What does Cruzan mean to the practicing physician?

The United States Supreme Court's recent decision in the Cruzan case declared that the states have broad powers to formulate their own rules in "right to die" cases. The Court held that competent adults have a constitutionally protected "liberty interest" that allows them to accept or refuse medical treatments. Since liberty interests are subject to rational state regulation, the narrow holding in Cruzan affirmed Missouri's authority to require a "clear and convincing" evidence standard to determine a patient's wishes before life-sustaining treatment could be withdrawn from a formerly competent adult now in a persistent vegetative state. For practicing physicians, some of the implications of Cruzan are as follows: (1) For competent adult patients, physicians should respect patient wishes regarding life-sustaining treatment. (2) Physicians also should discuss with competent patients their wishes for life-sustaining treatment at a future time, when a patient may no longer be able to participate in such decisions. (3) Physicians should record these wishes in a legally acceptable instrument that addresses two aspects of care that may arise in the future if the patient becomes incompetent. What would the patient want done? Who would the patient wish to designate as a surrogate or proxy? (4) For patients who are now incompetent, but for whom decisions must be made about life-sustaining treatment, physicians should focus on the previously expressed wishes of the patient rather than on the patient's current quality of life or on the wishes of the patient's family.

Academic emergency medicine's future. The SAEM Task Force on Emergency Medicine's Future. Society for Academic Emergency Medicine.

Emergency medicine (EM) will change over the next 20 years more than any other specialty. Its proximity to and interrelationships with the community, nearly all other clinicians (physicians and nonphysicians), and scientific/technologic developments guarantee this. While emergency physicians (EPs) will continue to treat both emergent and nonemergent patients, over the next decades our interventions, methods, and place in the medical care system will probably become unrecognizable from the EM we now practice and deliver. This paper, developed by the Society for Academic Emergency Medicine (SAEM) Task Force on Academic Emergency Medicine's Future, was designed to promote discussions about and actions to optimize our specialty's future. After briefly discussing the importance of futures planning, it suggests "best-case," "worst-case," and most probable future courses for academic EM over the next decades. The authors predict that EPs will practice a much more technologic and accurate form of medicine, with diagnostic, patient, reference, and consultant information rapidly available to them. They will be at the center of an extensive consultation network stemming from major medical centers and the purveyors of a sophisticated home health system, very similar to or even more advanced than what is now delivered on hospital wards. The key to planning for our specialty is for EM organizations, academic centers, and individuals to act now to optimize our possible future.

Principles of biomedical ethics.

Ethics is the application of values and moral rules to human activities. Bioethics is a subsection of ethics, actually a part of applied ethics, that uses ethical principles and decision making to solve actual or anticipated dilemmas in medicine and biology. This article focuses on the primary principles of biomedical ethics and their implications for physicians in the ED.

Ethical dilemmas in hematologic/oncologic emergencies.

Clinicians use ethical decision making in their practice by applying professional and societal values in an organized way to solve moral dilemmas. Moral dilemmas are those situations in which a decision must be made between conflicting goods or evils or rights or wrongs. Clinicians must understand the medical profession's and society's values and be able to apply them within ethical systems. This article describes those values, basic ethical systems, a rapid ethical decision-making model, and specific ethical dilemmas faced by emergency physicians who treat patients with hematologic and oncologic emergencies.

Airway trauma.

The mechanism of injury, diagnosis, and treatment of maxillofacial, laryngeal, tracheal, and bronchial trauma are considered. Also discussed is pulmonary barotrauma.

J.-F.-B. Charrière: the man behind the "French" gauge.

Joseph-Frédéric-Benoît Charrière, a 19th century Parisian maker of surgical instruments, has by virtue of his ingenuity and advanced thinking, continued to have his presence felt in medicine throughout the 20th century. His most significant accomplishment was the development of a uniform, standard gauge specifically designed for use in medical equipment such as catheters and probes. Unlike the gauge system adopted by the British for measurement of needles and intravenous catheters, Charrière's system has uniform increments between gauge sizes (1/3 of a millimeter), is easily calculated in terms of its metric equivalent, and has no arbitrary upper end point. Today, in the United States, this system is commonly referred to as French (Fr) sizing. In addition to the development of the French gauge, Charrière made significant advances in ether administration, urologic, and other surgical instruments, and the development of the modern syringe.

Critical leadership.

Leadership is the process of motivating others to think or act in a specific manner. In critical clinical situations leadership is often lacking. This results from a failure both to understand the leadership role and the elements necessary to carry out this role. The basic elements and models of leadership are described. Eleven basic principles needed to understand and teach medical crisis management are developed.

Intraosseous infusions in adults.

Intraosseous (IO) access in adults via the distal tibia has never been a widely accepted technique. Yet there have been occasional reports of the successful use of this procedure. This study was done to demonstrate the utility of IO infusions in the adult patient, including those patients in cardiac arrest. Twenty-two patients, aged 36 through 84 (mean 65.1 years), who arrived in the emergency department (ED) in cardiac arrest from nonhypovolemic causes and in whom an intravenous line was not established prior to arrival or was found to be inadequate (nonfunctioning or poorly functioning) upon arrival in the ED, had an IO needle (13-gauge Kormed/Jamshidi, Pharmaseal Division, Baxter Healthcare Corp., Valencia, CA) placed above the medial malleolus. The IO needle was then connected to a standard IV tubing, with a pressure bag or pressure device delivering 300 mm Hg to the solution bag. The resultant flow rate through the IV line ranged from 5 to 12 mL/min. The IO needle was placed and flow established in under one minute in all patients. Temporally related pharmacologic effects were observed after the IO administration of sodium bicarbonate, lidocaine, atropine, and vasopressors. This study shows that I.O. access can be quickly and easily obtained in adults in the medial supramalleolar position during cardiac arrest. This method of drug administration appears to hold promise as another useful modality for adults and older children during nontraumatic resuscitations.

Methemoglobinemia from dapsone therapy for a suspected brown spider bite.

Recent reports have suggested the use of dapsone for brown spider bites. This drug, for many years restricted to use in cases of leprosy and rare dermatologic disorders, has significant side effects that must be recognized. A case of methemoglobinemia is reported in one such patient treated with dapsone. The difficulty of making the diagnosis of brown spider bite is discussed.

The origins of the gauge system for medical equipment.

The gauge system for sizing medical catheters and equipment is used widely around the world. Yet both its origins and its interpretation, in terms of conventional measurements, have long been obscure. The gauge, formally known as the Stubs Iron Wire Gauge, was developed in early 19th century England. Developed initially for use in wire manufacture, each gauge size arbitrarily correlates to multiples of .0010 inches. This sizing system was the first wire gauge recognized as a standard by any country (Great Britain, 1884). It was first used to measure needle sizes in the early 20th century. Today it is used in medicine to measure not only needles, but also catheters and suture wires. However, owing to the potential confusion inherent in using a gauge system, the iron wire gauge is rarely used in manufacture of nonmedical equipment.