Project: Ghana Emergency Medicine Collaborative

Document Title: Administration: Ethics/ Medicolegal/ EMS/ etc.

Author(s): Joe Lex, MD (Temple University School of Medicine)

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Administration: Ethics /

Medicolegal / EMS / etc.

Joe Lex, MD, FACEP, FAAEM, MAAEM

Associate Professor of Emergency Medicine

Temple University School of Medicine

Philadelphia, PA USA

3

4

5

Today’s Menu

• Ethics

• Medico-legal

• EMS

• Non-hospital settings

• Disaster medicine

• Wellness & impairment

• Nuts & bolts 6

7

Ethics and The Law

• Societal values are incorporated

both within the law and within

ethical principles and decisions

• Good ethics makes good law

• Good law does not necessarily

make good ethics

• Significant overlap exists between

legal and ethical decision-making 8

Rights and Duties

• Active rights: right to act or not act

as one chooses

• Passive rights: right to not be acted

upon by others

• Duty: action required by rights of

others, law, higher authority, or

one’s conscience

9

Rights and Duties

• Without a duty to act, there can be

no rights

• Role / duty link occurs “whenever a

person occupies a distinctive place

or office in a social organization, to

which specific duties are attached

to provide for the welfare of

others...” 10

Values

• Standards by which human

behavior is judged

• Learned, usually at early age

– Observing behavior

– Secular, professional, religious

• In pluralistic society, clinicians

must be sensitive to alternative

beliefs and traditions 11

Professional Values

• To save lives when possible

• To relieve pain and suffering

• To comfort patients and families

• To protect staff and patients from

injury

12

Some Definitions

• Beneficence: duty to confer benefit

• Distributive justice: fairness in

allocation of resources, obligations.

• Personal integrity: adhering to

one’s own reasoned, defensible set

of values and moral standards

13

Beneficence vs Nonmaleficence

• Basic tenet: “First, do no harm”

• Derives from recognition that

physicians can harm as well as

help

• “given an existing problem, it may

be better not to do something, or

even to do nothing, than to risk

causing more harm than good.” 14

Malfeasance / Nonmaleficence

• Malfeasance: hostile, aggressive

action taken to injure the patient’s

interests

15

Autonomy

• Recognizes adult person’s right to

accept or reject recommendations

for medical care, even to the extent

of refusing all care, if that person

has appropriate decision-making

capacity

16

Autonomy

• Counterweight to long-practiced

paternalism

– Practitioner determined what was

“good” for patient, regardless of

whether patient agreed

• Coercion: threat or use of violence

to influence behavior or choice

17

Truth-Telling

• Absolute honesty: some people

feel that the patient has the right to

know the truth, no matter what the

circumstances

• Being honest does not mean being

brutal; truth is best tempered with a

modicum of compassion

18

Futility: Definition

• Intervention is effective in <1% of

identical cases, based on medical

literature (e.g. ED thoracotomy)

• Physiologic futility: known anatomic

or biochemical abnormalities will

not permit successful medical

interventions

19

Futility

• Proposed intervention will not

achieve patient's goals for medical

therapy in accordance with the

patient's values

• Futility concept should never be

used to deny care to dying patients

20

Using Newly Dead for Teaching

• It is unethical to prolong

resuscitative efforts to practice or

teach procedures or to complete

research protocols

21

Definition of Death

• Cardiopulmonary “death” not

necessarily inevitable, irreversible

• Brain death: irreversible failure of

clinical function of the whole brain

– Apnea

– Profound coma, unresponsiveness

– Absence of brainstem reflexes

22

Definition of Death

• In the ED, cardiopulmonary death

is the only death that can be

recognized

• Use of term brain dead is to be

avoided

23

Withholding Resuscitation

• In most EMS systems, verbal

requests to limit resuscitation are

not accepted, because of the

concern that out-of-hospital

providers cannot confirm that these

represent the patient’s current

wishes

24

Referral to Medical Examiner

• Traumatic death

• Death due to natural disaster

• In police custody / jail inmates

• Suspicion of homicide / suicide

• Suspicion of poisoning

• Sudden, unexplained death not

clearly related to prior disease 25

Newborns Left in ED

• Most states have laws allowing a

mother to leave a newborn infant at

a “safe-haven” in an attempt to

reduce the numbers of infanticides

and abandonments of children in

unsafe places

• Know laws in your state

• Every ED should have a policy 26

Translation Services

• Federal and state laws require use

of translators in health care setting

• Patient should be made aware of

availability of these services

• If not available: translation by

phone in same language

27

Duty to Third Parties

• Tarasoff: physician owes duty to a

foreseeable third party when aware

of reasonable risk to that individual

• Obligation to warn or protect others

against a variety of dangers:

