Best practice guideline for patients requiring discharge against medical advice from emergency department

Discharge against medical advice remains a problematic issue worldwide because it may not only lead to adverse medical outcomes for the patients but also medicolegal problems for emergency physicians. Recently, there have been cases in Korea in which a patient in the emergency room, who had been discharged from hospital without following medical instructions, filed a lawsuit against the hospital and emergency medical staff for their responsibility for their worsening disease since discharge. The court acknowledged the responsibility of the medical staff. To minimize the legal risk and reach the optimal ethical standard for these patients, this paper suggests the best practice guideline for the emergency physicians for patients who request discharge against medical advice from the emergency department in Korea.

Postmenopausal Spontaneous Umbilical Endometriosis: A Case Report

Endometriosis is a benign gynecologic disease that highly influences women of childbearing age. It is characterized by ectopic endometrial tissue. Primary umbilical endometriosis is a rare condition. It is a benign disease with endometrial tissue in an abnormal site in the navel. It may be accompanied with pain in the navel and a discolored bump. Among all locations with the potential for endometriosis, the navel has less than 1% incidence of primary umbilical endometriosis. In the present study, we reported a rare case of umbilical endometriosis revealed via a biopsy performed for a 49-year-old menopausal woman with the complaint of pain in the navel who underwent surgical excision and a biopsy after a scan.

A Retrospective Analysis to Determine Criteria for Termination of Resuscitation (TOR) for a Patient with an Out-of-Hospital Cardiac Arrest (OHCA) who Presents at the Emergency Department (ED)

PURPOSE: As public awareness of medical futility increases, more studies on pronouncement of death and related protocols in the field have been conducted overseas. However, it appears to be hard to declare death in the field in Korea due to a lack of proper treatment procedures for patients with out-of-hospital cardiac arrest (OHCA) under the current emergency medical service (EMS) system. As such, the objective of this study was to establish criteria to determine whether to perform cardiopulmonary resuscitation (CPR) for a patient who visits the ED with OHCA. METHODS: CPR results over an 8-year period, from January 2001 to December 2008, from patients with OHCA at Ewha Womans University, Mokdong Hospital were analyzed. The main factors affecting patients that survived for 24 hours after return of spontaneous circulation (ROSC) were identified retrospectively. RESULTS: A total of 782 patients visited the hospital due to OHCA during the study period. Of these, 752 met the inclusion criteria for our study. Of the 752, 162 (21.5%) survived over 24 hours after ROSC. Of the 752, 38 (5.1%) survived to hospital discharge and 18 (2.4%) survived to hospital discharge with good neurologic function. Among patients who survived over 24 hours after ROSC, factors that predicted survival included the presence of a witness (p<0.001), the implementation of CPR by a bystander (p=0.012), a short time from being found to time of arrival at the hospital (p<0.001) and younger age (p=0.042). Factors that predicted non-survival included no witness at the time of cardiac arrest, a prehospital time longer than 20 minutes, bystander CPR but the initial rhythm was asystole. The positive predict value was 95.6%. CONCLUSION: When an individual has an out-of-hospital cardiac arrest, termination of resuscitation should be considered when there are no witnesses, when there was no bystander to administer CPR, when the initial rhythm was asystole, and when prehospital time was longer than 20 minutes.

Law and Ethics in Emergency Medicine

Ethical problems in an emergency department (ED) are much more common than is usually recognized. But these difficult ethical dilemmas have not been dealt with by general medical ethicists. Most medical ethics guidelines tend to concentrate on chronic or at least relatively stable situations rather than on the acute, episodic cases that are typical in the ED. most ethical problems such as abortion, euthanasia, and professionalism can be solved after reflection and deliberation, and after a process of communication that reveals the values and interests of the patient or the patient's family. In contrast, when health care professionals in the ED recognize ethical problems, they often don't have enough time for an ethical consultation such as a Hospital Ethics Committee. Ethical principles such as autonomy, beneficence, nonmaleficence, and justice need to be applied to the unique setting of emergency medicine. Hence, it is necessary to develop ethics guidelines in emergency medicine and ethics education for health care professionals in emergency departments. At first, we collected cases involving ethical problems and reviewed the ethical and legal aspects of those cases. In this article, we summarize the ethical issues in emergency medicine, deal with actions in emergency medical services, and also consider the relationships between ethical issues and act on emergency medical services. We want to present the important factors that should be considered in ethical decision making within an emergency medicine department including patient decision making capacity, legal custody, and ethical principles.

