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That's a bit harsh. Nobody here has access to the medical records, we are largely discussing events as reported by a media barely more medically knowledgeable than us.

Frank is trying to be fair while avoiding pre-judgement, preferring instead to try to determine if there are scenarios where the actions of the medical team might be seen as reasonable and justifiable. That seems a worthwhile activity to me, even if I personally think that the medical team bear considerable responsibility for the tragic result.

keep to the Fen Causeway

by Helen (lareinagal at yahoo dot co dot uk) on Wed Nov 21st, 2012 at 01:37:10 PM EST
[ Parent ]

That's a bit harsh. Nobody here has access to the medical records

What metatone is saying (though he can correct me if I'm putting words in his mouth) is that we're debating whether there's a causal link between miscarriage and septicaemia, which he claims is well documented in developing countries and we in the west must have forgotten about because we weren't born when out grandmothers were giving birth without access to antibiotics and, in some cases, electricity or medical facilities. And thus the "debate" on the "link" is concern trolling.

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS

by Migeru (migeru at eurotrib dot com) on Wed Nov 21st, 2012 at 01:49:07 PM EST
[ Parent ]

Re: Concern Troll (4.00 / 3)

Actually I didn't think the link between miscarriage and septicaemia was contentious; indeed from the newspaper articles I've read the "medical" opinion seems to be that the moment the cervix opens from the "waters" breaking is when the susceptibility to disease goes from low to high.

So, I thought Frank was trying to determine if there was a medical justification beyond religiously-inspired negligence for allowing a woman to face this risk for over three days

keep to the Fen Causeway

by Helen (lareinagal at yahoo dot co dot uk) on Wed Nov 21st, 2012 at 02:03:38 PM EST
[ Parent ]

Ignaz Semmelweis - Wikipedia, the free encyclopedia

Actually I didn't think the link between miscarriage and septicaemia was contentious

That what is the whole debate about?

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS

by Migeru (migeru at eurotrib dot com) on Thu Nov 22nd, 2012 at 04:05:43 AM EST
[ Parent ]

Helen nails it (4.00 / 4)

How great is the risk of septicaemia, over a period of several days, in a woman whose waters have broken but has not yet miscarried?

I find it unlikely that accurate statistics exist for this risk, because it is such grave medical malpractice to allow such a situation to drag on for several days. Because, in particular, of the risk of septicaemia.

_{It is rightly acknowledged that people of faith have no monopoly of virtue
- Queen Elizabeth II}

by eurogreen on Thu Nov 22nd, 2012 at 04:47:41 AM EST
[ Parent ]

Re: Helen nails it (4.00 / 3)

As I understand it, whatever about the third world, the incidence of septicemia in or subsequent to miscarriage is very low in Ireland, which is partly why our maternal and child mortality rates are so low. It may also be why the medical team felt the "real and substantial risk to the life of the mother" standard wasn't met - until she actually did develop septicemia by which time (AFAIK, but I don't have a precise timeline) the foetus was already dead, but also by which time an abortion/womb evacuation/hysterectomy or other surgical procedure might only have increased the risks to her life.

The real issue here is that the current Constitutional standard in Ireland ("real and substantial risk to the life of the mother") is too high, and ANY risk to the life or health of the mother should have been taken into account - in which case an immediate abortion on admission would have been a no brainer, as the foetus had no chance of survival in any case.

It would require a Constitutional Amendment, by popular referendum, to change that standard. I don't sense any appetite, amongst the political parties, to go through the very bitter and divisive "right to life" Constitutional referenda campaigns of the 1980's all over again. The RC Church and "Pro-life" campaigns would attempt to spin any attempt to lower the Constitutional Standard (to real and substantial risk to the Life OR Health of the mother) as tantamount to abortion on demand and point to statistics in the UK where, apparently, the justification of risk to the mental health of the mother is utterly routine and used in the vast majority of abortions.

I'm not sure, in that context, whether such a referendum would pass and it would be very unlikely to do so unless at least some of the major political parties campaigned actively and energetically in favour. They show little inclination to do so, and so in that context I doubt such a referendum would pass.

Losing such a referendum could throw the the ongoing liberalization of Irish society into reverse and it might be at least another generation before women's rights to their own health and bodies were placed on a firmer Constitutional footing.

The bottom line is that Savita may have died because her medical team were justifiably reluctant to intervene aggressively and early enough in the context of current Irish law. It may sound callous (and it is), but the "Right to Life" movement will probably argue that one life lost in rare and exceptional circumstances is a small price to pay in the context of the thousands of "lives of unborn babies" that would be lost if Ireland were to introduce what they call abortion on demand on the British model.

