CONFERENCE NOTES 7-31-2012
CHASTAIN/GIRZADAS ORAL BOARDS
n CASE 1: Ethylene glycol poisoning.
n Intubate (PC)
n Treat with 4-Methyl Pyrazole ( fomepizole 15 mg/kg) or ETOH (PC,MK)
n Arrange Hemodialysis (MK,SBP)
n Give Antibiotics for aspiration pneumonia (MK, PC)
n Anion Gap= Na-(CL + HCO3)<15
n Osmolal Gap= 2X Na + Glucose/18(20) + BUN/2.8(3) + ETOH/4.6(5)
n Measured Value - Calculated Value <20
CASE 2: Femoral artery injury due to GSW
n IV fluid bolus 20ml/kg (PC)
n PRBC transfusion 15ml/kg (MK, SBP)
n Identify Hard Signs of vascular injury and perform ankle/brachial index (MK)
n Trauma/Vascular surgery consultation (SBP, PC)
n Hard signs of vascular injury mandate angiography or surgery.
n Pulsatile bleeding
n Pulsatile hematoma
n Absent/diminished pulse distal to injury=ABI<0.9
n Ischemic signs (pain, pallor, coolness, paralysis)
CASE 3: Pyloric Stenosis
n Consider Pyloric Stenosis (pmh, olive, BMP, U/S, Upper GI) (PC,MK)
n IV hydration (20ml/kg)
n Admission for planned surgery (SBP)
n Hypo-chloremic/kalemic/natremic metabolic alkalosis
n Today most are diagnosed prior to electrolyte abnormalities
n Males more common 5:1
n Associated with macrolide antibiotics
n Laproscopic Pyloromyotomy
WOOD MEDICAL-LEGAL ASPECTS OF EM
Philosophy: the study of questions that can’t be answered. Religion:the study of answers that can’t be questioned.
Case 1 Chronically ill elderly patient with hypoxia. Husband wants everything done. Autonomy is the primary ethical rule but pt’s have to have understanding. If pt can’t make decision. There is a principal of implied consent in situations of emergency. Husband has the power to decide for wife. But what if husband is demanding futile care? Decision making can only be taken away from husband if he lacks decisional capacity. Answer is to inform husand that further work up/treatment may worsen suffering and palliative care may lessen suffering. It is ok to discontinue ventilator. There is no distinction between action and inaction. Taking patient off ventilator is acceptable. It is ok to give small doses of opioids/benzodiazepines to relieve suffering. Don’t give a large dose that could kill a terminal patient. Document how the patient looks and document your intent to relieve suffering.
Case 2 Man found unresponsive in his car. He is a nurse who is abusing oxycontin. It is ok for doctors to speak with other MD’s if it is in the context of treating the patient. Confidentiality is well supported by law and custom but it is not absolute. Exceptions exist due to societal interest. Doctors are required to report child abuse or turn in weapons. Doctor-patient relationship is much less protected legally than attorney-client relationship. The doc has a duty to turn drugs (evidence) over to the police or security. You are more likely to get sued for not reporting something than for reporting something.
How do you determine decisional capacity. If you have a 0.8 etoh level, there is a legal presumption that you have lost the psycho-motor skill to operate a car. There is NOT the legal presumption that a patient gives up all their rights to leave the ED as long as they are not driving. An etoh level above 0.8 is not grounds alone to forcibly restrain a patient from leaving the ED.
Case 3 16yo female who had sexual encounter. Doctor refused to give post-coital contraception based on his own moral code. There is no statute in any state that says you must be 18yo to consent for medical care. No doctor has ever been successfully sued for non-negligent treatment of kids over 14 without consent from parents. 32 states have a statute saying it is ok for docs or pharmacists to not tell a patient about contraceptive/abortion options if it is against their conscience. If a patient asks the doc if there is a morning after pill option for her, the doc can’t lie and say there isn’t.
Dr. Woods Notes: Notes and Bibliography
Legal and Ethical Issues in Clinical practice.
Joseph P. Wood, M.D.,J.D
Principles of medical ethics
A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
A physician shall support access to medical care for all people.
Adopted by the AMA's House of Delegates June 17, 2001.
Case of Patient in a Vegetative State
Any person with an illness that is not able to function properly without artificial help.
As opposed to brain death and comatose, PVS is not recognized as death in any legal system. This ethical grey area has led to several court cases involving people in a PVS, those who believe that they should be allowed to die, and those who are equally determined that, if recovery is possible, care should continue. This ethical issue raises questions about autonomy, quality of life, appropriate use of resources, the wishes of family members, professional responsibilities, and many more.
The syndrome was first described in 1940 by Ernst Kretschmer who called it apallic Syndrome. The term persistent vegetative state was coined in 1972 by Scottish spinal surgeon Bryan Jennett and American neurologist Fred Plum to describe a syndrome that seemed to have been made possible by medicine's increased capacities to keep patients' bodies alive.
Terminology in this area is somewhat confused. While the term persistent vegetative state is the most frequent in media usage and legal provisions, it is discouraged by neurologists, who favour the terminology of the Royal College of Physicians (RCP) which refers only to the vegetative state, the continuing vegetative state, and the permanent vegetative state.
