Intro to EM Flashcards
1
Q
What additional factors are included in vital signs?
A
- observation
- general appearance
2
Q
Emergency Room vs. Department
A
- 1961: first full time EM MD’s
- 1969: first EM residency; ABMS 1979
- Trauma centers: level I, II, III
- Specialty Centers: cardiac, stroke
3
Q
PA’s hx in the ED
A
- 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
4
Q
charge RN
A
-coordinates, keeps track, fixes things, liaison
5
Q
triage RN
A
-takes the first hx
6
Q
Approach to the ED patient
A
- 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
7
Q
Recognizing “sick”
A
- 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…
8
Q
Who should you be careful with?
A
- Very young, the very old
- Pregnant
- Psychotic
- Intoxicated
- Immunocompromised
- Non-English speaking
- The difficult, offensive patient
- The “inherited” patient
9
Q
Not sick? Everybody else
A
- 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
10
Q
Sick?
A
- 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
11
Q
Airway “sick”
A
- Upright position, position preference
- “universal choking sign”
- Tachypnea
- Anxiety, exhaustion
- Diaphoresis
- Gurgling, hoarseness, or stridor
12
Q
Breathing “sick”
A
- Tachypnea
- Can’t talk, few words
- Mental status changes
- Diaphoresis
- Use of accessory muscles
- Unequal chest expansion or breath sounds
- Exhaustion
- Cyanosis
13
Q
Circulation “sick”
A
- Hypotension
- Arrhythmia
- Acute blood loss
- Decreased cerebral perfusion: anxiety, dizziness, ALOC, syncope, coma, etc…
- Decreased cardiac perfusion: chest pain, pulmonary edema, arrhythmias, AMI, etc…
14
Q
Disability “sick”
A
- Altered Level of Consciousness (ALOC)
- Acute paralysis or neglect
- Significant mechanism trauma
- Focal weakness
- Head injury
- Active seizure
15
Q
Environment/Exposure “sick”
A
- Hazmat Environmental Exposure
- Hyperthermia
- Hypothermia
- “Found down”
- Toxicology/Ingestion
- Burns/smoke inhalation
- Water exposure – drowning, near-drowning
16
Q
Triage - mass casualty
A
- 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
17
Q
Legal issues in emergency care
A
- Decision-Making Capacity and Consent
- AMA
- EMTALA, HIPAA
- Mandated reporting
- 5150
- Patient Safety
- Documentation
18
Q
Consent for emergency care
A
- 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
19
Q
Decision-making capacity
A
- 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
20
Q
questions a pt must be able to answer in order to have decision-making capacity
A
- 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?
21
Q
Caveats to DMC
A
- 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
22
Q
Informed consents
A
-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
23
Q
Consent in Minors
A
- 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
24
Q
emancipated minors
A
- 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
25
leaving against medical advice
- 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
26
EMTALA
- 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.
27
HIPPA
- 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
28
Mandated reporting
- 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
29
Involuntary Detainment - 5150
- 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
30
Patient safety/medical errors
- 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...
31
How we make mistakes
- 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
32
Patient Safety
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
