Administration Flashcards
Medical Ethics
2023.1 CBD Station - Consent & Treatment refusal
Prisoner, presents with abdo pain. history of ingesting foreign bodies. IVDU. has esophageal button battery. Refuses endoscopy.
Outline Differential Diagnoses for abdominal pain:
Ingested foreign body with perforated viscous
Surgical - cholecystitis, pancreatitis, renal colic, ischemic bowel, AAA, bowel obstruction
Medical - colitis, gastritis, UTI/pyelonephritis
Trauma - solid organ injury, duodenal haematoma, trauma induced pancreatitis
IVDU - endocarditis causing cardio-emboli and ischemic gut
The patient refuses to give any further history. Outline your approach.
- Establish rapport
- Explain need for further information to benefit patient outcome
- Recruit trusted others - family and friends
- Collateral history (prison health, transfer documents, previous notes, family and friends)
ETHICAL CONSIDERATIONS
RESPECT FOR PATIENT AUTONOMY
- every competent patient has the moral right to choose what happens to their body
- therefore patients have the right to freely accept or reject a physicians recommendations
BENEFICENCE
- acting in the best interest of the patient
DUTY OF CARE:
Common Law has established that doctors have a ‘duty of care’ to their patients that includes acting in the patients best interests if the patient is not competent to consent to or refuse treatment.
Patient refuses Endoscopy. Outline your approach.
Correct communication issues and check understanding
- address reason for treatment refusal (scared anxious, previous bad experience, lack of trust)
- recruit trusted others (friends, family)
- Assess capacity
- If patient has capacity and still refuses treatment, will need to consider medico-legal issues
- involve key stakeholders (prison, director of medical services, medicolegal department)
- documentation
ASSESSMENT OF CAPACITY:
“A patient with decisional capacity is one who has the mental ability to grasp and retain information about his or her condition, weigh risks and benefits, and demonstrate these abilities by verbalizing a medical decision”
- Cognitive ability to understand and retain information in regards to their medical situation
- Compare the treatment options and understand the consequences of each
- Engage in rational deliberation about the proposed treatment and communicate a choice
INVOLVE KEY STAKEHOLDERS:
- director of medical services
- medicolegal department
- prison SMO
- gastroenterology SMO
METICULOUS DOCUMENTATION:
- document behaviour and features of intact capacity with examples
- document investigations and treatments that were offered
- document the risks and benefits that were explained
Discharge Against Medical Advice
2022.1 interaction with registrar
Patient has high risk chest pain and wants to discharge against medical advice
Outline strategies to prevent patients discharging against medical advice.
Assessment of capacity
Explain the concept of Duty of Care.
Acknowledge patient autonomy
The most vulnerable patients are the ones that leave against medical advice
- lower socio-economic groups
- lack social supports
- psychiatric issues
- substance abuse
- homeless
- unlikely to have GP or follow up
They don’t leave because they don’t think that there is anything medically wrong.
There can be a good reason for wanting to leave:
- caregiver responsibilities
- financial obligations
- long wait times
- drug or alcohol dependence
Difficult balance between protecting patient autonomy and doing good for the patient.
ASSESS CAPACITY:
- Cognitive ability to understand and retain information in regards to their medical situation
- Compare the treatment options and understand the consequences of each
- Engage in rational deliberation about the proposed treatment and communicate a choice
Identifying barriers to decisional capacity:
- acute intoxication with alcohol or drugs
- acute psychiatric illness
- cognitive (dementia)
Identify the reason for wanting to leave:
- this maybe easily rectified
Involve trusted others
Educate the patient:
- about the risks associated with refusing to complete evaluation
Maintain rapport and invite the patient to represent if they have any concerns
Meticulous Documentation:
- document behaviour and features of intact capacity with examples
- investigations and treatments that were offered
- risks were explained
- advised patient that they are welcome to represent at anytime
Assessment of capacity, respecting patient autonomy, duty of care
2022.1 CBD station
elderly man presents to a rural hospital with abdo pain and hypotesion. the diagnosis is ruptured AAA.