The vegetative state is a chronic or long-term condition. This condition differs from a persistent vegetative state (PVS, a state of coma that lacks both awareness and wakefulness) since patients have awakened from coma, but still have not regained awareness. In the vegetative state patients can open their eyelids occasionally and demonstrate sleep-wake cycles. They also completely lack cognitive function. The vegetative state is also called coma vigil. The continuing vegetative state describes a patient's diagnosis prior to confirmation of the permanence of the condition. The permanent vegetative state occurs when the vegetative state is deemed permanent; a prediction is being made that the patient will never recover awareness. This prediction cannot be made with absolute certainty. However, the chances of regaining awareness diminish considerably as the time spent in the vegetative state increases (Royal College of Physicians, 1996).
This typology distinguishes various stages of the condition rather than using one term for them all. In his most recent book The Vegetative State, Jennett himself adopts this usage, on the grounds that "the 'persistent' component of this term ... may seem to suggest irreversibility". The Australian National Health and Medical Research Council has suggested "post coma unresponsiveness" as an alternative term.
Signs and symptoms
Most PVS patients are unresponsive to external stimuli and their conditions are associated with different levels of consciousness. Some level of consciousness means a person can still respond, in varying degrees, to stimulation. A person in a coma, however, cannot. In addition, PVS patients often open their eyes, whereas patients in a coma subsist with their eyes closed (Emmett, 1989).
PVS patients' eyes might be in a relatively fixed position, or track moving objects, or move in a disconjugate (i.e. completely unsynchronized) manner. They may experience sleep-wake cycles, or be in a state of chronic wakefulness. They may exhibit some behaviors that can be construed as arising from partial consciousness, such as grinding their teeth, swallowing, smiling, shedding tears, grunting, moaning, or screaming without any apparent external stimulus.
Individuals in PVS are seldom on any life-sustaining equipment other than a feeding tube because the brainstem, the center of vegetative functions (such as heart rate and rhythm, respiration, gastrointestinal activity), is relatively intact (Emmett, 1989).
(Available on Wikipedia.org with essentially no copyright restrictions).
Conflict with Surrogate Decision-Maker
1) Baruch Brody, Special Ethical Issues in the Management of PVS Patients, 20 L., Med. And healthcare 104 (1992)
2) In Re Wanglie, No. PX-91-283 (Minn.D.Ct. June 28, 1991)
(Hospital sought order to replace Husband as the surrogate decision-maker. Court did not address the substance of the decisions made by the Husband finding that the only materially relevant question was whether the Husband was in the best position to know what the patient would want done if she was able to speak for herself).
3) “The Physician-Surrogate Relationship” Archives of Internal medicine, June 11, 2007
4) “Time to Move Advance Care Planning Beyond Advance Directives” Chest 2000
May a Physician Sedate a Terminally ill Patient to the Point of Unconsciousness?
5) Vacco v. Quill, 117 S. CT. 22293 (US 1997)
6) Quill, T. E., Byock, I. R., for the ACP-ASIM End-of-Life Care Consensus Panel. Responding to
intractable terminal suffering: the role of terminal sedation and voluntary refusal of food and fluids.
Ann Intern Med. 2000;132:408-414.
7) See CEJA Report 5-A-08 Referred to Reference Committee on Amendments to Constitution and Bylaws (Available at www.ama-assn.org)
Privacy and Confidentiality
45 CFR 164.506(a) Healthcare entities (Hospitals, Doctors etc.) May share otherwise protected information on patient if purpose is to facilitate care.
45 CFR 164.510(b) May share information with family or close friend if this facilitates care and patient does not object.
For a good summary of HIPPA go to:
Treatment of Minors
“Informed Consent to the Treatment of Minors” Schlam and Wood, Journal of Law-Medicine Vol. 10 Number 2, Summer 2000 (Case Western Reserve University School of Law)
Healthcare Provider’s Right to Follow Their Conscience.
Curlin, Lawrence, Chin, Lantos: Religion, Conscience, and Controversial Clinical Practices; N Engl J Med 2007; 356: 593-600
(745 ILCS 70/) Health Care Right of Conscience Act.
(745 ILCS 70/2) (from Ch. 111 1/2, par. 5302)
Sec. 2. Findings and policy. The General Assembly finds and declares that people and organizations hold different beliefs about whether certain health care services are morally acceptable. It is the public policy of the State of Illinois to respect and protect the right of conscience of all persons who refuse to obtain, receive or accept, or who are engaged in, the delivery of, arrangement for, or payment of health care services and medical care whether acting individually, corporately, or in association with other persons; and to prohibit all forms of discrimination, disqualification, coercion, disability or imposition of liability upon such persons or entities by reason of their refusing to act contrary to their conscience or conscientious convictions in refusing to obtain, receive, accept, deliver, pay for, or arrange for the payment of health care services and medical care.
(Source: P.A. 90‑246, eff. 1‑1‑98.)
