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171 Cards in this Set
- Front
- Back
What are the levels of evidence for Clinical Decision Aids
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Derivation = Level IV
Validation (light)(validated in the population in which it was derived) = Level III Validation (heavy) (multicentre validation) = Level II Impact Analysis = Level I |
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What is a cross sectional study and what is it's use?
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A study where data are obtained from a population of patients at a single point in time.
It is an important study design for variables which cannot be mannipulated (HIV status, cigarette smoking) |
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What are types of longitudinal studies?
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Observational
-prospective -retrospective) Interventional -controlled -Uncontrolled |
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What are the components of a good randomized study question?
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PICO
Population and problem Intervention to be studied Comparison (control) intervention Outcome of interest |
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What is a convenience sample?
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Using patients who are available when the investigator is available
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What is selection bias?
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Excluding a subgroup who meet inclusion criteria
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What is stratified randomization?
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Used to ensure that patients with confounding factors are equally distributed in the control and test groups. Patients with the stratifying characteristics are randomized independently of those without the characteristic/
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What is double blinding? What can result if blinding is inadequate?
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Both the patient and the treating physician are blinded to the therapy/intervention.
Inadequate blinding can lead to false positive results |
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What is publication bias?
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The tendency for negative studies to be less likely to be submitted for publication than positive studies
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What is the null hypothesis?
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The finding of no difference between the groups
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What is the alternative hypothesis?
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The finding that the groups are different
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What is a type I error?
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The investigator concludes that a difference has been demonstrated between the two groups when no such difference exists (a false positive)
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What is the risk of a type I error?
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It is equal to alpha
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What is a type II error?
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Occurs when a difference exists between the two groups but the study fails to detect the difference (false negative)
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What is power?
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The probability of a trial to detect a treatment effect of a given size
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What is beta?
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1-power, which is the chance of missing a true treatment effect
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What power should you aim for?
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power>0.8
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What is a student's t-test?
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Used to test whether or not the means of measurements from two groups are equal assuming the data are normally distributed. (compares continuous variables)
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What is the Wilcoxen rank sum test?
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Used to test whether two sets of observations have the same distribution, similar in use to the t test but does not assume the data are normally distributed
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What is the chi-squared test?
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Used with categoric variables (two or more discrete treatments with two or more discrete outcomes)
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What is Fisher's exact test
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Similar to the chi-squared test but it may be used when less than five observations are expected in one or more categories of treatment outcome
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What is a one-way analyisis of variance (ANOVA)?
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Used to test the null hypothesis that three or more sets of continuous variables have equal means, assuming that the data are normally distributed -> the t test for 3 or more groups
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What is the Kruskal Wallis test?
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A nonparametric test (does not assume normal distribution) analogous to ANOVA
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What is the confidence interval?
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The range of possible treatment effects within which the true treatment effect lies.
It may indicate a treatment effect even when the p value is non significant. |
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What is the risk of multiple comparisons?
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The risk of false positive p values increases with each comparison that is made.
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What is the Bonferonni correction?
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It is a method for reducing type I error for the whole study by reducing the maximum p-value for each of the individual statistical tests. (overall desired risk of type I error is <5%)
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What is the down side of the Bonferonni correction?
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It increases the risk of a type II error
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What is the use of an intention to treat analysis?
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It estimates the effectiveness a therapy will have in real life
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What is multivariate modeling?
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It is a statistical tool used to determine the association between >/= 2 independent predictive variables and a single outcome
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What is Bayesian analysis?
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It incorporates a priori information in how tests are interpreted
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What is a meta-analysis?
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A statistical method for combining the results of multiple clinical trials that investigate identical or similar therapies
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What is the use of funnel plots?
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They assess for publication bias
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What is a sensitivity analysis?
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Perform a meta-analysis with only the studies of highest quality first and then sequentially include the studies of lower quality.
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What is data dredging?
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The process of making a large number of implicit or explicit comparisons in searching for possibly important differences
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What is validity?