communicable diseases, impaired

drivers

28

Viewing Resuscitation

• Nearly all survivors who witnessed

ED resuscitative efforts found it

helpful

– Grieving was facilitated

– Fewer episodes of flashbacks

– Lower levels of anxiety, grief,

depression, post-traumatic avoidance

behavior 29

30

Informed Consent

• Part of every patient / physician

interaction

• Legal standard under which

physicians educate patients (those

who have capacity to make

medical decisions or their legal

caretakers) about proposed

treatments and alternatives 31

Informed Consent

• General consent for treatment:

generally understood to cover

history taking, standard exams,

and basic procedures (blood

analysis, venipuncture)

• Does not provide consent for more

detailed, risky, invasive procedures

32

Informed Consent

• Allows patient to make decisions

consistent with personal values

• Based on belief that it fosters twin

concepts of patient well-being and

autonomy

33

Exceptions to Informed Consent

• Emergencies

• Therapeutic privilege

• Public health imperatives:

treatment of certain diseases

• Patient waiver of consent

• In ED: emergencies and public

health imperatives applicable 34

Capacity

• Definition varies among

jurisdictions

• In general, “individual’s ability to

make a decision based on

personal values and

comprehension of the likely

consequences of that decision”

35

Capacity Competence

• Competence often incorrectly used

interchangeably with capacity

• Legal term indicating a ruling by a

court that a person is unable to

manage his or her own affairs

36

Against Medical Advice

• Document capacity: with examples

• Discuss risks reviewed with patient

• Offer alternative treatments if

available

• Involve family, friends, or clergy in

decision

• Document treatment and follow-up

provided 37

Against Medical Advice

• Explain any potentially problematic

entries in the chart such as nursing

notes or abnormal laboratory

values

• For example, if the patient has an

elevated serum alcohol level,

document that the patient is

clinically sober and has capacity 38

Against Medical Advice

• Obtain patient’s signature: if

refuses to sign, document that fact

• State that an offer of care at any

time was provided to the patient

39

Treatment of Minors

• Generally considered to be anyone

<18 years of age

• Society and legal system have

adopted views that, in some

circumstances, older children may

make many medical decisions

independent of their parents

40

Treatment of Minors

• Emergencies

• Treatment of certain diseases and

conditions that are in the best

interest of the minor or society

• Minors emancipated under law

• Best interests of child are not being

addressed by parents 41

Treatment of Minors

• All states: STDs

• Nearly all states: alcohol or

substance abuse

• Many states: prenatal and

pregnancy-related care

• Sexual or physical abuse generally

permitted

42

HIPAA

• Health Insurance Portability and

Accountability Act

• PHI: Protected Health Information

• HIPAA allows covered entities to

use PHI without authorization for

purposes of treatment, payment,

and operations

43

HIPAA Do’s

1. Talk freely with patient’s primary

physician

2. Discuss PHI with consultants and

other members of the patient’s

health care team

3. Use PHI for reimbursement and

operational issues

44

HIPAA Do’s

4. Release records to the patient or

an authorized representative

5. Discuss patient PHI with family or

friends if the patient is in an

emergency situation, unable to

consent, and the information

would be beneficial to the patient

45

HIPAA Don’ts

1. Discuss patients or PHI in public

or unsecured areas

2. Leave computers with access to

PHI logged on and unattended

3. Discuss PHI in front of others

without permission

46

HIPAA Don’ts

4. Speak loudly when discussing

PHI, particularly in public areas

5. Look at records for which you

have no legitimate purpose as a

provider

47

Patient Transfer

• EMTALA: Emergency Medical

Treatment and Active Labor Act

• Applies to hospitals participating in

US federally financed Medicare

program

48

Patient Transfer

• All patients must receive medical

screening exam and be stabilized

before considering transfer to

another facility

• Receiving hospital must accept

transfer

49

EMTALA Obligations

• Provide a “medical screening

exam,” performed by “qualified

medical personnel,” to look for an

“emergency medical condition” for

all patients, who “come to the ED”

seeking care for medical condition

50

“medical screening exam”

