This article revisits the persistent problem of crowding in US hospital emergency departments (EDs). It begins with a brief review of origins of this problem, terms used to refer to ED crowding, ...proposed definitions and measures of crowding, and causal factors. The article then summarizes recent studies that document adverse moral consequences of ED crowding, including poorer patient outcomes; increased medical errors; compromises in patient physical privacy, confidentiality, and communication; and provider moral distress. It describes several organizational strategies implemented to relieve crowding and implications of ED crowding for individual practitioners. The article concludes that ED crowding remains a morally significant problem and calls on emergency physicians, ED and hospital leaders, emergency medicine professional associations, and policymakers to collaborate on solutions.
This 2-article series offers a conceptual, historical, and moral analysis of the practice of triage. Part I distinguishes triage from related concepts, reviews the evolution of triage principles and ...practices, and describes the settings in which triage is commonly practiced. Part II identifies and examines the moral values and principles underlying the practice of triage.
Abstract Background Hypnosis has been used in medicine for nearly 250 years. Yet, emergency clinicians rarely use it in emergency departments or prehospital settings. Objective This review describes ...hypnosis, its historical use in medicine, several neurophysiologic studies of the procedure, its uses and potential uses in emergency care, and a simple technique for inducing hypnosis. It also discusses reasons why the technique has not been widely adopted, and suggests methods of increasing its use in emergency care, including some potential research areas. Discussion A limited number of clinical studies and case reports suggest that hypnosis may be effective in a wide variety of conditions applicable to emergency medical care. These include providing analgesia for existing pain (e.g., fractures, burns, and lacerations), providing analgesia and sedation for painful procedures (e.g., needle sticks, laceration repair, and fracture and joint reductions), reducing acute anxiety, increasing children's cooperation for procedures, facilitating the diagnosis and treatment of acute psychiatric conditions, and providing analgesia and anxiolysis for obstetric/gynecologic problems. Conclusions Although it is safe, fast, and cost-effective, emergency clinicians rarely use hypnosis. This is due, in part, to the myths surrounding hypnosis and its association with alternative-complementary medicine. Genuine barriers to its increased clinical use include a lack of assured effectiveness and a lack of training and training requirements. Based on the results of further research, hypnosis could become a powerful and safe nonpharmacologic addition to the emergency clinician's armamentarium, with the potential to enhance patient care in emergency medicine, prehospital care, and remote medical settings.
Part I of this 2-article series reviewed the concept and history of triage and the settings in which triage is commonly practiced. We now examine the moral foundations of the practice of triage. We ...begin by recognizing the moral significance of triage decisions. We then note that triage systems tend to promote the values of human life, health, efficient use of resources, and fairness, and tend to disregard the values of autonomy, fidelity, and ownership of resources. We conclude with an analysis of three principles of distributive justice that have been proposed to guide triage decisions.
Remote extended expeditions often support scientific research and commercial resource exploration or extraction in hostile environments. Medical support for these expeditions is inherently complex ...and requires in-depth planning. To be successful, this planning must include substantial input from clinicians with experience in remote, emergency, and prehospital medicine and from personnel familiar with the proposed working environment. Using the guidelines discussed in this paper will help ensure that planners consider all necessary, medically relevant elements before launching an extended remote expedition. The 10 key elements of a workable remote healthcare system are to: 1. Optimize workers’ fitness 2. Anticipate treatable problems 3. Stock appropriate medications 4. Provide appropriate equipment 5. Provide adequate logistical support 6. Provide adequate medical communications 7. Know the environmental limitations on patient access and evacuation 8. Use qualified providers 9. Arrange for knowledgeable and timely consultations 10. Establish and distribute rational administrative rules Planners using these guidelines may better be able to generate a strategy that optimizes the participants’ health benefits, the expedition’s productivity, and the expedition sponsor’s cost savings.
Most disaster plans depend on using emergency physicians, nurses, emergency department support staff, and out-of-hospital personnel to maintain the health care system’s front line during crises that ...involve personal risk to themselves or their families. Planners automatically assume that emergency health care workers will respond. However, we need to ask: Should they, and will they, work rather than flee? The answer involves basic moral and personal issues. This article identifies and examines the factors that influence health care workers’ decisions in these situations. After reviewing physicians’ response to past disasters and epidemics, we evaluate how much danger they actually faced. Next, we examine guidelines from medical professional organizations about physicians’ duty to provide care despite personal risks, although we acknowledge that individuals will interpret and apply professional expectations and norms according to their own situation and values. The article goes on to articulate moral arguments for a duty to treat during disasters and social crises, as well as moral reasons that may limit or override such a duty. How fear influences behavior is examined, as are the institutional and social measures that can be taken to control fear and to encourage health professionals to provide treatment in crisis situations. Finally, the article emphasizes the importance of effective risk communication in enabling health care professionals and the public to make informed and defensible decisions during disasters. We conclude that the decision to stay or leave will ultimately depend on individuals’ risk assessment and their value systems. Preparations for the next pandemic or disaster should include policies that encourage emergency physicians, who are inevitably among those at highest risk, to “stay and fight.”
