Lecture one: ED Flashcards

Question

Prehospital EMS * Learn how to do what? * Evalute what? * Recognize what? * Protect and take what? * **Continue** what? * Verify what?

Answer 1

* Learn how to practice medicine with EMS * Evaluate a patient’s complaint per EMS * Recognize red flags * Protect and take good care of the patient * Continue **“process of critical decision making”** * Verify everything you're being told by EM

Answer 2

defined a goal to improve emergency medical care, 1973

Answer 3

* EMS includes the entire system of providing care to emergency patients **from the initial call to definitive care** * States set specific standards – Ambulance capability – Training requirements – Equipment

Answer 4

* **Improve** the **survival rate** of the injured via effective communication and transportation to definitive site of care * **Purpose**: **Train Providers** who do not manage major trauma on a daily basis

Answer 5

Standard of care for the **first hour of trauma care (GOLDEN HOUR),** whether the patient is treated in an isolated rural area or state-of-the art trauma center

Answer 6

* Not every hospital can safely accept every patient * Code Blue patients generally go to closest facility * Otherwise, more stable patients need to go to appropriate service facility unless unstable

Answer 7

## Footnote 89.6F 24hr hypothermia, and increase 0.5 degree F per hr to bring back.

Answer 8

* Paramedics administer nitroglycerin and aspirin (4 baby chew and swallow) – Check patient Rx before giving: Viagra etc because it will cause hypotension/tank them

Answer 9

Pre-hospital drug therapy (per Protocol)/Med Control – Improves the patient’s symptoms /outcome – Safe and effective

Answer 10

“Time is Muscle” EMS systems perform an EKG * Send/communicate it to the DOC in the ED * This reduces time to drug administration and in-hospital mortality

Answer 11

Hospital ER “CARDIAC ALERT” (90 minutes) * Cardiac cath lab notified * Cardiologist notified * 90 minute goal

Answer 12

## Footnote If malnourished – get them Thiamine IV when in hospital to prevent Wernicke encephalopathy.

Answer 13

## Footnote Romazicon – never used when benzos are used on daily basis – will result in withdrawal seizure and pat will have to go to ICU. Seizure causes brain hypoxia and we want to prevent it.

Answer 14

Most common pediatric emergencies: – Trauma –Respiratory (1st cause for arrest) – Seizures: Febrile

Answer 15

## Footnote Have peds and adult masks on OPA (oral pharyngeal airway); don’t have peds NPA – only adults.

Answer 16

Statutory, administrative, civil, criminal, contract, estate, etc

Answer 17

– Governing bodies: State BoM, CMS, HHS etc that make the rules of practice

Answer 18

– Provides clear explanation of rights/duties – Apologize for civil wrongs with money, not incarceration (i.e. cannot pay money to apologize for murder); therefore can buy insurance for this

Answer 19

* Difference from Criminal law is lack of INTENT, KNOWLEDGE, and RECKLESS DISREGARD (known as mens rhea) * **Litigants have to prove only 51% liability (more likely than not) vs. 95%** (beyond the reasonable doubt) – The “preponderance od evidence”-> This is why you can be found not criminally guilty, but civilly liable in wrongful death (OJ case)

Answer 20

Malpractice applies not just to medicine – Any Professional can be sued for negligence

Answer 21

Litigation is inevitable – Civil Tort Law * 75% of low-risk clinicians get sued at least once in their career * 99% of high-risk specialists eventually go through litigation

Answer 22

Duty Standard of Care * Breach of Duty Causation * Cause in Fact * Proximate Cause Damages ## Footnote The plaintiff has the burden of proof to show all elements of the cause of action

Answer 23

* If the patient is established, duty is owed * Outpatient NEW patient=noduty * If no duty is found, then no case exists

Answer 24

For BREACH to occur, injury has to be foreseeable by the provider, aka probability of injury in a specific scenario

Answer 25

by "custom" or community standard * If no local provider has an eye pressure tool and there is no EMS services in the county when patient presents to your office with symptoms of glaucoma, it would not be unreasonable to tell patient to see someone else not on immediate basis who has the device. Ultimately if they lose vision in between providers, original provider may win case if they can prove the community standard.

