This past weekend, my friend and fellow ethicist texted me a link to a new Serial podcast called The Retrievals.
The podcast follows the case of women treated at Yale Reproductive Endocrinology and Infertility Clinic experiencing serious harm during their egg retrieval procedures for IVF. A nurse stole fentanyl meant to sedate patients.
The series explores women’s pain, sedation for medical procedures & ethical care.
“But here’s the thing, and this is where it begins, is, you are treated like a hysterical woman from the second you walk in there… Here comes like Freud’s patient, the hysterical woman who’s childless, and angry, and hormonal, and terrified, and bitchy, and mean. And that’s how we’re going to treat her.”
~ Leah (patient)
As an anesthesiologist (sedation expert), ethicist, and woman, I’m very interested to see where this show takes us.
I’ve decided to write my reflections on each episode for you on Bioethics Today.
Spoiler Alert: This post discusses Episode 1 of The Retrievals.
Episode 1 was released on June 29, 2023. If you haven’t listened yet, you can listen here. (And here’s the transcript)
What is Egg Retrieval?
Egg retrieval is just one part of the complex, exhausting fertility journey for patients seeking in vitro fertilization (IVF). Patients undergo extensive testing, then take medications for ovarian stimulation and egg maturation. Egg retrieval takes place in a very narrow window of time. In the clinic, patients receive sedation while in stirrups.A fertility doctor places a transvaginal ultrasound in the vagina to find the follicles. Then, the doctor inserts a thin needle into the vagina and pokes into the follicles to retrieve the eggs.
The procedure is painful and uncomfortable – especially as the needle poke to retrieve each follicle. Sedation with powerful, short-acting medications for this procedure is typical.
Some patients will have no memory of the procedure, and others will have some memories. Some patients may require general anesthesia for surgical reasons or because there is a reason not to use the typical sedation protocol.
Being fully conscious is not the expectation.
Gaslighting Women’s Pain
In Episode 1, we hear from women who were supposed to be sedated for their painful IVF egg retrieval procedures but describe themselves as “sober” throughout.
Women’s pain is often dismissed. We are called hysterical, overly anxious, and difficult. We are blamed for the failures of numerous systems.
“You have to complain just the right amount to be taken seriously, but not so much that you seem shrill.”
They remember crying out and being unable to lie still because they could feel every time the long egg retrieval needle punctured them. Other women who received at least light sedation woke up from their procedures with out-of-control pain.
They endured it anyway because they wanted to get pregnant.
Patients got the message that they were the problem – they weren’t reacting to the fentanyl and midazolam as expected. They were too sensitive to pain. Not sensitive enough to the medications.
One of the patients who studies and teaches feminist concepts lays out how she can see how her gender negatively influenced her treatment. She gives a succinct overview of how when power dynamics are magnified, even gender bias experts fall victim to it.
Poor Quality Sedation
The women’s descriptions of their horrible pain and attempts to get care are astounding.
“I remember yelling or kind of making like, ahh, and then really looking in confusion at my nurse, the attending nurse and her saying, I’m giving you the most I can legally give you.”
~Katie (patient)
In anesthesiology, we talk about “titrating to effect” – which means starting with the dose we believe will be effective and adjusting our management based on each patient’s needs. I can’t imagine looking at a patient and saying “Despite all evidence to the contrary, I won’t be giving you any more medication.”
Why wasn’t someone else called when nurses in this clinic couldn’t effectively sedate these patients?
How many healthcare workers in the clinic tolerated this abysmal treatment?
Why weren’t the fertility doctors insisting on proper sedation?
Why did it take so long to figure out the fentanyl was actually salt water?
Why were the patents’ physicians so dismissive of their experiences?
“How could this happen at Yale?”
Brand Trust & Reputation Bias
Patients expect universities like Yale, with an international reputation for excellence in education and research, to deliver excellent medical care. Biases like the availability heuristic (our judgments are influenced by what springs most easily to mind) play a significant role.
Big-name companies and universities invest vast amounts of money and time in maintaining a positive public image and garnering public trust. Universities want to capitalize on these positive beliefs to drive business. This is not a dig on Yale. This is a universal issue in higher education and healthcare.
When organizations don’t deliver, patients find themselves feeling surprised and betrayed.
Organizational Betrayal
Yale’s letter to patients suggested that no harm had come to patients. The letter they received is a prime example of organizational betrayal.
Many victims emerge when drugs are diverted away from patients.
Just listening to Episode 1, I hear multiple harms:
- Patients: Patients experienced excruciating pain in being denied appropriate, effective sedation. Patients describe long-lasting trauma from the experience and how continues to impact their fertility journeys. Depending on how the nurse stole the medication, she may have exposed patients to infectious diseases.
- The nurse diverting the substances: The nurse diverting fentanyl has her own complex backstory leading to a substance use disorder and stealing medications from patients.
- Other healthcare workers: the nurse who stole the medications did so from the supply closet, so other nurses providing sedation didn’t know they weren’t really giving fentanyl to patients. They also likely felt betrayed by their colleague.
- Employer: When staff divert medications, it harms the organization. Drugs are missing, patients get poor care, and they are seen as complicit in criminal and harmful activity.
- Public: The public is now less certain they can trust this infertility clinic and Yale’s ability to provide even basic sedation care.
Healthcare Worker Substance Use Disorders
The nurse diverting fentanyl described in the show is also a woman. How will her pain be addressed in the show?
As an anesthesiologist, I am uniquely positioned to “divert substances” – taking medications like fentanyl for myself. Substance use is literally a workplace hazard for healthcare workers. This is a major, still largely unaddressed problem in healthcare.
When discussing well-being for healthcare workers, we must discuss substance use prevention and care. Organizations need to take steps to make it more difficult to divert medications (prevention) and monitor the healthcare environment for risk factors and lapses. We also need policies in place to ensure HCWs who are suffering either don’t turn to substance diversion or receive treatment and support ASAP.
Stay tuned for Episode 2!
Thanks for reading. Stay tuned for my analysis of The Retrievals, Episode 2.
If you have a question about a specific part of an episode, please contact me at the Blog.
Alyssa Burgart, MD, MA is co-editor of BioethicsToday and a clinical associate professor at Stanford University. She also writes at Poppies & Propofol.