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The degree to which a study represents the truth (RCT usually considered the most valid study)
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What threatens external validity?
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If the study is dissimilar to the study population or clinical setting
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What threatens internal validity?
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Inadequate blinding or randomization and use of historical control or absence of controls
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What is reliability?
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Reproducibility
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What is relevance?
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The degree with which the results address the clinical question
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What is the value of Observatio units in the US?
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They save 80% of patients who would otherwise be hospitalized an admission with a 50% cost savings (based on ED LOS of 2-3 hours)
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Which 2 groups of patients benefit from observation?
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Critical diagnostic syndrome (diagnosis unclear and will benefit from observation)
ED patients with selected emergency diagnoses not successfully treated during the ED stay |
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What are the nursing requirements for an observation unit?
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1 nurse/4-6monitored beds
1 nurse/6-9 non-monitored beds |
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What is the physician requirement for an observation unit?
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1 FTE/2000 patients observed per year
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What are critical diagnostic syndromes appropriate for observation units?
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Abdominal pain
Chest pain DVT GI bleed Syncope Trauma -blunt abdominal -blunt chest -penetrating abdominal -penetrating chest Head injury |
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What are emergency conditions appropriate for treatment in an observation unit?
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Asthma
Atrial fibrillation Congestive heart failure dehydration Infections -pneumonia -pyelonephritis |
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What are observation criteria for abdominal pain?
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Vital signs stable
Intermediate probability of appendicitis OR Low probability of appendicitis with RF (pregnancy, elderly >65, young <3) |
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How sensitive is the initial ECG for AMI?
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50%
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What are observation criteria for chest pain?
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Nontraumatic chest pain
Low probability of disease or risk of AE Stable vital sings Normal cardiac markers nondiagnostic ECG cocaine-induced chest pain |
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Why should blunt abdominal injuries be observed?
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33% of patients who do not have symptoms suggestive of abdominal injury on initial evaluation may have injury
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What is the value of observation units for penetrating trauma?
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It can be used to perform serial exams to r/o visceral injury in someone where peritoneum has been penetrated.
-stab wound to the abdo with negative DPL -tangential GSW -Penetrating wounds with negative CT and DPL in children |
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What is the value of observation units for blunt chest trauma?
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6-12 hours of ECG monitoring and trops
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What are observation criteria for asthma?
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Failed standard ED management
Stable VS Peak flow after 3rd beta agonist >32% predicted No concomitant illness successful ED management but high risk for relapse -second visit within 10 days -previous intubation or ICU admission -hospitalization in past year -Three or more ED visits in 6 months -oral steroids for more than 6 months |
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What are observation criteria for syncope?
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Low to intermediate risk of AE
Stable vital signs Loss of consciousness <10min No focal acute neurologic signs normal electrolytes and blood count no objective evidence of ischemia or injury by ECG or cardiac markers No history of congestive cardiac failure |
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What are the universally recognized indications for US to be performed by the emergency physician (5)?
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-pericardial tamponade
-intraabdominal hemorrhage -ruptured AAA -ectopic pregnancy -non-cardiogenic shock |
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What are the different modes of transmission of US waves?
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A - amplitude
B -brightness D - doppler M - motion |
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What are US wave properties?
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Penetration - US waves will pass through (penetrate) a medium to a certain depth
Attenuation - the process of losing some energy as they pass through a certain depth Reflection - reflected back towards the original source |
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What are the different tissue densities that are seen on US?
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Liquid (black)
Solid organs (can serve as acoustic windows) Bone (white) Gray (grey snowstorm appearance or scatter because US waves pass through gas easily but are immediately deflected in all directions) |
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What is the dead zone?
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The first few cm of the screen. No useful information can be obtained from this zone
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Define echogenic
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Material that produces echoes
The more echogenic a substance is, the whiter the image it produces on the screen |
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Define echolucent
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Material that does not produce echoes
The more echolucent a substance is, the blacker the image it produces on the screen |
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Define hyperechoic
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More echogenic than surrounding tissue
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Define hypoechoic
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Less echogenic than surrounding tissue
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What is the relationship between frequency and penetration in US?