The Effectiveness of Operating Fast Track by Board Certified Emergency Physician in Emergency Medical Center of Teaching Hospital

PURPOSE: The main reasons for overcrowding of the Emergency Department (ED) in Korea were delay in the department's decision making and entrance of non-emergency patients. The purpose of this study is to determine how primary care and in-hospital triage by board certified emergency physician can shorten the patients's length of stay and relieve overcrowding in the ED. METHODS: A prospective analysis of patients who visited the ED of a 700-bed tertiary care teaching hospital during holidays from April 2, 2006 to October 3, 2006 was done. We differentiated patients into a fast tract group and a non-fast tract group. Data compared were lengths of stay, decision time, number of unscheduled returns, and patient disposition. RESULTS: The patients in the fast track group have significantly shorter decision time than the 1,159 patients in the non-fast track group (p<0.01). The disposition decision time of the fast track group was shorter than the non-fast track group by an average of 29 minutes. The total residence time of the fast tract group was shorter by an average of 26 minutes than the non-fast tract group. The difference in decision time (disposition decision time and residence time) was larger in the patients that were discharged from the ED. There was no unscheduled return. CONCLUSION: This study demonstrates that setting up a fast track system run by a board certified emergency physician could be one of the solutions in minimizing ED being crowding by patients with non-emergency problems. Fast track system could shorten total residence time about 26 minutes.

Utility of Cuff Palpation in the Verification of Endotracheal Tube Positioning

PURPOSE: To confirm the utility of cuff palpation for the verification of the correct endotracheal tube position. METHODS: One hundred and one intubated patients were selected randomly every three days among the 344 intubated patients in the emergency room of a tertiary care hospital between July 2006 and March 2007. After endotracheal intubation was confirmed, we recorded the probability of successful cuff palpation. We also measured the patient's weight, height and neck length; the distance from ETT tip to the incisors, and distance from ETT tip to the carina of the patients. Sedatives or muscle relaxants that used were used were noted as well. RESULTS: In the cuff palpated group (n=61), 40 patients' had the ETT tip at 3~5cm from the carina while in the nonpalpated group (n=40), 35 patients had the ETT tip placed at less than 3 cm or more than 5 cm from the carina (p value <0.001). The cuffs of the ETTs inserted in patients whose neck lengths were below 10 cm were less palpable than in patients whose neck lengths were more than 10 cm.(p=0.004) There was no relation between cuff palpability and height, BMI and use of muscle relaxant or sedatives. In addition, 9 of 10 cases whose cuffs were non-palpable, which were randomly chosen among the non-palpated group (n=40) with incorrectly positioned cuff became palpable after the repositioning of the ETT. CONCLUSION: We concluded that cuff palpation is a simple and reproducible way to verify the correct depth of endotracheal tubes.

Death due to Sepsis in Emphysematous Cholecystitis

Emphysematous cholecystitis is an uncommon but life-threatening form of acute cholecystitis that is caused by gas- forming organisms such as Clostridia species, Escherichia coli, Klebsiella, and anaerobic streptococci. Emphysematous cholecystitis frequently affects elderly men, and is associated with diabetes mellitus. The risk of gangrene and perforation of the gallbladder is relatively high in emphysematous cholecystitis patients, and there is a 15% mortality compared with the 4% for acute cholecystitis. We report here a case of emphysematous cholecystitis in a 56-year-old woman, who had diabetes for 10 months. The patient presented with right upper abdominal pain and chills. The abdominal plain film showed a mottled gas pattern in the right upper quadrant. The laboratory value revealed massive intravascular hemolysis. The patient deteriorated rapidly during the course of the evaluation and required cardiopulmonary resuscitation. Despite the attempts to resuscitate the patient, she died 9 hours after the onset of symptoms.

