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1.
Trop Doct ; 51(1): 10-15, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33506737

RESUMO

Acute thoracic aortic dissection is an uncommon, although not rare, life-threatening condition. With protean signs and symptoms that often suggest more common cardiac or pulmonary conditions, it can be difficult to diagnose. Ultrasound has proven useful in making the correct diagnosis. This case demonstrates that training gained using standard ultrasound machines can be easily and successfully adapted to newer handheld ultrasound devices. The examination technique using the handheld device is illustrated with photos and a video.

2.
Camb Q Healthc Ethics ; 30(1): 136-145, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33371924

RESUMO

This paper describes the Antarctic environment, the mission and work setting at the U.S. research stations, the general population and living conditions, and the healthcare situation. It also dispels some common misconceptions that persist about this environment and about the scope and quality of medicine practiced there. The paper then describes specific ethical issues that arise in this environment, incorporating examples drawn from both the author's experiences and those of his colleagues. The ethics of providing healthcare in resource-poor environments implies two related questions. The first is: What can we do with the available resources? This suggests that clinicians must not only know how to use all available equipment and supplies in the standard manner, but also that they must be willing and able to go beyond standard procedures and improvise, when necessary. The second question is: Of all the things we can do, which ones should we do? This paper addresses both questions in relation to Antarctic medical care. It describes the wide range of activities required of healthcare providers and some specific ethical issues that arise. Finally, it suggests some remedies to ameliorate some of those issues.

3.
AEM Educ Train ; 4(4): 395-402, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33150282

RESUMO

Emergency physicians (EPs) often lack the information they need about their patients' outcomes so that they can both optimally adjust and refine their diagnostic and treatment processes and recognize their clinical errors. Patient-outcome feedback (POF) provides that information by informing clinicians about a patient's clinical course after that clinician's evaluation and treatment. This feedback may encompass the period after the EP has transferred a patient's care to another EP or after the patient has left the ED or hospital. EPs obtain POF through various active and passive methods, depending on their institutional and medical record systems. Active methods require that clinicians or others spend time and effort acquiring the information; passive methods deliver it automatically. POF is an excellent performance-based measurement that helps clinicians to stimulate their learning and to build their own validated mental library of outcomes with which to make clinical decisions, i.e., heuristics and System 1 thinking. POF offers especially useful feedback about patients who have been admitted, were referred to specialists, had major interventions, had potentially significant tests pending on discharge, or were handed off to another EP. The current health care system makes it difficult for EPs to discover their patients' outcomes, squandering significant educational opportunities. Three stimuli to improve this situation would be to require EPs to receive passive POF as part of hospital accreditation, for reviewing POF to be classified as a Category 1 Continuing Medical Education activity, and to reimburse clinicians for learning activities related to POF. Research indicates that our health care institutions and systems would be well served to provide clinicians with ongoing automatic information about their patients' outcomes.

4.
West J Emerg Med ; 21(4): 756-758, 2020 06 08.
Artigo em Inglês | MEDLINE | ID: mdl-32726236
5.
Camb Q Healthc Ethics ; : 1-10, 2020 Jun 05.
Artigo em Inglês | MEDLINE | ID: mdl-32498742

RESUMO

The world awaits a SARS-CoV-2 virus (i.e., COVID-19 disease) vaccine to keep the populace healthy, fully reopen their economies, and return their social and healthcare systems to "normal." Vaccine safety and efficacy requires meticulous testing and oversight; this paper describes how despite grandiose public statements, the current vaccine development, testing, and production methods may prove to be ethically dubious, medically dangerous, and socially volatile. The basic moral concern is the potential danger to the health of human test subjects and, eventually, many vaccine recipients. This is further complicated by economic and political pressures to reduce government oversight on rushed vaccine testing and production, nationalistic distribution goals, and failure to plan for the widespread immunization needed to produce global herd immunity. As this paper asserts, the public must be better informed to assess promises about the novel vaccines being produced and to tolerate delays and uncertainty.

