A code of conduct for academic emergency medicine. SAEM Ethics Committee. Society for Academic Emergency Medicine.
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Emergency Medicine↗
Biomedical subjects
G L Larkin
Publications and source records attributed to G L Larkin.
Evaluating professionalism in emergency medicine: clinical ethical competence.
While the teaching and assessing of technical skills have been an integral part of residency training, the demonstration of ethical and humanistic skills has been more or less left to chance. Only in the last two decades has the formal teaching of bioethics become an accepted component of Western medical education. In spite of the many ethics lectures, discussions, conferences, and courses, the clinical impact of this educational paradigm shift remains unclear. Most ethics assessments to date are conducted retrospectively by risk managers and attorneys. The few prospective evaluations of trainees have focused on single-researcher observations or student attitude surveys that are fraught with observer and recall biases, respectively. More reliable and valid methods of identifying clinical ethical competence are needed. This paper reviews a variety of evaluative tools and suggests a three-level approach to monitoring the ethical knowledge, capacity, and real-time performance of emergency medicine residents.
Clinical Competence↗
Cost-effectiveness of air bags in motor vehicles.
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Accidents, Traffic↗
Tramadol versus hydrocodone-acetaminophen in acute musculoskeletal pain: a randomized, double-blind clinical trial.
STUDY OBJECTIVE: To evaluate the efficacy of an oral tramadol preparation versus that of an oral hydrocodone-acetaminophen preparation in acute musculoskeletal pain. METHODS: A randomized, prospective, double-blind clinical trial was conducted in an urban teaching emergency department with an annual census of 41,000. Participants comprised a convenience sample of 68 adult ED patients with acute musculoskeletal pain caused by minor trauma. Thirty-three patients received tramadol (100 mg), and 35 patients received hydrocodone-acetaminophen (5 mg hydrocodone with 500 mg acetaminophen). The drugs were prepared in identical-appearing capsules. Pain was evaluated by a 100-mm visual analog scale (VAS) at baseline and at 30, 60, 90, 120, and 180 minutes after dosing. VAS scores were analyzed by 2-way repeated-measures ANOVA, and nominal data were analyzed by Fisher's exact test. RESULTS: Mean pain scores did not differ at baseline (tramadol, 68.3+/-21.8; hydrocodone-acetaminophen, 69.1+/-17.8; P=NS) but were significantly lower in the hydrocodone-acetaminophen group beginning at 30 minutes through 180 minutes. There were 6 dropouts as a result of reported inadequate analgesia, 3 in each group (P=NS). The discharge diagnoses and prevalence of side effects did not differ significantly between groups. CONCLUSION: Tramadol provides inferior analgesia to hydrocodone-acetaminophen in ED patients with acute musculoskeletal pain.
Acetaminophen↗
Professionalism in emergency medicine. SAEM Ethics Committee. Society for Academic Emergency Medicine.
The Society for Academic Emergency Medicine (SAEM), with the support and participation of the American Board of Emergency Medicine (ABEM), the Council of Residency Directors (CORD), the American College of Emergency Physicians (ACEP), the Emergency Medicine Residents Association (EMRA), the American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM), initiated a project entitled Professionalism in Emergency Medicine. Its concepts were developed by the SAEM Ethics Committee, and are intended to describe proper behaviors and attitudes of the successful practitioner of emergency medicine. The behaviors described are not primarily scientific or technical, since those are defined by the core curriculum for residency training and are tested through certification examinations. This document identifies attitudes and behaviors that enhance trust by placing the patient's interest above other interests. This concept serves as the operative definition of professionalism. The purpose of this article is to clarify the professional attitudes and knowledge that are important to the emergency physician (EP). While no physician is likely to meet idealized standards, all EPs must meet basic standards while striving for the ideal. Awareness of these standards must begin early in the socialization process of emergency medical professionals. The standards must be integrated into residency training as well as the clinical practice of all EPs.
Attitude↗
Managed care ethics: an emergency?
The rapid expansion of cost-consciousness and managed care into the medical marketplace has challenged the autonomy of physicians and patients. These challenges have taken a variety of forms, including limitations on reimbursement and restrictions on the amount and type of emergency care patients may receive. Challenges aside, the economic agenda of managed care must not threaten the primacy of patient welfare. The fidelity of the emergency physician-patient relationship and the integrity of the medical profession hangs in the balance.
Emergency Medical Services↗
Clinical decision rules discriminate between fractures and nonfractures in acute isolated knee trauma.