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Frequency and penetration are inversely related
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What is the relationship between frequency and resolution?
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Frequency and resolution are directly related
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What is the frequency of most general EDE probes and for the endovaginal probe?
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General EDE 2.5-4 (typically 3.5MHz)
Endovaginal probe 5.0-7.5MHz |
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What is lateral resolution?
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The ability of US waves to distinguish between two objects at the same depth. Increased focus results in increased lateral resolution
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What is axial resolution?
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The ability of the US waves to distinguish two objects that are one on top of the other (that are parallel to the US beam)
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How are US tranducers categorized?
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Format - refers to the field of view produced by the probe (sector (pie wedge shaped field) and linear (rectangular field)
Array - refers to the way the crystals are arranged - phased, flat linear, curved linear |
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Name 5 types of artefact?
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Refraction (US waves are deflected from their original path by passing close to a large, curved, fluid-filled object)
Shadowing (occurs when US waves hit something that blocks their path, everything behind the blocking structure appears black) Enhancement )US waves easily go through an area of low resistance and retain almost all of their energy - the US waves entering denser tissues on the far side glow more brightly Reverberation - results from multiple reflections at a given interface mirror - image - occurs when images that are beyond a strong reflector are repeated creating a mirror image. An empyema or lung abscess can be simulated by a mirror image artifact of a hepatic cyst |
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What are 2 key questions that can be answered by cardiac EDE?
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Is there a pericardia effusion?
Is there vigorous global cardiac activity? Yes -> the cause of hypotension is non-cardiogenic Abnormally beating heart -> must consider the scan indeterminate Heart not beating -> unless there is a defibrillatable rhythm on the monitor, this is cardiac standstill. There is a very low (but not zero) chance of survival |
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How much fluid does the pericardium normally contain?
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50mL
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With the patient in the supine position, how will pericardial effusions of the following volumes become apparent: ~100, 100-300, >300?
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~100cc - posteriorly, only in systole
100-300cc: posteriorly, throughout the cardiac cycle >300cc: anteriorly and posteriorly |
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How can you improve your cardiac image on the screen?
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Ask the patient to breathe in slowly
Ask the patient to flex the legs, which will relax the abdominal muscles If the patient has a less well developed left lobe of the liver and that it does not provide an optimal acoustic window, move the probe to the patient's right to get a better window. |
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What are the possible false positive when assessing for a pericardial effusion?
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-epicardial fat
-free fluid in the abdominal and pleural spaces (emphysema is also a problem) |
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What is the first key landmark to identify when assessing for the presence of AAA?
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The spine which appears as a bright image with a dark acoustic shadow projecting behind.
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What are the features that definitively identify the aorta on the US screen?
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Thickness of the vessel wall
Non-compressibility Lack of respiratory variability |
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What finding on US can allow you to exclude the presence of a AAA?
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Diameter of the aorta in the transverse plane all the way to the iliac bifurcation <3cm
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What abdominal EDE view will detect >80% of clinically significant cases of hemoperitoneum?
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Hepatorenal view (RUQ)
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What is the minimum amount of fluid must be present in the abdomen so that it can be detected by EDE US?
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500cc
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What maneuvers can help obtain better RUQ and LUQ US images?
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-place the patient in 5-10 degrees of trendelenburg
-have the patient hold their breath either at end-expiration or end-inspiration |
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What are the sources of false positive abdominal scans?
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Perinephric fat
Imitators of free fluid (ascites, CAPD fluid, fluid from a ruptured ovarian cyst, urine from a ruptured bladder Intraluminal bowel fluid |
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What are the sources of false negative abdominal scans?
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Adhesion from prior surgeries
Delayed presentations (12-24 hours after the bleed) LUQ variability (the spleen is smaller and more mobile, fluid superior to the splenorenal interface is more easily missed) |
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What area is imaged in the pelvic scan?
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Rectovesicular pouch (men)
Rectouterine pouch (Pouch of Douglas) in women |
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What are the sex-specific potential false-positives in the pelvis?
