A Review and Discussion of Full-Time Equivalency and Appropriate Compensation Models for an Adult Intensivist in the United States Across Various Base Specialties.

OBJECTIVES: Physicians with training in anesthesiology, emergency medicine, internal medicine, neurology, and surgery may gain board certification in critical care medicine upon completion of fellowship training. These clinicians often only spend a portion of their work effort in the ICU. Other work efforts that benefit an ICU infrastructure, but do not provide billing opportunities, include education, research, and administrative duties. For employed or contracted physicians, there is no singular definition of what constitutes an intensive care full-time equivalent (FTE). Nevertheless, hospitals often consider FTEs in assessing hiring needs, salary, and eligibility for benefits. DATA SOURCES: Review of existing literature, expert opinion. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSIONS: Understanding how an FTE is calculated, and the fraction of an FTE to be assigned to a particular cost center, is therefore important for intensivists of different specialties, as many employment models assign salary and benefits to a base specialty department and not necessarily the ICU.

Privacy and confidentiality of emergency department patient information: Contemporary considerations and challenges.

This article provides a brief review of moral and legal duties to respect confidentiality in emergency medicine. The article considers current challenges to confidentiality in emergency departments and proposes strategies to address them. It is offered as an update of the two-part review of confidentiality in emergency medicine in 2005 by Moskop et al published in 2005 in Annals of Emergency Medicine.

Characteristics of Patients Restrained in the Emergency Department and Evaluation for Disparities in Care.

BACKGROUND: Physical restraints are used in the emergency department (ED) for agitated patients to prevent self-harm and protect staff. Prior studies identified associations between sociodemographic factors and ED physical restraints use. OBJECTIVES: The primary objective was to compare characteristics of ED patients receiving physical restraints for violent and nonviolent indications vs. patients who were not restrained. The secondary objective was to compare rates of restraint use among ED providers. METHODS: This was a single-center cross-sectional study of adult ED patients from March 2019 to February 2021. Factors compared across groups were age over 50 years, gender, race, ethnicity, insurance, housing, primary language, Emergency Severity Index, time of arrival, mode of arrival, chief complaint, and medical admission. Odds ratios were reported. Rates of emergency physician restraint orders were compared using the chi-square test. RESULTS: Restraints were used in 1228 (0.9%) visits. Younger age, male gender, "unknown" ethnicity, self-pay or "other" nonprivate insurance, homelessness, arrival by first responders, and medical hospitalization were associated with increased odds of restraint. Black patients had lower odds of any restraint than White patients (odds ratio 0.93; 95% confidence interval 0.79-1.09) and higher odds of violent restraint than White patients, although not significant (odds ratio 1.55; 95% confidence interval 0.95-2.54). ED providers had significant differences in total and violent restraint use (p-values < 0.0001 and 0.0003, respectively). CONCLUSION: At this institution, certain sociodemographic characteristics were associated with receiving both types of physical restraint. Emergency physicians also differed in restraint-ordering practice. Further investigation is needed to understand the influence of implicit bias on ED restraint use.

PHYSICIANS' MORAL DUTIES DURING PANDEMICS.

BACKGROUND: Pandemics with devastating morbidity and mortality have occurred repeatedly throughout recorded history. Each new scourge seems to surprise governments, medical experts, and the public. The SARS CoV-2 (COVID-19) pandemic, for example, arrived as an unwelcome surprise to an unprepared world. DISCUSSION: Despite humanity's extensive experience with pandemics and their associated ethical dilemmas, no consensus has emerged on preferred normative standards to deal with them. In this article, we consider the ethical dilemmas faced by physicians who work in these risk-prone situations and propose a set of ethical norms for current and future pandemics. As front-line clinicians for critically ill patients during pandemics, emergency physicians will play a substantial role in making and implementing treatment allocation decisions. CONCLUSION: Our proposed ethical norms should help future physicians make morally challenging choices during pandemics.

Implementation of a regional extracorporeal membrane oxygenation program for refractory ventricular fibrillation out-of-hospital cardiac arrest.

BACKGROUND: eCPR, the modality of extracorporeal membrane oxygenation (ECMO) applied in the setting of cardiac arrest, has emerged as a novel therapy which may improve outcomes in select patients with out-of-hospital cardiac arrest (OHCA). To date, implementation has been mainly limited to single academic centres. Our objective is to describe the feasibility and challenges with implementation of a regional protocol for eCPR. METHODS: The Los Angeles County Emergency Medical Services (EMS) Agency implemented a regional eCPR protocol in July 2020, which included coordination across multiple EMS provider agencies and hospitals to route patients with refractory ventricular fibrillation (rVF) OHCA to eCPR-capable centres (ECCs). Data were entered on consecutive patients with rVF with suspected cardiac aetiology into a centralized database including time intervals, field and in-hospital care, survival and neurologic outcome. RESULTS: From July 27, 2020 through July 31, 2022, 35 patients (median age 57 years, 6 (17%) female) were routed to ECCs, of whom 11 (31%) received eCPR and 3 (27%) treated with eCPR survived, all of whom had a full neurologic recovery. Challenges encountered during implementation included cost to EMS provider agencies for training, implementation, and purchase of automatic chest compression devices, maintenance of system awareness, hospital administrative support for staffing and equipment for the ECMO program, and interdepartmental coordination at ECCs. CONCLUSION: We describe the successful implementation of a regional eCPR program with ongoing patient enrolment and data collection. These preliminary findings can serve as a model for other EMS systems who seek to implement regional eCPR programs.

Civility in Health Care: A Moral Imperative.

Civility is an essential feature of health care, as it is in so many other areas of human interaction. The article examines the meaning of civility, reviews its origins, and provides reasons for its moral significance in health care. It describes common types of uncivil behavior by health care professionals, patients, and visitors in hospitals and other health care settings, and it suggests strategies to prevent and respond to uncivil behavior, including institutional codes of conduct and disciplinary procedures. The article concludes that uncivil behavior toward health care professionals, patients, and others subverts the moral goals of health care and is therefore unacceptable. Civility is a basic professional duty that health care professionals should embrace, model, and teach.

Kinetic Projectile Injuries Treated During Civil Protests in Los Angeles: A Case Series.

INTRODUCTION: During protests following the death of George Floyd, kinetic impact projectiles (KIP) were used by law enforcement as a method of crowd control. We describe the injuries seen at a single Level 1 trauma center in Los Angeles over a two-day period of protests to add to the collective understanding of the public health ramifications of crowd-control weapons used in the setting of protests. CASE SERIES: We reviewed the emergency department visits of 14 patients who presented to our facility due to injuries sustained from KIPs over a 48-hour period during civil protests after the death of George Floyd. CONCLUSION: Less lethal weapons can cause significant injuries and may not be appropriate for the purposes of crowd control, especially when used outside of established guidelines.

Mandatory and permissive reporting laws: obligations, challenges, moral dilemmas, and opportunities.

The duty to report certain conditions to public health or law enforcement authorities is one that falls on all physicians and other health care workers as part of their duty to protect the public from harm. In an open society, others, such as teachers, clergy, police officers, or simply neighbors, share the responsibility of protecting individuals at risk, often by reporting them to authorities. The emergency physician and others in the emergency department are uniquely positioned to identify people at risk or who pose a risk, and to report them as required or allowed under the law. In some circumstances, these duties may conflict with ethical duties such as respect for patient autonomy or to protect confidentiality. This article will examine mandatory and permissive reporting laws in various states from an ethical perspective. It will also explore emerging issues such as the reporting of suspected human trafficking.