Behçet's disease in patients of west African and Afro-Caribbean origin.

AIM: To report the presence of Behçet's disease with ocular involvement in patients of west African or Afro-Caribbean origin. METHODS: Case series of eight patients reporting to a tertiary uveitis service. RESULTS: Eight patients with typical features of the disease are presented. Six of the eight patients were tested and found to be HLA-B51 negative. CONCLUSION: Behçet's disease has only been reported in sporadic case reports in the indigenous west African and Afro-Caribbean populations, in whom the incidence of HLA B51 is also very low. A series of patients from the London region presented with the typical symptoms and signs of disease, most of whom were also HLA B51 negative. The presence of disease in this population, when absent in the indigenous population, suggests either that ascertainment of disease is poor in the indigenous population or that acquired factors may be important in the aetiology of the disease.

The Emergency Medical Treatment and Labor Act as a federal health care safety net program.

Despite the greatest economic expansion in history during the 1990s, the number of uninsured U.S. residents surpassed 44 million in 1998. Although this number declined for the first time in recent years in 1999, to 42.6 million, the current economic slow-down threatens once again to increase the ranks of the uninsured. Many uninsured patients use hospital emergency departments as a vital portal of entry into an access-impoverished health care system. In 1986, Congress mandated access to emergency care when it passed the Emergency Medical Treatment and Labor Act (EMTALA). The EMTALA statute has prevented the unethical denial of emergency care based on inability to pay; however, the financial implications of EMTALA have not yet been adequately appreciated or addressed by Congress or the American public. Cuts in payments from public and private payers, as well as increasing demands from a larger uninsured population, have placed unprecedented financial strains on safety net providers. This paper reviews the financial implications of EMTALA, illustrating how the statute has evolved into a federal health care safety net program. Future actions are proposed, including the pressing need for greater public safety net funding and additional actions to preserve health care access for vulnerable populations.

Doing unto others? Emergency medicine residents' willingness to be treated by moonlighting residents and nonphysician clinicians in the emergency department.

OBJECTIVE: Contentious moonlighting policies and the proliferation of nonphysician clinicians (NPCs) in academic emergency departments (EDs) send conflicting messages to emergency medicine (EM) residents regarding appropriate ED staffing patterns. The objective was to assess EM resident (EMR) views on the ED utilization of unsupervised residents and NPCs from their perspectives as both physicians and prospective patients. METHODS: A survey was mailed to a random sample of senior EMRs (sampling fraction, 68%) from the Emergency Medicine Residents Association membership list. Respondents were instructed to assume the role of patient when presented with hypothetical clinical scenarios of increasing severity; outcomes included provider preferences and the impacts of medical urgency, time delays, costs, and supervision on those preferences. Survey items asked about willingness to see residents, nurse practitioners (CRNPs), and physician assistants (PAs), and perceived impact of NPCs on professional identity. RESULTS: A total of 251 EMRs responded. Senior EMRs are more willing to have their care handled by residents as opposed to mid-level providers. For a moderate illness or injury scenario, 54% agreed to be seen by a resident alone compared with only 17% and 24% willing to be seen by a CRNP and PA, respectively. Only a small fraction of the residents (22.7%) would allow another resident to treat them for a major injury or illness. Residents are more willing to be seen by mid-level providers if a savings in time can be realized but showed little interest in using NPCs to save money. Approximately one-third (34%) of the residents view mid-level providers as a professional threat, but logistic regression reveals this perception to be 2.25 (1.3, 4.0) times higher in male EMRs and 1.94 (1.1, 3.4) times higher in those with higher household incomes (> or =$75,000). CONCLUSIONS: When assuming the patient role, senior EMRs have preferences for ED care that are consistent with restrictive EMR moonlighting and NPC staffing policies.

A randomized comparison of helium-oxygen mixture (Heliox) and racemic epinephrine for the treatment of moderate to severe croup.

OBJECTIVE: To compare the additive effect of a helium-oxygen mixture (Heliox) or racemic epinephrine (RE) on croup scores (CSs) in children with moderate to severe croup treated with humidified oxygen and steroids. Design. A prospective, randomized, double-blind trial. SETTING: Emergency department and pediatric intensive care unit of an urban level I trauma center. PARTICIPANTS: Randomly assigned, consecutive children ages 6 months to 3 years presenting with moderate to severe croup (CS: >/=5). Interventions. After cool humidified oxygen and 0.6 mg/kg of intramuscular dexamethasone, patients were randomized to receive either Heliox or RE. Vital signs, oxygen saturation, and CSs were recorded at regular intervals. OUTCOME/ANALYSIS: Reductions in CSs were compared using repeated-measures analysis of variance. RESULTS: Thirty-three patients were enrolled. Three were excluded because of protocol violations, and 1 was excluded because of lack of documentation, leaving 29 patients for final analysis. The average age was 24.2 months, 20 were male (68.8%). Both Heliox and RE were associated with improvement in CSs over time. There were no significant differences in mean CS, oxygen saturation, respiratory rate, or heart rate between groups at baseline or at the end of the treatment period. CONCLUSION: In patients with moderate to severe croup, the administration of Heliox resulted in similar improvements in CS compared with patients given RE.

