In February 2023, Kyleigh Thurman, experiencing the severe pain and bleeding of an ectopic pregnancy, was discharged from a Texas emergency department (ED) without treatment. Despite the life-threatening nature of her condition, medical staff, citing the state’s abortion ban, refused to provide necessary care, according to legal claims made by her lawyers.
Similarly, Mylissa Farmer faced a harrowing ordeal when her water broke prematurely. Emergency physicians in Missouri and Kansas informed her that while her fetus was not viable and she was at high risk of infection and hemorrhage, state laws prevented them from terminating her pregnancy, as detailed in an amicus brief. She was forced to travel for four hours, in labor, to receive the critical medical attention she desperately needed.
The Associated Press reported another distressing case in Florida, where a 15-weeks-pregnant patient waited in an ED waiting room for an hour while leaking amniotic fluid, only to miscarry in a public restroom.
These are not isolated incidents. Since the U.S. Supreme Court’s Dobbs decision in 2022, which overturned Roe v. Wade and eliminated the constitutional right to abortion, numerous similar cases have emerged across the country, as documented by the AP and other sources.
In the 13 states with outright abortion bans and others with severe restrictions, Emergency Doctors are operating in an environment of fear and uncertainty. The threat of severe penalties for violating these bans, including lengthy prison sentences in states like Texas, coupled with confusion surrounding exceptions for life-saving procedures, is profoundly impacting emergency medical care for pregnant patients.
Dr. Atsuko Koyama, an emergency medicine (EM) physician in Arizona, explains the chilling effect: “ED staff sometimes are afraid to perform any sort of procedure, such as those for miscarriage management, that could be interpreted as ending a pregnancy, even though these are not elective abortions.”
Each year, U.S. emergency departments handle approximately 3.8 million visits from pregnant patients. These patients present with a wide range of emergencies, some rapidly escalating from manageable to life-threatening, such as severe hypertension.
Dr. Alison Haddock, president of the American College of Emergency Physicians (ACEP), highlights the unprecedented dilemma facing emergency doctors: “It’s a different ball game now in terms of balancing the criminal consequences of state laws … against what are tenets of foundational care for us.”
These fundamental tenets are rooted in the Emergency Medical Treatment & Labor Act (EMTALA), a federal law mandating that virtually all Medicare-funded EDs must provide stabilizing treatment to patients experiencing a medical emergency. In July, the Department of Health and Human Services clarified that EMTALA necessitates abortion procedures when essential to stabilize a patient’s emergency condition, overriding conflicting state laws. While this guidance has faced legal challenges, the Supreme Court has, to date, declined to intervene, leaving the legal landscape unclear and fraught with risk for emergency doctors.
“It’s a different ball game now in terms of balancing the criminal consequences of state laws … against what are tenets of foundational care for us.”
Alison Haddock, MD President, American College of Emergency Physicians
The ramifications for emergency medicine are far-reaching. Concerns about practicing in restrictive states are deterring future emergency physicians, while current providers grapple with the complex realities, including managing patients forced to continue high-risk pregnancies.
Dr. Maya Barker*, an emergency physician at a major academic hospital in Texas, voices the distress felt by many in her field: “I feel handicapped in helping patients, and I feel hopeless. I never thought I would see this day. It’s been devastating.”
Navigating Legal Uncertainty in Emergency Pregnancy Care
Currently, four U.S. states permit abortions only when necessary to save the pregnant patient’s life. Nine additional states with abortion bans include exceptions for serious health risks, such as “serious permanent impairment of a life-sustaining organ.” However, the criteria for these exceptions often lack medical precision, leading to ambiguity and confusion for emergency doctors on the ground.
This legal vagueness forces EM physicians to navigate pregnancy-related emergencies in a dramatically altered and precarious environment.
One such emergency is premature rupture of membranes (PROM), or water breaking. Dr. Barker recounts a disturbing case: “I had a terrifying case early on in which a patient’s water broke in the second trimester. Those fetuses frequently do not survive, and the condition put the mother at risk of sepsis, which could have killed her. But the fetus still had a heartbeat,” preventing Dr. Barker from providing what she considered the appropriate and necessary treatment. She describes this as “moral injury,” the profound emotional distress experienced by physicians when they feel unable to deliver adequate care.
“Now, worried doctors sometimes say, ‘You’re not bleeding so much. You’re not dying. Go home and miscarry there.’”
Andreia Alexander, MD, PhD Indiana University School of Medicine
Ectopic pregnancy, where a fertilized egg implants outside the uterus, rendering the pregnancy nonviable, is another frequent emergency situation. Dr. Haddock notes that even in these cases, the presence of a fetal heartbeat can deter some emergency doctors from terminating the pregnancy, despite the grave health risks to the patient, including fallopian tube rupture, severe shock, and hemorrhage.