STUDY OBJECTIVE: To develop criteria that optimize clinical decisionmaking in the use of radiography after isolated knee trauma in adults. DESIGN: A prospective survey of emergency department patients over a 7-month period. Standardized data forms were completed by emergency physicians, residents, and certified physician assistants. SETTING: A large suburban community teaching hospital. PARTICIPANTS: Two hundred forty-two patients older than 17 years with isolated knee injuries sustained less than 24 hours previously. RESULTS: We constructed a clinical decision model, calculating sensitivity, specificity, and odds ratios. Twenty-eight patients (11.6%) had fractures, with the patella the most commonly fractured osseous structure. Patients able to walk without limping had not experienced a fracture, nor had patients with twist injuries without effusion. Sensitivity of this model for detecting fracture was 1.0 (99% confidence interval, .97 to 1.0), and specificity was .337 (99% confidence interval, .26 to .42). CONCLUSION: Clinical decision rules are effective in detecting knee fractures with 100% sensitivity and with sufficient specificity to eliminate 29% of knee radiographs in the ED. These findings require prospective validation.
Adolescent↗
Experimental amitriptyline poisoning: treatment of severe cardiovascular toxicity with cardiopulmonary bypass.
STUDY OBJECTIVE: To compare cardiopulmonary bypass (CPB) with more conventional therapy in the treatment of severe amitriptyline poisoning. DESIGN: Prospective, randomized, controlled, laboratory investigation. INTERVENTIONS: Profound cardiovascular toxicity was induced in 20 anesthetized Yorkshire swine (72 +/- 8.3 kg) by amitriptyline infusion at 0.5 mg/kg/min. Ventilation was adjusted to keep arterial pH at 7.50 +/- 0.05 and the PCO2 at 35 mm Hg. The swine were randomized in a 1:1 ratio to one of two groups, CPB or control. Both groups received amitriptyline infusion until they experienced near-lethal toxicity, defined as a systolic blood pressure below 30 mm Hg for one minute. The control group was then given supportive treatment, including IV fluids, sodium bicarbonate, vasopressors, and standard pharmacologic (advanced cardiac life support) interventions. Control animals failing to respond to supportive measures after five minutes were given open-chest cardiac massage for 30 minutes or until the return of spontaneous circulation. The CPB group received only mechanical support by CPB for 90 to 120 minutes. No sodium bicarbonate, antiarrhythmics, or cardiotonic agents were provided to the CPB group during this resuscitation. RESULTS: All 20 animals experienced cardiac conduction delays, dysrhythmias, and progressive hypotension within 30 minutes of receiving IV amitriptyline at 0.5 mg/kg/min. The ten swine receiving CPB as treatment for cardiovascular toxicity were able to completely correct the dysrhythmias, cardiac conduction abnormalities, and hypotension produced by the amitriptyline; however, only one of ten control animals could be resuscitated (P = .0001). Nine of ten swine treated with CPB were easily weaned off bypass without any pharmacologic intervention; however, one required norepinephrine to be weaned. All 11 resuscitated swine were able to be salvaged. CONCLUSION: CPB improved survival in our swine model of severe amitriptyline poisoning.
Amitriptyline↗
The emergency physician and patient confidentiality: a review.
Confidentiality is a promise rooted in tradition, law, and medical ethics. Emergency physicians treat a variety of patients to whom confidentiality is of vital importance: employees, celebrities, victims of violence or disaster, minors, students, criminals, drug abusers, and patients with STDs. EDs should develop methods of ensuring confidentiality for all patients. Although confidentiality is an important principle that should be respected and guarded, it is not absolute. Various laws mandate disclosure of certain patient information; in addition, an overriding moral duty may occasionally require a breach of confidentiality. As Beauchamp and Childress noted, "the therapeutic role may sometimes have to yield to one's role as citizen and as protector of the interests of others." In general, however, circumstances requiring a breach of confidentiality are rare.
Adult↗
See one, do one, teach one?
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Education, Medical↗
A randomized, double-blind, comparative study of the efficacy of ketorolac tromethamine versus meperidine in the treatment of severe migraine.
STUDY OBJECTIVE: To evaluate the relative efficacy of ketorolac tromethamine and meperidine hydrochloride in the emergency department treatment of severe migraine. DESIGN: Prospective, randomized, double-blind trial. SETTING: University hospital ED. PARTICIPANTS: Patients presenting to the ED with an isolated diagnosis of common or classic migraine. INTERVENTIONS: Subjects were randomized to receive a single intramuscular injection of either 30 mg ketorolac or 75 mg meperidine. MEASUREMENTS AND MAIN RESULTS: Of the 31 patients completing the trial, 15 received ketorolac and 16 received meperidine. The demographic characteristics of both groups were comparable. At one hour, ketorolac was significantly less effective than meperidine in reducing headache pain (P = .02) and in improving clinical disability (P = .01). Ketorolac also was less effective at reducing nausea, photophobia, and the need for rescue medication (P less than .05). Sustained headache relief was experienced by 44% of the patients treated with meperidine at 12- to 24-hour follow-up, compared with 13% of the patients treated with ketorolac (P = NS). No significant side effects were observed for either group. CONCLUSION: IM ketorolac tromethamine is less effective than meperidine in the ED treatment of severe migraine.
