Reprint of: Achilles tendon rupture in the emergency department.

Complete submission template and then save to your computer: Make sure to address each prompt or your submission cannot be accepted. Upload (1) the saved template and (2) at least one image or video into the submission system.

Artificial Intelligence in Emergency Medicine: Benefits, Risks, and Recommendations.

BACKGROUND: Artificial intelligence (AI) can be described as the use of computers to perform tasks that formerly required human cognition. The American Medical Association prefers the term 'augmented intelligence' over 'artificial intelligence' to emphasize the assistive role of computers in enhancing physician skills as opposed to replacing them. The integration of AI into emergency medicine, and clinical practice at large, has increased in recent years, and that trend is likely to continue. DISCUSSION: AI has demonstrated substantial potential benefit for physicians and patients. These benefits are transforming the therapeutic relationship from the traditional physician-patient dyad into a triadic doctor-patient-machine relationship. New AI technologies, however, require careful vetting, legal standards, patient safeguards, and provider education. Emergency physicians (EPs) should recognize the limits and risks of AI as well as its potential benefits. CONCLUSIONS: EPs must learn to partner with, not capitulate to, AI. AI has proven to be superior to, or on a par with, certain physician skills, such as interpreting radiographs and making diagnoses based on visual cues, such as skin cancer. AI can provide cognitive assistance, but EPs must interpret AI results within the clinical context of individual patients. They must also advocate for patient confidentiality, professional liability coverage, and the essential role of specialty-trained EPs.

Ethical issues in the access to emergency care for undocumented immigrants.

Patients who are undocumented immigrants (UIs) frequently present to emergency departments in the United States, especially in communities with large immigrant populations. Emergency physicians confront important ethical issues when providing care for these patients. This article examines those ethical issues and recommends best practices in emergency care for UIs. After a brief introduction and description of the UI population, the article proposes central principles of emergency medical ethics as a framework for emergency physician decisions and actions. It then considers the role of law and public policy in health care for UIs, including the Emergency Medical Treatment and Labor Act, the Patient Protection and Affordable Care Act, and current practices of the US Immigration and Customs Enforcement agency. The article concludes with discussion of the scope of emergency physician practice and with recommendations regarding best practices in ED care for UIs.

A Journal of the COVID-19 (Plague) Year.

The essays in this special issue of HEC Forum provide reflections that make explicit the implicit anthropology that our current pandemic has brought but which in the medical ethics literature around COVID-19 has to a great extent ignored. Three of the essays are clearly "journalistic" as a literary genre: one by a hospital chaplain, one by a medical student in her pre-clinical years, and one by a fourth-year medical student who reports her experience as she completed her undergraduate clerkships and applied for positions in graduate medical education. Other essays explore the pandemic from historical, sociological, and economic perspectives, particularly how triage policies have been found to be largely blind to structural healthcare disparities, while simultaneously unable to appropriately address those disparities. Central issues that need to be addressed in triage are not just whether a utilitarian response is the most just response, but what exactly is the greatest good for the greatest number? Together, the essays in this special issue of HEC Forum create a call for a more anthropological approach to understanding health and healthcare. The narrow approach of viewing health as resulting primarily from healthcare will continue to hinder advances and perpetuate disparities. Health outcomes result from a complex interaction of various social, economic, cultural, historical, and political factors. Advancing healthcare requires contextualizing the health of populations amongst these factors. The COVID-19 pandemic has made us keenly aware of how interdependent our health as a society can be.

Utilitarian Principlism as a Framework for Crisis Healthcare Ethics.

