Re: vbac on demand
From: verner nellsch (vnellsch@eastex.net)
Sat May 24 19:22:59 2008
sorry to be gone for awhile, but i have been ill. pneumonia and pleurisy.
pleurisy is everything bad that is said about it. so,to tell, as paul harvey
used to say, the rest of the story. i gave the lady her options of cesarean,
transfer to a different institution if i could get one to take her, or
waiting to see if the baby became sick or labor began. it reminded me of a
kubler-ross scenario of the different stages of dealing with bad news.
first, she was in denial that she should be treated as having had two
previous cesareans, rather than as she argued, that this should just be
treated as a first pregnancy and labor. then, she became angry that her
wishes would not be followed without question. then she bargained, wanting
to know how sick the baby would have to become, how long to wait on labor,
how long if no progression, how much distress, how much she could get of her
dream birth. then, upset, she left and went to her mom's house. the next
day, 24 hours ruptured, she came to my office, no appointment, depressed. no
labor, continued drainage of fluid, good fetal heart tones and movement. we
went through the same discussion. finally, she seemed to accept the
situation, she went to l&d , we did a repeat cesarean, and the kid was okay.
mom and baby went home in three days.
as lynn montgomery pointed out, it was for free. out of state medicaid.
vnellsch
>----- Original Message -----
From: "Efrain Ramirez" <eramirezt@coqui.net>
To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@mail.obgyn.net>
Sent: Saturday, May 24, 2008 6:38 PM
Subject: Re: vbac on demand
> Jamie - let's push this issue a bit further to see how would you react..
> the patient has 3 previous C/S.. she is 42 weeks - she demands a TOL ..
> induction that is.. she refuses another C/S...
>
> Ef
>
> At Fri, 23 May 2008, Jamie wrote:
>>
>>Would that be that the physician's right to do whatever he wants trumps
>>the patient's right to informed consent? Or that the physician's legal
>>and financial risk are more important than the patient's physical risk?
>>Because I really can't see how the relative risks aren't important to
>>this woman's decision about her body.
>>
>>At Thu, 22 May 2008, Efrain Ramirez wrote:
>>>
>>>You missed the central, fundamental issue of the discussion..
>>>
>>>Ef
>>>
>>>> At Wed, 21 May 2008, Jamie wrote:
>>>>
>>>>What are the statistics for an unaugmented VBA2C vs a third c/s?
>>>>
>>>>At Thu, 15 May 2008, Efrain Ramirez wrote:
>>>>>
>>>>>El-- she is not refusing treatment - she is not consenting to one of
>>>>>the
>>>>>treatment options .. jeopardizing her unborn child but for her,
>>>>>apparently, is of no concern. -- BTW - how did the whole drama turn
>>>>>out?
>>>>>
>>>>>Ef
>>>>>
>>>>> At Wed, 14 May 2008, Dr Eberhard W Lisse wrote:
>>>>>>
>>>>>>Lynn,
>>>>>>
>>>>>>the statute reads to me, that if a patient refuses treatment she is
>>>>>>not
>>>>>>covered by EMTALA any more.
>>>>>>
>>>>>>I am not saying or have ever said that that one should even
>>>>>>contemplate forcing surgery. I am also not saying that an "own"
>>>>>>doctor should abandon her.
>>>>>>
>>>>>>The way I read EMTALA is that someone who does *not* have an
>>>>>>"own" physician can not be dumped, unless, and that I still
>>>>>>maintain, unless she refuses treatment, which is reasonable
>>>>>>as in this case, an ACOG recommendation.
>>>>>>
>>>>>>The statute says hospital, not physician, and I am not sure, emergency
>>>>>>treatment under the statute without payment establishes a
>>>>>>doctor-patient
>>>>>>relationship.
>>>>>>
>>>>>>But, the idea can not be to use this statute to force an obstetrician
>>>>>>to perform a VABC against his wishes on a patient he's never
>>>>>>seen before.
>>>>>>
>>>>>>el
>>>>>>
>>>>>>On May 14, 2008, at 17:12, Lynn Montgomery wrote:
>>>>>>
>>>>>>> EL,
>>>>>>> Unfortunately, in the US, most hospitals have call schedules that
>>>>>>> all
>>>>>>> obstetricians with privileges are required to participate in call
>>>>>>> "town
>>>>>>> call" or "no-doc call", etc. When you are on that call, you are
>>>>>>> required to care for any patients who happen to drop into the
>>>>>>> hospital
>>>>>>> and don't have a physician with privileges at that hospital. If
>>>>>>> that
>>>>>>> patient is in "labor", EMTALA strictly prohibits transport of a
>>>>>>> "laboring patient". Here in Missoula, we only have one hospital
>>>>>>> that
>>>>>>> provides obstetrics and I get saddled with this type of patient all
>>>>>>> the
>>>>>>> time. If a patient with a previous cesarean section presented in
>>>>>>> this
>>>>>>> circumstance and refused repeat cesarean, other than providing
>>>>>>> informed
>>>>>>> consent, I would be stuck to abide by her wishes, unless of course I
>>>>>>> could get another physician to take care of her, which would not
>>>>>>> happen.
>>>>>>> If I assert surgery without her consent, it is felony assault, not
>>>>>>> to
>>>>>>> mention the civil liability.
>>>>>>>
>>>>>>> In addition, I must mention that I don't get paid for the vast
>>>>>>> majority
>>>>>>> of this care provided, I am liable if the patient decides to sue and
>>>>>>> I
>>>>>>> must provide care emergency care (so if she is not really in labor
>>>>>>> and
>>>>>>> is discharged, but shows up 2 weeks later in labor, she is mine) for
>>>>>>> 30
>>>>>>> days even if I fire her from my care.
>>>>>>> Lynn
>>>>>>>
>>>>>>> Lynn D. Montgomery, M.D.
>>>>>
>>>>>--
>>>>>"I can accept failure, but I can't accept not trying." - Michael Jordan
>>>>>
>>>>--
>>>>JFields, RN, BSN
>>>>
>>>--
>>>"I can accept failure, but I can't accept not trying." - Michael Jordan
>>>
>>--
>>JFields, RN, BSN
>>
>
> --
> "I can accept failure, but I can't accept not trying." - Michael Jordan
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