Outline your differential diagnoses
Outline your assessment:
- history
- examination
- investigations
DIFFERENTIAL DIAGNOSES:
- ruptured AAA
- ischemic gut
Infection:
- cholecystitis
- ascending cholangitis
- appendicitis
- diverticulitis
- pyelonephritis
- epididymo-orchitis (with referred pain to the abdomen)
Pancreatitis
GI haemorrhage
Perforated viscous
- perforated peptic ulcer
ASSESSMENT:
History:
SOCRATES
- fever
- nausea, vomiting
- diarrhoea
- GI bleeding
surgical history
known AAA
gallstones
renal stones
UTI’s
Alcohol
Abdominal traum
Anticoagulation
AF or coagulopathy predisposing to ischemic gut
POCUS:
ED AAA POCUS - 99% sensitive 98% specific
curvilinear probe
xiphoid to bifurcation
IVC on patients right side
aorta on patients left side
vertebral body deep
measure diameter (outer wall to outer wall)
normal < 2cm
rupture usually occurs >5.5cm
limitations of POCUS:
- obesity
- overlying bowel gas
- need to see aorta in entirety
- can’t assess for retroperitoneal haemorrhage
INVESTIGATIONS:
Urianlysis - WCC, nitrites, blood
VGB - lactic acidosis with end-organ perfusion and ischemic gut
Lipase - pancreatitis
LFT’s - obstructive hepatitis in cholangitis
Inflammatory markers - CRP, WCC
UEC - renal failure with hypoperfusion
FBC - Hb in haemorrhage
Group and Screen - for transfusion
CT abdomen -
ASSESS CAPACITY:
- Cognitive ability to understand and retain information in regards to their medical situation
- Compare the treatment options and understand the consequences of each
- Engage in rational deliberation about the proposed treatment and communicate a choice
RESPECT FOR PATIENT AUTONOMY
- every competent patient has the moral right to choose what happens to their body
- therefore patients have the right to freely accept or reject a physicians recommendations
DUTY OF CARE:
Common Law has established that doctors have a ‘duty of care’ to act in the best interest of their patients.
Discussion with family members
Respecting the patients wishes
Establish goals of care as per patient
Open Disclosure
Previous stations:
- 17y F documented anaphylaxis to penicillin given flucloxacillin –> intubated on adrenaline infusion. Discussion with parent.
DOMAINS & MARKING
Professionalism:
- openly discloses ‘medical error’
- apologises
- accepts responsibility/is not defensive
- outlines patients care plan and provides reassurance
- does not overtly criticise other clinicians management
Communication:
- shows empathy
- establish and maintain rapport
- allow opportunity for parent to ask questions
- appropriate language
- appropriate body language
Leadership/Management:
- displays understanding of likely multiple factors contributing to medical error (systems and individual)
- outlines plan to investigate error and take steps to prevent future occurrences
- expresses intent to meet with parent and patient in the near future
Open disclosure:
- gauge what they know so far
- explain what has happened
- discuss consequences of mistake
- acknowledge and apologise
Patient care:
- reassure safety and care
- ensure good care going forward
- ensure they are happy with this plan
Investigate the incident to learn what has happened.
Explain that the cause of the error is often multifactorial and not attributed to one person.
SYSTEMS:
- busy department
- lack of doctors due to sickness or poor rostering
- lack of senior doctors to provide adequate supervision to our junior staff
PROCESS:
- senior doctor review prior to discharge
- xray reporting times
- acknowledging test results
INDIVIDUAL:
- lacking experience in this area and need for educational development
- fatigue, stress, anxiety (overworked, burn out)
INVESTIGATE
- review the medical records
- interview medical staff involved in patient care
- review our current departmental processes
I will formalise the findings with recommendations
I will submit the case to be reviewed at out next mortality and morbidity meeting
Provide education to the staff involved
Ensure QUALITY IMPROVEMENT and implement the necessary changes to prevent this from happenng again
I will notify you of the outcomes as soon as possible.
ASSIST WITH COMPLAINTS PROCESS:
SUBMIT INCIDENT REPORT - hospital will also conduct a review
ARRANGE FOLLOW UP MEETING
- check progress
- answer any further questions that you might have
Access block & Overcrowding
2023.2 Station
Ep 129 ED Overcrowding and Access Block – Causes and Solutions
Ep 174 Is Less More? Saving EM and Traumatic Pneumothorax – Highlights from CAEP 2022
DEFINITION OF ACCESS BLOCK
- inability to move admitted ED patients to appropriate inpatient beds in a timely manner (within 8hrs)
CAUSES OF ACCESS BLOCK
Demand surge - major event - thunderstorm asthma, heat wave
Lack of access to primary care - public holiday, long weekend
Other facilities on ‘bypass’ due to an internal disaster - CT scanner malfunction, power outage
Lack of senior staff
Absolute staff deficiency - sick leave, poor rostering
Delayed clinical decision making
Delays to patient referral
Delay to inpatient review
Delays in laboratory and radiology reporting
Lack of services such as HITH
Lack of inpatient beds
- Ageing population - longer hospital stays
- Elective surgeries
- Inadequate discharge planning
MARKERS OF OVERCROWDING:
- ambulance ramping
- Increases Waiting times and ‘did not wait’ rate
- increase in violence
Negatively impacts Quality of care
(increase in mortality and morbidity)
- delayed time to critical treatments (antibiotics and analgesia)
- increased rate of medical error and complications
- increased risk of infectious disease transmission (covid)
- poor care of the elderly (increased pressure areas, falls, bed soiling, delirium)
Negatively impacts ED staff
Increases Workload in ED - caring for admitted patients waiting for inpatient beds
- stress, burn out, high staff turnover
Occupational health and safety risk
- patients being treated in non-clinical areas
- patients boarding in corridors blocking access
EMERGENCY MANAGEMENT:
Notify hospital executive to activate hospital wide Disaster Plan
Assign staff to review ramped patients to identify deteriorating critically ill
SURGE CAPACITY
- direct admission of suitable patients directly to ward - inpatient teams can review on the ward
- moving suitable patients to SSU
Ensure adequate staffing – call in on-call staff
Early rounding in ED to ensure early decision making
Early identification of well patients for potential discharge
STRATEGIES: Government level
- invest in primary care
- build bigger hospital, create more beds
STRATEGIES: whole hospital
- Manage as outpatients where possible
- Utilise community based programmes HITH
- Consultant lead daily morning ward round and early identification of potential discharges
- Use of transit lounge to improve AM discharges
- Multidisciplinary patient flow meetings and discharge planning
Strategies that the Emergency Departments can employ to ensure that the NEAT target is met.