Rational Use of Antimicrobial Agents in Traumatic Simple Wounds

PURPOSE: The primary goal of wound management is to avoid infection. Wounds in all patients presenting to the Emergency Department are contaminated with bacteria. Despite this, there is a low incidence of infection. Unfortunately, physicians continue to use antimicrobial agents indiscriminately. The authors intended to determine the effect of selective antimicrobial agents and the indications for appropriate antimicrobial agent use in traumatic simple wounds. METHODS: This prospective study was performed from Jul. 2005 to Aug. 2005. A pilot study had been performed from Nov. 2003 to Jul. 2004 at the Ewha Woman's University Mokdong Hospital. Structured data sheets were completed at the times of the patient's visits to the Emergency Department and to the Outpatient Department for follow-up. Infection was determined at the time of follow-up. The indications of antimicrobial agent use are immunocompromised patients, wounds contaminated for 3 hours or longer, devitalized tissue, and extremity wounds except hand wounds caused by sharp objects. RESULTS: The study enrolled 216 injured patients. The general characteristics of patients and wounds between the two groups were not significantly different. The antimicrobial agent use and infection rate of the pilot study were 227 cases (90.4%) and 10 cases (4.0%), and those of this study were 100 cases (46.3%) and 9 cases (4.1%). In this study, antibiotic use was reduced to almost half compared with the previous study, but the infection rate was similar (p<0.001). CONCLUSION: Rational use of antimicrobial agents in simple wounds reduced the use of antimicrobial agents in the Emergency Department without increasing the infection rate.

Study of the Appropriateness of 11 9 Rescue Usage

PURPOSE: In order to elicit efficient and effective operation of the Korean Emergency Medical Service System, we observed patients brought in by way of the Emergency Center by 119 ambulances and analyzed the appropriateness of the transport and the level of emergency care provided. METHODS: For the month of August 2002, patients who visited a university hospital emergency unit in Seoul were separated and evaluated according to the study protocols. The appropriateness of the 119 transport was based on a patient questionnaire and an evaluation of medical records and was categorized as follows; 1) need for emergency care or urgency/emergency transport by 119 ambulance, 2) need for emergency care or urgency/emergency transport by non 119 ambulance, 3) no need for emergency care or subemergency/nonemergency transport by 119 ambulance, 4) no needs for emergency care or subemergency/ nonemergency transport by non 119 ambulance. Of these, category 1 is viewed as the appropriate level of transport to the hospital emergency unit by 119 rescuers whereas category 3 is considered inappropriate transportation by 119 rescuers. The analysis of the appropriateness of the level of emergency care was based on sorting patients into 5 service categories; 1) emergency care required - appropriate operation, 2) emergency care required - no operation, 3)emergency care required - inappropriate operation, 4) no emergency care required - operation, 5) no emergency care required - no operation. Within these, categories 1 and 5 are considered appropriate and categories 2, 3 and 4 as inappropriate. RESULTS: Over the course of the study, 1,376 out of 1,451 patients transported to the hospital emergency unit qualified to be included under study protocols. Among them, the proportion of patients who needed emergency care or urgency/emergency transport was 22.8% (314 patients), and the proportion of those who received appropriate transport by the 119 emergency team was 62.6% (196 patients). Among the 282 patients who were transported by 119 emergency teams, in 195 patients (69.1%), emergency care was indicated while only 81 of the 195 patients (41.5%) received operations with an emergency or critical level of care. Of these 81, 47 patients (58.0%) received the appropriate operation. Therefore, the overall appropriateness of emergency care was 45.0% (127 patients), including emergency care required - appropriate operation (47 patients) and no emergency care required - no operation (80 patients). CONCLUSION: From this study, the appropriateness of transport by 119 rescuers is 62.6% but if subemergency cases are included, the appropriateness of transport increases to 95.2%. However, the appropriateness of care is only 45.0%, implying a need for continuing training for 119 emergency medical technicians and further organization of the medical control system.