6.
J Emerg Med ; 58(4): 667-672, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32245688

RESUMO

BACKGROUND: Inhaled ß-agonists are the cornerstone of acute treatment for asthma and chronic lung disease. Upon emergency department (ED) discharge, patients optimally receive prescriptions for metered-dose inhalers (MDIs) with instructions on their proper use. Yet prior studies suggest that ED personnel have limited knowledge of proper MDI techniques. It is unclear how effectively brief education will improve this knowledge to enable them to provide adequate patient instructions. OBJECTIVE: Our aim was to evaluate ED medical personnel's baseline knowledge of MDI use and the utility of brief education on their ability to use MDIs. METHODS: After providing written consent, a spirometry nurse evaluated emergency physicians and nurses on their ability to properly perform three (open-mouth/two-finger, spacer, and closed-mouth) MDI techniques. The same spirometry nurse then gave a short educational session demonstrating the proper MDI techniques. Two weeks later, the nurse re-evaluated the same personnel on their MDI techniques. RESULTS: All emergency medical personnel initially performed poorly in demonstrating proper MDI technique, averaging 29.8% steps done correctly. Two weeks after their educational session, they improved greatly, averaging 89.4% steps done correctly. CONCLUSIONS: This study demonstrated both that ED personnel had poor initial knowledge about MDI techniques and that a brief educational intervention improved most people's ability to use, and presumably to instruct patients/parents in proper use of, MDIs.

7.
West J Emerg Med ; 21(3): 477-483, 2020 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-32302284

RESUMO

As clinicians and support personnel struggle with their responsibilities to treat during the current COVID-19 pandemic, several ethical issues have emerged. Will healthcare workers and support staff fulfill their duty to treat in the face of high risks? Will institutional and government leaders at all levels do the right things to help alleviate healthcare workers risks and fears? Will physicians be willing to make hard, resource-allocation decisions if they cannot first husband or improvise alternatives?With our healthcare facilities and governments unprepared for this inevitable disaster, front-line doctors, advanced providers, nurses, EMS, and support personnel struggle with acute shortages of equipment-both to treat patients and protect themselves. With their personal and possibly their family's lives and health at risk, they must weigh the option of continuing to work or retreat to safety. This decision, made daily, is based on professional and personal values, how they perceive existing risks-including available protective measures, and their perception of the level and transparency of information they receive. Often, while clinicians get this information, support personnel do not, leading to absenteeism and deteriorating healthcare services. Leadership can use good risk communication (complete, widely transmitted, and transparent) to align healthcare workers' risk perceptions with reality. They also can address the common problems healthcare workers must overcome to continue working (ie, risk mitigation techniques). Physicians, if they cannot sufficiently husband or improvise lifesaving resources, will have to face difficult triage decisions. Ideally, they will use a predetermined plan, probably based on the principles of Utilitarianism (maximizing the greatest good) and derived from professional and community input. Unfortunately, none of these plans is optimal.


Assuntos
Infecções por Coronavirus , Tomada de Decisões , Pandemias , Pneumonia Viral , Alocação de Recursos , Atitude do Pessoal de Saúde , Betacoronavirus , Comunicação , Infecções por Coronavirus/epidemiologia , Tomada de Decisões/ética , Desastres , Surtos de Doenças , Pessoal de Saúde , Humanos , Liderança , Médicos , Pneumonia Viral/epidemiologia , Alocação de Recursos/ética , Risco
8.
West J Emerg Med ; 21(3): 484-489, 2020 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-32302285

RESUMO

During the current COVID-19 pandemic, the limited surge capacity of the healthcare system is being quickly overwhelmed. Similar scenarios play out when an institution's systems fail, or when local or regional disasters occur. In these situations, it becomes necessary to use one or more alternative care sites (ACS). Situated in a variety of non-healthcare structures, ACS may be used for ambulatory, acute, subacute, or chronic care. Developing alternative care facilities is the disaster-planning step that moves communities from talking to doing. This commitment pays real dividends if a disaster of any magnitude strikes. This paper discusses the basic criteria for selecting, establishing and ultimately closing an ACS, difficulties of administration, staffing, security, and providing basic supplies and equipment.