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Women: small amounts of physiologic fluid in the rectouterine pouch
Men: the prostate can be quite hypoechoic( if in doubt, have someone perform an exam and press on the prostate to confirm) |
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Where does the free fluid in the pelvis appear in male vs female scans?
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Anterior to the rectum (Mickey mouse ears)
Anterior to the uterus (Mickey Mouse ears) or in the pouch of Douglas in Women (Bow tie) |
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What is the FAST?
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Focused Assessment with Sonography in Trauma
a limited US examination directed solely at identifying the presence of free intraperitoneal or pericardial fluid RUQ: the hepatorenal space LUQ: the splenorenal space pelvic view: the anterior vesicouterine space and the posterior rectouterine space subziphoid view : the pericardial space |
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What is the E-FAST?
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FAST exam plus evaluation of potential pneumothorax and pleural effusion.
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What is the sensitivity and specificity of the FAST?
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Sensitivity ranges from 60-99%
Specificity ranges from 80-99% |
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In which patient populations does the FAST have limited performance?
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Patients with penetrating trauma to the anterior abdomen (sensitivity is poor because significant bowel injuries can occur without significant hemoperitoneum)
Patients with pelvic fractures (the free fluid may actually be uroperitoneum from a bladder injury, clouding the decision for laparotomy vs pelvic embolization) |
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What is the accuracy of the FAST exam in children?
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Very similar to that in adults, but caution is advised because many pediatric patients can be observed or treated non-operatively with angiography.
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What is the shape of the uterus in the transabdominal longitudinal view vs the transverse view?
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Longitudinal: uterus looks like an elongated pear
Transverse: uterus looks like a circle |
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What is the only contraindication to performing a transvaginal EDE?
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Recent gynecologic surgery
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What is the shape of the uterus in the transvaginal coronal view vs the sagittal view?
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Sagittal image: Uterus is oval or pear-shaped (like in the transabdominal longitudinal view)
Coronal image: uterus has a circular shape (like in the transabdominal transverse view) |
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What structure must always be identified before making any decisions about the uterine contents?
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The bladder.
It will appear: across the entire top of the screen in the TA transverse and TV coronal views At the top right of the screen in the TA longitudinal view At the top left of the screen in the TV sagittal view |
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What are the criteria for diagnosing an IUP?
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1. Decidual reaction (strongly echogenic - white - lining)
2. Gestational sac (anechoic area - black - contained in the decidual reaction) 3. Yolk sac (another thick echogenic layer found within the gestational sac) These 3 structures are the "double ring sign" The presence of a fetal pole trumps the aforementioned three criteria and confirms the presence of an IUP Any other finding must be read as no definitive IUP (NDIUP) |
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How early can IUP be detected using EDE?
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5 weeks gestation by TV EDE
6-7 weeks gestation by TA EDE Remember that towards the end of the 1st trimester, the uterus exits the pelvis and an IUP can actually be out of range of the TV probe. Scanning transvaginally at this point will give the operator the impression that the uterus is empty, since only the most caudal part of the uterus is seen |
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What constitutes proof of live intrauterine pregnancy (LIUP)?
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Identification of fetal cardiac activity
-possible starting the 6th week by TV EDE and the 7th or 8th week by TA EDE -should always be detectable if the fetal pole exceeds 5mm by TV EDE or 10mm by TA EDE -HR must be >100 to be consistent with good fetal outcome |
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What should never be used to assess for fetal cardiac activity?
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The D (doppler) mode because there is a risk of later malformation
The M (motion) mode can be used though |
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What is the probability of miscarriage if fetal cardiac activity is detected towards the end of the 1st trimester?
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2%
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What is a pseudogestational sac?
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It is identical to the gestational sac within a decidual reaction, but it contains no yolk sac. This can be seen in early pregnancy but also in ectopic pregnancy
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What is a blighted ovum?
