”. The casual manner in which they dehumanize life never stops shocking me. Sometimes I think they don’t know the underlying assumptions they stand on when they try to give a logical, medical, or ethical argument. Clumps of tissue are worthless garbage scraps. Inflamed appendix. Plantar wart. Feces. Fetus. I don’t see how they think that someone who disagrees with that line of thinking, is anti-life.
    Then they flip their own argument, almost in the same breath. Requiring abortionist physicians to take care of their patients, after they removed the worthless clump, seems reasonable. Every other physician who treats patients with a procedure, has to be available to deal with the complications that can arise from said procedure. Should the surgeon who removed a patient’s gallbladder not be required to come and treat the patient when they become febrile and yellow a few hours after the procedure? Not under the treatment plan advocated by the Left. One would think that showing the logical conclusion to their argument, would give them pause. After all, they are open-minded. To summarize: doctors who do a procedure on a clump of tissue that can be life, do not need to be able to handle the complications, and doctors who do a procedure on an actual lump of tissue, have to be immediately available for treating complications.
    Another angle is trying to show how others will be better off by having an elective abortion. If only we could get someone to pay for their abortions, The Poor wouldn’t be poor anymore. Many of them, through no fault of their own, are afflicted with illnesses like leg-spreadage syndrome, or bingedrinkandsex. The only cure for these maladies is to scrape out as many clumps as possible. If not, they might contract Be-responsible-for-your-actions type depression (somewhere between regular depression and dysthymic disorder. Abortions are necessary to stop the “horrifying double standard” that so-call pro-lifers are putting on The Poor. Somehow, The Poor’s lives will doubtless become “brutally difficult” if the Pro-Lifers would stop trying to have life live.
    Why wouldn’t doctors say things to patients like, “Great news! You had a miscarriage”, or “Dang. We couldn’t get the head out on this one, so you are going to have get another one in the oven. Wanna do lunch?” And don’t forget about victims of rape and incest who become pregnant as a result. Restrictions on abortions will ruin their lives. All twelve of them. Ordinarily, we don’t make national policy decisions that will affect everyone, on the basis of such small numbers of victims. But this is different, this time. The article raises many questions about life and our treatment of it, but, fortunately, they can all be answered with an abortion.

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