Saturday, April 30, 2011

Emergency Departments Should Be Aware of Sexually Transmitted Infection Risk in Patients: One-Quarter of Symptomatic Adolescent Females Tested Positive for an STI

ScienceDaily (Apr. 30, 2011) — All adolescent females who show up in the emergency department (ED) complaining primarily of lower abdominal pain and/or urinary or genital symptoms should be tested for sexually transmitted infections (STIs), according to the authors of a study presented on April 30 at the Pediatric Academic Societies (PAS) annual meeting in Denver.

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Previous studies have shown that when adolescents seek treatment for symptoms suggestive of an STI, they are not always tested, partly because health care professionals may not be aware of the risk of STIs in these patients. If not identified and treated, STIs can have serious long-term consequences such as infertility, ectopic pregnancy, chronic disease and death in babies, and cervical cancer. The presence of an STI also can increase the likelihood of acquiring HIV.
Researchers, led by Monika Goyal, MD, sought to determine how common STIs are in symptomatic adolescent females. Over the six-month study period, 236 females ages 14-19 years who sought treatment at a pediatric ED for symptoms of lower abdominal, pelvic or flank pain and/or genitourinary complaints were tested for three of the most common STIs: Neisseria gonorrhoeae , Chlamydia trachomatis and Trichomonas vaginalis .
Results showed that 26.3 percent of the patients had an STI. The most common was chlamydia (20 percent), followed by trichomoniasis (10 percent) and gonorrhea (3.5 percent). In addition, 19 percent of patients infected with chlamydia also had trichomoniasis, while 6.7 percent had both chlamydia and gonorrhea.
"Adolescents represent a high-risk group for sexually transmitted infections, and many providers are unaware of this association and the consequences that potentially occur due to infection," said Dr. Goyal, instructor of pediatrics and attending physician in the Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania.
In addition, other studies have shown that adolescents often do not have a primary care doctor and go to the ED for medical care instead.
"Therefore, ED providers should be assessing STI risks in adolescents who come to the ED for care, as this may be the only point of contact of these patients and an opportunity to intervene," Dr. Goyal said.

Ethical Issues: " the duties of clinical care"

Clinical Choices created by advances in medical technology are essentially ethically rather than scientific.Doctors like to think of themselves as men and women of science: Assess the symptoms, order the tests, make a diagnosis, and administer the treatment. The modern world is making that model more complicated. Political debates about abortion and assisted suicide and technological advances that allow doctors to artificially extend life are posing all kinds of new ethical dilemmas. In general, to address these dilemmas a society heavily relies upon moral beleif and arguments. As it pertains to medicine, the law esteblises boundries for what government and the courts, through statute and common law, have deemed to be acceptable professional practice.
As complaints against doctors contribute toward bringing the medical profession into desrepute ( wheather that are successful or not), it becomes very crucial to know what are " the duties of clinical care". Three basic rule of clinical care are as follows:
1. Protect life and health
           -Treatment for them who need it
           -treatment should not be prescribed just because patients request them.
  2. Respect autonomy
           -Humans have the ability to reason, plan and make choices about the future.
           -by giving respect to these attributes one preserves human dignity
           - Autonomy of patient led to two futher rights a) Informed Consent b) Confidentiality
3. Protect life and health and respect autonomy with fairness and justice
          - Every human being has right to expect to be treated equally,
          -the access to, and quality of care should be based only on the dictate of needs rather
           than arbitrary perjudice or favouritism

Ethical Decision in Emergency Medicine

A 32 year old woman was admitted to the Trauma Intensive Care Unit following a motor vehicle accident; she had multiple injuries and fractures, with several complications which continued to develop over the first couple of weeks. The patient rapidly developed Adult Respiratory Distress Syndrome, was on a ventilator, and was continuously sedated. Shortly after the patient's admission, her parents were contacted and remained vigilant at her bedside. The parents reported that the patient was one month away from having her divorce finalized. The patient's husband was reportedly physically and emotionally abusive to her throughout their five years of marriage. The parents had not notified this man of the patient's hospitalization, and reported that visit by him would be distressing to the patient if she were aware of it. The patient's soon to be ex-husband is her legal next of kin.

Should the husband be responsible for treatment decisions which the patient cannot make?
What are the legal and ethical parameters?

To understand these issues, we deemed to understand concepts of informed consent, implied consent and surrogate decision making.

Informed consent is the process by which a fully informed patient can participate in choices about her health care. It originates from the legal and ethical right the patient has to direct what happens to her body and from the ethical duty of the physician to involve the patient in her health care.

What is informed consent?

