Ethics seminars: Consent and refusal in an urban American emergency department: two case studies.

Patients in the emergency department frequently voice refusals of care or are unable or unwilling to consent to care. While general principles surrounding consent and refusal can be articulated in theory, it is often far more complicated in the real setting. Further, it is impossible to contemplate in advance every possible situation that might arise. In order to properly care for patients, the emergency physician has an obligation to understand ethical principles and the reasoning process one must go through to resolve an ethical dilemma. Emergency physicians face such complex decisions on a routine basis. Ethical reasoning skills are obviously a core competence in emergency medicine, even if easy answers are elusive. Two cases are presented that illustrate this complexity, and routes to resolution are discussed.

Diversion of ALS ambulances: characteristics, causes, and effects in a large urban system.

OBJECTIVE: To characterize the reasons for and effects of diversions of advanced life support (ALS) ambulances in a large urban area with a high concentration of receiving hospitals. METHODS: A retrospective study was performed in a large urban region during a consecutive three-month period. Diversion was defined as the ALS transport of a patient to an emergency department (ED) other than the designated primary receiving facility. Case-matched concurrent cohorts of patients who were and were not diverted were studied to establish emergency medical services (EMS) time intervals, including total prehospital interval (TPI), on-scene interval (OSI), and patient transfer interval (PTI); age; gender; Glasgow Coma Score (GCS); ALS interventions; and insurance status. The reasons for diversion and the chief complaints of diverted patients were also studied. RESULTS: During the study period, 2,534 ALS runs occurred, of which 147 (5.8%) were diverted. Twenty-four (16.3%) diversions had incomplete run times, leaving 123 (83.7%) for analysis. The most common chief complaints of diverted patients were shortness of breath (SOB), chest pain (CP), and altered mental status (AMS). The most common reason for diversion was special consideration (SC), defined as a diversion requested by a patient, family member, law enforcement officer, or private medical doctor. Diverted ambulances had significant increases in TPI, 36.4 [95% confidence interval (95% CI) 35.1-37.7] vs. 33.4 [95% CI 32.13-34.7], and PTI, 10.3 [95% CI 9.4-11.2] vs. 7.9 [95% CI 7.2-8.6], compared with nondiverted ambulances. Further analysis demonstrated that SC diversions accounted for all of the increases in TPI (p<0.001) and PTI (p<0.001) when compared with other types of diversions and nondiverted transports. CONCLUSION: "Special consideration" was the most common reason for diversion in this study. Special consideration diversions increased TPI and PTI, causing delays in arrival to the ED and decreased ALS ambulance availability.

Distracting painful injuries associated with cervical spinal injuries in blunt trauma.

UNLABELLED: Distracting painful injuries (DPIs) may mask symptoms of spinal injury in blunt trauma victims and form an important element in a decision instrument used to identify individuals who require cervical spine radiography. OBJECTIVE: To identify the types and frequencies of injuries that actually act as DPIs among blunt trauma patients undergoing cervical spinal radiography. METHODS: This was a prospective observational study of consecutive blunt trauma victims presenting to an urban Level 1 regional trauma center between April 1, 1998, and September 30, 1998. Prior to cervical spinal radiography, treating physicians evaluated each patient to determine whether a DPI was present or absent and, if present, what type of injury was sustained. Injuries were categorized as fractures, soft-tissue injuries and lacerations, burns, visceral injuries, crush injuries, or other injuries. RESULTS: Data were collected for 778 patients, between 1 month and 98 years old, of whom 264 (34%) were considered to have DPIs. Physicians were unable to determine the DPI status in 47 (6%) additional cases. Fractures accounted for a majority of DPIs (154, or 58%), 42 (16%) were soft-tissue injuries or lacerations, and 86 (34%) were due to a variety of other entities, including visceral, crush, burn, or other miscellaneous injuries. Among the 37 (5%) patients with an acute cervical spinal injury, 20 (54%) had a DPI, including three (8%) who had DPI as the only indication for cervical radiography. CONCLUSIONS: A significant number of blunt trauma patients are believed by clinicians to have DPIs that can possibly mask the presence of cervical spinal injury. Fractures and trauma to soft tissues are the most common types of DPI.

Rapid identification of group A streptococcus as the cause of necrotizing fasciitis.

Group A beta-hemolytic Streptococcus pyogenes (GAS) causes a spectrum of highly aggressive, invasive infections. We report two cases of necrotizing fasciitis in which GAS was identified as the presumptive causative organism with the use of the standard rapid streptococcal diagnostic kit. We believe the rapid test kits may be a useful adjunct in the diagnosis and treatment of this catastrophic illness and may play a role in limiting the spread of infection.

The use of vasoactive agents in the treatment of refractory hypotension seen in tricyclic antidepressant overdose.

In this review, the physiologic and pharmacologic effects of tricyclic antidepressants are discussed as they apply to an overdose situation. Systemic arterial hypotension is a frequent occurrence in major overdoses. Occasionally conventional resuscitative measures such as crystalloid or colloid infusion are inadequate and vasoactive agents must be employed in an attempt to normalize blood pressure. The use of these agents is discussed in terms of their physiologic and pharmacologic actions in the management of refractory hypotension induced by tricyclics.

Application of the Cardiotrak pacemaker monitor to prehospital care.

The Cardiotrak is a small, lightweight device originally developed for use by pacemaker patients to transmit their electrocardiograms (ECGs) by telephone to their doctor or to a hospital. The Cardiotrak seemed well suited for use by paramedics and was field tested on 76 patients. In 69 patients, clear ECGs were transmitted with ease; in the remaining seven, only minor, correctable problems were noted. The Cardiotrak appears to have advantages over other devices used to transmit ECGs to base station hospitals from paramedics.