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It is a gestational sac without a yolk sac, just like a pseudogestational sac, but it is larger. (>20mm -> blighted ovum should be suspected; >25mm -> diagnosis of blighted ovum)
The finding of a blighted ovum eliminates ectopic pregnancy just as effectively as any other IUP |
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What is the appearance of a molar pregnancy on US?
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Traditionally described as a "snowstorm"
It is actually a mass of small cysts -> you will see a fairly homogenous mass inside the uterus full of small, fluid filled black holes |
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What are the B-HCG discriminatory thresholds for the detection of IUP by TA and TV approaches?
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TA: 3000mIU/mL
TV: 1500 mIU/mL These numbers are inferior limits below which you cannot see an IUP. It does not mean that beyond those numbers, you must see an IUP |
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What constitutes strong evidence of the presence of an ectopic pregnancy?
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Empty uterus (no gestational sac visible) and a quantitative B-HCG above the discriminatory threshold
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What is the crown-rump length?
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The distance from the top of the skull to the base of the pelvis. A CRL >5mm without a visible fetal heart is unlikely to proceed to viability.
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What is the rate of ectopic pregnancy in the general population?
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1:80
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What is the rate of heterotopic (extra and intra-uterine) pregnancy?
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General population: 1:30,000
endemic chlamydia 1:4000 Fertility treatment 1:100 |
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What procedures can be performed in the ED using US guidance?
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VAscular access
Torso fluid collections Cardiac pacer placement MSK Soft tissue Anesthesia Airway Urinary bladder Neurologic |
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What are findings of cholecystitis on biliary US?
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Sonographic Murphy's
Dilated GB Increased GB wall thickness Pericholecystic fluid |
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What finding on US is highly suggestive of eventual cholecystitis?
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Non-mobile stone in the GB neck
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What may be an indicator of choledocholithiasis on US?
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CBD >6mm if <60yo
or CBD <10mm in elders |
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What are basic skills in an intercultural curriculum?
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-communicate an interest in and respect for the patient's culture
-tactfully and respectfully ask if culture-specific interventions have been attempted (remedies, acupuncture, coining, moxibustion or others) -Elicit the patient's understanding of and beliefs about illness or health problems -Request information regarding folk medicine beliefs - for instance "mal ojo" (the evil eye or evil spirit) among Mexican Americans, voodoo among Haitians, yin and yang among Chinese patients, "rootwork" among African Americans and "spiritism" (the ability of spits to make people sick or cure them) among Puerto Ricans -Interpret verbal and nonverbal behaviors in a culturally relevant manner -negotiate a culturally appropriate health care plan with the patient and his or her family as partners -demonstrate an ability to work as a team with a medical interpreter in the bilingual medical encounter |
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What is the difference between intrinsic and extrinsic characteristics of the ED?
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Intrisic characteristics are not amenable to change and extrinsic characteristics are.
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What are intrinsic characteristics of the ED that make vulnerable to failures and that affect performance?
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Human cognitive properties
High level of uncertainty High decision density High cognitive load Narrow windows of opportunity Multiple interuptions/distractions Low signal-to-noise ratio (low likelihood of critical diagnosis compared with a benign diagnosis for similar presentation) Surge phenomenon (rapid changes in volume and acuity) Novel or infrequently occurring conditions Patient factors (acuity, language, delirium) |
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What are extrinsic characteristics of the ED that make it vulnerable to failures and that affect performance?
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high communication load
poor teamwork overcrowding production pressures high ambient noise levels report delays inadequate staffing poor feedback inexperience inadequate supervision sleep deprivation/debt fatigue multiple transitions of care poorly designed procedures emergency department layout |
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What areas are more at risk for failures in the ED?
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Triage
Technical procedures Radiology Transitions in patient care (sign-overs) Orphaned patients (patients brought in by EMS who wait hours on a stretcher prior to being admitted to the ED, LWBS, LAMA, patients leaving the ED for diagnostic tests) Medical errors (largest proportion of failures in the ED) |
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What are possible policies for institution improvement in cultural sensitivity?
