Tuesday, March 24, 2009

On The Defensive

A scenario:
Dr. Wes: "I wonder if I could treat a pregnant woman, 36 weeks gestation, who wants to breast feed, is hemodynamically stable but has atrial fibrillation with rapid ventricular response unresponsive to digoxin/beta blockers, with short-acting Ibutilide?"

Dr. Google: "Several case reports exist treating pregnant patients with atrial fibrillation and atrial flutter without injury to mother or fetus and with no adverse effects."

The Obstetrician: "What's ibutilide?"

The Neonatologist: "Ibutilide? Has teratogenic potential at high dose in animals, including cleft lip and scoliosis, but at 36 weeks?...Maybe... Let me check with a pediatric electrophysiologist..."

Pediatric electrophysiologist: "We've used it in kids, but very cautiously... Never in pregnancy."

Pharmacist: "We have some concern, given the lack of human data."

ACC Guidelines 2006-Atrial fibrillation in Pregnancy(pdf): (Level of evidence: II-b or not II-b): "Ancient ineffective antiarrhyhmic drugs like quinidine sulfate or procainamide are generally thought to be safe in pregnancy."
Guess which drug I used?

Although I'm not proud of this, I caved to the paranoia. She stayed in the hospital another 18 hours because of it. A small price to pay, I suppose, but I am convinced I did not render the best care, just the safest care... for me.

It never ceases to amaze me how the threat of litigation constantly influences the medical care we deliver.



Anonymous said...

Aw, I saw how excited you were. You loved it anyway.


shadowfax said...

Would you have treated differently in a no-litigation environment? It's no secret that docs are risk-averse in general. Sometimes I think docs use "liability" as a proxy for all the other stuff that happens when "something bad" happens -- post-facto criticism by supervisors, having to defend yourself at QA meetings, and of course the human cost when things go bad. These are all powerful deterrents, and more common than being sued. I wonder whether behavior would change if these negative incentives for risk-taking were the *only* ones.

And of course you highlight a challenging area -- where the stakes are perceived to be very high, and the data marginal at best.

DrWes said...
This comment has been removed by the author.
DrWes said...


There is no question I would have treated this patient differently in a no-litigation environment. Ibutilide, a newer Class III antiarrhythmic, is very short-acting (gone in 4 hours, typically) and quite effective at terminating atrial fibrillation. People are awake when we give it (no need to be NPO), it avoids the risk of sedation or anesthesia (for cardioversion), has minimal effects after four hours (permitting her the ability to breast feed), and there was experience in its use in this circumstance, albeit in a small series of patients from overseas.

In this case, I think I had a strong argument for the use of this drug, weighing all of the factors involved. After all, if Mom goes bad, so too goes the baby. But then again, if anything had gone wrong, I'd have little evidence-based footing on which to stand.

I think this experience also showed me how our clinical "guidelines" can be a deterrent to innovation or risk-taking in medicine (effectively quelling the "art" of what we do.)

Anonymous said...

From the perspective of the patient...when one has several overlapping medical conditions, several specialists in various fields, and gets conflicting opinions such as you've described - what the heck is the patient supposed to do?

Lisa said...

A baby delivered at 36 weeks is considered full term. Did anyone think of just delivering the baby and then treating mom?

DrWes said...

anony 07:25-

In medicine, these scenarios are all too common. Hopefully, it's called "using our best judgement."


Yes, this was considered (and Mom was at the point she would have been happy to comply), but her obstetrician wanted to wait at this point, because she was hemodynamically stable and baby appeared to be doing fine - (maybe because of potential legal concerns??)

Margaret Polaneczky, MD (aka TBTAM) said...

That's a shame - if they would have given it to the kid outside the womb, at 36 weeks, everything is formed, why not give it now?

I would not have delivered her in a fib.

Nice post.

Anonymous said...

In reality at 36 weeks organogenesis is over. Risks are minimal but if something goes wrong you can bet a lawyer will blame you. How about another example which you are very familiar with...cisapride. Yes it has a dangerous side effect profile. However it does have a role in those gastroparesis patients that have failed everything else. Thanks to the lawyers no doc would ever prescribe it under any circumstances (even though technically they are allowed to). Is this really in the best interest of people with severe refractory gastroparesis?