Assuntos
Infecções por Coronavirus , Planejamento em Desastres , Instalações de Saúde , Pandemias , Pneumonia Viral , Capacidade de Resposta ante Emergências , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Assistência à Saúde , Planejamento em Desastres/organização & administração , Desastres , Humanos , Pneumonia Viral/epidemiologia
9.
West J Emerg Med ; 21(3): 490-496, 2020 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-32302286

RESUMO

In disasters such as the COVID-19 pandemic, we need to use all available resources to bolster our healthcare workforce. Many factors go into this process, including selecting the groups of professionals we will need, streamlining their licensing and credentialing processes, identifying appropriate roles for them, and supporting their health and well-being. The questions we must answer are these: How many staff will we need? How do we provide them with emergency licenses and credentials to practice? What interstate licensing compacts and registration systems exist to facilitate the process? What caveats are there to using retired healthcare professionals and healthcare students? How can we best avoid attrition among and increase the numbers of international medical graduates? Which non-clinical volunteers can we use and in what capacities? The answers to these questions will change as the crisis develops, although the earlier we address them, the smoother will be the process of using augmentees for the healthcare system.


Assuntos
Infecções por Coronavirus , Pessoal de Saúde , Mão de Obra em Saúde , Licenciamento , Pandemias , Pneumonia Viral , Estudantes de Medicina , Voluntários , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Assistência à Saúde , Desastres , Humanos , Pneumonia Viral/epidemiologia , Recursos Humanos
10.
J Clin Ethics ; 31(1): 76-78, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32213695

RESUMO

Magical thinking, distortions of reality based on fantasy, are pervasive in society and may influence patients' healthcare decisions. These distortions can "nudge" people to make decisions using System 1 thinking (a heuristic and error-prone decisional pathway that is always "on"), rather than a slower, deliberative, and more labor-intensive process that evaluates evidence (System 2). Physicians have been castigated for subtly nudging their patients toward evidence-based decisions. Yet when patients demonstrate magical thinking in their decision making, physicians have a professional responsibility to do more than nudge; they should shove patients toward decisions that will most likely achieve the healthcare goals they seek.


Assuntos
Cultura , Tomada de Decisões , Fantasia , Magia , Pacientes , Medicina Baseada em Evidências , Humanos , Pacientes/psicologia , Relações Médico-Paciente , Médicos , Pensamento
11.
J Emerg Med ; 58(5): 771-774, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32001125

RESUMO

BACKGROUND: Ketamine's application in psychiatry have expanded, but it appears never to have been previously used to diagnose and treat patients with catatonia-like syndrome that occasionally present to emergency departments. CASE REPORT: A 23-year-old male was observed to suddenly stop talking. His ED GCS was 8 and had normal vital signs. While verbally unresponsive, he refused to open his eyes, demonstrated waxy flexibility of his arms, but the balance of his physical, neurological, and laboratory exams were normal. Strongly suspecting a catatonic state, they needed to rapidly confirm that diagnosis or begin evaluating him for potentially life-threatening non-psychiatric illnesses. Lacking other diagnostic modalities, they administered low-dose ketamine boluses. Ketamine 25 mg (1 mL) was diluted in 9 mL NS (2.5 mg/mL). Based on similar protocols, 1 mL of the solution (0.03 mg/Kg) was given intravenously every few minutes. After 12.5 mg ketamine, he was conscious and verbal. Subsequent history confirmed a prior episode requiring an extensive, non-productive medical evaluation. Psychiatry later confirmed the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with catatonia-like states pose a difficult diagnostic and therapeutic dilemma. Multiple interventions have been used with varying success. Optimal interventions provide a rapid resolution (or demonstrate that a psychiatric cause is not likely), be safe, encompass few contraindications, and be familiar to the clinician. In our patient, subanesthetic doses of ketamine fulfilled these criteria and successfully resolved the condition. If shown effective in other cases, ketamine would be a valuable addition to our psychiatric armamentarium.

12.
HEC Forum ; 32(4): 293-312, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29352754

RESUMO

The ethics of providing health care in resource-poor environments is a complex topic. It implies two related questions: What can we do with the resources on hand? Of all the things we can do, which ones should we do? "Resource-poor" (i.e., resource-challenged, resource-constrained) environments are situations in which clinicians, organizations, or healthcare systems have the knowledge and skills, but not the means, to carry out highly effective and beneficial interventions. Determinants of a population's health often rely less on disease and injury management than on recognizing and meeting their basic needs. Many of the world's people with the greatest health problems live in fragile contexts and remote areas. Their access to food, safe water, personal safety, improved sanitation facilities, and health care remains elusive, with availability often based on socioeconomic status, gender, ethnicity, or geography. Of course, ethical international healthcare work also requires an understanding of the illnesses and injuries that most frequently plague the population. To function ethically and to know both what can and what should be done with available resources, individuals and organizations involved in international healthcare must be experienced, adaptable, culturally sensitive, inspired, situationally aware, beneficent, courageous, honest, and fair.