A more winnable proposition, in the short term, for the pro-choice movement might be to argue that where the death of a foetus is inevitable, an abortion should be permissible if it would reduce ANY risk to the life or health of the mother. The "pro-life movement" will undoubtedly argue that this is a form of euthanasia and that it is open to abuse by doctors exclusively concerned about the health of the mother and who might be over eager to declare a threatened miscarriage unavoidable or a fetus unviable, and thus a foetal death inevitable.

However doctors generally, and maternity services more particularly, still have a very high standing and reputation in Ireland. Any attempt by the "Pro-life movement" to impugn the integrity of the profession would not go down well, and such a proposal would probably pass in parliament. What is not clear to me is whether it would require a Constitutional amendment to be passed. Any attempt by the Dail to legislate to that effect would probably be challenged as unconstitutional by the "pro-life" movement, and depending on how the Supreme Court ruled, a referendum might be necessary.

It might only be a small step forward for women's rights in Ireland, but at least it sounds to me like a winnable campaign and it would probably have saved Savita's life.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 06:41:26 AM EST
[ Parent ]

Re: Concern Troll (4.00 / 5)

Migeru:

we in the west must have forgotten about because we weren't born when out grandmothers were giving birth without access to antibiotics

giving birth != miscarriage

In fact why our "grandmothers" (Early Modern ancestresses) died of infection in or after childbirth (and they did, massively) was because the physicians of the time infected them with dirty hands -- until antiseptic precautions became understood and standard. Poor women who could afford neither physicians nor midwives were better off because they did not undergo the intervention of professionals who came hotfoot, bearing pathogens, from other births.

Frank's diary suggested an iatrogenic e.coli infection, which prompted my comments above. However, if this were not the case, a miscarriage is sufficiently dangerous of itself, and this was a long, fraught miscarriage that did not conclude (except in the death of the patient).

Refusing to consider an abortion and leaving this woman to suffer with either insufficient monitoring or a deliberate decision (or both) not to place her life before that of a condemned foetus's heartbeat (when did they diagnose septicemia and realize they would save neither the mother nor the foetus?) was an evident dereliction of medical duty.

by afew (afew(a in a circle)eurotrib_dot_com) on Wed Nov 21st, 2012 at 02:39:00 PM EST
[ Parent ]

PN (4.00 / 4)

afew:

Poor women who could afford neither physicians nor midwives were better off because they did not undergo the intervention of professionals who came hotfoot, bearing pathogens, from other births.

Midwives were better at physicians, that was in part how Semmelweis discovered the importance of washing hands. And physicians came not only from other births but also from things like autopsies.

Best was probably having a midwive coming to the home. That was the practise up here until the physicians monopolised childbirths through legislation.

Sweden's finest (and perhaps only) collaborative, leftist e-newspaper Synapze.se

by A swedish kind of death on Thu Nov 22nd, 2012 at 04:01:42 AM EST
[ Parent ]

Re: PN (4.00 / 2)

Yes, midwives were better because they intervened less than physicians, and may have had the advantage of traditional practices like hand-washing (though a ready supply of clean water in homes was problematic, in cities at least). Yet a poor woman who gave birth aided only by a family member or neighbour was probably "best off", because more isolated from causes of infection.

by afew (afew(a in a circle)eurotrib_dot_com) on Thu Nov 22nd, 2012 at 04:41:37 AM EST
[ Parent ]

and he recieved the usual warm welcome (4.00 / 3)

Despite various publications of results where hand-washing reduced mortality to below 1%, Semmelweis's observations conflicted with the established scientific and medical opinions of the time and his ideas were rejected by the medical community. Some doctors were offended at the suggestion that they should wash their hands and Semmelweis could offer no acceptable scientific explanation for his findings. Semmelweis's practice earned widespread acceptance only years after his death, when Louis Pasteur confirmed the germ theory and Joseph Lister practiced and operated, using hygienic methods, with great success. In 1865, Semmelweis was committed to an asylum, where he died of septicemia at age 47.

we reserve usually for those who come to show us what should be obvious...

'The history of public debt is full of irony. It rarely follows our ideas of order and justice.' Thomas Piketty

by melo (melometa4(at)gmail.com) on Thu Nov 22nd, 2012 at 06:06:26 AM EST
[ Parent ]

Re: and he recieved the usual warm welcome (none / 1)

It is ironic he died of Septicemia when he spent his life trying to reduce its incidence. I wonder if the doctors treating him at the asylum didn't approve of his hand washing theories and succeeded in infecting him...