The most important goal of informed consent is that the patient have an opportunity to be an informed participant in his health care decisions. It is generally accepted that complete informed consent includes a discussion of the following elements:

What are the elements of full informed consent?

the nature of the decision/procedure
reasonable alternatives to the proposed intervention
the relevant risks, benefits, and uncertainties related to each alternative
assessment of patient understanding
the acceptance of the intervention by the patient

In order for the patient's consent to be valid, he must be considered competent to make the decision at hand and his consent must be voluntary. It is easy for coercive situations to arise in medicine. Patients often feel powerless and vulnerable. To encourage voluntariness, the physician can make clear to the patient that he is participating in a decision, not merely signing a form. With this understanding, the informed consent process should be seen as an invitation to him to participate in his health care decisions. The physician is also generally obligated to provide a recommendation and share her reasoning process with the patient. Comprehension on the part of the patient is equally as important as the information provided. Consequently, the discussion should be carried on in layperson's terms and the patient's understanding should be assessed along the way.
Basic consent entails letting the patient know what you would like to do and asking them if that will be all right. Basic consent is appropriate, for example, when drawing blood. Decisions that merit this sort of basic informed consent process require a low-level of patient involvement because there is a high-level of community consensus.

How do you know when you have said enough about a certain decision? Most of the literature and law in this area suggest one of three approaches:

1)reasonable physician standard: what would a typical physician say about this intervention?
2)reasonable patient standard: what would the average patient need to know in order to be an informed participant in the decision?
3)subjective standard: what would this patient need to know and understand in order to make an informed decision? i.e
it requires tailoring information to each patient.

In most cases, it is clear whether or not patients are competent to make their own decisions. Occasionally, it is not so clear. Patients are under an unusual amount of stress during illness and can experience anxiety, fear, and depression. The stress associated with illness should not necessarily preclude one from participating in one's own care. However, precautions should be taken to ensure the patient does have the capacity to make good decisions. There are several different standards of decision making capacity. Generally you should assess the patient's ability to:

When is it appropriate to question a patient's ability to participate in decision making?

understand his or her situation,
understand the risks associated with the decision at hand, and
communicate a decision based on that understanding.

When this is unclear, a psychiatric consultation can be helpful. Of course, just because a patient refuses a treatment does not in itself mean the patient is incompetent. Competent patients have the right to refuse treatment, even those treatments that may be life-saving. Treatment refusal may, however, be a flag to pursue further the patient's beliefs and understanding about the decision, as well as your own.
Patients can move in and out of a coherent state as their medications or underlying disease processes ebb and flow. You should do what you can to catch a patient in a lucid state - even lightening up on the medications if necessary - in order to include him in the decision making process.

What about the patient whose decision making capacity varies from day to day?

If the patient is determined to be incapacitated/incompetent to make health care decisions, a surrogate decision maker must speak for her. There is a specific hierarchy of appropriate decision makers defined by state law . If no appropriate surrogate decision maker is available, the physicians are expected to act in the best interest of the patient until a surrogate is found or appointed.

What should occur if the patient cannot give informed consent?

What is presumed/implied consent?
The patient's consent should only be "presumed", rather than obtained, in emergency situations when the patient is unconscious or incompetent and no surrogate decision maker is available. In general, the patient's presence in the hospital ward, ICU or clinic does not represent implied consent to all treatment and procedures. The patient's wishes and values may be quite different than the values of the physician's. While the principle of respect for person obligates you to do your best to include the patient in the health care decisions that affect his life and body, the principle of beneficence may require you to act on the patient's behalf when his life is at stake.

There is implied consent by law for provision of "emergency" medical treatment. Hospital policy defines what the hospital will consider an "emergency" and sets an institutional documentation standard:

As, consent for care is implied by law when immediate treatment is required to preserve life or to prevent serious impairment of bodily functions and it is impossible to obtain the consent of the patient, his/her legal guardian, or next-of-kin. In that situation, where a medical emergency exists the physician should consult, whenever possible, with the patient's attending physician or with another physician faculty member about the existence of an emergency.

Therefore,when implied consent is relied on by the health care providers, it becomes imperative to document this in the patient's medical record, together with statements by each physician that the emergency treatment was necessary for the reasons specified. These notations should clearly identify the nature of the threat to life or health, its immediacy, and its magnitude. It should be in accordance with legal and institutional standards.

ANSWER

If the patient already filed for divorce, it is likely that there is a temporary court order in effect and this order may affirmatively remove the patient's estranged husband from making medical decisions for her. Also, it is common in divorce paperwork to have mutual restraining orders which prevent both spouses from contacting each other. The patient's parents should be asked to provide the name of her divorce attorney to obtain copies of the relevant legal papers - which can then be placed in the legal section of the patient's medical record. With the husband thus removed as her surrogate decision-maker, it appears the patient's parents would become the highest level class of surrogate decision-maker and could provide informed consent for her care if the patient is unable to do so.