Miscarriages, affecting 10% to 20% of pregnancies, are a routine part of emergency department workload. “We see miscarriages daily,” states Dr. Andreia Alexander, PhD, assistant professor of emergency medicine at the Indiana University School of Medicine. “Ideally, we have a few approaches at our disposal, including providing medication to expedite the passing of tissue. Now, worried doctors sometimes say, ‘You’re not bleeding so much. You’re not dying. Go home and miscarry there.’” This shift from standard medical practice to risk-averse discharge highlights the chilling impact of abortion restrictions on emergency care.
Divergent Opinions and Difficult Decisions in Emergency Rooms
Not all emergency physicians in states with abortion bans perceive the laws as confusing. Dr. Haddock points out, “Some physicians feel like these laws are not about the care we provide because they are intended for elective abortions. There is great diversity in opinions in emergency medicine.”
Some argue that the perceived confusion is fueled by opponents of abortion bans, not the legal restrictions themselves, and that the laws clearly permit treatment for dire emergencies like ectopic pregnancies.
However, others contend that real-world pregnancy emergencies are rarely clear-cut. Determining the precise level of risk to a pregnant patient can be incredibly challenging in the fast-paced, high-stakes environment of an emergency department.
Dr. Alexander shares a concerning example: “I’ve seen a bleeding pregnant patient who otherwise looked great and who I believe got sent home because of lack of clarity around abortion laws. A few hours later she came back by ambulance in very bad shape.” This case underscores the potential for misjudgment and the critical importance of clear, legally sound protocols for emergency doctors.
In response to these challenges, some hospitals are proactively developing resources to support ED providers in navigating these complex situations. “Our health care system did a really good job,” says Dr. Alexander. “They set up decision pathways so that our staff would know what to do. We also have an OB/GYN on call 24 hours to advise us, and if they think it’s necessary, they can bring in the hospital’s attorneys.” Unfortunately, Dr. Haddock notes that such comprehensive, EM-specific support systems are not yet widespread.
Even when legal provisions exist, awareness among emergency doctors may be lacking. Dr. Barker mentions that while the Texas legislature added a legal defense for physicians treating ectopic pregnancies and PROM, “but some doctors still don’t know about that.”
Patient understanding of these legal complexities is even lower. Dr. Alexander recounts, “I had a bleeding patient who waited to be seen because she’d had an abortion in the past and worried that she would get in trouble because we’d assume she had one now. She wound up needing a blood transfusion.” This illustrates how fear and misinformation can further complicate emergency care for pregnant patients.
Broader Impacts on Emergency Medical Practice
The repercussions of abortion restrictions extend beyond immediate emergency care, impacting various facets of emergency physicians’ professional lives.
In Texas, Dr. Barker expresses frustration with the state’s mandated abortion-related documentation: “We need to report any complication related to abortion, even if the procedure was performed long ago or in another state, which seems Big Brotherish to me. Also, it’s stressful having to remember to do this after a busy shift, since there’s a 72-hour deadline.”
These reporting requirements add administrative burden and psychological stress to already demanding roles. Furthermore, abortion restrictions can impede open communication with pregnant patients. “We diagnose pregnancy all the time in EDs, and sometimes those are unwanted. But because of penalties for aiding and abetting abortions, I find myself treading cautiously. I’ve been advised to say only that a patient can seek a second opinion in a nonrestrictive state,” Dr. Barker explains. This cautious approach can hinder patient-physician relationships and limit the scope of care emergency doctors can offer.
In states where abortion counseling is permitted, time constraints add another layer of complexity. “In some cases, the clock is ticking. Indiana allows abortions up to 10 weeks in instances of rape, so we need to connect patients to help quickly,” says Dr. Alexander. Emergency doctors must now also factor in legal timelines when providing care and referrals.
Interstate transfers for medically necessary pregnancy terminations further complicate emergency care. Dr. Jessica Kroll, president of Idaho’s ACEP chapter, describes the logistical and ethical challenges: “In a high-risk, complicated pregnancy, we’re on the phone with our maternal-fetal doctor, our risk management department, our lawyers, and out-of-state hospitals. We ask, ‘Can we treat the person here legally? How time-sensitive is their need? Is a bed available in another state? And is this patient stable enough for a three-hour helicopter ride?’” These complex coordination efforts divert resources and time, potentially delaying critical care.
The Human Cost: Doctors’ Well-being and Patient Desperation
Emergency physicians are also witnessing a disturbing trend: increasingly desperate actions by patients facing unwanted pregnancies.