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 06:55:46 AM EST
[ Parent ]

On Daily Kos I have commented that an explanation is still possible which does not involve:

There have been allegations of Roman Catholic dogma determining the medical treatments available to non-Catholics in Irish hospitals; allegations of racism; and allegations of a patriarchal medical system and culture that would rather have a woman suffer in acute pain rather than give her appropriate treatment and relief.

and that the medical team treating Savita may have taken the view that an abortion in this particular case would not reduce her risks of infection or that an abortion carried at least as many risks as benefits. That raises two issues:

Were the medical team correct in their assessment based on the available evidence - e.g. no evidence of infection at that time, and the very low incidence of septicemia following miscarriage in Ireland? Doctors aren't infallible, mistakes happen, and even very low risks materialize in a very few cases. So the question here is a straightforward medical practice one - was she properly diagnosed, monitored and treated based on the available evidence, did the medical team make a good faith mistake, were they negligent in some way, or was this a case of medical malpractice requiring, at the very least, a disciplinary response if not a criminal prosecution. It is just about possible that this is one of the rare occasions where a patient dies even though proper medical protocols were adhered to. Unlikely, but still possible, in my view, depending on what the inquiry finds.
But why then was she apparently told she couldn't have an abortion because "this is a Catholic country" and not that the team's medical judgement that an abortion carried as many risks as benefits? It is possible that she WAS told that an abortion carried as many risks as benefits and that the team was therefor not going to carry one out. It is possible that she then she decided that she wanted an abortion anyway, and that she was THEN told that abortion of demand is not possible because "this is a Catholic country".

My point is that we have only heard her husband's allegations, but have heard no testimony for the medical team themselves. We haven't even seen the medical records. So it is to prejudge the issue to make firm assertions at this stage. The medical team, too, are entitled to a presumption of innocence until the facts are fully investigated. My concern is that a rush to judgement which turns out to be wrong could be damaging to the pro-choice movement. Hell, any rush to judgment in the absence of all the evidence being heard is damaging to the credibility of any community which claims to be reality based and which claims to respect due process.

Some here have accused me here of being a concern troll. I am most certainly concerned that all the evidence is heard before judgement is made. I consider the reputation of Daily Kos being at greater risk because of some of the prejudicial, ill-informed and intemperate commentary here.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 08:05:12 AM EST
[ Parent ]

Re: Concern Troll (4.00 / 4)

I fear that the Kossacks on average does not care about the effects on the Irish abortion debate, but only the effects on the US abortion debate. And while in Ireland the eventual outcome of the inquiry will be important, Savita will be forgotten in a week or two in the US so they better get the most outrage out of it while it lasts.

Sweden's finest (and perhaps only) collaborative, leftist e-newspaper Synapze.se

by A swedish kind of death on Thu Nov 22nd, 2012 at 08:30:54 AM EST
[ Parent ]

Unpleasantly similar to a creationism or second amendment debate ...

by Number 6 on Thu Nov 22nd, 2012 at 10:49:13 AM EST
[ Parent ]

You are right about the screeching crowd over there, and I appreciate your raising arguments in advance, before the foetus firsters do so. Your argument hinges on the risk of an infection by the abortion, though. Even if I concede for argument's sake that this might be true for an operation, there is still prostaglandine. Where is the heightened infection risk for that? Your scenario is really far-fetched and makes me wonder if you aren't wrong too when you say this is not the best moment for a campaign to alter the law.

by Katrin on Thu Nov 22nd, 2012 at 08:41:04 AM EST
[ Parent ]

European Tribune - Would an abortion have saved Savita Halappanavar?

I said in the diary that:

It might also have been possible to accelerate the process by inducing an earlier delivery.

I don't know if this was considered, and if so why that option was rejected. Presumably her medical records will shed some light on this. Given that miscarriage is basically premature childbirth triggered if there is some malfunction - I'm not sure if it is known precisely why or how - but which is a naturally occurring end to many pregnancies, perhaps the medical team felt - at the time - there was no need to accelerate the process, or that it was proceeding normally and naturally and with no excessive risk to the mother.

I share your view that this is a somewhat far fetched scenario given that, reportedly, her membrane had ruptured, and that this posed a significant risk of infection. I do know that many successful child-births can take a long time and that induction is often used to accelerate the process, so the suspicion has to be that this was not done here because it was known the foetus was unviable and so that an induction at that time could be construed as an abortion.

However the Catholic Church has often used the somewhat Jesuitical distinction between a treatment intended directly to abort a foetus, and a treatment required by the mother and which has the "side-effect" of aborting the foetus, and so it seems to me the medical team where not "theologically" precluded from pursuing this option. However the failure of the Irish Parliament to legislate to provide greater clarity as to what is and is not legally allowed under the current Constitution may have contributed to uncertainty and procrastination on their part.