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-Educate ED personnel about the circumstances of patients' lives and the interesting cultures that have evolved to deal with these circumstances
-Meet with community organizations to build trust and create partnerships for preventive education -hire employees who reflect the culture, ethnicity and socioeconomic background of ED patients -provide interpreter services, visual aids and other education materials in a variety of languages -participate as an institution in community health fairs |
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What is a violation producing factor?
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violation of organizational policies, rules and procedures. In the context of ED error one would think that this is always a bad thing but some violations are actually necessary for the safe functioning of the system (i.e.. normalization of deviance - accumulated tolerance to small variations from safe operating conditions)
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What are violation producing factors?
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Gender (males are more likely to violate)
Mood Ill health Risk seeking-risk aversion Normalization of deviance Maladaptive group pressures Maladaptive copying behavior Underconfidence/overconfidence Perceived authorization to deviate Authority gradient effects (obeying authority figures or absence of disapproving authority figure) Likelihood of detection |
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What are the effects of sleep deprivation?
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longer reaction time
lapses in attention or concentration lost information errors of omission poor short-term memory poor mood reduced motivation distractability sleepiness poor psychomotor performance (at circadian low points, when sedentary, on long, difficult or externally paced tasks, in unchanging surroundings - with reduce light or sound or with low motivation) |
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What are rational approaches to shift work?
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Optimize circadian-friendly schedules
Employ proper sleep hygiene Modulate circadian rhythm Eat healthy Promote a healthy lifestyle and workstyle Avoid pharmaceuticals |
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What are ways of optimizing circadian friendly schedules?
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Forward rotating
Rapid changes Minimize consecutive nights 24-48hours after nights allow social time, including some weekends 8 hour shifts institute regular, predictable template |
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What is proper sleep hygiene?
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sleep friendly room: darkened, lack of white noise, no phones, family aware
regular sleep routine anchor sleep avoid caffeine, EtOH and drugs prophylactic naps |
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How do you moderate circadian rhythms?
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exercise
consider bright light |
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What are the 6 bioethical principles?
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autonomy
personal integrity beneficence nonmaleficence confidentiality distributive justice |
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Define autonomy
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self-determination: a person's ability to make personal decisions, including those affecting personal medical care
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Define personal integrity
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Adhering to one's own reasoned and defensible set of values and moral standards
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Define beneficence
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doing good. A duty to confer benefits
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Define nonmaleficence
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not doing harm, prevention of harm, and removal or harmful conditions
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define confidentiality
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the presumption that what the patient tells the physician will not be revealed to any other person or institution without the patient's permission
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Define distributive justice
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fairness in the allocation of resources and obligations
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Define futility
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-intervention for which no survivors have been reported in similar circumstances
-intervention that is effective in <1% of identical cases -meaningful life will not result from the proposed intervention |
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Give examples of futile interventions
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-ED thoracotomy for blunt chest trauma
-attempting CPR on a patient with rigor mortis -resuscitation post decapitation |
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In what situations should CPR be withheld? (5)
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Advance directive (living will, durable power of attorney, prehospital advanced directive)
Valid DNAR order Signs of irreversible death (rigor mortis, dependent lividity) injuries incompatible with life (decapitation) Disaster situation where health care resources are limited |
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In what ways is bioethics similar to the law?
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case based (casuistic)
has existed since ancient times changes over time strives for consistency incorporates societal values basis for health care policies |
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In what way is the law different from bioethics?
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There are some unchangeable directives
There are formal rules for process The law is adversarial |
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In what way is bioethics different from the law?
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It relies heavily on individual values
It is interpretable by medical personnel It has the ability respond rapidly to a changing environment |
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What are commonly accepted moral rules?
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Do not kill
Do not cause pain Do not disable Do not deprive of freedom Do not deprive of pleasure Do not deceive Keep your promises Do not cheat Obey the law Do your duty |
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How is the ED setting different from the Primary care setting?