This paper introduces the model of Utilitarian Principlism as a framework for crisis healthcare ethics. In modern Western medicine, during non-crisis times, principlism provides the four guiding principles in biomedical ethics-autonomy, nonmaleficence, beneficence, and justice; autonomy typically emerges as the decisive principle. The physician-patient relationship is a deontological construct in which the physician's primary duty is to the individual patient and the individual patient is paramount. For this reason, we term the non-crisis ethical framework that guides modern medicine Deontological Principlism. During times of crisis, resources become scarce, standards of care become dynamic, and public health ethics move to the forefront. Healthcare providers are forced to work in non-ideal conditions, and interactions with individual patients must be considered in the context of the crisis. The COVID-19 pandemic has forced healthcare to shift to a more utilitarian framework with a greater focus on promoting the health of communities and populations. This paper puts forth the notion of Utilitarian Principlism as a framework for crisis healthcare ethics. We discuss each of the four principles from a utilitarian perspective and use clinical vignettes, based on real cases from the COVID-19 pandemic, for illustrative purposes. We explore how Deontological Principlism and Utilitarian Principlism are two ends of a spectrum, and the implications to healthcare as we emerge from the pandemic.

Enlightened Self-interest in Altruism (ESIA).

Altruism and the medical profession have been linked throughout the history of medicine. Students are drawn to the calling of medicine because of altruistic values, dedication to service, and the desire to alleviate suffering and promote healing. Despite a dedication to these values, altruism in medicine is threatened by empathy erosion that develops in the clinical years of medical school and an increasing rate of medical student burnout. Currently, there are two widespread movements in medicine aimed at addressing the dual loss of altruism and physician and student burnout-professionalism and wellness. Despite widespread recognition of the problems and programs aimed at improving them, there has been little headway, and even calls to abandon altruism in the modern marketplace of medicine. What is needed is not an abandonment of a fundamental, defining value of the profession, but a re-evaluation of the meaning of altruism in medicine and a framework that allows for students and physicians to provide altruistic care for a sustainable, rewarding career in the healing profession. This paper proposes the Enlightened Self-Interest in Altruism (ESIA) model as an ethical framework to allow medical students to synergize the interests of the self with those they serve in a mutually beneficial relationship to improve patient care and the healthcare system at large. The ESIA model acknowledges that egoism and altruism are intertwined, dynamic motivators of behavior. In the enlightened self-interest approach, the interests of the group are also the interests of the self. The physician-patient relationship is a dyad in which egoism and altruism may converge in an enlightened way that acknowledges that the interests of one are the interests of the whole. This is a paradigm shift from the historical view of egoism and altruism as opposing motivations. This paper will present the threats to altruism, explore the interface of egoism and altruism in a clinical vignette, and then present the ESIA framework as an educational approach to aligning the interests of providers and patients to prevent burnout and promote altruism.

Post-traumatic stress and stress disorders during the COVID-19 pandemic: Survey of emergency physicians.

OBJECTIVE: Emergency physicians routinely encounter stressful clinical situations, including treating victims of crime, violence, and trauma; facing the deaths of patients; and delivering bad news. During a pandemic, stress may be increased for healthcare workers. This study was undertaken to identify symptoms of post-traumatic stress disorder (PTSD) among emergency physicians during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This cross-sectional survey was developed using the Life Events Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (DSM-5) and the PTSD Checklist for DSM-5 (PCL-5). The survey was distributed to members of the American College of Emergency Physicians from May 21, 2020, through June 22, 2020. RESULTS: Among 1300 emergency physicians, a significant number of participants (22.3%; 95% confidence interval, 20.3-24.3%) reported symptoms of stress consistent with PTSD (PCL score ≥ 33). Higher PCL-5 scores were associated with age younger than 50 years (P < 0.05) and <10 years in practice (P < 0.05). The major sources of stress identified by participants included disinformation about COVID-19, computer work/electronic medical record, personal protective equipment concerns, and workload. The most common consequences of workplace stress were feeling distant or cut off from other people and sleep disturbance, such as trouble falling or staying asleep. CONCLUSIONS: A significant number of emergency physicians reported symptoms of stress consistent with PTSD. Higher PCL-5 scores were associated with age younger than 50 years and <10 years in practice.