- Early consultant clinical decision making models - e.g. rapid assessments
- Appropriate test ordering
- Direct admissions
- Roster clinical staff to demand
- Use of EMU/SSU models
- Treat as outpatients where possible - Use hospital in the home
Managing the Aggressive Patient
Majority of patients are not bad people
There is often a reason for behaviour
VERBAL DE-ESCALATION
Prepare yourself
- stay calm
- don’t react
- be aware on non-verbal communication ‘open body language’
introduce yourself
offer a hand if safe to do so
address patient by name
Speak to the patient in a calm, empathetic non-judgemental manner
Show genuine concern and compassion
Listen - Let the patient voice their concerns
Act as ally
Explain that you are here to help and advocate on their behalf
Identify and manage the trigger for the escalation in behaviour
Identifying unmet needs that are easily corrected (e.g. inadequate pain control, hungry for food and drink)
Recruit trusted others to help (e.g. family, friends, case managers)
Provide food, drinks or other assistance as required (e.g. seating, access to a telephone, a warm blanket)
Offer oral medication to alleviate patient distress
Lay down the law and set clear limits
Show of force - involve security staff. This may persuade the patient to cooperate.
Otherwise physical restraint and parenteral chemical restraint will be required to ensure safety of the patient and staff
PHARMALOGICAL MANAGEMENT:
lorazepam 1-2mg orally
diazepam 10-20mg orally
olanzapine 10mg orally
olanzapine 10mg IM
droperidol 10mg IM
midazolam 5-10mg IM
RESCUE SEDATION (when all else fails)
ketamine 5mg/kg up to 400mg IM
droperidol 10mg IV
midazolam 5mg IV
diazepam 5-10mg IV
SIDE EFFECTS OF ANTIPYSCHOTICS:
- Extrapyramidal - dystonic reactions, tardive dyskinesia
- Neuroleptic malignant syndrome
- QT prolongation and Torsade’s de pointes
Patient Complaint
2021.2 Station
Meet with a registrar to discuss a complaint from the family of a patient the registrar saw the previous week.
The patient was a Culturally and Linguistically Diverse (CALD) person
Needed to address issues around registrar work load
Disaster Medicine
Activate hospital wide disaster plan
Call in ED staff
Cancel nonessential services (elective surgery)
Create ED capacity
- clear Resuscitation rooms - move stable patients to ICU
- transfer all stable admitted patients to ward beds
- discharge stable patients (treatment to be completed by GP at later time)
Prepare ED
- Designate triage area and allocate Triage team
- Prepare equipment relevant to expected injuries
- Obtain blood products (massive transfusion packs)
- Form resuscitation teams and allocate roles
NOTIFY:
- Hospital administrator on-call who will activate a hospital wide disaster plan
- Chief Executives and Head of departments
- Trauma teams - ICU, anaesthetics, surgery, orthopaedics, theatres
- Radiology, laboratory and blood bank
Deactivate all nonessential services to create capacity - stop all elective surgery
SURGE CAPACITY:
quickly generate ED capacity
Admit patients to the ward
Assign a registrar to review patients for discharge
STAFF CALL BACK:
SUPPLIES:
ALTERNATE CARE SITES:
End of Life Discussion
2023.2 Communication station
Discussion with a relative of a patient regarding end of life care
90yo from nursing home with dementia. recurrent aspiration pneumoniae.
Reduced LOC
Temp 39
HR 130
BP 80/60
SETTING THE SCENE:
- Private, quiet space
- Patients family and social supports
- Allow enough time
- No interruptions
Introduce
My name is…
I am the emergency doctor caring for your mother
Thank you for coming into the hospital
Is it okay if we discuss your mothers condition in more detail?
Do you have a support person or other family members who you wish to be here?