(745 ILCS 70/6) (from Ch. 111 1/2, par. 5306)
Sec. 6. Duty of physicians and other health care personnel. Nothing in this Act shall relieve a physician from any duty, which may exist under any laws concerning current standards, of normal medical practices and procedures, to inform his or her patient of the patient's condition, prognosis and risks, provided, however, that such physician shall be under no duty to perform, assist, counsel, suggest, recommend, refer or participate in any way in any form of medical practice or health care service that is contrary to his or her conscience.
Nothing in this Act shall be construed so as to relieve a physician or other health care personnel from obligations under the law of providing emergency medical care.
(Source: P.A. 90‑246, eff. 1‑1‑98.)
A Simpler Ethical Code:
Harry Truman was a different kind of President. He probably made as many important decisions regarding our nation's history as any of the other 42 Presidents. However, a measure of his greatness may rest on what he did after he left the White House.
The only asset he had when he died was the house he lived in, which was in Independence Missouri His wife had inherited the house from her mother and other than their years in the White House, they lived their entire lives there.
When he retired from office in 1952, his income was a U.S. Army pension reported to have been $13,507.72 a year. Congress, noting that he was paying for his stamps and personally licking them, granted him an 'allowance' and, later, a retroactive pension of $25,000 per year.
After President Eisenhower was inaugurated, Harry and Bess drove home to Missouri by themselves. There was no Secret Service following them.
When offered corporate positions at large salaries, he declined, stating, "You don't want me. You want the office of the President, and that doesn't belong to me. It belongs to the American people and it's not for sale."
Even later, on May 6, 1971, when Congress was preparing to award him the Medal of Honor on his 87th birthday, he refused to accept it, writing, "I don't consider that I have done anything which should be the reason for any award, Congressional or otherwise."
As president, he paid for all of his own travel expenses and food.
Modern politicians have found a new level of success in cashing in on the Presidency, resulting in untold wealth. Today, many in Congress also have found a way to become quite wealthy while enjoying the fruits of their offices. Political offices are now for sale.
Good old Harry Truman was correct when he observed, "My choices in life were either to be a piano player in a whorehouse or a politician. And to tell the truth, there's hardly any difference."
AAEM is an outstanding organization representing the board certified emergency physician.
GARRET-HAUSER ETHICAL ISSUES
Breaking Bad News: Ask patient what they are concerned about. It may help discuss bad news.
Warn the patient that bad news is coming. Use non-technical terms so patient can understand. Anticipate the level of their understanding.
ED conversations with patients can veer toward being too blunt due to time constraints. Be cautious about being too blunt. Give enough time to be human with the patient or family.
C. Kulstad comment: When discussing concerning test results like a lung mass on ct, We have an obligation to tell the patient that the most likely diagnosis is cancer based on the test findings. Other faculty agreed with this.
Tell patients what the next step is going to be.
Telling family that someone died: Find out who the family members are in the room. Get some info from family if you need it before you tell them the person died. Gotta use the word dead, died or death so families fully understand the irrevocable nature of the situation.
Family requests for non-disclosure of results to the patient: Ask the family why the request is being made. Negotiate with the family the best way to handle this situation. You can ask the patient if they prefer to get the infothemselves or discuss with the family. You may want to inform families of the standard of truthfulness with patients in this country. You have a duty to ask patients how they want medical information handled. If they want the info given to them, you need to give it to them despite the family’s wishes.
Power of Attorney gives the surrogate the same decisional capacity as the patient would normally have. There cannot be 2 powers of attorney. It can only be one person. There can be a successor named but they cannot make decisions if the power of attorney is present.
Surrogate act allows spouse, adult children or moving down the hierarchy, other family members or close friends to make decisions for a patient with a qualifying condition who doesn’t have decisional capacity.
To fill out the form to withdraw care (like taking out the ET tube or taking out feeding tube) you need two docs to sign off the WITHDRAWL OF CARE FORM that patient has a terminal condition.
Harwood comment: Utilize ethics committee to help with management of difficult clinical decisions when there is some time. Also when breaking news to a family that a patient has died he prefers tell them the patient has died very early in the conversation.
KUTKA M AND M TRAUMA
21yo male shot in buttock.
Get prepared prior to patient arrival even if the EMS report on the radio says “stable vitals”
DDX of Combative behavior: guy is a jerk, intoxication, hypoperfusion. Assume hypoperfusion until proven otherwise.
Even if bleeding seems venous don’t downplay the volume or significance of the blood loss.
Even if it appears to be a “simple” trauma don’t treat it like that. Treat aggressively and discuss your concerns with attending.
When giving blood products in a bleeding patient be sure to give enough prbcs AND ffp and platelets. Follow the massive transfusion protocol.
Criteria for Massive Transfusion: Penetrating mechanism, positive fast, arrival BP<90, arrival HR>120. 2criteria=40% chance and 4criteria=100% chance of needing massive transfusion.
When breaking bad news: discuss with Chaplain, have security with you, limit the # of family members in the quiet room, make sure you have an exit strategy.
Barounis comment: If you order the massive transfusion protocol and don’t use all the blood, it will be sent back to the blood bank to be used again.