• Process required to reach, with

reasonable clinical confidence, the

point at which it can be determined

whether an emergency medical

condition does or does not exist

• Must be same for every patient

presenting with similar symptoms

or complaints 51

“medical screening exam”

• Nurse triage does not meet

obligation to provide a medical

screening examination

• May not delay examination and

stabilizing treatment to inquire

about method of payment or

insurance status

52

“qualified medical personnel”

“The examination must be conducted by an individual who is determined qualified by hospital bylaws or rules and regulations”

• Does not specify what type of provider (registered nurse, medical doctor, physician’s assistant, etc.) should perform the medical screening examination

53

“emergency medical condition”

• Acute symptoms of sufficient

severity, including severe pain,

such that absence of immediate

medical attention could place

individual’s health at risk

• Pregnant woman with contractions:

insufficient time to transfer patient

before delivery 54

“come to the ED”

• If on hospital property and makes a

request, or has a request made on

his / her behalf

• Prudent layperson would believe

that patient needs evaluation or

treatment

55

“come to the ED”

• Hospital property: “physical area

immediately adjacent to the

provider’s main buildings, other

areas and structures that are not

strictly contiguous to the main

buildings but are located within 250

yards of the main buildings.”

56

Stabilized

• “treatment as necessary to assure,

within reasonable medical

probability, that no material

deterioration of the condition is

likely to result from or occur during

the transfer of an individual from a

facility or that…the woman has

delivered the child and placenta” 57

Receiving Hospitals

Hospital with specialized capabilities or

facilities such as (but not limited to) burn

units, trauma units, or regional referral

centers may not refuse to accept a

transfer from a referring hospital

anywhere in the U.S. when the patient in

question requires the specialized

capabilities and the receiving hospital has

the capacity to treat the patient. 58

Receiving Hospitals

• Should the accepting hospital find

that the transfer was not

appropriate or improperly

motivated, it is both their duty and

remedy to report the transferring

hospital for a potential violation

• Failure to report an EMTALA

violation is itself a violation 59

Reportable

• Assault: gunshot and stab wounds,

sexual assault, physical assault

• Communicable diseases: venereal,

high contagious (hepatitis,

pertussis, influenza)

• Abuse

– Mandatory for child, elderly

– Domestic partner: varies by state 60

Reportable

• Deaths: already covered

• National Practitioner Data Bank:

– Disciplinary action following formal

peer review

– Any amount paid in judgment of

written malpractice claim

61

High Risk of Diagnostic Error

• Chest pain /

missed MI

• Wounds: FB,

nerve / tendon

• Fractures

• Abdominal pain

(includes AAA,

appendicitis)

• Pediatric fever

• Meningitis

• CNS bleed

• Stroke

• Embolism

• Trauma

• Spinal cord

• Ectopic

pregnancy

62

Malpractice

• Four components:

