Intro to EM

Question 1

What additional factors are included in vital signs?

Answer 1

• observation

- general appearance

Question 2

Emergency Room vs. Department

Answer 2

• 1961: first full time EM MD’s
• 1969: first EM residency; ABMS 1979
• Trauma centers: level I, II, III
• Specialty Centers: cardiac, stroke

Question 3

PA’s hx in the ED

Answer 3

• by early 1980s - one of the fastest growing
• LAC/USC EM residency for PA’s - first one
• society for emergency medicine physician assistants (SEMPA) 1989
• per NCCPA - >12000 PAs in EM in 2016
• Postgraduate Specialty residency - 19 programs

Question 4

charge RN

Answer 4

-coordinates, keeps track, fixes things, liaison

Question 5

triage RN

Answer 5

-takes the first hx

Question 6

Approach to the ED patient

Answer 6

• History and PE cannot be overestimated
  
  • They drive everything else
• Slow down, 2 minute rule, OPQRST each c/o
• Allow the story to come out, nail it down, do not ignore what was just said
• PE must be focused, complete for each specific c/o
• Keep the worst possibilities in mind, remove them or keep them, one by one with your Hx and PE
• Treat pain promptly
• Start from scratch; here to care for you
• Elicit/address pt’s concerns
• Non-judgmental, no need to “win”
• Be transparent in decision-making
• DDx during Hx/PE – formed when leave the room
• Order all diagnostics/tests at same time

Question 7

Recognizing “sick”

Answer 7

• Most are not sick, common things are common
• Patient posture
• Vital signs, changes
• Pattern of breathing
• Diaphoresis
• Anxiety or lethargy
• Not acting “right”
• Getting worse/progressing/could…

Question 8

Who should you be careful with?

Answer 8

• Very young, the very old
• Pregnant
• Psychotic
• Intoxicated
• Immunocompromised
• Non-English speaking
• The difficult, offensive patient
• The “inherited” patient

Question 9

Not sick? Everybody else

Answer 9

• Read triage, EMS record thoroughly – must account for each complaint or discrepancy
• Review old records, past visits
• DDx -> order any tests -> follow-up on them
• Present the patient to supervising MD early
• Chart in SOAP format – pertinent ROS positives AND negatives - must account for DDx
• Reassess the patient frequently, document
• Fewer “auto-admit” than assumed: look at pt

Question 10

Sick?

Answer 10

• Take a cleansing breath…
• Get help in the room
• Rapid assessment using “ABCDE’s”
• Treat patient while assessing them
• Remember the patient!
• Airway
• Breathing
• Circulation
• Disability
• Environment/Exposure

Question 11

Airway “sick”

Answer 11

• Upright position, position preference
• “universal choking sign”
• Tachypnea
• Anxiety, exhaustion
• Diaphoresis
• Gurgling, hoarseness, or stridor

Question 12

Breathing “sick”

Answer 12

• Tachypnea
• Can’t talk, few words
• Mental status changes
• Diaphoresis
• Use of accessory muscles
• Unequal chest expansion or breath sounds
• Exhaustion
• Cyanosis

Question 13

Circulation “sick”

Answer 13

• Hypotension
• Arrhythmia
• Acute blood loss
• Decreased cerebral perfusion: anxiety, dizziness, ALOC, syncope, coma, etc…
• Decreased cardiac perfusion: chest pain, pulmonary edema, arrhythmias, AMI, etc…

Question 14

Disability “sick”

Answer 14

• Altered Level of Consciousness (ALOC)
• Acute paralysis or neglect
• Significant mechanism trauma
• Focal weakness
• Head injury
• Active seizure

Question 15

Environment/Exposure “sick”

Answer 15

• Hazmat Environmental Exposure
• Hyperthermia
• Hypothermia
• “Found down”
• Toxicology/Ingestion
• Burns/smoke inhalation
• Water exposure – drowning, near-drowning

Question 16

Triage - mass casualty

Answer 16

• TRIAGE IS NOT SYNONYMOUS WITH SEVERITY!!!
• Determines the priority, order of resource use
• NOT synonymous with severity
  
  • Those likely to live, regardless of care they receive
  • Those likely to die, regardless of care they receive
  • Those for whom immediate/timely care may make a difference in the outcome
• Multiple scoring systems
  
  • Focus on respirations, perfusion, mental status

Question 17

Legal issues in emergency care

Answer 17

• Decision-Making Capacity and Consent
• AMA
• EMTALA, HIPAA
• Mandated reporting
• 5150
• Patient Safety
• Documentation

Question 18

Consent for emergency care

Answer 18

• Direct (Express Consent)
  
  • Registration form
  • Limited contract for screening evaluation and treatment
• Implied (the Emergency Exception)
  
  • Injury that threatens life/limb, need immediate care
  • Pt can’t comprehend –> LOC, mental status change, acute psychosis, dementia, severe intoxication, language barrier
  • Both must be true/present to treat

Question 19

Decision-making capacity

Answer 19

• the right to accept, reject, w/d consent for tx - everyone is presumed to have it, by default. Must be determined by the MD, NOT THE PA ALONE!
• Based on objective data - must have mental capacity to understand info, must be able to evaluate and deliberate the info, must realize condition present and suggested tx, must be able to present a choice and reasons for it. We must consider LOC< orientation, vital signs, mini-mental status exam helpful, we must consider language, personal values.
• DMC is not “competence” - that is a LEGAL term!
• A pt is allowed to make bad choices if they have DMC
• If a person does not have DMC, they cannot refuse tx

Question 20

questions a pt must be able to answer in order to have decision-making capacity

Answer 20

• What do you think is wrong with you?
• How will the tx suggested affect you?
• What will happen if you refuse the tx?
• How will the benefits/risks of tx affect your life?
• Help me understand how you reached your decision
• What makes the treatment worse than no treatment?
• What can I/we do to help you get the tx you need?