14.
J Emerg Med ; 57(4): 554-559, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31564443

RESUMO

BACKGROUND: More than 1500 scorpion species exist worldwide, with a few scorpion species potentially lethal to humans. About 1 million stings annually result in >3000 deaths, but the incidence and mortality vary greatly by species and location. Physicians working internationally must recognize that resulting toxidromes vary significantly by region. Over the past few decades, South America has reported relatively few deaths and low case mortality rates from envenomations. In Guyana, a small tropical country on its northeast coast, they have been extremely rare. A sudden fatal case cluster suggests an extension of the black scorpion's habitat, an increase in venom toxicity, or both. CASE REPORTS: During a 12-month period, Guyana experienced 3 deaths, including 1 adult, from black scorpion (Tityus obscurus) envenomation. The 30-year-old man and 2 young children experienced the same symptom complex, initially appearing well except for pain at the sting site. They soon developed persistent emesis and leukocytosis. All were flown from remote jungle areas to the only public tertiary care hospital where they received maximal available medical support. They gradually developed profound cardiopulmonary failure requiring ventilation and, eventually, dysrhythmias. None had hyperglycemia or pancreatitis, and they had no neurologic abnormalities until developing progressive obtundation immediately before intubation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Scorpion envenomation symptoms, outcomes, and treatment are geographically specific. Patients benefit when clinicians recognize the worldwide variations in grading systems and treatment options, which we discuss and compare to our patients.


Assuntos
Mortalidade/tendências , Venenos de Escorpião/efeitos adversos , Escorpiões , Adulto , Animais , Pré-Escolar , Guiana/epidemiologia , Humanos , Masculino , Venenos de Escorpião/sangue
16.
Am J Emerg Med ; 37(12): 2248-2252, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31477361

RESUMO

Emergency physicians, organizations and healthcare institutions should recognize the value to clinicians and patients of HIPAA-compliant audiovisual recording in emergency departments (ED). They should promote consistent specialty-wide policies that emphasize protecting patient privacy, particularly in patient-care areas, where patients and staff have a reasonable expectation of privacy and should generally not be recorded without their prospective consent. While recordings can help patients understand and recall vital parts of their ED experience and discharge instructions, using always-on recording devices should be regulated and restricted to areas in which patient care is not occurring. Healthcare institutions should provide HIPAA-compliant methods to securely store and transmit healthcare-sensitive recordings and establish protocols. Protocols should include both consent procedures their staff can use to record and publish (print or electronic) audiovisual images and appropriate disciplinary measures for staff that violate them. EDs and institutions should publicly post their rules governing ED recordings, including a ban on all surreptitious or unconsented recordings. However, local institutions may lack the ability to enforce these rules without multi-party consent statutes in those states (the majority) where it doesn't exist. Clinicians imaging patients in international settings should be guided by the same ethical norms as they are at their home institution.


Assuntos
Serviço Hospitalar de Emergência/ética , Gravação em Vídeo/ética , Confidencialidade , Serviço Hospitalar de Emergência/legislação & jurisprudência , Health Insurance Portability and Accountability Act , Humanos , Consentimento Livre e Esclarecido , Estados Unidos , Gravação em Vídeo/legislação & jurisprudência
17.
J Emerg Med ; 56(5): 544-550, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30890375