Answer 26

* There must be a causal connection between patient's injury and provider's breech * Two types: Cause in fact (substantial factor) and proximal cause

Answer 27

Cause in Fact (Substantial Factor) * "If it wasn’t for the physician operating on the wrong leg, the plaintiff wouldn’t have been injured." Proximal Cause * Requires provider to be an actual link to the injury, cannot be remote or not foreseeable * "If it wasn’t for the discharge from the ER, patient wouldn’t have been struck by lightning." * Contraceptive case (too remote)

Answer 28

within 2 years from the date of injury/death

Answer 29

Litigation can last decades Does not apply to minors – Minor involved cases could be as long as 18+2 years for intent to sue 0 to be filed (some case exceptions are 18+4)

Answer 30

In VA cases, Federal Government will substitute itself as the defendant.

Answer 31

Florida’s (the only state) “free-kill” loophole concerns wrongful death lawsuits in the context of medical malpractice

Answer 32

– Specifically, it refers to a restrictive exemption buried in the Florida Wrongful Death Act that limits who can and cannot recover certain damages in a medical malpractice-specific wrongful death lawsuit. – What is basically means is: **If you're a single adult over 25 with no minor children, or if you have adult children without spouse, who dies as a result of medical negligence, your family (parents) has no legal recourse** specifically from recovering damages for pain and suffering | – Section 768.21(8) Florida Statute

Answer 33

Health Insurance Portability and Accountability Act * Covered entities may disclose protected patient PHI only as permitted * Does not apply to Legal Duty to Disclose (infectious disease to state Dept of Health (HIV), communication to health insurance plan, child abuse, duty to warn imminent risk of harm (TB), HHS/OIG, etc)

Answer 34

* Disclosures are subject to "Minimum Necessary" limitation, to accomplish the purpose of the disclosure (Need HIV test, only give HIV test, not the whole blood panel) * Incidental Disclosures could lead to violations (civil and criminal), unless you have exercised sensible oversight

Answer 35

can result in first-degree misdemeanor; leading to 5 years mandatory prison sentence if found to be malicious

Answer 36

* Emergency Medical Treatment and Active Labor Act * Enacted in 1986, regulated in 1994 (42 CFR section 489.24)

Answer 37

Stems from Duty to Treat and Patient Dumping * Studies show 97% of hospital transfers were due to finances, not medical necessity. * Most had lack of informed consent, and many were unstable * Average delay in care was 4 hours in rendering appropriate care

Answer 38

Requires hospitals that *receive any federal Medicare funds* with a dedicated Emergency Department to provide **Medical Screening Exam (MSE)** to every person presenting to ED * Patient does not have to have Medicare or any insurance * Care cannot be delayed due to lack of insurance * Patient must be stabilized if the patient has an emergency, admitted or transferred in good faith.

Answer 39

* EMTALA is not a substitute (statute) for medical malpractice-> IT IS FEDERAL LAW * EMTALA does not define what is an adequate MSE * Triage may or may not satisfy the exam (might need more than physical exam)

Answer 40

Most frequently scrutinized issue is adequacy of exam * Someone denied service but later found to have and emergency condition * Case by case specific, so not everyone needs labs and imaging for adequate MSE

Answer 41

* The definition of emergency is subjective, not objective

Answer 42

– Flexible definition of "sufficient severity", including severe pain, experienced by a lay person with average knowledge of health and medicine. – According to 42 USC §1395dd(e)(1), an emergency medical condition means “a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain). – All it means is that any patient has to truly believe they have an emergency for the condition to be certified as an emergency. **It is NOT what the provider thinks is an emergency.**

Answer 43

No material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility, or with respect to labor, that the patient has delivered the child and the placenta.

