The Ethics of the Missing Straw
The patient was a 34-year-old female with a chief complaint of abdominal pain. Her triage vitals were blood pressure 110/57; heart rate 93; respiratory rate 16; temperature 36.4°C. She stated she fell in her yard several days ago resulting in abdominal pain with some vaginal bleeding starting the morning of presentation. Upon further discussion during the physical exam, the patient admitted she missed her period and, in an effort to initiate it, stuck a drinking straw into her vagina. She inserted the whole straw inside and could still feel it poking her. She denied being pregnant and insisted she simply wanted to begin her period. Her pelvic exam was benign with a closed os, minimal blood in the vault, minimal right adnexal tenderness, and no signs of a foreign body or any lacerations. Basic labs revealed the patient was pregnant with a βHCG of 90,034. A subsequent ultrasound showed an intrauterine foreign body that appeared implanted within the myometrium with the width of a common straw and an indeterminate length. An approximately 8-week-old live intrauterine device (IUP) was noted next to the foreign body. Upon discussing these findings with the patient, she admitted she knew she was pregnant and was trying to perform an abortion with the straw.\nAn obstetrics (OB) consultation was placed. The initial OB consultant stated the patient was at high risk for septic shock and miscarriage. Recommendation, prior to the consultant seeing the patient, was to admit the patient for observation and antibiotics, as well as possible dilatation and curettage if she became unstable. However, shortly after requesting the consultation, a new OB attending took over the service. The new attending stated they did not believe the patient was in any danger of infection and thought it unlikely that anything had been inserted into the uterus dismissing the ultrasound finding simply as an “artifact.” The new OB consultant’s recommendation was to discharge the patient with outpatient follow-up. Feeling uncomfortable with simply discharging a patient who was potentially at high risk for infection, the EP performed a literature search which failed to provide guidance on the management of a patient with an intrauterine foreign body that was placed post-conception and/or non-sterilely. To make matters more confusing, the patient was an African immigrant and stated she did not want her husband to know of her condition or why she was in the hospital. She listed this as one reason why she would be unable to follow-up with an outside clinic. By this time, the husband arrived at the hospital and was becoming annoyed no one would tell him about his wife’s condition. The husband’s behavior was appropriate for the (unusual) situation and the patient denied sexual, physical or emotional abuse at home. With the EP present, the patient eventually discussed the situation with her husband. Both the patient and her husband repeatedly requested removal of the foreign body due to pain, and both unequivocally stated they felt the patient’s health was more important to them than the health of the fetus. The patient was reluctant to be discharged home. At the request of the patient and her husband, the EP contacted another hospital, and the OB on call there refused to accept the patient’s transfer.