Even if the patient's husband remains as her legal surrogate decision-maker, his decisions on the patient's behalf are constrained by legally imposed standards. First, a surrogate is legally required to provide "substituted judgment" on behalf of the patient. This means that the surrogate must act in accordance with the patient's wishes. If substituted judgment isn't possible (i.e., unknown what the patient would want under the current medical circumstances), then the law requires the surrogate to act in the patient's "best interests." Since the medical team has significant input about what would medically be in the patient's interest, a decision by a surrogate which doesn't adhere to this standard should not be automatically followed and may need to be reviewed by the institutional ethics committee, risk management, or legal counsel.

The patient's husband may be willing to waive his surrogate decision-maker role to his estranged wife. If this occurs, then he would agree to remove himself from the list of potential surrogate decision-makers and the next highest level surrogate decision-maker(s) would be contacted as necessary to provide informed consent for the patient.

A final option may be for the patient's parents to file to become the patient's legal guardians for health care decision-making.

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A final option may be for the patient's parents to file to become the patient's legal guardians for health care decision-making.

(Source: ETHICS IN MEDICINE University of Washington)

Saturday, April 23, 2011

Opoid Use in Non Malignant Pain and Mortality

Higher Opioid Dose for Nonmalignant Pain Linked to Mortality

Laurie Barclay, MD

April 22, 2011 — In patients given opioids for nonmalignant pain, the daily dose is strongly associated with opioid-related mortality, particularly at doses over thresholds recommended in recent clinical guidelines, according to the results of a population-based, nested, case-control study reported in the April 11 issue of the Archives of Internal Medicine.
"Opioids are widely prescribed for chronic nonmalignant pain, often at doses exceeding those recommended in clinical practice guidelines," write Tara Gomes, MHSc, from the Institute for Clinical Evaluative Sciences in Toronto, Ontario, Canada, and colleagues. "However, the risk-benefit ratio of high-dose opioid therapy is not well characterized. The objective of this study was to characterize the relationship between opioid dose and opioid-related mortality."
The study population consisted of 607,156 residents of Ontario, Canada, 15 to 64 years old, who were eligible for publicly funded prescription drug coverage and who had received an opioid from August 1, 1997, through December 31, 2006, for nonmalignant pain. Opioid-related death, as diagnosed by the investigating coroner, was the main study endpoint.
The investigators compared the risk for opioid-related mortality among patients treated with various daily doses of opioids using a case-control design of 498 eligible patients with opioid-related deaths and 1714 matched control participants.
Compared with low daily opioid doses (< 20 mg of morphine, or equivalent), an average daily dose of 200 mg or more of morphine or equivalent was associated with close to a 3-fold increase in the risk for opioid-related mortality (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.79 - 4.63), after extensive multivariable adjustment. With intermediate doses of opioids, increases in opioid-related mortality risk were still significant but somewhat attenuated (50 - 99 mg/day of morphine: OR, 1.92; 95% CI, 1.30 - 2.85, and 100 - 199 mg/day of morphine: OR, 2.04; 95% CI, 1.28 - 3.24).
"Among patients receiving opioids for nonmalignant pain, the daily dose is strongly associated with opioid-related mortality, particularly at doses exceeding thresholds recommended in recent clinical guidelines," the study authors write.
Limitations of this study include lack of generalizability to other populations; possible misclassification of opioid-related deaths; and inability to identify unused prescription drugs, those obtained illicitly, and those paid for out of pocket. In addition, the indication for opioid therapy could not be determined, and case patients and control participants differed on several baseline characteristics that could be associated with the risk for addiction and drug-related adverse events.
"Our findings have important implications, largely because most opioid-related deaths were avoidable and occurred in young people," the study authors conclude. "We believe physicians should carefully assess the appropriateness of long-term use of opioids to treat chronic, noncancer-related pain, particularly at high doses."
In an accompanying invited commentary, Mark D. Sullivan, MD, PhD, from the Department of Psychiatry and Behavioral Sciences at the University of Washington in Seattle, notes that opioid therapy has other harms associated with prescribed daily dose, including opioid misuse, alcohol- and drug-related medical encounters, fractures, and opioid and other drug abuse.
"Professional organizations and patient advocacy groups see any limitation to opioid dosing as an unnecessary constraint on the ability of prescribers to provide pain relief for the most distressed patients," Dr. Sullivan writes. "But at this time, we have clearer evidence of the harm provided to patients through high-dose opioid therapy than we do of the benefits. As long as there are means to override dosing guidelines in appropriate cases through specialist review (as is the case in Washington), some effort to limit the risk associated with high-dose opioid therapy seems reasonable."
.
Arch Intern Med. 2011;171:686-691, 691-693. Abstract Extract

(Source: Medscape News)

Emergency Medicine : Know your drugs

ADENOSINE

A 67-year-old man who has suffered a previous stroke is admitted with collapse. His drug history includes the use of dipyridamole. On examination he has a regular pulse of 150 bpm. You elect to try intravenous adenosine to slow his heart down. Which of the following best fits the characteristics of adenosine?

