I recently listened to the podcast mini-series The Retrievals. It was fascinating and absolutely worth a listen. It’s the story of a Yale infertility clinic where a nurse was stealing fentanyl and replacing it with normal saline. As a result, women ended up getting egg retrievals with only midazolam, no pain control. There were interviews with women who described the horrific pain of the procedures but didn’t feel that they had any other choice as the procedure is incredibly time-dependent. The series opens with questions regarding women’s pain and why these women were ignored.
This brought up a lot of questions for me. Mainly, what would I do as the doctor in that scenario? I have definitely paused procedures and given repeat doses of pain medications in the past. But if I am watching what I believe to be multiple doses of fentanyl being pushed up to the max, what would my response be? We all understand the dangers of opiate overdoses, and conscious sedation is usually strictly controlled in non-OR settings. There was no discussion about the policies and procedures regarding sedation safety and maximum medication dosage. They did state that no propofol or moderate sedation was available, which seems more common for egg retrievals these days.
I think any physician in a procedural-based specialty occasionally has a patient whose pain is difficult to control. Whether it’s physiology or narcotic tolerance, sometimes it seems like nothing you do is helping. But when do you get suspicious when that becomes more and more common? It was unclear exactly how much of this fentanyl was being replaced. Was this happening in every procedure? Every fourth? In big practices with many doctors and nurses, what kind of patterns were they actually seeing? What is enough to raise suspicion that something else is going on?
To be clear, I am not blaming the doctors involved. Likely for legal reasons, none of the doctors were interviewed, and their perspective was not given. I don’t think any of us would immediately jump to thinking that the drugs we watched someone draw up and push didn’t actually contain the requested medication. Mostly, I put myself in their shoes and wonder what they saw, wonder if I would have done anything differently.
Because the thing I struggled with listening to the podcast was how it opened and closed with discussions regarding how women’s pain is treated and how they aren’t listened to. Which are very valid questions, as these are known biases in the medical world. I am not saying the doctors did things right. But several people blatantly did wrong — mainly the nurse and administration — and I don’t think it was any of the doctors. But as usual, doctors take disproportionate blame for anything in medicine.
The other question I couldn’t answer for several episodes was how did this happen? How, in this day and age, does a nurse steal hundreds of vials worth of fentanyl? I know how closely narcotics are monitored in hospitals. These days, you can’t get a Tylenol without checking it out of the Pyxis. But finally, in episode 4, my question was answered. The clinic didn’t have a Pyxis machine because the Yale administration didn’t want to spend the money on it. The fentanyl was in a storage room that was frequently unlocked, and there were minimal narcotic records. This all happened because of money and poor decisions by the administration. It seems like the clinic manager was getting increased reports of pain from patients, and their complaints were not being investigated.
We are all familiar with these stories. Administration making decisions for money instead of patient care and staff protection. The system failed, and the public-facing clinical professionals take the brunt of the blame, not the suits in the offices who made the initial bad calls. Sure, Yale is being sued. But I doubt that affects any of them in the way a malpractice suit affects a doctor.
Fertility clinics seem to be big business these days. While I don’t have any numbers, a quick Google search showed that they are becoming increasingly profitable and being acquired by private equity. Another Google search showed that a Pyxis is $20,000 to $30,000 for a machine, depending on the size. I highly doubt that the clinic wasn’t profitable enough to afford that, but even if they were, the entirety of Yale didn’t have that? For a hospital system budget, that seems like a very small amount of money for a crucial piece of equipment.
In a lot of circumstances, doctors are out of control but bear the responsibility for the outcome. This is a huge factor in moral injury and burnout. We are not making those big decisions but have to practice within their constraints. We are tired of being manipulated by people making decisions based on the wrong things.
I enjoyed the podcast and would recommend it, though it left me with a haunted feeling. Like any good piece of journalism, it definitely made me ask questions. Again, what would I have done in those circumstances? Why do doctors seem to bear the brunt of the responsibility for a systemic failure, for decisions they did not make? How can we collectively do better in regards to treating women’s pain? I may not have any answers, but I have things to consider.
Valerie LeComte is a medical-legal consultant.