GAUGE PERCEPTION
- Assess their understanding about the current clinical situation and prognosis
“what is your understanding of your loved ones illness”
- establish baseline level of function
“what is her day to day life like”
Assess activity of daily living:
- bed ridden
- dependent on all activities (feeding, bathing, toileting, dressing)
Quality of life:
INVITATION TO RECEIVE INFORMATION:
“would you like me to tell you all the details of your mother’s condition?
KNOWLEDGE OF THE CONDITION
- provide the bad news
- check for patient understanding
“I feel badly to have to tell you this, but….
“I’m afraid the news is not good….
“Your mother’s advanced medical condition cannot be cured, and her illness has made her defenceless against the bacteria in her own body. Treating her again and providing another round of intensive care will not bring her health or immune system back to normal, but may only prolong her suffering.”
EMPATHY & EXPLORATION
- offer tissues
- acknowledge feelings
- give time to respond
- remind patient you won’t abandon them
“I imagine this is very hard for you to hear”
“We will do whatever we can to help you”
Patient Goals of Care:
- have you had any discussions about advanced care directives or end of life care?
“To meet the goals we’ve discussed, I’ve asked the palliative care team to visit with you; they are experts in treating the symptoms you are experiencing. They can help your family deal with the changes brought on by your illness”
DISPOSITION:
Hospice referral
Community palliative care
End of Life Discussion
2022.1
Management of a patient with end stage COPD
Ask the question ‘If treatment could prolong your life, what level of quality of life would be acceptable to you’.
Steer away from the concept ‘All or nothing’ and emphasise that although palliation has been chosen, everything will be done to ensure patient comfort.
Patient Factors which can assist in goal direction:
Age of patient and where the patient resides?
The general state of the patient-skin integrity, nutritional state, continence
Quality of life-use the Karnofsky2 performance status scale or simply ‘How much time do you spend in bed’
Cognitive state
Always remember to involve the Social Worker and Spiritual/Pastoral care if required.
Your patient is deteriorating as the discussion is being held/fine tuned?
Initiate stabilization measures
Airway/Breathing - Oxygen, Non-Invasive Ventilation can buy time
Circulation/Hypotensive - Fluids, remember that Adrenaline can be given peripherally short-term while considering the level of patient treatment
Pain - Give analgesia
The decision cannot be reached or the patient’s requests differ from your management plan?
Involve your ICU and consider a trial of critical care over an agreed timeframe.
End of Life Discussions
2016 communication station
86y nursing home resident, dementia, recurrent hospitalisations with aspiration pneumoniae. presents septic with aspiration pneumoniae.
discussion with patients daughter.
Key Actions Expected from Candidate:
- introduce themselves, explain the current situation, make an effort to
- assess the level of functioning of the patient
- assess the patient’s likely wishes / the daughter’s understanding and wishes,
- discuss the benefits of palliative care of the patient in the nursing home, the aims of care and the
expected outcome, in a caring and compassionate manner.
End of Life Discussions
2021.1 Communication station
candidates were required to interact with the relative of a patient about end of life care in the setting of dementia.
ASSESS:
- premorbid function and quality of life
- cognitive status - severe dementia
- advanced care directive/patient wishes
- confirm who the surrogate decision maker is
- life limiting co-morbid conditions - end stage COPD/CHF
DIAGNOSIS & PROGNOSIS
Diagnosis:
Prognosis: most likely to be a life-ending event, if survived will have severe neurological deficits.
ESTABLISH GOALS OF CARE:
- patient’s wishes
- comfort cares
EXPLAIN CLINICAL COURSE & PLAN:
- Expected course of illness/ disposition
d)
arrange private room for patient and family
explain to the family what to expect - clinical course of they dying patient
offer religious supports i.e. chaplain/priest
consistent nursing presence
remove all monitoring, remove catheters and cannulas
stop all life sustaining treatments including IV fluids
analgesia through a subcutaneous butterfly needle
PRN MEDICATIONS:
pain & dyspnoea - morphine 5mg sc Q1h PRN
agitation & anxiety - midazolam 5mg sc Q1h PRN
respiratory secretions - glycopyrolate 200mcg sc Q2h
nausea & vomiting - ondansetron 4mg sublingual wafers Q8h
End of Life Discussion
2023.1 CBD
Outline an overall plan for ongoing treatment of a patient.
* Adapt and initiate standard therapies to that patient, e.g., drugs, fluids, gases, and monitoring.
* Consult / refer to inpatient team (palliative care).
- co-ordiate with community palliative care
Breaking Bad News
A patient has had a catastrophic intracranial haemorrhage that is not survivable. Meet with the son to break the bad news.
Give the diagnosis and prognosis
Breaking Bad News
A 85yo man presents with a ruptured AAA. He is hypotensive and confused. Meet with the son to break the bad news.