Answer 44

* Specialists that are on ER call are EMTALA bound to provide emergency services when in hospital – Not bound to see these patients outpatient if they are not established * 250 Yard rule for EMTALA – Means an ER team has to go to a patient down within 250 yard of their ER. – Boundary limitations are broken by a major road * EMTALA obligations end when patient is discharged or admitted(Inpatient only)

Answer 45

provide emergency care to stabilize a patient

Answer 46

Needing higher level of service/medically necessary (stable or unstable) AFTER MSE is completed and consent from patient/proxy is obtained – **Transfer form must be signed by physician** Per patients/Proxy's request (regardless of stability state) – Accepting physician in a geographically closest hospital is obligated to accept the transfer, with few exceptions All pertinent records must accompany the patient

Answer 47

Allows you to make your choices about healthcare or designate someone (Healthcare Surrogate) to make choices for you

Answer 48

* Person designated to make decisions for you in time of incapacity (temporary or permanent) * Can amend your living will if they do not have limitation of authority listed (if they do then they cannot)

Answer 49

Specifies preferred life-extending care in time of terminal condition or when patient is unable to communicate because of illness

Answer 50

* Has to be present in original or certified copy, signed by physician and patient/surrogate to have legal weight * Tattoo does not qualify * Verbal statement not by patient or surrogate will necessitate life-sustaining measures

Answer 51

* Next of Kin

Answer 52

Next of kin relatives are your children, parents, and siblings, or other blood relations. Since next of kin describes a blood relative, a spouse doesn't fall into that definition.

Answer 53

– Is a FELONY (cannot be accidental, has intent) – Billing for services that were never provided or upcoding – Distributing pre-signed blank narcotics scripts

Answer 54

Overutilization/misuse of services ("I don’t care attitude” which results in unnecessary costs) * Ex: MRI on hurt ankle after X-ray was negative. MRI in ED is only for Spinal cord injuries

Answer 55

Medically unnecessary services beyond defensive medicine ("Shotgun orders")

Answer 56

## Footnote Federal Healthcare Programs

Answer 57

* Prohibits the exchange of anything of value for referral for services that are payable by a federal program * Is a FELONY under 42 U.S.C. §1320a-7b(b) * Getting paid in return of selling a product or being a "speaker" for the company (diabetic strips, DME etc), and requires malicious intent * Careful with pharmaceutical reps

Answer 58

Willful acceptance of referrals from someone conspiring to bill federal programs

Answer 59

* Referral is made by a healthcare provider to a designated health services entity, in which the provider (or family member) has a financial interest in or from which they receive compensation * Applies to PHYSICIANS only and does not require malicious intent * Applies to Medicare and Medicaid only * Many exceptions

Answer 60

federal civil rights law that prohibits discrimination against people with disabilities.** Health care organizations that provide services to the public are covered by the ADA.** * Reasonable Modifications of Policies, Practices, and Procedures * Effective Communication * Accessible Facilities

Answer 61

Presumes that patient is not underinformed and retains decision-making capacity

Answer 62

– Frequently comes up when determining need/benefit of a particular intervention – Ultimate responsibility of a provider is to restore health; or provide comfort if restoration is not possible – Must consider patient prognosis, burden to benefit ratio, values and goals of treatment of the patient

Answer 63

When therapy is nonbeneficial and inconsistent with patients' goals and values, focus should be on comfort and spiritual support

Answer 64

* Goal is to support autonomy and self-determination * Requires that the patient be provided with sufficient information to be able to give meaningful consent to proposed medical care without coercion (FS §766.103) – Assumes patient has decisional capacity

Answer 65

1. Negligence 2. battery

Answer 66

**IC is a discussion, not a signed piece of paper** – IC is frequently scrutinized in court – A signed consent without discussion is VOID – You should have discussion and execute consent if you are performing the services – Witness is not required by law, but may improve or worsen defense – Witness could be anyone (i.e. housekeeping) – Consent is assumed in true emergency

Answer 67

if plaintiff can prove that would not have consented to a procedure should the appropriate risks had been disclosed

Answer 68

* ETOH intoxication * Police/DLE custody * Minors * Psychiatric problems * Narcotic abusers

Answer 69

restraints could be utilized as determined by physician authority, unless competency is reached

Answer 70

Senate Bill 698, 7/1/2020 – The written consent requirement applies to pelvic examinations by a “healthcare practitioner, a medical student, or any other student receiving training as a health care practitioner.” * “...a manual examination of the organs of the female reproductive system using the health care provider’s gloved hand or instrumentation. The term does not include a visual assessment, imaging, or a non- diagnostic medical or surgical procedure.”