Abstract Background Improved diagnostic tests would aid in diagnosing and treating community-acquired meningitis. Objective To analyze the diagnostic value of interleukin-6 (IL-6) in the ...cerebrospinal fluid (CSF) of patients presenting with symptoms of acute meningitis. Material and Methods In a 6-month prospective, observational, cross-sectional emergency department (ED) study, serum and CSF samples were obtained from all patients with a headache and fever in whom the physician suspected meningitis. Patients were excluded if computed tomography findings contraindicated a lumbar puncture, if they had bleeding disorders, or if their serum indicated bleeding. IL-6 levels were measured and compared in patients with (Group A) and without (Group B) bacterial meningitis. Results Samples were obtained from 53 patients, of whom 40 were ultimately found to have meningitis. These 40 patients averaged 49.6 ± 21.9 years, with number of men 18 (45%), hospitalizations 21 (52%), mortality 3 (.07%), and IL-6 average rating 491 (median: 14.5; range 0000–6000). Findings in the two groups were: Group A (with meningitis): n = 13, average IL-6 level: 1495 (median: 604; 25/75 percentiles: 232.5–2030; 95% confidence interval CI 371.7–2618.6; range 64–6000). Group B (with aseptic meningitis): n = 27, average IL-6 level: 7.34 (median: 5; 25/75 percentiles: 0.0/15.1; 95% CI 3.94–10.73; range 0–23.6). Mann-Whitney rank sum test: p < 0.0001. Conclusions In patients with acute bacterial meningitis, CSF cytokine concentrations are elevated. Measuring CSF inflammatory cytokine levels in patients with acute meningitis could be a valuable ED diagnostic tool. Using this tool could improve the prognosis of patients with bacterial meningitis by allowing more rapid initiation of antibiotic treatment.
Orbital compartment syndrome acutely threatens vision. Lateral canthotomy and cantholysis ameliorate the compartment syndrome and, to save a patient’s vision, must be performed in a timely manner. ...This requires appropriate tools. In resource-poor settings, the straight hemostat and iris scissors that are generally used for this procedure may be unavailable. In such situations, safe alternatives include using a multitool in place of a hemostat and a #11 scalpel blade instead of the iris scissors. As when using hemostats of varying sizes, the pressure applied to the multitool must be carefully modulated. When using a scalpel blade for the lateral canthotomy, the hemostat arm remains beneath the lateral canthus as a “backstop” to protect deeper tissues. For the cantholysis, use the back of the blade to “strum” for the ligaments, reversing its direction only to cut the ligament when it is identified.
Abstract Hip fractures can cause considerable pain when untreated or under-treated. To enhance pain relief and diminish the risk of delirium from typically administered parenteral analgesics and ...continued pain, we tested the efficacy of using fascia-iliaca blocks (FICB), administered by one of four attending physicians working in the emergency department (ED), with commonly available ED equipment. After informed consent, a physician administered one FICB to 63 sequential adult ED patients (43 women, 20 men; ages 37–96 years, mean 73.5 years) with radiographically diagnosed hip fractures. Under aseptic conditions, a 21 g, 2-inch IM injection needle was inserted perpendicularly to the skin 1 cm below the juncture of the lateral and medial two-thirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt twice (fascia lata and fascia iliaca), at which point 0.3 mL/kg of 0.25 bupivacaine was infused. The physician tested the block’s efficacy by assessing sensory loss. Pain assessments were done using a 10-point Likert Visual Analog Scale (VAS) before, and at 15 min, 2 h, and 8 h post-block. Block failure was having the same level of pain as before the block. Oral analgesics were administered as needed. The IRB approved this study. Post-procedure pain was reduced in all patients, but not completely abolished in any. Before the FICB, the pain ranged from 2 to 10 points (average 8.5) using the VAS; at 15 min post-injection, it ranged from 1 to 7 points (average 2.9); at 2 h post-injection, it ranged from 2 to 6 points (average 2.3); at 8 h post-injection, it ranged from 4 to 7 points (average 4.4). Analgesic requests in the first 24 h after admission averaged 1.2 doses (range 1 to 4 doses) of diclofenac 75 mg. There were no systemic complications and only two local hematomas. Resident physicians learned the procedure and could perform it successfully with less than 5 min instruction. Physicians rarely use the FICB in EDs, although the technique is simple to learn and use. This rapid, effective, and safe method of achieving excellent pain control in ED patients with hip fractures can be performed using standard ED equipment.
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