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In the ED:
-Patient is often brought in by ambulance, police or friends (whereas in the primary care setting the patient chooses to enter the medical care system) -patient does not choose physician in the ED -ED personnel must gain a patient's trust -Patient experiences an acute change in health status (whereas in the primary care setting the patient has chronic medical problems) -Anxiety, pain, alcohol and altered mental status are common -decisions are made quickly -physician makes decisions independently -physician represents institution and medical staff -work environment is open and less controlled -ED personnel frequently have a stressful work schedule |
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What is the impartiality test?
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asks whether the physician would accept this action if he were in the patient's place
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What is the universalizability test?
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asks if the physician would feel comfortable having all practitioners perform their action in all relevant similar circumstances (generalizing the action to all colleagues then asking whether the rule for the contemplated behavior is reasonable)
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What is the interpersonal justifiability test
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Whether the physician can supply good reasons to others for the actions (peers, supervisors, public satisfied with the answer)
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What is a rapid approach to ethical problems in the ED?
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Has the problem been encountered and worked out in the past, if so, follow the rule
If the problem has been not been worked out apply the impartiality test, universlizability test or interpersonal justifiability test (unless you are able to buy time and delay the decision) Affirmative to any of the tests means that the proposed action falls within the scope of ethically acceptable actions |
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What are the components of decision making capacity?
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Knowledge of the options
Awareness of the consequences of each option Appreciation of personal costs and benefits of options in relation to relatively stable values and preferences |
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What is presumed consent?
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When a patient is told what will occur and does not refuse treatment
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What is implied consent?
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Operative when a patient actively cooperates with the procedure
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What is informed consent?
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Patient has decision making capacity and is given all the pertinent facts regarding the risks and benefits of a particular procedure, understands them and voluntarily undergoes the procedure
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What is capacity?
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A patient's ability to make decisions about health care recommendations
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Who are surrogate decision makers?
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Spouse (not divorced or legally separated)
Majority of adult children Parents (of an adult) Domestic partner Sibling Close friend Attending physician in consultation with the bioethics committee |
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What are situations where prolonged resuscitative efforts may be successful?
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Prearrest hypothermia
Drug induced events lightening or electrical shock Infants/children with refractory VF or tachycardia |
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What are the 6 steps involved in delivering bad news?
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-physician preparation
-what does the patient know -how much does the patient want to know -sharing the information -responding to feelings -planning and follow-up |
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Should consent be obtained from relatives before any procedures are performed on the newly dead?
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Yes
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What are the elements of empathic death disclosure?
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Introduce self/role
Sit down assume comfortable communication distance use acceptable tone/rate of speech make eye contact maintain open posture give advance warning of bad new deliver new of death clearly tolerate survivor's reaction explain medical attempts to save patient use no medical jargon offer viewing offer to be available to survivor conclude appropriately |
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what are palliative treatment options to enhance quality of life?
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Pain control
Control of fluid and electrolyte imbalance Nausea/vomiting/constipation management Radiation therapy for bone pain, cord compression, hemorrhage from tumors Drainage tubes for malignant effusions/obstructions Treatment of intercurrent infections Management of incontinence Supplemental oxygen Anxiolytics, antidepressants, appetite stimulants when appropriate |
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What are 3 different types of consent?
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Presumed
Implied Informed |
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What are elements of informed consent?
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Patient has decision-making capacity
Patient is informed of options (including risks and benefits) Patient understands options Patient is free of coercion |
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What are essential elements of decision-making capacity?
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Knowledge of options
Understanding the consequences of options Ability to weigh options in relation to stable values and preferences |
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What is the difference between capacity and competency?
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Capacity: determined by a physician
Competency: determined by a court |
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Discuss consent in minors?
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Parents and legal guardians have the right to consent on behalf of their minor children. However, they must act reasonably and in the best interests of their children. If they do not, their right to consent can be abrogated by the courts. If one parent agrees with a proposed treatment and the other does not, consent may be accepted from the agreeing parent
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Who can given consent for care for adult patients that have been declared incompetent or incapable?