–Duty

–Breach of duty

–Harm

–Proximate cause

63

Mitigate Risk

• Communicate respectfully

• Value your patient’s time

• Thank the patient

• Document thought process legibly

• Manage patient expectations

• No absolutes

• Discharge with time / action

specific instructions 64

65

Manpower

• First responders: often first to

arrive at medical emergency,

• Typically police officer, firefighter,

first aid team

• Can perform CPR, immobilize

spine, control hemorrhage, other

basic interventions while awaiting

ambulance 66

Manpower

• Plan 1 ambulance response / day

for every 10,000 people in area

served

• 75% of EMTs are volunteers,

especially in rural areas

• When paid, salaries are 50% of

budget

67

Manpower

• EMT-B: trained to take care of

immediate life-threats

• Administer oxygen, perform CPR,

use an AED, control hemorrhage

• Extricate, immobilize, transport

emergency victims

68

Manpower

• EMT-I: training includes additional

patient assessment plus insert IV,

interpret basic ECG, administer

some cardiac medications

69

Manpower

• EMT-P: highest EMT skill level

• Greater training, broader scope of

practice

• Function under a designated

physician's medical license

70

Communications

• Use of 911 as nationwide

emergency telephone number in

US facilitated public access to

emergency medical care

• Emergency call takers: collect

information from caller, dispatch

appropriate medical resources,

offer first aid information 71

Communications

• Most EMTs operate under standing

orders and patient care protocols

developed by physicians

• Communications: weakest link

in most disaster responses

• EMS communication systems must

have built-in redundancy

72

Transportation

• Most important: ambulance design

allows providers to provide airway

and ventilatory support while

transporting patient safely

73

Transportation

• BLS ambulances: appropriate

equipment for EMT-B level

– Oxygen, bag-mask ventilation

devices, immobilization & splinting

devices, dressings for wound care

– Do not carry medication

– Cannot transport patients requiring

IVs or cardiac monitoring

– Some carry AEDs 74

Transportation

• ALS ambulances: equipped for

EMT-Ps or other advanced health

care personnel

– IV supplies, IV medication, intubation

devices, cardiac monitoring and

defibrillation

– Other specialized techniques unique

to specific areas: hypothermia

application after cardiac resuscitation 75

Transportation

• Ground transportation appropriate

for majority of patients, especially

in urban and suburban areas

• Helicopter should be considered

for critically ill patients when

ground transport time dangerously

long or if in difficult terrain

76

Public Safety Agencies

• EMS systems need strong ties with

police / fire departments

• Public safety agencies can provide

first responder services

– Often first on scene of emergency

• EMS provide medical support to

police and fire departments in

hazardous circumstances 77

Equipment: Defibrillators

• Early defibrillation: most important

factor in surviving cardiac arrest

• Paramedic-staffed ALS services

typically carry manual monitor /

defibrillators, often with additional

functions

– 12-lead ECG, external cardiac

pacing, synchronized cardioversion 78

Equipment: Defibrillators

• Increasing percentage of BLS

services carry AEDs

• Analyzes rhythm determines if

rhythm meets defibrillation criteria

informs operator that shock is

advised charges capacitor

defibrillates when operator pushes

appropriate button 79

Equipment: Defibrillators

• AEDs only shock ventricular

fibrillation and very fast ventricular

or supraventricular tachycardias

(>180 beats/min)

• Easy to use and effective:

promoted for first-responder public

safety personnel and for public-

access defibrillation by laypersons 80

Equipment: Vascular Access

• Same as hospital: tourniquets,

cleaning agent, IV catheters, IV

fluid bags, and IV tubing

• Intraosseous access devices

increasingly popular if difficult

vascular access

81

Equipment: Spine Boards

• Preservation of integrity of spinal

column and cord of paramount

importance in prehospital setting

• Carrying boarded patients hard on

EMTs and paramedics

• Evaluating boarded patient more

expensive, time-consuming in ED

82

Equipment: Cervical Collars

• Two pieces, back and front

• One piece folded into shape

• Collars alone not adequate for

cervical immobilization

• Adequate immobilization: strapped

on back board and secured with

head blocks and head straps 83

Extremity Immobilization

• Field fractures splinted for patient

comfort, ease of transport

• Air splints adequate for most distal

fractures

• Sling and swathe

• Tie legs together with cravats

• Wrap pillow around extremity,

secure with tape 84

Helicopter Transport

• 867 helicopters in use in U.S. as of

early 2010

• Cost: $750,000 to >$5 million each

• Annual operating costs >$2 million

• Generally transport patients 1000

to 3500 feet above ground level

• Altitude-related problems tend to

be mild / non-existent 85

86

Mass Gatherings

• Considered to be events that have

at least 1000 people

• Same principles for athletic events

with <1000 people, cruise ships,

airplanes, wilderness environments

• Incidence of usage of medical

care: 4 to 440 patients per 10,000

87

Mass Gatherings

• Key to successful medical

response: reliable communication

among medical personnel, event

organizers, outside resources

• All events should have identified

physician medical director who is

responsible for developing medical

action plan 88

Ultra-Distance Athletic Events

• Common situation: management of

fluid and electrolyte repletion

• Massive sodium loss from sweat

• Overhydration with free water

• Risk factors for developing severe

hyponatremia (<125 mEq/L):

