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a "clear and convincing" evidence standard to determine a patient's wishes before life-sustaining treatment could be withdrawn from a formerly competent adult now in a persistent vegetative state.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.

Federal advance directives legislation: potential effects on emergency medicine.

On December 1, 1991, a new federal law designed to increase public use of advance directives takes effect. After that date, health care facilities must provide written information about advance directives to all adult patients. This information must describe (1) the patient's rights to make medical care decisions under state statutes and case law, and (2) how patients can secure these rights within the scope of the provider's policies. The law also requires that institutions educate their staffs and the communities about advance directives and document the existence of any advance directive in the patient's medical record. The new federal law will benefit American society, U.S. health care, and the practice of emergency medicine. However, emergency physicians should anticipate that the law will provide not only benefits, but also some burdens. Many institutions will expect emergency department personnel to disseminate and explain the required information, and annotate the medical record. It is the specialty's responsibility to gather empirical data that can guide the use of advance directives in emergency departments.

Hypnosis for pediatric fracture reduction.

Hypnosis can diminish pain and anxiety for many emergency patients during examinations and procedures. While hypnosis has been used for millennia and was demonstrated to be of use in clinical medicine more than a century ago, modern physicians have been reluctant to adopt this technique in clinical practice. This article describes four children with angulated forearm fractures who had no possible access to other forms of analgesia during reduction, and in whom hypnosis was used successfully. A simple method for hypnotic induction is described.

Emergency burn treatment in Denmark.

Historically, burn treatment in Denmark has included several unique elements. Current Danish treatment includes prolonged tap water irrigation of burns, which largely replaces the use of narcotics for pain control in both the inpatient and outpatient settings. Burns on hands and feet are dressed for maximum mobility. Other burns are left open. Mortality is 10% to 15% below expectations.

The critical patient who refuses treatment: an ethical dilemma.

In clinical practice, emergency physicians must often make decisions in their patients' best interests when the patients are unable to do so themselves. The usual requirement for informed consent stems from recognizing individuals' autonomy and their right to make decisions affecting their bodies. Abandoning a requirement for consent is an emergency exception to the ethical and legal principles and comes into play only when a person lacks decision-making capacity. In some instances, it may be unclear whether a patient has this capacity, confounding the physician's management decisions. How should emergency physicians assess a patient's decision-making capacity? When may they ethically and legally override a patient's expressed desire for treatment or nontreatment? These issues are discussed in the context of an actual case.

Pulmonary and aortic punctures--complications of an attempt at internal jugular venipuncture.

A case of pulmonary and aortic punctures occurred during an attempted internal jugular venipuncture in a patient with a dilated aortic arch. Procedural errors contributing to the complications included an inexperienced operator, inappropriate medial and caudal angulation of the needle, and failure to use a "finder" needle or Seldinger technique. Use of proper procedural technique will reduce the risk of complications in performing this procedure.

The feasibility of 12-gauge intravenous catheter use in the prehospital setting.

Intravenous fluid therapy is a mainstay in the treatment of trauma and hypovolemia. However, controversy exists as to its effective use by prehospital personnel. We reasoned that 12-gauge catheters, shown to have significantly greater fluid flow than 14- or 16-gauge catheters, might allow prehospital care providers to have a more significant role in patient resuscitation. This study was designed to see if 12-gauge intravenous catheters can successfully be placed and used in the prehospital care arena. During a six-month period, commercial peripheral 12-gauge catheter-over-needle intravenous units were placed in any hypovolemic or potentially hypovolemic patient in whom paramedics thought that rapid fluid therapy was, or might become, necessary. They experienced an overall success rate of 84% and a success-per-attempt rate of 74%. The catheters were placed under normal field conditions. Per preexisting protocols, departure from the scene and transport to the hospital were not delayed for any paramedic interventions, including starting intravenous lines. The 12-gauge catheters can be successfully used by paramedics, both to establish large bore intravenous access prior to arrival at the emergency department and to institute effective fluid therapy where time and circumstances allow.

