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171 Cards in this Set

  • Front
  • Back
What are the levels of evidence for Clinical Decision Aids
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
What is a cross sectional study and what is it's use?
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)
What are types of longitudinal studies?
Observational
-prospective
-retrospective)
Interventional
-controlled
-Uncontrolled
What are the components of a good randomized study question?
PICO
Population and problem
Intervention to be studied
Comparison (control) intervention
Outcome of interest
What is a convenience sample?
Using patients who are available when the investigator is available
What is selection bias?
Excluding a subgroup who meet inclusion criteria
What is stratified randomization?
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/
What is double blinding? What can result if blinding is inadequate?
Both the patient and the treating physician are blinded to the therapy/intervention.

Inadequate blinding can lead to false positive results
What is publication bias?
The tendency for negative studies to be less likely to be submitted for publication than positive studies
What is the null hypothesis?
The finding of no difference between the groups
What is the alternative hypothesis?
The finding that the groups are different
What is a type I error?
The investigator concludes that a difference has been demonstrated between the two groups when no such difference exists (a false positive)
What is the risk of a type I error?
It is equal to alpha
What is a type II error?
Occurs when a difference exists between the two groups but the study fails to detect the difference (false negative)
What is power?
The probability of a trial to detect a treatment effect of a given size
What is beta?
1-power, which is the chance of missing a true treatment effect
What power should you aim for?
power>0.8
What is a student's t-test?
Used to test whether or not the means of measurements from two groups are equal assuming the data are normally distributed. (compares continuous variables)
What is the Wilcoxen rank sum test?
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
What is the chi-squared test?
Used with categoric variables (two or more discrete treatments with two or more discrete outcomes)
What is Fisher's exact test
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
What is a one-way analyisis of variance (ANOVA)?
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
What is the Kruskal Wallis test?
A nonparametric test (does not assume normal distribution) analogous to ANOVA
What is the confidence interval?
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.
What is the risk of multiple comparisons?
The risk of false positive p values increases with each comparison that is made.
What is the Bonferonni correction?
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%)
What is the down side of the Bonferonni correction?
It increases the risk of a type II error
What is the use of an intention to treat analysis?
It estimates the effectiveness a therapy will have in real life
What is multivariate modeling?
It is a statistical tool used to determine the association between >/= 2 independent predictive variables and a single outcome
What is Bayesian analysis?
It incorporates a priori information in how tests are interpreted
What is a meta-analysis?
A statistical method for combining the results of multiple clinical trials that investigate identical or similar therapies
What is the use of funnel plots?
They assess for publication bias
What is a sensitivity analysis?
Perform a meta-analysis with only the studies of highest quality first and then sequentially include the studies of lower quality.
What is data dredging?
The process of making a large number of implicit or explicit comparisons in searching for possibly important differences
What is validity?
The degree to which a study represents the truth (RCT usually considered the most valid study)
What threatens external validity?
If the study is dissimilar to the study population or clinical setting
What threatens internal validity?
Inadequate blinding or randomization and use of historical control or absence of controls
What is reliability?
Reproducibility
What is relevance?
The degree with which the results address the clinical question
What is the value of Observatio units in the US?
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)
Which 2 groups of patients benefit from observation?
Critical diagnostic syndrome (diagnosis unclear and will benefit from observation)
ED patients with selected emergency diagnoses not successfully treated during the ED stay
What are the nursing requirements for an observation unit?
1 nurse/4-6monitored beds
1 nurse/6-9 non-monitored beds
What is the physician requirement for an observation unit?
1 FTE/2000 patients observed per year
What are critical diagnostic syndromes appropriate for observation units?
Abdominal pain
Chest pain
DVT
GI bleed
Syncope
Trauma
-blunt abdominal
-blunt chest
-penetrating abdominal
-penetrating chest
Head injury
What are emergency conditions appropriate for treatment in an observation unit?