exercise time >4 hours, female

sex, low body mass index 89

Commercial Airline Flights

• Special mass gathering scenario

• Unique factors: lower O2 partial

pressure, potential exposure to dry

air, chemical irritants, virulent

airborne particles, venous stasis

• May aggravate normal health

behaviors through alcohol

ingestion, dehydration 90

Commercial Airline Flights

• Airline crew members educated in

basic first aid and CPR

• Most large commercial flights have

passengers with medical training

• Assuming care rendered is

voluntary, Good Samaritan laws

should provide protection from

medical malpractice liability 91

FAA Mandated Equipment

First Aid Equipment

Bandages Stethoscope Gloves

Antiseptic Sphygmomanometer BVM

Ammonia Oral airways AED

Splints Syringes

Tape Needles

Scissors IV Tubing

92

FAA Mandated Equipment

Medications

NSAIDs Epinephrine

Antihistamine Lidocaine

Atropine Nitroglycerin

Aspirin Normal Saline

Bronchodilator Oxygen

Dextrose

93

Cruise Ship Medicine

• ~10 million people travel on cruise

lines each year

• Average passenger age ~55 years

• Large vessels: >2000 passengers

and 1000 crew

• Most common complaints:

shortness of breath, minor injuries 94

Cruise Ship Medicine

• Typical week-long cruise with 1100

passengers: estimated average of

4 potentially life-threatening

conditions, with one patient

terminating the cruise early as a

result

95

96

Disaster

• World Health Organization: sudden

ecologic phenomenon of sufficient

magnitude to require external

assistance

• Overwhelms resources of region or

location in which it occurs

97

Disasters

• When normal ED procedures may

be interrupted by an event, there

must be policies and procedures in

place to activate a disaster

response, direct the mobilization of

personnel and equipment, and

permit rapid triage, assessment,

stabilization, and definitive care 98

Disasters

• External: physically separate from

hospital

– e.g., transportation, industrial

accident

• Internal: within confines of hospital

– e.g., bomb scare, laboratory accident

involving radiologic agents, power

failure, fire, etc. 99

Disaster Characteristics

• Event large number of minimally

injured patients presenting to the

nearest hospitals: minutes

• Then prehospital transport of most

affected patients to same hospitals:

peak at 2-3 hours

• ~80% self-transported by car, van,

police vehicle, cabs, foot, etc. 100

Joint Commission Requirements

• The Joint Commission (formerly

JCAHO) requires that member

hospitals have a written plan for

timely care of casualties arising

from both external and internal

disasters, and the hospital must

document the training and exercise

of these plans 101

Training / Disaster Drills

• Help familiarize staff with their

disaster roles and responsibilities

• Point out weaknesses or omissions

in the plans that require additions

or revisions

• The Joint Commission requires two

drills a year to reflect incidents

likely to occur in the community 102

Training / Disaster Drills

• From full-scale community-wide

simulations with moulage victims,

to tabletop triage scenarios, mini-

drills that test only certain

components of the disaster plan

(such as call-up of personnel), and

test of communications

103

Surge Capacity

• Ability to increase hospital bed

capacity over normal limits

• May include doubling patients in

rooms, converting acute care ward

to intensive care level unit, opening

previously closed wards, or caring

for patients in typically nonclinical

locations, such as the cafeteria 104

Communications System

• Good communications critical in

any disaster / mass casualty

• Without clear communications best

disaster plans fail

• Difficult to achieve for a variety of

reasons

• Cellular telephones, in particular,

are often overwhelmed in disasters 105

Communications System

• Disaster planning must include a

multi-tiered plan for communication

– Intrahospital: blackboard, two-way

radios, messengers/couriers

– Interhospital: citizen band groups,

cellular telephones, satellite

telephones, two-way radios

106

Decontamination

• Performed in area outside of

clinical care area of the ED

• Typically external to ED but may

be in internal locations

• Allow for removal of clothing and

cleansing of skin and hair of

patients exposed to a chemical or

radioisotope 107

Triage

• Patient entry restricted to only one

location, the triage area

• Primary function: rapid assessment

of incoming casualties, registration

and identification, assignment of

management priorities, distribution

to appropriate treatment areas

108

Treatment

• Resuscitation

• Minor treatment

• Presurgical holding / surgical triage

• Psychiatric care

• Morgue facilities

109

Field Triage

110

Start triage

Is patient breathing?

Yes No

≥30 breaths

per minute

< 30 breaths

per minute

Immediate care Is radial pulse

present?

No Yes

Open patient’s airway. Is

patient breathing?

No Yes

Dead or dying Immediate care

Control bleeding

Immediate care

Assess mental

status. Can patient

follow commands?