Answer 71

* If it is purely a visual exam, then verbal consent is sufficient and necessary, but given that most exams will require touching to examine skin folds, YOU should obtain the written consent * Both verbal and written consents for a “pelvic examination” must be (a) provided by the patient or the patient’s legal guardian; (b) in writing; and (c) “executed specific to, and expressly identifying, the pelvic examination.”

Answer 72

* Pelvic examination **may not be done on an anesthetized or unconscious patient without written consent** * Court ordered exam does not require consent, only if the exam is to assess serious to bodily function or to collect evidence.

Answer 73

* Determined by Court (with expert guidance) * Permanent until re-adjudicated in court * Is usually requested but not determined by ER clinician * Person may not contract

Answer 74

* Temporary or wax/wane * Maybe determined by any professional * Capacity restored when underlying cause resolved (ETOH, hypoglycemia) * May depend on the day (Alzheimer's)

Answer 75

* The right of an adult of sound mind to refuse medical treatment outweighs the state's interest in preserving life, preventing suicide, and maintaining the ethical integrity of the medical profession * First Amendment violation of constitutional right to freedom of religion

Answer 76

diagnosis and treatment are not expected to exceed 24 hours but may extend to 48 hours, but no longer than 48 hours without a discharge or admission – Two midnight rule: hospital inpatient admissions are considered reasonable and necessary for patients whose stays cross two midnights

Answer 77

* Observation patients are billed as an outpatient service (under Medicare Part B). * Inpatient admissions are billed under inpatient services (under Medicare Part A). * Observation patients may have insurance co-pays and deductibles associated with the outpatient terms of their health insurance policy.

Answer 78

“A service for patients with potentially recoverable conditions who can benefit from more detailed observation and invasive treatment than can safely be provided in general wards or high dependency areas.”

Answer 79

1. Irreversible cessation of circulatory and respiratory functions 2. Irreversible cessation of all functions of the entire brain, including the brainstem, is dead. A determination of death must be made in accordance with accepted medical standards.

Answer 80

In PVS, brainstem is still intact, higher brain is dead * Some form of “consciousness” may still exist

Answer 81

In Clinical Death, there is cessation of blood circulation/breathing necessary to sustain the life * There's a window of about 4 minutes from the moment of cardiac arrest to the development of serious brain damage. If blood flow can be restored (either by CPR or by getting the heart pumping again) the victim could come back from clinical death.

Answer 82

* absence of pupillary light(pons) * AND no response to pain * AND no cranial nerve reflexes * AND no spontaneous respirations

Answer 83

* absence of a response to corneal stimulation and * absence of inducible eye movements: no eye mvmt toward the side of irrigation of the TM with 50-60 ml of ice water.

Answer 84

by the apnea test: no ventilatory movements in the setting of maximum CO2 stimulation

Answer 85

requires the cause of the coma be known, and that it be adequate to explain the clinical findings of brain death.

Answer 86

* Asystole usually occurs with days, even if vent support is continued. * Recovery s/p documented brain death has not occurred * Removal of vent results in terminal rhythms * Purely spinal motor movements may occur in the interval of terminal apnea: arching of the back, neck turning, stiffening of the legs, and upper extremity flexion

Answer 87

Supportive studies – MRI/MRA, two flat ECGs, negative brain flow study (EEG), lack of reflexes (central and peripheral), lack of unassisted respirations, positive apnea test, lack of cerebral blood flow on angiography In Florida, PAs can sign death certificate

Lecture one: ED Flashcards

(157 cards)