Emergency determination of decision-making capacity: balancing autonomy and beneficence in the emergency department.

The determination of decision-making capacity (DMC) is an essential component of securing voluntary informed consent, for either treatment or refusal of care. Decision-making capacity should be determined on some level during each patient encounter. Decision-making capacity includes the ability to receive, process, and understand information, the ability to deliberate, the ability to make choices, and the ability to communicate those preferences. For patients in whom DMC may be uncertain, a more explicit approach to determination of DMC is recommended. However, DMC determination must neither compromise patient safety nor delay needed care. When DMC determination is challenging, or when the ramifications of a decision are serious, the assistance of a third party (such as a surrogate, a consultant, or another clinician) may be valuable in discerning the most appropriate action. In addition to the obvious clinical utility of DMC assessment, the steps taken in the very establishment of DMC may promote patient trust, professionalism, and humanistic clinical practice. While DMC may be conditional, the compassion and respect we have for our patients must be unconditional.

Ethics seminars: beyond authorship requirements-ethical considerations in writing letters of recommendation.

Letters of recommendation may serve a number of vital functions related to the evaluation, selection, and promotion of candidates. The lure of academic celebrity or the desire of an individual candidate for a flattering letter must not threaten the veracity of the content. Letters of recommendation should be appropriately authored to meet the needs of the institution or individual requesting the letter, while keeping authenticity paramount. Length and content should be complete but not overly verbose. Relevant elements suggested by standardized formats should typically be included, such as nature of contact with the applicant, commitment to emergency medicine, work ethic, ability to develop a differential and treatment plan, personality, interpersonal interactions, and an overall comparative ranking. The seven cardinal elements of an exemplary letter of recommendation are that it should be: 1) authentic (based on adequate first-hand knowledge of the candidate's skills); 2) honest (accurate; avoiding exaggeration or hyperbole); 3) explicit (avoidance of veiled omissions); 4) balanced (taking care to incorporate both strengths and weaknesses); 5) confidential (avoiding unnecessary or unanticipated disclosure); 6) of appropriate detail and length (content relevant to the institutional or individual requests); and 7) technically clear (avoidance of unnecessary abbreviations and jargon). The implied duty to future students, colleagues, researchers, and patients who might come in contact with the applicant should motivate authors to write honest, explicit, appropriate, and complete letters.

Ethics seminars: case studies in "futility"-challenges for academic emergency medicine.

The concept of "futility" and its determination in emergency medicine pose unique challenges to emergency physicians, patients, and society. The term "futility," although commonly used, is problematic in its scope, meaning, and interpretation. To bridge this gap in understanding, the authors suggest the construct of clinically nonbeneficial interventions (CNBI), instead of "futility. " This language better informs discussions of nonbeneficial interventions across the risk spectrum of emergency medical practice, while retaining the focus on the patient's interests. Two cases are presented, which underscore the need for prudence and empathetic communication when addressing issues of CNBI. Determinations of expected benefit should be based on established scientific evidence, and the goals and values of patients, not on individual biases regarding quality of life or other subjective matters. While physicians are under no ethical obligation to provide treatments that they judge have no realistic likelihood of clinical benefit, the context in which these determinations take place is of critical importance. When certain interventions are appropriately withheld, concerted efforts should be made to maintain effective communication, comfort, support, and counseling for patients, friends, and families. In all aspects of clinical decision making, the value of various interventions and therapies must be based on expected risks and benefits to the patients, first and foremost.

Effect of an administrative intervention on rates of screening for domestic violence in an urban emergency department.

OBJECTIVES: This study measured the effects of an administrative intervention on health care provider compliance with universal domestic violence screening protocols. METHODS: We used a simple, interrupted-time-series design in a stratified random sample of female emergency department patients 18 years or older (n = 1638 preintervention, n = 1617 postintervention). The intervention was a 4-tiered hospital-approved disciplinary action, and the primary outcome was screening compliance. RESULTS: Preintervention and postintervention screening rates were 29.5% and 72.8%, respectively. Before the intervention, screening was worse on the night shift (odds ratio [OR] = 0.46, 95% confidence interval [CI] = 0.31, 0.68) and with psychiatric patients (OR = 0.34, 95% CI = 0.14, 0.85); after the intervention, no previous screening barriers remained significant. CONCLUSIONS: An administrative intervention significantly enhanced compliance with universal domestic violence screening.

Patients' perceptions of route of nonsteroidal anti-inflammatory drug administration and its effect on analgesia.