No Yes

Immediate care Delayed care

ED Disaster Response

• Notify nurse / physician in charge

• Discharge / transfer nonemergent

• All available litters / wheelchairs to

ambulance entrance

• Security diverts nonessential

vehicles one way flow only

111

Disaster Triage at ED

• Triage establishes priorities for

care, determines clinical treatment

area

• Triage at ED entrance, even if

done at scene

• Do most good for greatest number

• Care at triage: manually opening

airway, control external bleeding 112

Disaster Triage at ED

• Most common triage classification

in U.S. assigns patient to color-

coded category depending on

injury severity and prognosis

– Red: first priority, most urgent

– Yellow: second priority, urgent

– Green: third priority, non-urgent

– Black: dead / expectant 113

Natural Disasters

Because standard amenities, such

as power, running water, and

sanitation methods may be

unavailable for extended periods of

time, all medical disaster planning

must include practical, simple

alternatives to technologies that are

likely to fail during a disaster. 114

Disease Burden: Trauma

• Acute phase: direct trauma from

collapsing structures, flying debris

• Second spike: clean-up phase

• Most is minor

• Adequate anesthesia, blood

products, surgical equipment and

ability to sterilize them, ICU

capacity, operating rooms 115

Disease Burden: Infections

• Combination of communicable

disease and population

malnutrition is major cause of

morbidity and mortality in most

disasters, with majority of deaths

occurring in acute postevent phase

116

Disease Burden: Infections

• Respiratory illness ~20% of natural

disaster deaths in children <5yo

• Flood / tsunami: aspiration

pneumonia from inhaled

contaminated water

• Most outbreaks several weeks

postdisaster, spreads through

shelters and settlement camps 117

Disease Burden: Infections

• Both disaster victims and rescue

workers at risk for respiratory

illness due to crowded conditions

and compromised sanitation

• Tuberculosis presents a special

challenge for public health officials

118

Disease Burden: Infections

• ~40% of deaths in acute postevent

phase (80% children): diarrhea

• Water quality and availability,

sanitation, and cleaning materials

• Incidence of GI disease often

peaks several weeks after disaster,

infections are generally mild

119

Disease Burden: Chronic

• Inability to properly control chronic

diseases, such as hypertension,

diabetes, asthma, or coronary

artery disease, may well be the

biggest unanticipated health threat

to a postdisaster population

120

Disease Burden: Mental

• Often-overlooked is psychological

burden

• Post Hurricane Katrina survivors:

rates of post-traumatic stress

disorder were 10 times expected

population incidence and on par

with rates in returning Vietnam War

veterans 121

122

Impairment

• Exists when physician’s

professional performance is

adversely affected due to illness

(physical or mental), aging,

alcoholism, chemical dependence

• Generally pattern rather than single

event

123

Impairment

• Prompt and careful intervention

• Perform immediately after

precipitant event

• Nonthreatening, nonjudgmental

confrontation

• Document impaired behaviors

• Plan intervention goals in advance

• Prevent relapse 124

Wellness

• Positive work environment

• Progressive shifts of reasonable

length (<10 hours)

• Management strategies for difficult

/ violent patients

• Strengthen / maintain interpersonal

relationships: family, social

• Be financially responsible 125

126

Observation Medicine

• Extension of ED services to

address unmet patient needs

• Observation: 80% of patients sent

home without hospitalization

• Cost to evaluate and treat is half

that incurred by admission

• in inadvertent release home of

patients with serious disease 127

Observation Medicine

• Designated area to provide short-

term services for up to 24 hours

• Chest pain unit, clinical decision

unit, rapid diagnostic treatment unit

• NOT a holding unit

– Patients admitted to hospital are held

passively until inpatient hospital bed.

128

Observation Medicine

Typical complaints for evaluation

• Abdominal pain

• Chest pain

• Deep vein thrombosis

• Upper gastrointestinal bleeding

• Syncope

• Transient ischemic attack 129

Observation Medicine

Typical complaints for treatment

• Asthma

• Atrial fibrillation

• Congestive heart failure

• Dehydration

• Pneumonia

• Pyelonephritis 130

Observation Medicine

Trauma complaints for observation

• Blunt abdominal injury

• Penetrating abdominal injury

• Blunt chest trauma

• Penetrating chest injury

131

Ultrasound

• Emergency ultrasound is one of

three competency assessments

required of EM residents by the

Residency Review Committee for

Emergency Medicine

132

Ultrasound

• Trauma (FAST)