Presumably the inquiry team will question them precisely on this point.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 09:15:53 AM EST
[ Parent ]

I share your view that this is a somewhat far fetched scenario given that, reportedly, her membrane had ruptured, and that this posed a significant risk of infection. I do know that many successful child-births can take a long time and that induction is often used to accelerate the process, so the suspicion has to be that this was not done here because it was known the foetus was unviable and so that an induction at that time could be construed as an abortion.

Well, I know wikipedia is not an authoritative source and all that, but...

Premature rupture of membranes (PROM) is a condition that occurs in pregnancy when there is rupture of the membranes (rupture of the amniotic sac and chorion) more than an hour before the onset of labor. PROM is prolonged when it occurs more than 18 hours before labor. PROM is preterm (PPROM) when it occurs before 37 weeks gestation. Risk factors for PROM can be a bacterial infection, smoking, or anatomic defect in the structure of the amniotic sac, uterus, or cervix. In some cases, the rupture can spontaneously heal, but in most cases of PROM, labor begins within 48 hours. When this occurs, it is necessary that the mother receives treatment to avoid possible infection in the newborn.
...
Maternal _risk factors for a premature rupture of membranes include chorioamnionitis or sepsis. ...
...
... Current obstetrical management includes an induction of labor at approximately 12 hours if it has not already begun though many physicians believe it to be safe to induce labor immediately, and consideration of Group B Streptococcal prophylaxis at 18 hours.
...
Infection

Maternal: If chorioamnionitis [inflammation of the amniotic sac] is present at the time of PPROM, antibiotic therapy is usually given to avoid sepsis, and delivery is indicated. If chorioamnionitis is not present, prompt antibiotic therapy can significantly delay delivery, giving the fetus crucial additional time to mature. In preterm premature rupture of membranes (PPROM), antibiotic therapy should be given to decrease the risk of sepsis. Ampicillin or erythromycin should be administered for 7 days

Fetal: If the GBS status of the mother is not known, Penicillin or other antibiotics may be administered for prophylaxis against vertical transmission of Group B streptococcal infection.

I distribute. You re-distribute. He gives your hard-earned money to lazy scroungers. -- JakeS

by Migeru (migeru at eurotrib dot com) on Thu Nov 22nd, 2012 at 09:47:39 AM EST
[ Parent ]

we ... have heard no testimony for the medical team themselves. We haven't even seen the medical records.

How then can we even ask (but you do) this question:

Were the medical team correct in their assessment based on the available evidence

What assessment? What evidence?

no evidence of infection at that time

At what time? This took place over several days. Evidence of infection should have been constantly watched for during that time.

the very low incidence of septicemia following miscarriage in Ireland

What kind of miscarriage? This one wasn't over quickly, three days went by in which the risk of sepsis was constantly rising. This case called for careful monitoring and attentive reassessment more than once a day. It evidently didn't get it -- I see no reason to doubt the husband's testimony that it was only when his wife collapsed on the third evening that it was realized she needed antibiotics.

Of your three sets of allegations, religious bias and racism will be hard to determine, it will be one person's word against another's. But "a patriarchal medical system and culture that would rather have a woman suffer in acute pain rather than give her appropriate treatment and relief" seems to me clearly established.

by afew (afew(a in a circle)eurotrib_dot_com) on Thu Nov 22nd, 2012 at 09:15:59 AM EST
[ Parent ]

afew:

Frank Schnittger:
we ... have heard no testimony for the medical team themselves. We haven't even seen the medical records.
How then can we even ask (but you do) this question:
Frank Schnittger:
Were the medical team correct in their assessment based on the available evidence
What assessment? What evidence?
Frank Schnittger:
no evidence of infection at that time
At what time? This took place over several days. Evidence of infection should have been constantly watched for during that time.

I am not referring to the public evidence available to us now, but to the evidence available to the medical team at the time, and which will now, presumably, be minutely examined by the inquiry team.

What I am saying is that we are not currently in a position to draw definitive conclusions from the publicly available evidence, but that is precisely what the inquiry team should be doing based on a minute investigation of the currently private medical records and interviews with all the parties involved.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 09:27:03 AM EST
[ Parent ]

Then I suppose there's no point in discussing this further, it's up to the "inquiry team" (that we may trust with pretty much as much trust as we usually bestow on inquiry teams).

by afew (afew(a in a circle)eurotrib_dot_com) on Thu Nov 22nd, 2012 at 09:41:34 AM EST
[ Parent ]

HSE asks Hiqa to carry out Savita Halappanavar inquiry - The Irish Times - Thu, Nov 22, 2012

The Hospital has apparently released Savita's medical records to her husband, so they may well end up in the public domain shortly. His lawyer's first reaction is to note they make no reference to Savita's requests for an abortion. So their completeness and accuracy is immediately open to question.