OBJECTIVE: There is a commonly held belief among health care providers that patients respond better to parenteral nonsteroidal anti-inflammatory drugs (NSAIDs) than to oral forms by virtue of the patients' belief that getting an injection means they are receiving "stronger" medicine. To the authors' knowledge, this effect has never been adequately documented in the literature. The objective of this study was to compare the effects of a placebo analgesic injection vs placebo oral analgesia on patients with acute musculoskeletal pain. METHODS: A convenience sample of emergency department (ED) patients with acute musculoskeletal pain secondary to trauma were enrolled. Patients received 225 mL of orange-flavored drink containing 800 mg of ibuprofen. Patients then received either a physiologically inactive starch tablet resembling ibuprofen 800 mg in taste and appearance or a physiologically inactive saline intramuscular (IM) injection resembling ketorolac 60 mg. Both patients and research nurses were blinded to the addition of ibuprofen to the drink and the inactive nature of subsequent medication. Pain was evaluated at time 0 and at 30, 60, 90, and 120 minutes on a 10-mm visual analog scale (VAS). RESULTS: Sixty-four patients completed the study protocol. The VAS scores between groups did not differ significantly at baseline or at each subsequent interval (p = 0.86). CONCLUSIONS: These results contradict the belief that parenteral medications confer a selective placebo effect stemming from patients' beliefs regarding route of administration and efficacy. Therefore, the routine use of IM administration of NSAIDs for suspected enhanced analgesia appears unwarranted.

Research ethics: ethical issues of data reporting and the quest for authenticity.

The search for truth and its unbiased reporting are ultimate goals of conducting scientific research. Ideally, the reporting of research data ought to be an objective task. In practice, however, it is fraught with numerous statistical and ethical pitfalls, seldom addressed in formal emergency medicine training. The lure of academic celebrity and related influences may persuade researchers to report results in ways that make data appear more interesting, or worthy of publication. Several examples of potentially misleading data reporting are illustrated, including using inappropriate statistical tests, neglecting negative results, omitting missing data points, failing to report actual numbers of eligible subjects, using inappropriate graph labels or terminology, data dredging, and others. Although potentially inaccurate or inflated methods of data reporting may not constitute overt scientific misconduct, the intentional misrepresentation of data is a form of fraud or deception. Publicly funded academic inquiry is a privilege and honor enjoyed by a trusted few. Regardless of outcome, every effort should be made to report data in the most scientifically accurate method. To this end, the Society for Academic Emergency Medicine Code of Conduct and American College of Emergency Physicians Code of Ethics provide important guidance toward the accurate, compassionate, competent, impartial, and honest conduct of scientific research. Accuracy and authenticity in data reporting are first and foremost a matter of individual integrity, and are crucial to the preservation of academic credibility, the protection of future patients, and the public's trust in the medical research enterprise.

Determination of "futility" in emergency medicine.

The practice of emergency medicine routinely requires rapid decisionmaking regarding various interventions and therapies. Such decisions should be based on the expected risks and benefits to the patient, family, and society. At times, certain interventions and therapies may be considered "futile," or of low expected likelihood of benefit to the patient. Various interpretations of the term "futility" and its practical application to the practice of emergency medicine are explored, as well as background information and potential application of various legal, ethical, and organizational policies regarding the determination of "futility. "Decisions regarding potential benefit of interventions should be based on scientific evidence, societal consensus, and professional standards, not on individual bias regarding quality of life or other subjective matters. Physicians are under no ethical obligation to provide treatments they judge to have no realistic likelihood of benefit to the patient. Decisions to withhold treatment should be made with careful consideration of scientific evidence of likelihood of medical benefit, other benefits (including intangible benefits), potential risks of the proposed intervention, patient preferences, and family wishes. When certain interventions are withheld, special efforts should be made to maintain effective communication, comfort, support, and counseling for the patient, family, and friends.

Ethical issues of managed care.

In a competitive, monetized medical system, a clash of principles is inevitable; however, amid the tumult in the medical marketplace, the underlying tenets of emergency medical ethics remain inviolate. Although the goals of providing excellent and cost-effective care are not mutually exclusive, the conflicts encountered can only be resolved by appeal to a higher goal: the good of the patient. Both MCOs and EPs must function as agents of individual patients first and foremost. The enterprise of healthcare rests on fidelity, integrity, and trust; therefore, physicians and MCOs must accept and take seriously their important moral, legal, and social obligations to patients and society. Otherwise, third-party cost considerations and provider greed irreversibly could pervert the practice of medicine and destroy the last vestiges of fidelity in the patient-physician relationship.

Universal screening for intimate partner violence in the emergency department: importance of patient and provider factors.