The value of harm reduction for injection drug use: A clinical and public health ethics analysis.

The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.

Physician-assisted Death: Ethical Implications for Emergency Physicians.

Physician-assisted death (PAD) has long been a strongly debated moral and public policy issue in the United States, and an increasing number of jurisdictions have legalized this practice under certain circumstances. In light of changing terminology, laws, public and professional attitudes, and the availability of published data about the practice, we review key concepts and terms in the ongoing PAD debate, moral arguments for and against PAD, the current legal status of PAD in the United States and in other nations, and data on the reported experience with PAD in those U.S. jurisdictions where it is a legal practice. We then identify situations in which emergency physicians (EPs) may encounter patients who request PAD or have attempted to end their lives with physician assistance and consider EP responses in those situations. Based on our analysis, we offer recommendations for emergency medical practice and professional association policy.

The Ethics of Real-Time EMS Direction: Suggested Curricular Content.

Ethical dilemmas can create moral distress in even the most experienced emergency physicians (EPs). Following reasonable and justified approaches can help alleviate such distress. The purpose of this article is to guide EPs providing Emergency Medical Services (EMS) direction to navigate through common ethical issues confronted in the prehospital delivery of care, including protecting privacy and confidentiality, decision-making capacity and refusal of treatment, withholding of treatment, and termination of resuscitation (TOR). This requires a strong foundation in the principles and theories underlying sound ethical decisions that EPs and prehospital providers make every day in good faith, but will now also make with more awareness and conscientiousness. Brenner JM , Aswegan AL , Vearrier LE , Basford JB , Iserson KV . The ethics of real-time EMS direction: suggested curricular content. Prehosp Disaster Med. 2018;33(2):201-212.

Failure of the Current Advance Care Planning Paradigm: Advocating for a Communications-Based Approach.

The purpose of advance care planning (ACP) is to allow an individual to maintain autonomy in end-of-life (EOL) medical decision-making even when incapacitated by disease or terminal illness. The intersection of EOL medical technology, ethics of EOL care, and state and federal law has driven the development of the legal framework for advance directives (ADs). However, from an ethical perspective the current legal framework is inadequate to make ADs an effective EOL planning tool. One response to this flawed AD process has been the development of Physician Orders for Life Sustaining Treatment (POLST). POLST has been described as a paradigm shift to address the inadequacies of ADs. However, POLST has failed to bridge the gap between patients and their autonomous, preferred EOL care decisions. Analysis of ADs and POLST reveals that future policy should focus on a communications-based approach to ACP that emphasizes ongoing interactions between healthcare providers and patients to optimize EOL medical care to the individual patient.

An intensive massed practice approach to retraining balance post-stroke.

BACKGROUND AND PURPOSE: Falls are highly prevalent and a significant source of complications post-stroke. This study tested the efficacy of standard physical therapy (based on the task-oriented approach) delivered in a massed practice paradigm. The purpose of this study was to test if the intensive massed practice intervention (6h/day for 2 consecutive weeks) could significantly improve balance function post-stroke. METHODS: A single-subject multiple baseline design across subjects with probes was utilized with ten subjects with chronic stroke disability. Clinical tests and time to stabilization (TTS) of the center of pressure in response to a platform perturbation were calculated during baseline, intervention, and the maintenance phases. RESULTS: The ability of the subjects to recover from a balance threat improved, with mean TTS decreasing from 2.35 +/- .51 s during baseline, to 1.58+/-.23s during training, and further still to 1.45 +/- .29 s during the maintenance phase, ending 3 months post-intervention. Clinical findings demonstrated improvements in anticipatory and steady-state balance control. In addition weight-bearing symmetry improved and the number of falls sustained reduced. CONCLUSIONS: Intensive massed practice of standard physical therapy produced significant results in balance retraining with patients post-stroke. Our finding support the need to offer additional practice to maximize the efficacy of physical therapy sessions.