RESUMO

BACKGROUND: The three U.S. Antarctic research stations' medical facilities exist in an isolated, harsh environment, typical of many such facilities throughout the world. Emergency physicians frequently staff these medical facilities; however, most who are considering this have many misconceptions about the stations and about the scope of medical practice that exists there. OBJECTIVE: This article illuminates how Antarctic medical practice is comparable with and dissimilar to other emergency medicine experiences and highlights information that any emergency physician-applicant to an isolated medical position should learn prior to accepting the position. DISCUSSION: Antarctic medical care both parallels and differs from typical emergency medical practice in many ways, including the patient population, facilities, supplies, equipment, clinical duties (e.g., providing out- and inpatient medical and dental care, performing laboratory tests and imaging), and nonclinical duties (e.g., disaster planning, teaching, food service inspection, and public health officer). Climate-related limitations on medical evacuation epitomize the stations' isolation. Medical practice may be complicated by ethical issues common in other small isolated settings, such as a lack of privacy and confidentiality. Clinicians considering an isolated practice opportunity should ask basic questions to learn as much detailed information as possible prior to taking the positions. CONCLUSION: Medical practice at U.S. Antarctic stations, as at many remote health care facilities throughout the world, has similarities to standard emergency medical practice. Even so, significant differences result in a steep learning curve. Any clinicians considering practicing in these locations should carefully evaluate the practice and the environment in advance of any deployment.


Assuntos
Medicina de Emergência/métodos , Regiões Antárticas , Planejamento em Desastres/métodos , Humanos , Transferência de Pacientes/métodos , Transferência de Pacientes/tendências
18.
Am J Emerg Med ; 37(5): 942-946, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30712948

RESUMO

Emergency Physicians are frequently called upon to treat family members, friends, colleagues, subordinates or others with whom they have a personal relationship; or they may elect to treat themselves. This may occur in the Emergency Department (ED), outside of the ED, as an informal, or "curbside" consultation, long distance by telecommunication or even at home at any hour. In surveys, the vast majority of physicians report that they have provided some level of care to family members, friends, colleagues or themselves, sometime during their professional career. Despite being common, this practice raises ethical concerns and concern for the welfare of both the patient and the physician. This article suggests ethical and practical guidance for the emergency physician as to how to approach these situations.


Assuntos
Medicina de Emergência/ética , Família , Encaminhamento e Consulta/ética , Ética Médica , Amigos , Humanos
19.
AEM Educ Train ; 3(1): 105-112, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30680357

RESUMO

Professionalism is one of the Accreditation Council for Graduate Medical Education's (ACGME) Core Competencies, but the breadth of its content often makes this a difficult topic, both in remedial counseling and when presenting the topic to medical trainees and practicing clinicians. Physician professionalism encompasses both clinical competence and the virtues that comprise the physician's social contract. This difficult subject may best be approached tangentially, through the lens of professional identity. Professional identity describes clinicians' affinity for, acculturation into, and identification with the practice of medicine. One method to highlight the benefits that individuals accrue by adopting professionalism's elements is to pose questions that optimize listeners' self-reflection about their lives and aspirations-in essence, their professional identity. Discussing professionalism this way often yields in-depth discussions of how trainees believe their professional identity was formed and will impact their long-term goals. Both in teaching and in counseling, educators can frame their discussions using professionalism and professional identity's overlapping and reinforcing elements to show listeners how to advance their personal and professional goals and avoid the short- and long-term consequences of unprofessional behavior. To engage the audience, educators and supervisors can emphasize how adhering to the elements of professionalism may determine their career opportunities, the professional respect they receive, and their career fulfillment and, ultimately, longevity. In this way, educators can better guide trainees and clinicians to understand their personal reasons for acting professionally, that is, doing the right thing, at the right time, in the right way, and for the right reason.

20.
Ann Emerg Med ; 74(3): 357-364, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30579619

RESUMO

This article revisits the persistent problem of crowding in US hospital emergency departments (EDs). It begins with a brief review of origins of this problem, terms used to refer to ED crowding, proposed definitions and measures of crowding, and causal factors. The article then summarizes recent studies that document adverse moral consequences of ED crowding, including poorer patient outcomes; increased medical errors; compromises in patient physical privacy, confidentiality, and communication; and provider moral distress. It describes several organizational strategies implemented to relieve crowding and implications of ED crowding for individual practitioners. The article concludes that ED crowding remains a morally significant problem and calls on emergency physicians, ED and hospital leaders, emergency medicine professional associations, and policymakers to collaborate on solutions.


Assuntos
Aglomeração , Serviço Hospitalar de Emergência/normas , Medicina de Emergência/normas , Serviço Hospitalar de Emergência/legislação & jurisprudência , Serviço Hospitalar de Emergência/tendências , Humanos , Qualidade da Assistência à Saúde/normas , Estados Unidos
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