A woman arriving at an emergency department with heavy bleeding, significant pain, chills, weakness, dizziness, fainting, fever, or other pregnancy-related distress should first receive an appropriate emergency evaluation to determine what is happening and whether she has an emergency medical condition. Bleeding and pain can reflect a miscarriage, but they can also signal an ectopic pregnancy, serious blood loss, infection, retained pregnancy tissue, or another dangerous complication. ACEP guidance says a patient with a known pregnancy and increased pain or bleeding should generally be evaluated with ultrasound, together with the history, physical examination, and pregnancy-related laboratory testing. (ACEP)
Under EMTALA, once an emergency medical condition is identified, the hospital must provide treatment so the condition is unlikely to materially worsen, or arrange an appropriate transfer if the hospital lacks the capability to provide that care. Insurance questions may be asked during registration, but they cannot delay the screening examination or emergency treatment. (CMS)
What “stabilization” should mean
Stabilization is not one specific procedure, and it does not necessarily mean that every symptom has disappeared.
Depending on the patient’s condition, emergency stabilization may include:
- Immediate triage and repeated blood-pressure, pulse, temperature, oxygen, and bleeding assessments.
- IV access, fluids, and possibly blood products if substantial blood loss or shock is suspected.
- Laboratory testing to evaluate anemia, infection, pregnancy status, and the possible need for transfusion.
- Ultrasound and examination to determine the pregnancy’s location, whether the loss is complete or incomplete, and whether internal bleeding or ectopic pregnancy is possible.
- Pain and nausea treatment.
- Antibiotics when infection or sepsis is suspected.
- Urgent obstetric or gynecologic consultation.
- Medication, uterine evacuation, surgery, or another procedure when clinically indicated to control bleeding, remove infected or retained tissue, or treat an ectopic pregnancy.
- Transfer to a hospital with the necessary specialists, operating room, blood bank, or higher level of care if the first facility cannot safely provide it.
ACOG specifically states that surgical treatment for early pregnancy loss is recommended when there are signs of infection, heavy bleeding, or certain other medical conditions. (ACOG)
Texas law should not mean waiting until she is near death
There is a complicated federal-state conflict concerning abortion-specific EMTALA enforcement in Texas. CMS currently notes that a federal injunction prevents HHS from enforcing its earlier interpretation that EMTALA overrides Texas abortion law in certain circumstances. However, CMS also states that EMTALA’s general requirements for medical screening, stabilizing treatment, and appropriate transfer remain in effect. (CMS)
Texas law itself contains an exception when, in a physician’s reasonable medical judgment, a pregnancy-related physical condition places the woman at risk of death or serious impairment of a major bodily function. (Texas Statutes)
Most importantly, the Texas Supreme Court has said that the law does not require the patient’s death to be imminent or require her to suffer physical impairment before a physician acts. The court said physicians may address the risk before the woman suffers the consequences of that risk. (Texas Courts)
So, from both a patient-safety standpoint and the language of Texas’s own highest court, a woman should not have to become septic, lose dangerous amounts of blood, or reach the verge of death before her condition is taken seriously.
The real questions in the Callaway complaint
The questions we need answered are:
What symptoms, vital signs, laboratory results, ultrasound findings, and clinical changes did each emergency department have?
Did the medical screening adequately evaluate hemorrhage, ectopic pregnancy, infection, sepsis, or incomplete pregnancy loss?
If an emergency condition was found, what treatment was provided to keep it from worsening?
What did the hospitals mean when they considered her stable enough for discharge?
Were appropriate treatment or escalation delayed, and did any delay contribute to additional harm?
That final question remains an allegation and causation issue, it has not been established. But it is exactly the right patient-safety question to keep asking. The issue is not simply whether she was experiencing a miscarriage.
It is whether the emergency departments recognized and responded to the dangerous medical conditions that can accompany a miscarriage before she became more seriously ill.
We will continue to monitor this case.