The Chairman of the inquiry team is a senior professional with a very high international reputation. Given that he has advocated for wider availability of abortion in countries where it is currently very restricted seems to indicate he is at least not a "pro-life" nut job like those medics who recently passed the Dublin Declaration.

The other members of the inquiry team are all Irish medical professionals/administrators/advocates who probably have no great desire to throw their colleagues in Galway under a bus. However the reputation of the profession is at stake, so I doubt they would cover up clear medical malpractice. They may, however, be tempted to pass responsibility onto the politicians who have failed to provide a clear legal framework so that professionals know where they stand and what treatment options are available to them under what circumstances.

I suspect their remit is only to examine the circumstances of Savita's death. They will probably not make specific recommendations for legislative, much less Constitutional changes. So there will be lots of wriggle room and controversy as to what legal changes are required even if the Inquiry finds legislative changes are required.

Indeed the original Inquiry - in addition to having it's three Galway Hospital based members removed - now seems to be downgraded to the status of a "Clinical Review" and with Health Information and Quality Authority being asked to initiate a Statutory Inquiry. Perhaps this will satisfy Savita's husband demand for an independent public inquiry.

The Health Service Executive has asked the State's health watchdog Hiqa to initiate a statutory inquiry into the death of Savita Halappanavar.
Separately, Praveen Halappanavar's solicitor Gerard O'Donnell has said there is no record in Ms Halappanavar's medical file of her requests for a termination while she was being treated in University Hospital Galway.
The director general designate of the HSE Tony O'Brien said even if Ms Halappanavar's family decided not to co-operate with the executive's inquiry, the review "must be brought to a conclusion".
"There was 'no way' the inquiry could be stopped as it would be "criminally negligent" not to proceed, he said.
Mr Halappanavar's decision not to participate in the inquiry "does not absolve the HSE of an obligation to ensure that the inquiry proceeds" he said. The HSE inquiry would provide it with a clinical information that may be of "immediate value" in the hospital,he said.
In order to give "further reassurance" to her family and the public, Mr O'Brien said he told the Hiqa chief executive he will request that Hiqa initiate its own statutory inquiry. This could take place before the HSE inquiry concluded, he said.
It was not "either or" as to a public review and the HSE clinical inquiry, he told RTÉ Radio's News at One. There will also be a coroner's process under way shortly which has "many attributes of a public inquiry," he said.
Mr O'Donnell said he had studied the medical records given to the family closely and had written to the HSE about them on Monday.
Mr O'Donnell's main concern was that there was no request documented in the Savita Halappanavar's medical records that she or her husband had repeatedly sought a termination.
"There's absolutely no entry by the medical team of this in the medical records," he told RTÉ.
In response Mr O'Brien said any information that Mr Halappanavar had that would "speak to any inconsistencies between what's in the record and his personal knowledge would be of great value to the review team".
He also that the HSE was not as "aware as it should have been of the wider context that was emerging" and was focused on the "clinical aspects" in its inquiry.

Asked about the inclusion of three Galway clinicians in the original review team, he said Minister for Health Dr James Reilly was not aware of the total composition before it was announced because that was a matter for the HSE.

Once the HSE heard the concerns of the family it took steps to have the Galway clinicians stand down, he said.
Earlier today, Minister for Social Protection Joan Burton welcomed President Michael D Higgins's intervention in the controversy over the inquiry into the death of Savita Halappanavar.
Ms Burton said she had read and heard the comments made by the President and believed they were considerate, thoughtful, reflectful and humane, she added.
President Michael D Higgins yesterday intervened in the continuing row over the inquiry into the death of Ms Halappanavar, saying it must meet the needs of her family as well as those of the State.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 10:15:06 AM EST
[ Parent ]

They may, however, be tempted to pass responsibility onto the politicians who have failed to provide a clear legal framework so that professionals know where they stand and what treatment options are available to them under what circumstances.

Yes, and that produces pressure for legislation. I assume that one needn't alter that constitution of yours in order to define "substantial risk to the life of the mother".

by Katrin on Thu Nov 22nd, 2012 at 10:32:18 AM EST
[ Parent ]

No - the purpose of legislation is to define the constitution in more detail. A new can be challenged as "unconstitutional", and then the Supreme court had the final word on whether it is or not.

Index of Frank's Diaries

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Thu Nov 22nd, 2012 at 10:44:41 AM EST
[ Parent ]