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Emergency Medicine > Principles of Emergency Medicine > Flashcards

Principles of Emergency Medicine Flashcards

1
Q

What is Emergency Medicine (EM)?

primary mission

A
  • evaluate, manage, and provide tx to pts with a condition perceived by pt or someone on his or her behalf as an emergency (or last resort)
  • an unexpected injury or illness requiring immediate medical or surgical evaluation and tx
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2
Q

1st goal as EM providers?

A

Determine “Does the patient have a life or limb threatening problem?”
EM is not necessarily about making a diagnosis

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3
Q

Responsibilities of an EM provider?

A
  1. Provide care to **pts of all ages **
  2. Make medical decisions with** limited time and info in a fast-paced environment**
    - Limited time: acuity and severity of patient illnesses
    - Limited information: labs/imaging may be limited due to availability or patient stability
  3. Act as the pt advocate
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4
Q

8 Principles of Emergency Medicine

A
  1. Is the patient about to die? (Triaging) - most important
  2. What steps must be undertaken to stabilize the pt? - Primary survey - ABC, neuro deficits
  3. What are the diseases most likely to be the cause of the presentation? - Top ddx should be “worst case scenario”
  4. Could there be multiple causes of the presentation?
  5. Can a tx assist in the dx in an otherwise undifferentiated illness?
  6. Is a dx mandatory or even possible?
  7. Does this pt need admitted to the hospital?
  8. If the patient is not being admitted, is the disposition safe and adequate for the patient? - Be thorough with verbal and written instructions
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5
Q

3 categories of triage

A
  1. Is the pt critical?
    - Requires immediate life-saving intervention
  2. Emergent
    - The illness/injury may progress if treatment is not initiated soon
  3. Nonurgent
    - Can the patient wait to be seen?
    Low chance of a rapid progression of symptoms

1 > 2 > 3 > 4 > 5 acuity

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6
Q

Patients will die… how to debrief with your staff/colleagues/self

A
  • Why did the patient die?
  • Will the illness have an impact on survivors?
  • Does the illness put health care workers and/or society at risk?
  • Should an autopsy be performed for medical or legal reasons?
  • Does the family desire organ donation?
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7
Q

how to deliver bad news to others/families?

A
  • Be straightforward but empathetic in the verbage used
  • Have security close by and leave the door open due to occasional violent reactions from survivors
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8
Q

The number of ED malpractice claims and the size of malpractice judgments are increasing, leading to ?

A

practice of “defensive medicine”, which results in a higher overall cost of healthcare

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9
Q

what is EMTALA

A

Emergency Medical Treatment and Labor Act

  • Duty to provide emergency care
  • Applies to any facility which has a “Medicare contract” and receives payment from Medicare or Medicaid
  • Requires that any pt who presents with an emergency medical condition must be appropriately and sufficiently examined and evaluated
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10
Q

Legal Aspects of Emergency Medicine

EMTALA

A
  • If an emergent condition is r/o, then the duty to pt under EMTALA ends
  • If an emergency condition exists, the duty continues to stabilize pt and either admit or transfer
  • A receiving hospital, especially with specialized capabilities, may not refuse an appropriate transfer, unless they do not have the capacity or there is another facility that can manage the patient
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11
Q

What is EMTALAs effect on the ED

A
  1. becomes a routine source of healthcare for the uninsured, even for non-emergent conditions
  2. pt crowding and longer wait times
  3. financial strain on hospitals and physicians
    - Difficulty obtaining specialty physician consults/referrals
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12
Q

what is informed consent?

A

a process providing the patient with adequate info about proposed diagnostic or therapeutic procedure in order to make an informed decision about his/her own body

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13
Q

5 components of informed consent

A
  • patient’s diagnosis
  • purpose of the treatment
  • risks and expected outcomes of treatment
  • alternative treatments and their risks
  • consequence of no treatment
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14
Q

what are the Exceptions to Informed Consent

A
  1. Medical emergencies in which…
    - pt is unable to communicate
    - no one available to make decisions
    - no time to obtain consent
  2. When patient receives recurrent tx (ex: dialysis)
  3. When a pt waives their right to be informed
  4. Doctrine of therapeutic privilege
    - can be invoked (rarely) when a patient is so anxious or fragile that full disclosure might cause serious emotional or physical harm
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15
Q

Who can obtain informed consent?