STUDY OBJECTIVE: Screening for intimate partner violence has been widely advocated in the health care setting, but efforts to assess effectiveness and ensure adequacy of universal screening are largely untested. We sought to identify barriers to screening of female emergency department patients for intimate partner violence during the first year of implementation of a screening protocol. METHODS: A retrospective, structured medical chart review of 1,638 randomly identified visits included demographic factors of age, race, marital status, employment status, insurance status, arrival mode, mechanism of presenting complaint, severity of condition, presentation time, and nurse gender. The study was conducted an an inner-city Level I trauma center with 43,000 annual ED visits and universal procedures for screening for intimate partner violence in place since February 1994. The participants were a cohort of 1,509 female patients, 18 years of age or older, who were discharged from the ED between July 1994 and June 1995. The main outcome measure was the odds of being screened as a function of patient and provider variables. Statistical analyses involved univariate and multivariate logistic regression on screening rates (Yes/No) as derived from universal screening instrument variables. RESULTS: Of 1,638 records reviewed, 483 patients (29.5%) were screened for intimate partner violence. Univariate analyses revealed that women presenting with nonpsychiatric, less acute complaints and those who presented during daylight hours were more likely to be screened than women who presented with psychiatric or more acute complaints, or during the night shift. Male and female nurse providers were equally likely to screen for intimate partner violence. Step-down multivariate analyses agreed with these findings. CONCLUSION: In this random sample of female patients, screening rates varied by severity of the patient's condition, type of presenting complaint, and presentation time.

Evaluating professionalism in emergency medicine: clinical ethical competence.

While the teaching and assessing of technical skills have been an integral part of residency training, the demonstration of ethical and humanistic skills has been more or less left to chance. Only in the last two decades has the formal teaching of bioethics become an accepted component of Western medical education. In spite of the many ethics lectures, discussions, conferences, and courses, the clinical impact of this educational paradigm shift remains unclear. Most ethics assessments to date are conducted retrospectively by risk managers and attorneys. The few prospective evaluations of trainees have focused on single-researcher observations or student attitude surveys that are fraught with observer and recall biases, respectively. More reliable and valid methods of identifying clinical ethical competence are needed. This paper reviews a variety of evaluative tools and suggests a three-level approach to monitoring the ethical knowledge, capacity, and real-time performance of emergency medicine residents.

Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic.

To compare the efficacy of intramuscular ketorolac and meperidine in the emergency department (ED) treatment of renal colic, a prospective, controlled, randomized, double-blind trial was conducted in an academic ED with 76,000 annual visits. Participants were volunteer ED patients with a diagnosis of ureterolithiasis confirmed by intravenous pyelogram. Subjects were randomized 1:1 to receive a single intramuscular injection of either 60 mg ketorolac or 100 to 150 mg meperidine, based on weight. Of the 70 patients completing the trial, 33 received ketorolac and 37 received meperidine. Demographic characteristics and baseline pain scores of both groups were comparable (P = NS, Mann Whitney U). Ketorolac was significantly (P < .05) more effective than meperidine in reducing renal colic at 40, 60, and 90 minutes as measured on a 10-cm visual analogue scale. Similar proportions of patients in each group were given rescue analgesia and admitted. Of patients who were discharged home without rescue, those treated with ketorolac left the ED significantly earlier than those treated with meperidine (3.46 v 4.33 h, P < .05). These results show that intramuscular ketorolac as a single agent for renal colic is more effective than meperidine and promotes earlier discharge of renal colic patients from the ED.

Effectiveness of ignition interlock devices in reducing drunk driving recidivism.

OBJECTIVE: To determine if ignition interlock devices reduce driving while intoxicated (DWI) recidivism. SEARCH STRATEGIES: Cochrane Collaboration search strategies were used. SELECTION CRITERIA: Studies for selection examined the effectiveness of interlock programs in a defined population. Studies were required to have a clear description of the program and outcomes evaluated, to have a comparison group and to provide interpretable data. DATA COLLECTION AND ANALYSIS: A total of 31 studies were found. Ten studies met the selection criteria. Three of these studies were eliminated from further analysis because they did not contain original data. A fourth study was eliminated due to methodologic weaknesses, leaving six studies for final review and analysis. Pooled analyses were not done because studies did not follow similar methods over comparable time periods. MAIN RESULTS: Five of the six studies found interlocks were effective in reducing DWI recidivism while the interlock was installed in the car. In the five studies demonstrating a significant effect, participants in the interlock programs were 15%-69% less likely than controls to be re-arrested for DWI. The only reported randomized, controlled trial demonstrated a 65% reduction in re-arrests for DWI in the interlock group, compared with the control group. CONCLUSIONS: Alcohol ignition interlock programs appear to be effective in reducing DWI recidivism during the time period when the interlock is installed in the car. Future studies should attempt to control for exposure (i.e., number of miles driven) and determine if certain sub-groups are most benefited by interlock programs.