RESUMO
BACKGROUND: Direct current cardioversion is a common management option for termination of tachydysrhythmias, including atrial fibrillation and atrial flutter. It is generally safe and effective with infrequent reporting of side effects. Pulmonary edema is a rare complication with reported incidence of 1-3% and mortality of 18%. Our literature search did not reveal any reported cases of postcardioversion pulmonary edema in the emergency medicine literature. CASE REPORT: We report a case of an 80-year-old woman with a history of atypical atrial flutter on warfarin, paroxysmal atrial fibrillation, and rheumatic mitral valve disease who presented with shortness of breath 12 h after transesophageal echocardiography and subsequent direct current cardioversion with reversion to sinus rhythm. She was found to be in acute pulmonary edema. She was placed on noninvasive ventilation and diuresis with eventual symptom resolution. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Postcardioversion pulmonary edema is a rare complication that may occur after reversion to sinus rhythm. Emergency physicians should be cognizant of patients, especially those with underlying structural heart disease, who present with dyspnea after a recent cardioversion procedure or after cardioversion in the emergency department. Patients cardioverted in the emergency department may be observed for around 3 h and counseled on the development of respiratory symptoms.
Assuntos
Fibrilação Atrial , Flutter Atrial , Dispneia , Edema Pulmonar , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Fibrilação Atrial/terapia , Flutter Atrial/terapia , Dispneia/etiologia , Cardioversão Elétrica , Feminino , Humanos , Edema Pulmonar/etiologia , Edema Pulmonar/terapiaRESUMO
OBJECTIVES: Shared decision-making (SDM) is receiving increasing attention in emergency medicine because of its potential to increase patient engagement and decrease unnecessary healthcare utilisation. This study sought to explore physician-identified barriers to and facilitators of SDM in the ED. METHODS: We conducted semistructured interviews with practising emergency physicians (EP) with the aim of understanding when and why EPs engage in SDM, and when and why they feel unable to engage in SDM. Interviews were transcribed verbatim and a three-member team coded all transcripts in an iterative fashion using a directed approach to qualitative content analysis. We identified emergent themes, and organised themes based on an integrative theoretical model that combined the theory of planned behaviour and social cognitive theory. RESULTS: Fifteen EPs practising in the New England region of the USA were interviewed. Physicians described the following barriers: time constraints, clinical uncertainty, fear of a bad outcome, certain patient characteristics, lack of follow-up and other emotional and logistical stressors. They noted that risk stratification methods, the perception that SDM decreased liability and their own improving clinical skills facilitated their use of SDM. They also noted that the culture of the institution could play a role in discouraging or promoting SDM, and that patients could encourage SDM by specifically asking about alternatives. CONCLUSIONS: EPs face many barriers to using SDM. Some, such as lack of follow-up, are unique to the ED; others, such as the challenges of communicating uncertainty, may affect other providers. Many of the barriers to SDM are amenable to intervention, but may be of variable importance in different EDs. Further research should attempt to identify which barriers are most prevalent and most amenable to intervention, as well as capitalise on the facilitators noted.
Assuntos
Tomada de Decisão Compartilhada , Relações Médico-Paciente , Médicos/psicologia , Adulto , Idoso , Atitude do Pessoal de Saúde , Medicina de Emergência/métodos , Medicina de Emergência/normas , Serviço Hospitalar de Emergência/organização & administração , Feminino , Grupos Focais/métodos , Humanos , Masculino , Pessoa de Meia-Idade , New England , Participação do Paciente/psicologia , Pesquisa QualitativaRESUMO
BACKGROUND: Physicians need to rapidly and effectively facilitate patient-centered, shared decision-making (SDM) conversations, but little is known about how residents or attending physicians acquire this skill. OBJECTIVE: We explored emergency medicine (EM) attending physicians' use of SDM in the context of their experience as former residents and current educators and assessed the implications of these findings on learning opportunities for residents. METHODS: We used semistructured interviews with a purposeful sample of EM physicians. Interviews were transcribed verbatim, and 3 research team members performed iterative, open coding of transcripts, building a provisional codebook as work progressed. We analyzed the data with a focus on participants' acquisition and use of skills required for SDM and their use of SDM in the context of resident education. RESULTS: Fifteen EM physicians from academic and community practices were interviewed. All reported using SDM techniques to some degree. Multiple themes noted had negative implications for resident acquisition of this skill: (1) the complex relationships among patients, residents, and attending physicians; (2) residents' skill levels; (3) the setting of busy emergency departments; and (4) individual attending factors. One theme was noted to facilitate resident education: the changing culture-with a cultural shift toward patient-centered care. CONCLUSIONS: A constellation of factors may diminish opportunities for residents to acquire and practice SDM skills. Further research should explore residents' perspectives, address the modifiable obstacles identified, and examine whether these issues generalize to other specialties.
Assuntos
Tomada de Decisões , Medicina de Emergência , Corpo Clínico Hospitalar , Participação do Paciente , Adulto , Atitude do Pessoal de Saúde , Serviço Hospitalar de Emergência , Humanos , Entrevistas como Assunto , Assistência Centrada no Paciente , Pesquisa Qualitativa , Teoria SocialRESUMO
BACKGROUND: Shared decision making (SDM) is increasingly recognized as an important facet of patient-centered care. Despite growing interest in SDM in the emergency department (ED), little is known about emergency physicians' (EPs') motivations for using SDM. Understanding current patterns of SDM use and EP's rationale for using SDM is essential for the development of interventions to increase use. OBJECTIVES: Recognizing the EP as an important stakeholder in SDM research, we sought to identify and explore factors that may motivate EPs' engagement in SDM. METHODS: In this qualitative study, informed by the Theory of Planned Behavior and Social Cognitive Theory, we conducted semistructured interviews with a purposeful sample of EPs. Interviews were recorded and transcribed verbatim. Using a directed qualitative content analysis approach, three members of the research team performed open coding of the transcripts in an iterative process, building a provisional code book as coding progressed. Respondent validation was employed to ensure methodologic rigor. RESULTS: Fifteen EPs, ages 31-65, from both academic and community practice settings, were interviewed. Several had not heard of the specific phrase "shared decision making," but all understood the concept and felt that they used SDM techniques to some degree. Most noted they had often had an agenda when they used SDM, which often motivated them to have the conversation. Agendas described included counteracting an algorithmic or defensive approach to diagnosis and treatment, avoiding harmful tests, or sharing uncertainty. All participants believed that patients benefited from SDM in terms of satisfaction, engagement, or education. Nearly all participants identified research outcomes that they felt would encourage their use of SDM (e.g., improvements in patient engagement, mitigation of risk) and many prioritized patient-centered outcomes over systems outcomes such as improved resource utilization. Little consensus was seen, however, regarding the importance of individual outcomes: of eight potential research outcomes participants endorsed, no single outcome was endorsed by even half of the physicians interviewed. CONCLUSION: Emergency physicians identified many factors that motivated them to use SDM. This study informs current research on SDM in the ED, particularly regarding the motivations of the physician-as-stakeholder.