1.	Its half-life is decreased by dipyridamole
2.	It may be used after beta-blockade
3.	The half-life of adenosine is around 15 seconds
4.	It is effective in cardioverting ventricular tachycardia
5.	It can be used in cases of sick-sinus syndrome

Answer: 3. may be used after beta-blockade

Adenosine is an ultra short-acting antiarrhythmic drug with a half-life of 8–10 seconds, although this is prolonged when administered in patients taking dipyridamole. Unlike verapamil it may be used following beta-blockade.

Indications for adenosine are rapid cardioversion of supraventricular tachycardia including those associated with accessory pathways, eg Wolff–Parkinson–White syndrome, and for the diagnosis of rapid arrhythmias. It is contraindicated in patients with second- or third-degree heart block and sick-sinus syndrome. Adenosine does not convert ventricular tachycardia. Side-effects include transient facial flushing and a choking sensation, where patients often clutch their chest (worth warning patients of this in advance if possible). An escalating dose schedule of 3, 6 and 12 mg is usually employed.0.1 mg/kg rapid IV push(1to3 second) follow immediately with >5 ml NS flush

Saturday, April 9, 2011

Emergency Medicine:Basic Medico-legal Consideration(PART-2)

General Responsibility of the Emergency Care Physician

Working as an emergency care physician, we are not operating any different realm, rather it is imperative to work along the general medical practice principle  conscientiously. Responsibilities of the emergency care physician lies in following broad categories.
1) Assessment and initial Managment
The major responsibilities of the physician in the emergency department are a) Resuscitation and       stabalization and
b) to generate a minimum data base which must include history, physical examination, and certain ancilliary     diagnostic procedures.

2) Documentation
The physician's Best Source of protection is a legible, well docmented medical record. the law is process oriented and is less freqently concerned with outcome or with the rightness or wrongness of a decision than is with its jstifiability. the standard is what a reasonable physician would do in a similar situation. A judgment error may be defensible, but the thought process that went into the diagnostic or therapeutic decision must be noted on the record.
As a minimum, the medical record should contain the following information:
1. Adequate patient identification
2. Time of arrival, means of arrival, and mode of arrival
3. History of injury or illness, including emergency care rendered before arrival, as well as as pertinent past medical   history,current medications and allergies
4. Physical findings
   5. Laboratory data base
   6. Diagnosis
   7. Treatment giveni
   8. Condition and time of patient discharge or transfer
   9. Final disposition
   10. Instruction relative to follow up care
   11. Signature of the attenting physician

3) Discharge of the physician-Patiet relationship
    Emergency Physician must decide on follw-up care at the conclusion of the treatment to avoid aditional    risks associated with the injuriy or illness.
It can be anyone of the follwing three forms:
   i) admit the patient to the same hospital in which emergency care was given,
   ii) transfer the patient to another facility for follow up care, or
   iii) provide for ambulatory follow up care

ADMISSION TO THE HOSPITAL

If the emergency physician found that patient need in patient department it becomes his legal responsibility to ensure that the physician or physicians responsible for the patient assume the follow-up care at an appropriate time and place. Until the attending physician physically assume responsibility to follow-up care of the patient,thepatient remains the legal responsibility of the emergency department physician.

TRANSFER OF THE PATIENT

Transfer a patient to anther facility from the emergency department should not been done arbitrarly. It should be based on scientific medically sound judgment. A recomended protocol is as follows:

Finally hospital administrator of transfering facility should be notified about the transfer and reason for it.

Ambulatory Care Follow-up

Ambulatory care follow up usually fall into one of the following categories:

1	The “as necessary,” or “prn” follow-up care	For minor or self limited medical problem.
2	The semi urgent, planned follow- up care	Whose original problem demands that a follow up re-evaluation be planned at specific time and place to reassess the patient’s progress because there may have been some question as to exact diagnosis or instituted therapy at the time of original visit.
3	Nonurgent planned follow-up	Being followed up in a necessary but less urgent fashion

However, no matter what form it takes, the patient must understand fully whathe or she is to do continue treatment untill the followup visit. Instrtuction should be specific and clearly written with a copy to attach in the patient's permanent record. Idealy, patient should sign therecord, indicating that he or she was given a copy of the instruction.

4) Follow-up of Database
The emergency department physician is responsible for conducting a follow up study of data specifically lab data compiled during the patient's original visit.

Failure onthe part of the emergency department physician to provide follow up care may constitute abondonment. ABONDONMENTis the unilateral severance of the professional relationship between the physician and apatient without resonable notice at a time when patient still need medical attention.

(Follw this blog for specific medicolegal issues in emergency departments.........NEXT)