Traumatically injured Jehovah's Witnesses: a sixteen-year experience of treatment and transfusion dilemmas at a level I trauma center.

Traumatically injured Jehovah's Witnesses pose difficult management problems because of their refusal to accept blood transfusions. This retrospective review of all inpatient traumatically injured Jehovah's Witnesses at a level I trauma center over the past 16 years revealed 77 patients with 92% blunt and 8% penetrating injuries. The primary physician was aware of their unique religious status in only 32% of cases. Transfusion was performed in only 4 (5.2%) cases even though it was desired by the physician in 11 (14%) cases. One transfusion was performed against the patient's will. One minor was transfused using a court order. Two transfusions were performed in the trauma room before the patients' religious status was known. Major changes in therapeutic plans were made as a result of the patients' Jehovah's Witness status in 10 cases (13%). Early knowledge of the patient's religious status is essential to optimize patient care.

Tactical emergency medical services: an emerging subspecialty of emergency medicine.

Law enforcement agencies are recognizing the need to have emergency medical care available at the scene of any incident involving tactical operations. The potentially volatile and dangerous atmosphere surrounding tactical operations is conducive to severe injury to officers, hostages, suspects, and bystanders. This mandates the immediate availability of basic and advanced life support services. However, a purely traditional approach to emergency medical services in the tactical environment may not be feasible and may expose prehospital personnel to greater danger. It also may disrupt the law enforcement mission. These factors mandate a different set of field assessment and treatment priorities. To meet these needs, selected prehospital personnel and emergency physicians train to work with and support special weapons and tactics teams.

Psychological reaction to hospitalization and illness in the emergency department.

Each personality type presents with different methods of coping. Physicians should be aware of the impact on a patient's psychological functioning and ability to cope with illness and hospitalization, to understand and more effectively manage the patient. The physician must try to assess the patient's baseline personality from their past and present behavior. Establishing a good physician-patient relationship is important as a source of information about behavior of patients and how they will respond to their illness. Depending on the specific personality type, each patient will respond differently to the stress of illness. The effort of the emergency physician to identify personality types will aid in medical management of the patient and enable the physician to help each patient cope effectively with the illness and the hospitalization. The specific issues that seem to be threatening to traumatized patients include the following: helplessness, humiliation, blurring of body image, and gaps in memory filled with distortions. The traumatized patient experiences an altered state of consciousness which is either due to a physiologic cause or an emotional cause. Emotional causes are usually based on defensive dissociation. People who have been in an auto accident characteristically report loss of memory of the intense pain that the accident produces initially. Oftentimes, the core experience for the traumatic patient is not somatic, it is unconscious. The interesting feature is that so many patients do not remember the accident. The mind seems to be filled with all kinds of distortions and irrelevant and perhaps totally inconsistent fantasies, such as imprisonment, confinement, or deathlike experiences. Some report that they are being incarcerated, others recall being in a featureless cubicle with no contact with the normal world in which there are no windows, no pictures, no flowers. Others remember only being surrounded by masked, hatted, uniformed wardens who are standing over them with nasogastric tubes, intravenous lines, Foley catheters, arterial blood gases, subclavians, and dermal cut-downs. This is an overwhelming nightmare that can be relieved only by the empathic and caring physician and emergency department staff. The stress of medical illness and/or hospitalization can be overwhelming for some patients and is usually followed by some form of psychological response. Current understanding of the psychological impact of illness is based upon psychological defenses, coping mechanisms, and individual personality. It is the ability of the emergency physician to identify defenses, coping skills and personality types that will aid him or her in the medical management of the patients in their time of illness and hospitalization.