Acute Disease↗
Occupational atropine poisoning via aerosol.
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Adult↗
Airbag-mediated corneal injury.
This is the first report of airbag-induced facial and corneal abrasions associated with several weeks of blurred vision in a patient without previous visual or ocular problems. Similar episodes of minor trauma from airbags are becoming commonplace, reflecting the increasing popularity of these lifesaving devices. Nonetheless, airbag-associated injuries, especially facial and ocular injuries, should be monitored and reported to both increase physician awareness and to determine if further airbag design improvements are necessary.
Accidents, Traffic↗
Congenital malaria in a hyperendemic area.
The prevalence of Plasmodium falciparum malaria was evaluated in all near-term pregnant women and their newborns at the Macha Hospital in the Southern Province of Zambia during part of the rainy season, when malaria prevalence is at its peak. Peripheral parasitemia was noted in 19 (29%) of 65 newborns and in 40 (63%) of 63 mothers. All but one of the infected neonates had an infected mother, and 17 of 40 infected mothers gave birth to infected newborns. The parasite densities measured were uniformly low (less than 25,000/cc), and only seven of 19 infected neonates had fever within 48 hours of delivery suggestive of malaria infection. Parasitized newborns had a 469-gm lower average birthweight, but they did not have a higher incidence of prematurity or preterm delivery compared with uninfected newborns. In addition, the Apgar scores of infected and uninfected newborns were not significantly different. There was no correlation between neonatal parasitemia and either the sex of the child or the parity of the mother. Maternal chloroquine prophylaxis did not appear to be effective in preventing infection in the fetus or the gravida, and the emergence of chloroquine resistance may explain, in part, the greater prevalence of congenital malaria in endemic areas in recent years.
Animals↗
Depletion of O6-alkylguanine-DNA alkyltransferase activity in mammalian tissues and human tumor xenografts in nude mice by treatment with O6-methylguanine.
We have previously shown that exposure of cells in culture to O6-methylguanine significantly reduces their level of the repair protein, O6-alkylguanine-DNA-alkyltransferase (AGT), thus rendering cells more sensitive to the cytotoxic effects of chemotherapeutic chloroethylating agents. Experiments were carried out in mice to determine whether the AGT content of tissues and tumors could be reduced by in vivo treatment with O6-methylguanine. There was a dose-dependent decrease in AGT activity in liver tissues of CD-1 mice to 24% of basal levels after four hourly intraperitoneal injections of O6-methylguanine (110 mg/kg). Although the decline in AGT activity in the liver was reversible, the activity remained at 75% of basal levels for up to 25 h after the final injection. The effect of O6-methylguanine treatment on AGT activity was measured in mouse tissues as well as human colonic carcinoma tumors (HT29 and BE) grown in Swiss athymic nude mice. The activity in the liver, kidney, and spleen of these mice decreased to 33%-35% of control levels, whereas the activity in HT29 tumors was likewise diminished to 25% of control levels after four hourly injections of O6-methylguanine (100 mg/kg). There was no enhancement of the tumoricidal effectiveness of chloroethylating agents on the HT29 tumor after O6-methylguanine treatment, probably due to a disproportionately higher level of AGT in human tissue than in murine tissue. However, these studies suggest that O6-methylguanine can be given in vivo to examine the role of the AGT protein in protecting against the toxic and carcinogenic effects of alkylating agents.
Animals↗
Giant urethral calculus: a rare cause of acute urinary retention.
We present a case of a 98-yr-old woman with acute urinary retention secondary to a large urethral calculus. This is a unique cause of obstructive uropathy for several reasons. First, urethral calculi are extremely rare in American-born Caucasian females. Second, urethral stones in females are nearly always associated with underlying genitourinary pathology; however, subsequent work up failed to reveal any strictures, diverticula, or related processes that may have predisposed this patient to urethral calculus formation. The epidemiology, pathogenesis, clinical presentation, and emergency management of large urethral calculi are reviewed.
Acute Disease↗
Resource utilization in the emergency department: the duty of stewardship.
As the pool of available health care resources continues to evaporate, emergency physicians will be increasingly required to guard against the provision of expensive, unnecessary, and marginally beneficial care. This article proposes that emergency physicians embrace the ethic of prudent resource stewardship to ensure the continued availability of emergency services to all who need them. When making resource allocation decisions, emergency physicians must consider the likelihood, magnitude, and duration of benefits to patients, the urgency of the condition, and the cost and burdens of treatment to patients, payers, and society. These considerations go beyond professional duties to individual patients and suggest that ignoring the burdens of emergency department microallocation decisions is socially and morally irresponsible.
Emergency Service, Hospital↗