Research on critically ill and injured patients: rules, reality, and ethics.

Much of today's medical care relies on experience unsupported by investigation, and emergency medical care is no exception; research is necessary to improve this care. Critically ill and injured patients are the patients who will benefit the most from improvements in emergency medical diagnostic and treatment methods. Yet, the federal bureaucracy has effectively banned research on these patients, since they cannot generally give "informed consent." We argue that, with the proper safeguards, research on critically ill and injured patients should be performed in the emergency medicine (EDs and EMS) settings without informed consent. To require such consent when not obtainable compromises both the researchers who must get such consent and the patients who must continue to endure old, and often untested therapies.

Confirmation of high blood flow rates through 150 mu filter/high-flow tubing.

Many new products designed to assist in rapid blood infusion are appearing. Some highly touted and routinely used devices for intravenous (IV) infusion have recently been shown to be, at least in part, defective. A tubing with an in-line 150 mu filter (150 mu High-Flow Blood Filter; Saftifilter Blood Administration Sets; Cutter Biological, Berkeley, CA 94710) has recently been introduced to facilitate rapid blood transfusion. It is claimed that at least 8.5 units of blood can be rapidly run through each set before replacement is necessary. To test this under simulated clinical conditions, four sets of ten random units of outdated erythrocytes at 4 to 9 degrees C were each admixed with 250 mL 70 degrees C 0.9 NaCl and infused through the system under a constant 300 mmHg pressure. Two sets infused through unmodified tubing flowed at an average of 25 mL/sec (1500 mL/min) before there was an appreciable slowing of the flow rate. Two sets with 8 Fr catheters attached infused at an average of 22 mL/sec (1320 mL/min) before there was an appreciable slowing of the flow rate. Even after the flow slowed, the 9th and 10th units infused at an average greater than 10 mL/sec (600 mL/min). The tubing/filter exceeded the manufacturer's published claims. This tubing/filter appears to be one element that could be an effective component of a high-flow infusion system.

Flow characteristics of admixed erythrocytes through medex tubing with a pall filter.

Resuscitation with fluid and blood components is the mainstay of therapy for hypovolemic patients. This study evaluated the flow rate and resultant temperature of 6 degrees C erythrocytes admixed with warmed saline passing through a new commercial large bore tubing. The tubing is 183 cm long and is 0.57 cm in diameter. The effect on the outflow fluid temperature when catheters of various sizes were added to the system distally was also assessed. The admixed solution temperature averaged 36.2 degrees C and the outflow temperature of the mixture from the distal tubing averaged 34.9 degrees C. There was an average drop in temperature over the length of the tube of 1.5 degrees C. The filter in the Medex Hi-Flow Trauma Quad system collapsed, severely restricting fluid flow, after only four units. The problem of filter clogging was overcome by the in-line addition of a Pall filter. Addition of this in-line filter had a negligible effect on the flow rate. The flow rate with the Pall filter in-line averaged 1,150 mL/min. As the catheters that were added distally to the system diminished in size, there was a predictable decrease in the admixed fluid flow rate. A warmed saline-erythrocyte solution may be very rapidly infused through commercial large-bore tubing modified with an in-line filter. The size of the catheters used determines the ultimate flow rate.

Pressurization of i.v. bags: a new configuration and evaluation for use.

External pressure devices are often utilized to increase the flow rates of IV fluids in exsanguinating patients. However, increasing the flow rate by this method also increases the rate at which IV bags need changing. Time is lost and valuable personnel are preoccupied in maintaining the numerous hand-pumped external pressure devices and IV bags. A systematic evaluation comparing the hand-pumped device with a new, pneumatic external pressure device (Infusor-1, Medical Innovations, Inc., Phoenix, AZ) is presented. A new multiunit configuration (Infusor-Rack) for the pneumatic device is also described. We found a significant decrease in IV bag take-down/setup time with the new pneumatic pressure device. This system is faster, more reliable, and easier to use than the standard hand-pumped pressure bag and should be viewed as a practical improvement in the fluid delivery system.