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Attorney for personal care
Spouse or partner Adult child Parent Brother or sister Any other relative (blood, marriage or adoption) Close friend Public Guardian and Trustee |
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What are the 7 steps involved in informed refusal of care?
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-involving the Emergency physician
-determining decision-making capacity -ensuring an informed decision (explain the medical condition, the risks related to the condition, the suggested treatment, the consequences of refusing) -involve the patient's family, friends and personal physician when possible -provide the best possible treatment within the scope allowed by the patient -provide adequate discharge instructions -document the refusal process appropriately (chart and refusal form) |
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Does a parent or guardian have the right to refuse care for a minor?
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Parents are NOT allowed to refuse treatment for a child with a life-threatening emergency condition
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Discuss the refusal of a blood transfusion in Jehovah's witnesses?
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Competent: has the right to refuse a transfusion regardless of whether his refusal to do so arises from fear of adverse reactions, religious beliefs, recalcitrance or cost
incompetent: in an emergency, if the Jehovah's witnesses beliefs are unknown, physicians may transfuse the patient because consent will be implied, regardless of the refusal of other family members to allow transfusion. Accept objective evidence of the patient's wishes (signed card carried by the patient) Minor: all jurisdictions hold that a parent's right to freedom of religion does not include the right to deny life-sustaining medical intervention for that person's children |
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Name 3 types of advanced directives
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Living will (requests that HCP not perform resuscitative measures or that HCP take all measures to keep the patient alive)
Durable power of attorney: specifies a surrogate decision maker for health care Prehospital advanced directive DNAR orders are not advance directives but rather physician orders; they are not patient or surrogate initiated |
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What illnesses/events must be reported to local public health authorities?
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Violent acts (GSW/stabs, suspected child or elder abuse, information suggesting risk of danger)
Health care frauds Health information regarding prisoners in correctional facilities Births, still births, deaths Reports to the coroner of certain deaths Conditions impairing operation of plane, train, boat, air traffic control and driving Incapacitated physician or sexual abuse by a physician (or other regulated health professional) Reporting of patient information to occupational health and safety Animal bites/contacts that may result in rabies infection Adverse vaccine reactions communicable diseases |
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What are nationally notifiable diseases?
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Acute flaccid paralysis
Amebiasis AIDS Anthrax BOtulism Brucellosis Campylobacteriosis Chancroid Chickenpox Chlamydia/gonorrhea Cholera Crutzfeldt Jakob Diphtheria Hantavirus Hepatitis A Hepatitis B Hepatitis C HIV Pertussis Polio Rubella Rabies Mumps Typhoid West nile virus Measles Syphilis Tetanus TB |
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What deaths must be reported to the coroner?
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Deaths from violence, poisoning, accident, suicide or homicide
Any sudden death in someone in apparently good health The identity of the deceased is unknown Any death occurring in jail, prison, or correctional institution or in police custody Any death occurring under suspicious, unusual or unnatural circumstances The body is going to be transported outside of the province |
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What are shift work strategies?
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Work the same shift as much as possible and keep the same sleep patterns
Work isolated night shifts Consider Thomas schedule (one physician works extended night schedule with isolated nights off covered by other group members) Schedule shift rotations in a clockwise direction Eight hour shifts Sleed in darkened rooms Use anchor sleep, split sleep periods or napping Start the awake period with a high protein meal Use bright lights for 2 hours after arising Exercise regularly Plan regular quality time with family and friends Do not try to live a day shift lifestyle while working night shifts |
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What is burnout
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Feeling of job dissatisfaction caused by work related stress
long term physical and emotional exhaustion associated with decreased productivity, less satisfaction with work, higher job turnover, lower self esteem Symptoms of burnout are precursors of more severe manifestations of impairment including alcoholism, drug abuse and suicide |
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What patterns suggest physician impairment?
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History of family difficulties
Frequent job changes Unexplained time intervals between periods of professional employment Neglected patient care responsibilities Poor medical judgement |
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What are the 4 major stressors in the ED?
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Difficult patient and professional relationships
Diversity of practice elements Diminished resources Difficult decisions |