Question 21

Caveats to DMC

Answer 21

• Patients cannot be allowed to harm themselves or anyone else – including ED staff
• Pt’s can be restrained in order to prevent harm to themselves or others, or when their DMC is in question
• Pt’s must be protected when they lack DMC due to illness, injury, intoxication, impairment
• Intoxication changes – reassess, stabilize

Question 22

Informed consents

Answer 22

-consent for procedure, treatment; after discussion

• components:
  
  • The condition requiring tx/procedure
  • Description (name), purpose of the tx
  • Potential complications, “material risks”
  • Benefits, chances of success
  • Risks of failing to do it/have it
  • Alternatives: risks and benefits of those too
  • Identity of who will do it/administer it
  • Documentation – consent form/signature/witness/date/time

Question 23

Consent in Minors

Answer 23

• Minor = <18yo
• unless emergent, parental/guardian consent required - reasonable treatment initiated until consent obtainable
• may consent to tx but cannot refuse it
• cannot refuse tx if parent consents
• can consent for themselves if they are an emancipated minor

Question 24

emancipated minors

Answer 24

• 16yo or older
• live on their own, responsible for own expenses
• Active duty military, married, pregnant, are a parent
• anyone requesting treatment for reproductive health, STI, sexual assault
• requests mental health or substance abuse services

Question 25

leaving against medical advice

Answer 25

• Anyone with DMC can leave AMA at any time
• Not good - inform supervising MD immediately
• Discuss pt concerns, reasons, how can we help (Basically, assess DMC. No DMC? Should not be allowed to leave or sign AMA form)
• Discuss risks, alternatives
• Involve family, friends, social services, clergy, etc
• AMA form – signed by MD, witnessed
• Specific return precautions, f/u plan, document. Provide tx when possible

Question 26

EMTALA

Answer 26

• Emergency Treatment and Active Labor Act ‘86
  
  • Any person presenting to an ED must have a “medical screening exam” to determine if an emergency exists, regardless of ability to pay
  • If an emergency exists, pt must be evaluated and stabilized before transfer
  • Emergency: absence of care = health jeopardy, etc
  • Stabilized: no deterioration likely during transport
• Exceptions
  
  • Pt can request transfer before stabilization
  • If benefits of transfer outweigh the risk of transfer (higher level of care)

-EMTALA is part of COBRA: Consolidated Omnibus Reconciliation Act, 1985. COBRA allows for persons to continue to receive health care insurance coverage when leave current job – as well as many other provisions included in the law.

Question 27

HIPPA

Answer 27

• Health Insurance Portability/Accountability Act
• All health information that can identify pt
• In the ED:
  
  • Need signed consent to get records from elsewhere
  • Discussions regarding patients in public spaces
  • Discussions by phone, in person w/ other providers, police, “family members”
  • Taking any pt info home – identifiers best
  • VIP’s in the ED
  • DO NOT mention/post photos of pt’s on social media

Question 28

Mandated reporting

Answer 28

• in CA, PAs are required to report:
  
  • Suspected child, elder, or domestic violence
  • Felonious assaults and sexual assaults
  • Serious dog bites
  • Certain contagious diseases
  • Diseases causing impairment of driving - To local police, To Public Health dept, To DMV

Question 29

Involuntary Detainment - 5150

Answer 29

• Allows “peace officers” and MDs to “hold” pt for up to 72 hours; must get psych evaluation:
  
  • At immediate risk for endangering others or themselves (suicidal, homicidal)
  • Unable to care for themselves (gravely disabled)
• The pt cannot be allowed to sign out AMA
• Does NOT permit medical treatment if refused by patient – may sedate pt for safety
• If emergent tx needed – determine DMC

Question 30

Patient safety/medical errors

Answer 30

• Pace and milieu of the ED predisposes us
• Majority of errors do not result in signif pt harm
• Risk factors for errors
  
  • Age extremes (medication dosing, end-organ damage)
  • Psych or intoxicated pt’s (poor hx, bias, poor f/u)
  • Language (incomplete understanding)
  • Cognitive (we are tired, stressed, hurried, etc)
  • Inexperienced, “just following orders”
• Types of errors: information, study, med, dose, pt/chart, communication, equipment, etc…

Question 31

How we make mistakes

Answer 31

• Anchoring
  
  • We decide what the Dx is early on and stick to it: avoid consideration of a relevant DDx
• Confirmation Bias
  
  • Follow our hunch, even though hypothesis is weak
  • Stop searching for Dx
• Diagnostic Momentum
  
  • Establish a Dx w/o adequate evidence to match
  • That Dx gains momentum, we stop searching

Question 32

Patient Safety

Answer 32

If a mistake occurs while you are working: Stop, re-assess situation, Inform your supervising MD immediately, Disclose the error to the pt

• Inform an error has occurred, apologize
• Describe how it occurred
• Implications of the error
• Why it occurred
• How we will prevent it in future
• Apologize for the error again