A

informed consent MUST come from the provider who is ordering/performing the tx/procedure

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16
Q

How is informed consent documented?

A
  1. avoid blank statement documentation
    Ex: “All risk, benefits and alternatives to treatment have been discussed”
  2. Be SPECIFIC in your documentation
    - preferably in the chart in addition to Informed Consent form provided to the pt for signature
  3. Document any witnesses present during your discussion with the pt (family, friends, nursing staff ect.)
17
Q

Who may give consent?

A

All adults are presumed competent

18
Q

if an adult is deem incompetent, how do you get informed consent?

A

should be obtained from a competent surrogate
Detailed documentation justifying incompetency and attempts to obtain consent from surrogate must be documented in the patient’s chart

19
Q

what specific populations have other considerations to getting informed consent?

A
  1. Intoxicated pts - Assume too altered to provide informed consent
    - consent should be obtained from a surrogate
  2. Police custody - Incarcerated or impending incarceration does not affect their rights to informed consent
  3. Minors - Cannot give consent, unless pt is emancipated
    - Emergent exceptions exist as previously discussed
    - Variations in state laws may allow consent for various conditions - Ex: pregnancy, STD’s, chemical dependency
20
Q

If a pt is competent but refuses consent/tx, what is the next step?

A

Requires explanation of risk to pt (by provider) and request for patient signature on an AMA document

21
Q

If a psychiatric pt who pose a threat to self or others and refuses tx, what is the next step?

A

hold for psych eval even if they have capacity to make medical decisions

22
Q

what is the next steps for Narcotic overdoses treated with naloxone (Narcan) who want to leave AMA and why?

A

hold for 1 - 1 ½ hours (1 half-life of naloxone dose)

half life of most narcotics > naloxone, placing the pt at risk for rsp arrest when naloxone wears off

23
Q

if a Jehovah’s Witness patients refuses blood products, what is the next step?

A
  1. Pt may refuse blood products
  2. Consult legal counsel for assistance if JW parent refuses treatment for minor
  3. Parents do not have the right to withhold life-saving treatment from their child
    - Consult legal counsel assistance
    — Temporary custody of the child may be revoked based on grounds of child neglect
    — Courts typically do not allow parents to withhold life-saving treatment from a minor for any reason
24
Q

Follow up Care of legal aspects of EM

A

Ensure outpatient follow-up. If unsuccessful, recommend ER follow-up

25
Q

DC instructions

Legal Aspects of EM

A
  • written, verbally reviewed with and signed by patient, copy provided to patient/family
  • Include new prescriptions, follow up instructions, signs/symptoms to watch for, etc. Be SPECIFIC!
26
Q

what reportable events do you need to do for legal aspects of EM

A

Know your state laws on reporting child/elder abuse, rape, gunshot or stab wounds, assaults, seizures, STDs, HIV, animal bites, etc.

27
Q

Medical record/documentation is vital, why?

A
  • Records information for patient care now and for future use
  • Confirms level of billing
  • Supports compliance with standard of care in a medicolegal evaluation
28
Q

who may read your documentation?

A
  • insurance reviewer
  • accreditation reviewer
  • the patient/patient family
  • other healthcare providers/staff
  • lawyers, judge, jury
29
Q

The medical record must include:

A
  1. Patient identifiers - age, gender, race, patient ID
  2. Time and means of arrival - Ex: via EMS, PMV
  3. Appropriate VS
  4. Pertinent H&P findings
    - document “onset” using specific info
    - appropriate use of “acute distress”
  5. List of allergies with reaction
  6. List of medications - name, frequency, route, dose
  7. Diagnostic orders with results
  8. Any emergency care given prior to arrival - response to intervention
  9. ER Course - interventions, changes in patient status (VS, S/S ect.), discussions with other providers
  10. Details of procedures
  11. Medical Decision Making (MDM) - DDX
  12. Diagnostic impression
  13. Final disposition (where/whom)
  14. Patient condition on discharge/transfer
  15. Documentation of discharge instructions
30
Q

The medical record should include when applicable:

if indicated

A
  • Possibility of pregnancy
  • Immunizations, when pertinent
  • Patient’s other healthcare providers
  • Any telephone consultations with specialists/providers
  • Documentation of prescriptions
  • Documentation of informed consent
  • Documentation of leaving AMA or refusing consent

Emergency Medicine (20 decks)

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