“If they don’t know they can go out of state, or if they can’t for some reason, patients may resort to self-harm,” says Dr. Alexander. “Between 2018, when I started working here, and 2023, when the law went into effect, I had never seen a pregnant patient who attempted suicide or tried to harm the fetus. I’ve now seen five.” This stark increase in self-harm attempts highlights the profound impact of abortion bans on vulnerable individuals and the emotional toll on emergency doctors who must respond to these tragic situations.
Dr. Alexander recounts a particularly distressing case: “One person I saw really sticks with me. She threw herself from a moving car.”
The emotional and psychological burden on emergency physicians themselves is significant. “It’s been a roller coaster for almost two years, as abortion access has worked its way through the courts. We’re not talking about just a possible fine or malpractice suit, but a felony conviction,” says Dr. Kroll. The constant stress of potential criminal charges, coupled with the moral distress of compromised patient care, is taking a heavy toll on the mental health of emergency doctors.
As ACEP chapter president, Dr. Kroll has experienced heightened pressure: “We’ve had a lot of harassment of health care workers here, and I was getting a lot of media calls. At times, I’ve been afraid for myself and my family.” The personal safety concerns and professional anxieties are adding to the already demanding and stressful nature of emergency medicine.
Shaping the Future of Emergency Medicine: Residency and Training
Beyond the immediate crisis, abortion laws are reshaping the future of emergency medicine by influencing where new doctors choose to train.
Recent data reveals a significant trend. In the 2023-2024 Match® cycle, nearly 40% of medical school respondents reported that state reproductive health laws had moderately or strongly impacted their residency application decisions. Furthermore, applications to EM residencies in states with abortion bans decreased by 7.1% in 2024, while increasing by 2.4% in states with abortion access, according to an AAMC report.
“We saw a relatively sharp decline [in EM residency applications] in states with bans,” notes Dr. Atul Grover, PhD, executive director of the AAMC Research and Action Institute. “That’s concerning in part because underserved populations will be hardest hit. Many states with restrictions are those already facing physician shortages, and physicians often stay in states where they train. About half stay in the state where they complete residency, and the rate is even higher if they’ve gone through medical school there as well.” This trend threatens to exacerbate healthcare disparities in already underserved regions.
“We saw a relatively sharp decline [in EM residency applications] in states with bans. That’s concerning in part because underserved populations will be hardest hit.”
Atul Grover, MD, PhD Executive director, AAMC Research and Action Institute
For some trainees, avoiding restrictive states is a matter of personal reproductive safety. “I was a medical student in Georgia when Roe was overturned, and I was terrified,” says Dr. Trupti Patel, now an EM resident at Mount Sinai in Manhattan. “Even on the 1% chance I would become pregnant, I was concerned about my options. I worried about the effect on my career, my limited finances, and my future.”
Others prioritize comprehensive medical education and legal clarity. “I did apply to residencies in restrictive states because students can’t risk applying only where they most hope to train,” says Susan Jones,* a Boston University School of Medicine student. “But it’s a priority for me to receive the full gamut of education. Plus, trying to interpret convoluted laws [as a resident] seemed mind-boggling.”
Dr. Patel, now training in New York, recognizes the educational gaps created by restrictions. Despite rotations in emergency medicine and OB-GYN in two Southern states during medical school, she had not witnessed a dilation and evacuation (D&E) procedure, crucial for both abortions and miscarriage management, until her New York residency.
Emergency medicine leaders are actively addressing these educational concerns. A 2023 Journal of Graduate Medical Education article outlined recommendations for adapting EM residencies post-Dobbs, including facilitating resident travel to less restrictive states for training in necessary procedures.
Dr. Barker in Texas has initiated a reproductive health course for EM residents and medical students, covering emergency contraception and ED-initiated birth control. She also launched a project to enhance training in miscarriage management medications. “Miscarriage is truly a time-sensitive emergency, and it can be difficult to get those medications from pharmacies because they are also used for some abortions,” Dr. Barker explains.
Despite these efforts, many trainees remain hesitant about practicing in restrictive states. “I don’t want to be constrained in the care I provide patients,” states Dr. Patel, recalling a formative experience as an ED scribe: “I was working as a scribe in the ED, and a patient found out she was pregnant. She said, ‘I’m in an abusive relationship. I can’t have this baby.’ It was so heartbreaking to see how afraid she was. I don’t want a legislature to tell me how I can help a patient right in front of me.”
The stories and experiences of emergency doctors across the U.S. reveal a profession grappling with unprecedented legal and ethical challenges. As abortion restrictions continue to shape the landscape of healthcare, the dedication and adaptability of emergency physicians remain crucial to ensuring the best possible care for all patients, especially in the face of complex and evolving legal constraints.
*Not her real name
