GEMC- Administration: Ethics/ Medicolegal/ EMS/ etc. - Resident Training


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This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License:

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GEMC- Administration: Ethics/ Medicolegal/ EMS/ etc. - Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Administration: Ethics/ Medicolegal/ EMS/ etc. Author(s): Joe Lex, MD (Temple University School of Medicine) License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit use. Any medical information in this material is intended to inform and educate and is not a tool for self- diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  3. 3. 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
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  6. 6. Today’s Menu • Ethics • Medico-legal • EMS • Non-hospital settings • Disaster medicine • Wellness & impairment • Nuts & bolts 6
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  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. Malfeasance / Nonmaleficence • Malfeasance: hostile, aggressive action taken to injure the patient’s interests 15
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. Using Newly Dead for Teaching • It is unethical to prolong resuscitative efforts to practice or teach procedures or to complete research protocols 21
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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. 30. 30
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. Patient Transfer • EMTALA: Emergency Medical Treatment and Active Labor Act • Applies to hospitals participating in US federally financed Medicare program 48
  49. 49. Patient Transfer • All patients must receive medical screening exam and be stabilized before considering transfer to another facility • Receiving hospital must accept transfer 49
  50. 50. 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
  51. 51. “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
  52. 52. “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
  53. 53. “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
  54. 54. “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
  55. 55. “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
  56. 56. “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
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. Reportable • Deaths: already covered • National Practitioner Data Bank: –Disciplinary action following formal peer review –Any amount paid in judgment of written malpractice claim 61
  62. 62. 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
  63. 63. Malpractice • Four components: –Duty –Breach of duty –Harm –Proximate cause 63
  64. 64. 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. 65. 65
  66. 66. 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
  67. 67. 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
  68. 68. 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
  69. 69. Manpower • EMT-I: training includes additional patient assessment plus insert IV, interpret basic ECG, administer some cardiac medications 69
  70. 70. Manpower • EMT-P: highest EMT skill level • Greater training, broader scope of practice • Function under a designated physician's medical license 70
  71. 71. 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
  72. 72. 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
  73. 73. Transportation • Most important: ambulance design allows providers to provide airway and ventilatory support while transporting patient safely 73
  74. 74. 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
  75. 75. 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
  76. 76. 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
  77. 77. 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
  78. 78. 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
  79. 79. 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
  80. 80. 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
  81. 81. 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
  82. 82. 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
  83. 83. 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
  84. 84. 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
  85. 85. 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. 86. 86
  87. 87. 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
  88. 88. 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
  89. 89. 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
  90. 90. 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
  91. 91. 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
  92. 92. FAA Mandated Equipment First Aid Equipment Bandages Stethoscope Gloves Antiseptic Sphygmomanometer BVM Ammonia Oral airways AED Splints Syringes Tape Needles Scissors IV Tubing 92
  93. 93. FAA Mandated Equipment Medications NSAIDs Epinephrine Antihistamine Lidocaine Atropine Nitroglycerin Aspirin Normal Saline Bronchodilator Oxygen Dextrose 93
  94. 94. 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
  95. 95. 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. 96. 96
  97. 97. 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
  98. 98. 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
  99. 99. 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
  100. 100. 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
  101. 101. 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
  102. 102. 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
  103. 103. 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
  104. 104. 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
  105. 105. 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
  106. 106. 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
  107. 107. 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
  108. 108. 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
  109. 109. Treatment • Resuscitation • Minor treatment • Presurgical holding / surgical triage • Psychiatric care • Morgue facilities 109
  110. 110. Field Triage 110 Start triage Is patient breathing? YesNo ≥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
  111. 111. 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
  112. 112. 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
  113. 113. 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
  114. 114. 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
  115. 115. 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
  116. 116. 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
  117. 117. 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
  118. 118. 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
  119. 119. 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
  120. 120. 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
  121. 121. 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. 122. 122
  123. 123. 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
  124. 124. Impairment • Prompt and careful intervention • Perform immediately after precipitant event • Nonthreatening, nonjudgmental confrontation • Document impaired behaviors • Plan intervention goals in advance • Prevent relapse 124
  125. 125. 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. 126. 126
  127. 127. 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
  128. 128. 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
  129. 129. Observation Medicine Typical complaints for evaluation • Abdominal pain • Chest pain • Deep vein thrombosis • Upper gastrointestinal bleeding • Syncope • Transient ischemic attack 129
  130. 130. Observation Medicine Typical complaints for treatment • Asthma • Atrial fibrillation • Congestive heart failure • Dehydration • Pneumonia • Pyelonephritis 130
  131. 131. Observation Medicine Trauma complaints for observation • Blunt abdominal injury • Penetrating abdominal injury • Blunt chest trauma • Penetrating chest injury 131
  132. 132. Ultrasound • Emergency ultrasound is one of three competency assessments required of EM residents by the Residency Review Committee for Emergency Medicine 132
  133. 133. Ultrasound • Trauma (FAST) • Pelvic • Cardiac • Abdominal vascular • Biliary • Renal • Extremity vascular • Thoracic / tracheal • Ocular • Soft tissue • Musculoskeletal • Transcranial Doppler • Testicular • Procedure guidance 133
  134. 134. 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
  135. 135. 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
  136. 136. 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
  137. 137. 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
  138. 138. 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
  139. 139. 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
  140. 140. 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
  141. 141. 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
  142. 142. 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
  143. 143. 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
  144. 144. Role: The Good Patient… …gets better …“bad patients” keep coming back, have chronic recurrent conditions, and have confusing or difficult to resolve problems 144
  145. 145. 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
  146. 146. 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. 147. 147
  148. 148. 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
  149. 149. 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
  150. 150. 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
  151. 151. 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
  152. 152. 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
  153. 153. Conclusions • The Joint Commission requires two disaster drills annually to reflect incidents likely to occur in the community 153
  154. 154. 154