Asthma
Atrial fibrillation
Congestive heart failure
dehydration
Infections
-pneumonia
-pyelonephritis
What are observation criteria for abdominal pain?
Vital signs stable
Intermediate probability of appendicitis
OR
Low probability of appendicitis with RF (pregnancy, elderly >65, young <3)
How sensitive is the initial ECG for AMI?
50%
What are observation criteria for chest pain?
Nontraumatic chest pain
Low probability of disease or risk of AE
Stable vital sings
Normal cardiac markers
nondiagnostic ECG
cocaine-induced chest pain
Why should blunt abdominal injuries be observed?
33% of patients who do not have symptoms suggestive of abdominal injury on initial evaluation may have injury
What is the value of observation units for penetrating trauma?
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
What is the value of observation units for blunt chest trauma?
6-12 hours of ECG monitoring and trops
What are observation criteria for asthma?
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
What are observation criteria for syncope?
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
What are the universally recognized indications for US to be performed by the emergency physician (5)?
-pericardial tamponade
-intraabdominal hemorrhage
-ruptured AAA
-ectopic pregnancy
-non-cardiogenic shock
What are the different modes of transmission of US waves?
A - amplitude
B -brightness
D - doppler
M - motion
What are US wave properties?
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
What are the different tissue densities that are seen on US?
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)
What is the dead zone?
The first few cm of the screen. No useful information can be obtained from this zone
Define echogenic
Material that produces echoes
The more echogenic a substance is, the whiter the image it produces on the screen
Define echolucent
Material that does not produce echoes
The more echolucent a substance is, the blacker the image it produces on the screen
Define hyperechoic
More echogenic than surrounding tissue
Define hypoechoic
Less echogenic than surrounding tissue
What is the relationship between frequency and penetration in US?
Frequency and penetration are inversely related
What is the relationship between frequency and resolution?
Frequency and resolution are directly related
What is the frequency of most general EDE probes and for the endovaginal probe?
General EDE 2.5-4 (typically 3.5MHz)
Endovaginal probe 5.0-7.5MHz
What is lateral resolution?
The ability of US waves to distinguish between two objects at the same depth. Increased focus results in increased lateral resolution
What is axial resolution?
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)
How are US tranducers categorized?
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
Name 5 types of artefact?
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
What are 2 key questions that can be answered by cardiac EDE?
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
How much fluid does the pericardium normally contain?
50mL
With the patient in the supine position, how will pericardial effusions of the following volumes become apparent: ~100, 100-300, >300?
~100cc - posteriorly, only in systole
100-300cc: posteriorly, throughout the cardiac cycle
>300cc: anteriorly and posteriorly
How can you improve your cardiac image on the screen?
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.
What are the possible false positive when assessing for a pericardial effusion?
-epicardial fat
-free fluid in the abdominal and pleural spaces
(emphysema is also a problem)
What is the first key landmark to identify when assessing for the presence of AAA?
The spine which appears as a bright image with a dark acoustic shadow projecting behind.
What are the features that definitively identify the aorta on the US screen?
Thickness of the vessel wall
Non-compressibility
Lack of respiratory variability
What finding on US can allow you to exclude the presence of a AAA?
Diameter of the aorta in the transverse plane all the way to the iliac bifurcation <3cm
What abdominal EDE view will detect >80% of clinically significant cases of hemoperitoneum?
Hepatorenal view (RUQ)
What is the minimum amount of fluid must be present in the abdomen so that it can be detected by EDE US?
500cc
What maneuvers can help obtain better RUQ and LUQ US images?
-place the patient in 5-10 degrees of trendelenburg
-have the patient hold their breath either at end-expiration or end-inspiration
What are the sources of false positive abdominal scans?
Perinephric fat
Imitators of free fluid (ascites, CAPD fluid, fluid from a ruptured ovarian cyst, urine from a ruptured bladder
Intraluminal bowel fluid
What are the sources of false negative abdominal scans?
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)
What area is imaged in the pelvic scan?