• Pelvic

• Cardiac

• Abdominal

vascular

• Biliary

• Renal

• Extremity vascular

• Thoracic / tracheal

• Ocular

• Soft tissue

• Musculoskeletal

• Transcranial

Doppler

• Testicular

• Procedure guidance

133

Multiculturism

• 2000: 12% of U.S. population

foreign born, 20% spoke language

other than English at home

• 2030: Hispanics will to 20%

• Racial and ethnic minorities in US

> 40%

134

Multiculturism

• Patients with limited English

proficiency more likely to defer

needed services, leave against

medical advice, miss

appointments, fail to adhere to

treatment regimens, lack a regular

provider

135

Disparities

• Hispanics and African Americans

receive fewer analgesics for

extremity fractures and for

musculoskeletal pain

• Opioids less likely to be prescribed

to African Americans (23%) and

Hispanics (24%) for pain relief than

whites (31%) 136

Disparities

• Mechanisms used to cope with

stress of racism shown to backfire

by adding to health risks: smoking,

substance abuse, overeating

• Disparities profiling can result in

both under- and overdiagnosis and

thus contribute to medical error

137

Alternative Care

• 1997: US population made ~629m

visits to alternative health care

providers

• 243 million more visits than to

conventional health care providers

• 44% used at least one

complementary alternative therapy

138

Role: The Good Patient…

…is acutely ill but waits patiently

until called without complaining,

requesting pain medications,

getting angry, or being disruptive

…understands the triage system and

provides a clear, concise, pertinent

history with enough information for

accurate diagnosis 139

Role: The Good Patient…

…does not take up physician time

with minor complaints, feelings, or

tangentially related information

…who does not speak English

brings someone to interpret,

someone who can bridge the

cultural divide and help with

transportation upon discharge 140

Role: The Good Patient…

…accepts invasive examinations

and procedures without protest,

agrees to admission or to a

discharge plan, does not require

long explanations of rationale for

treatment, and has a support

system in place for a safe

discharge 141

Role: The Good Patient…

…does not moan, scream for a

nurse or doctor, or act violently

…does not have family members

who are emotionally upset, stir up

trouble, or challenge providers

... share a trust, understanding, and

belief in scientific technological

medicine and its value 142

Role: The Good Patient…

…uses seat belts, maintains

personal hygiene and normal

weight, takes prescribed

medications, avoids drugs and

cigarettes, and exercises

…help maintain the flow through the

emergency department; “bad

patients” obstruct the flow 143

Role: The Good Patient…

…gets better

…“bad patients” keep coming back,

have chronic recurrent conditions,

and have confusing or difficult to

resolve problems

144

Why Do Patients Abuse Us?

1. Individuals seen in the ED don’t

need an appointment to get care

2. EDs provide sophisticated

medical technology

3. EDs operate 24 hours a day

4. ED services are often covered by

health insurance, while other

options are not 145

Why Do Patients Abuse Us?

5. EDs have a tradition of free care

6. Many communities lack culturally

competent private practitioners

7. EDs are often close to inner-city

neighborhoods, whereas many

primary care providers have

abandoned the city center

environs for the suburbs 146

147

Conclusions

• Significant overlap exists between

legal and ethical decision-making

• Physician owes duty to third party

when aware of reasonable risk to

that individual (Tarasoff)

• Capacity: individual’s ability to

make decision based on personal

values and comprehension of

consequences of that decision 148

Conclusions

• All states allow treatment of minors

for sexually transmitted diseases

• EMTALA mandates the all patients

must receive medical screening

exam and be stabilized before

transfer to another facility

• Failure to report an EMTALA

violation is itself a violation 149

Conclusions

• Competence is not the same as

capacity

• The four components of

malpractice are: duty, breach of

duty, harm, proximate cause

• Good communication skills

mitigates much malpractice

150

Conclusions

• On-scene physician who wishes to

direct care by EMS must be able to

prove identity and licensure

• Primary advantage of helicopter

transport is to reduce times

• Disaster is present when needs of

the casualties exceed available

resources 151

Conclusions

• Triage is classification of patients

into treatment priorities and is a

fluid process

• The guiding principle of disaster

triage: greatest amount of good for

the greatest number of people

• Four categories of triage: critical,

priority, delayed, expectant 152

Conclusions

• The Joint Commission requires two

disaster drills annually to reflect

incidents likely to occur in the

community

153

154