Rectovesicular pouch (men)
Rectouterine pouch (Pouch of Douglas) in women
What are the sex-specific potential false-positives in the pelvis?
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)
Where does the free fluid in the pelvis appear in male vs female scans?
Anterior to the rectum (Mickey mouse ears)

Anterior to the uterus (Mickey Mouse ears) or in the pouch of Douglas in Women (Bow tie)
What is the FAST?
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
What is the E-FAST?
FAST exam plus evaluation of potential pneumothorax and pleural effusion.
What is the sensitivity and specificity of the FAST?
Sensitivity ranges from 60-99%
Specificity ranges from 80-99%
In which patient populations does the FAST have limited performance?
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)
What is the accuracy of the FAST exam in children?
Very similar to that in adults, but caution is advised because many pediatric patients can be observed or treated non-operatively with angiography.
What is the shape of the uterus in the transabdominal longitudinal view vs the transverse view?
Longitudinal: uterus looks like an elongated pear
Transverse: uterus looks like a circle
What is the only contraindication to performing a transvaginal EDE?
Recent gynecologic surgery
What is the shape of the uterus in the transvaginal coronal view vs the sagittal view?
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)
What structure must always be identified before making any decisions about the uterine contents?
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
What are the criteria for diagnosing an IUP?
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)
How early can IUP be detected using EDE?
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
What constitutes proof of live intrauterine pregnancy (LIUP)?
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
What should never be used to assess for fetal cardiac activity?
The D (doppler) mode because there is a risk of later malformation
The M (motion) mode can be used though
What is the probability of miscarriage if fetal cardiac activity is detected towards the end of the 1st trimester?
2%
What is a pseudogestational sac?
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
What is a blighted ovum?
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
What is the appearance of a molar pregnancy on US?
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
What are the B-HCG discriminatory thresholds for the detection of IUP by TA and TV approaches?
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
What constitutes strong evidence of the presence of an ectopic pregnancy?
Empty uterus (no gestational sac visible) and a quantitative B-HCG above the discriminatory threshold
What is the crown-rump length?
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.
What is the rate of ectopic pregnancy in the general population?
1:80
What is the rate of heterotopic (extra and intra-uterine) pregnancy?
General population: 1:30,000
endemic chlamydia 1:4000
Fertility treatment 1:100
What procedures can be performed in the ED using US guidance?
VAscular access
Torso fluid collections
Cardiac pacer placement
MSK
Soft tissue
Anesthesia
Airway
Urinary bladder
Neurologic
What are findings of cholecystitis on biliary US?
Sonographic Murphy's
Dilated GB
Increased GB wall thickness
Pericholecystic fluid
What finding on US is highly suggestive of eventual cholecystitis?
Non-mobile stone in the GB neck
What may be an indicator of choledocholithiasis on US?
CBD >6mm if <60yo
or
CBD <10mm in elders
What are basic skills in an intercultural curriculum?
-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
What is the difference between intrinsic and extrinsic characteristics of the ED?
Intrisic characteristics are not amenable to change and extrinsic characteristics are.
What are intrinsic characteristics of the ED that make vulnerable to failures and that affect performance?
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)
What are extrinsic characteristics of the ED that make it vulnerable to failures and that affect performance?
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
What areas are more at risk for failures in the ED?
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)
What are possible policies for institution improvement in cultural sensitivity?
-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
What is a violation producing factor?
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)
What are violation producing factors?
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
What are the effects of sleep deprivation?
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)
What are rational approaches to shift work?
Optimize circadian-friendly schedules
Employ proper sleep hygiene
Modulate circadian rhythm
Eat healthy
Promote a healthy lifestyle and workstyle
Avoid pharmaceuticals
What are ways of optimizing circadian friendly schedules?
Forward rotating
Rapid changes
Minimize consecutive nights
24-48hours after nights
allow social time, including some weekends
8 hour shifts
institute regular, predictable template
What is proper sleep hygiene?
sleep friendly room: darkened, lack of white noise, no phones, family aware
regular sleep routine
anchor sleep
avoid caffeine, EtOH and drugs
prophylactic naps
How do you moderate circadian rhythms?
exercise
consider bright light
What are the 6 bioethical principles?
autonomy
personal integrity
beneficence
nonmaleficence
confidentiality
distributive justice
Define autonomy
self-determination: a person's ability to make personal decisions, including those affecting personal medical care
Define personal integrity
Adhering to one's own reasoned and defensible set of values and moral standards
Define beneficence
doing good. A duty to confer benefits
Define nonmaleficence
not doing harm, prevention of harm, and removal or harmful conditions
define confidentiality
the presumption that what the patient tells the physician will not be revealed to any other person or institution without the patient's permission
Define distributive justice
fairness in the allocation of resources and obligations
Define futility
-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
Give examples of futile interventions
-ED thoracotomy for blunt chest trauma
-attempting CPR on a patient with rigor mortis
-resuscitation post decapitation
In what situations should CPR be withheld? (5)
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
In what ways is bioethics similar to the law?
case based (casuistic)
has existed since ancient times
changes over time
strives for consistency
incorporates societal values
basis for health care policies
In what way is the law different from bioethics?
There are some unchangeable directives
There are formal rules for process
The law is adversarial
In what way is bioethics different from the law?
It relies heavily on individual values
It is interpretable by medical personnel
It has the ability respond rapidly to a changing environment
What are commonly accepted moral rules?
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
How is the ED setting different from the Primary care setting?
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
What is the impartiality test?
asks whether the physician would accept this action if he were in the patient's place
What is the universalizability test?
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)
What is the interpersonal justifiability test
Whether the physician can supply good reasons to others for the actions (peers, supervisors, public satisfied with the answer)
What is a rapid approach to ethical problems in the ED?
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
What are the components of decision making capacity?
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
What is presumed consent?
When a patient is told what will occur and does not refuse treatment
What is implied consent?
Operative when a patient actively cooperates with the procedure
What is informed consent?
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
What is capacity?
A patient's ability to make decisions about health care recommendations
Who are surrogate decision makers?
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
What are situations where prolonged resuscitative efforts may be successful?
Prearrest hypothermia
Drug induced events
lightening or electrical shock
Infants/children with refractory VF or tachycardia
What are the 6 steps involved in delivering bad news?
-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
Should consent be obtained from relatives before any procedures are performed on the newly dead?
Yes
What are the elements of empathic death disclosure?
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
what are palliative treatment options to enhance quality of life?
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
What are 3 different types of consent?
Presumed
Implied
Informed
What are elements of informed consent?
Patient has decision-making capacity
Patient is informed of options (including risks and benefits)
Patient understands options
Patient is free of coercion
What are essential elements of decision-making capacity?
Knowledge of options
Understanding the consequences of options
Ability to weigh options in relation to stable values and preferences
What is the difference between capacity and competency?
Capacity: determined by a physician
Competency: determined by a court
Discuss consent in minors?
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
Who can given consent for care for adult patients that have been declared incompetent or incapable?
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
What are the 7 steps involved in informed refusal of care?
-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)
Does a parent or guardian have the right to refuse care for a minor?
Parents are NOT allowed to refuse treatment for a child with a life-threatening emergency condition
Discuss the refusal of a blood transfusion in Jehovah's witnesses?
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
Name 3 types of advanced directives
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
What illnesses/events must be reported to local public health authorities?
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
What are nationally notifiable diseases?
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
What deaths must be reported to the coroner?
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
What are shift work strategies?
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
What is burnout
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
What patterns suggest physician impairment?
History of family difficulties
Frequent job changes
Unexplained time intervals between periods of professional employment
Neglected patient care responsibilities
Poor medical judgement
What are the 4 major stressors in the ED?
Difficult patient and professional relationships
Diversity of practice elements
Diminished resources
Difficult decisions