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Speciality Medicine > Lecture one: ED > Flashcards

Lecture one: ED Flashcards

1
Q

Basics of EM
* What keeps you for litigation? What are the things you need to think of?

A

Being aware of worst possible outcome is what is going to keep you from litigation
* Your goal is to rule-out life threatening condition and recognize patterns, since most patients are not book examples
* Ask yourself “What will kill patient fastest?”
* You are the gatekeeper: admit or discharge
* Do not order a test if it is not going to change your plan of care

  • Will see all walks of life, usually at their worst
  • Not everyone that comes to ER has life threatening complaints
  • EM is very algorithm oriented
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2
Q

What is the top hospitals and the ones that Dr.S work at in terms of charge to cost ratios?

A

Top: Ponciana Medical Center

Dr.S:
* 3: Oak hill hospital
* 8: St pete general hospital
* 13: Bayfront health brooksvill

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3
Q

How many PAs go into ER?

A
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4
Q

Credentialing Process
* How often do you need to do this?

A

Essentially ask permission to perform services, renewed every 2 years

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5
Q

Who is on the ER team?

A
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6
Q

PA Role in ER:
* Where does the PA practive fall within?
* Practice laws require what?
* What about APRN?

A
  • PA Practice falls within the scope of supervising physician
  • Practice laws require supervisory position of collaborating physician which means “responsible supervision and control”
  • APRN colleagues are lateral and perform same tasks within the department as PAs
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7
Q

Triage levels
* Why are they important?
* Patient that has not been triaged could be what?
* What does metrics depend on?
* What should happen with a level four?

A
  • Triage is very important because it determines waiting room situation
  • Patient that has not been triaged could be Level 1
  • Metrics depend on triage
  • Level 4 discharge should happen within 85 minutes
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8
Q

What is level one- five?

A
  • Level 1: Resuscitation (CPR, Resp Failure)
  • Level 2: Emergent (ACS, Stroke)
  • Level 3: Urgent (Abd pain)
  • Level 4: Less Urgent (Laceration)
  • Level 5: Non-urgent (Med refill)

* X-ray: Min 4
* X-ray+blood work: Min 3

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9
Q

What is the approach to an ER patient?

A
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10
Q

What are Things to Help You in EM Rotations?

A
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11
Q

Patient Experience is Important
* What is used to gage experience?

A

Press-Ganey Scoring
* Utilized by hospitals and provider employers to rate their services and compare apples to oranges across the entire healthcare system
* Each patient receives a report card following their visit
* 5 Questions concerning ED care are used to rate YOU and your care

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12
Q

What are the four Cultural Issues?

A
  • Language barrier (foreign/deaf)
  • Religion
  • Disability
  • Incarceration/Detention
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13
Q

Language barrier:
* What does the hospital need to provide?
* What can it fall under?

A

– Hospital interpretation services
– Google translate app
– Can fall under ADA litigation

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14
Q

Religion
* What type of stigma is present?

A

– Complaints and gender stigma

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15
Q

What is the issue with Disability?

A

Cannot dc all to facilities or shelters with Durable medical equipment (DME)

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16
Q

Incarceration/Detention
* Do not form what?
* What do you need to be careful with MRI?

A

– Do not form bias based on charge
– Ankle monitors and MRI

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17
Q
  • What is the best way to protect yourself? What does it also do?
A

The best way to protect yourself is through appropriate documentation of the visit
– Documentation also justifies billing and your paycheck
– Billing depends on Severity of your attention to the patient

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18
Q

Documentation
* What does billing depend on?

A

5 levels of Service 99281-99285

Other billing depending on the patient
* Critical care
* Procedure documentation: Lacerations, I&D, intubation, conscious sedation etc

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19
Q

What is medical decision making? What does it determine?

A

Medical Decision Making – determines the code
* Rationale of what you are thinking and why you are doing what you’re doing
* Differential diagnosis and how you worked through them to rule in or out, MUST ADDRESS ALL
* Interventions on the patient
* Will likely determine your billing
* What other information you reviewed: Old charts, labs, XR, NH/ALF records, EMS records, cardiac cath/ECHO reports, radiology reports, etc

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20
Q

What do you need to document?

A

PLEASE document & time a reevaluation
* Response to treatment
* Information shared with patient
* Additional therapy if needed

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21
Q

Documentation:
* what else do you need to document?

A

Calls/Consults – Admitting, Poison Control, PCP, Psych, Radiology, Pharmacy, Social Work

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22
Q

What is this an example of?

  • 20 yo WF, h/o prior ectopic presents with RLQ pain concerning for ectopic, appy, ovarian torsion, PID, renal stone. Will order CBC, CMP, UA, UHCG. Will add serum HCG if (+) and obtain US. If neg will CT.
  • Reviewed prior gyn note which showed neg UHCG, GC/chlamydia. Will tx with IVF, pain meds, antiemetics.
A

Documentation MDM Example

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23
Q

What’s a MIPS Measure?

A
  • NOT a minor in possession
  • NOT a maximum inspiratory pressure
  • Merit-Based Incentive Payment System
    – Attached to your NPI and follows you throughout your career
    – Reimbursement, therefore, YOUR PAY can depend on it
    – Essentially Delineates standard of care
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24
Q
A

Negative reporting follows you your entire career as it is attached to your NPI number,impactshospitalreimbursement and could affect futurejobs.

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25
Q

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

A
  • 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
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26
Q

Emergency Medical Services

Public Law 93-154 define what?

A

defined a goal to improve emergency medical care, 1973

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27
Q

Emergency Medical Services: Public Law 93-154
* What does EMS include?
* States set what specific standards?

A
  • 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
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28
Q

What are the Elements of EMS Systems?

A
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29
Q

EMS Personnel
* What are the different ones? What are their scope?

A
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30
Q

EMS/Advanced Trauma Life Support
* What does it improve?
* What is the purpose?

A
  • 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
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31
Q

What is the golden hour?

A

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

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32
Q

EMS/Trauma Care
* What saves lives? What is the exceptation?
* What is always TOP PRIORITY?
* What do you do make golden hour to work?
* What is crucial?

A
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33
Q

EMS
* Not every hospital can do what?
* Where do Code blue patients go?
* Otherwise, more stable patients need to go where?

A
  • 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
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34
Q

What are the ACS Trauma Service Level 1-4?

A
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35
Q

Sudden Cardiac Arrest
* What is the most effective txt for ventricular fibrillation?
* Common or not?
* Over 20% of patients were what? What should you do?
* No survival without what?

A

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

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36
Q

Automated External Defibrillators
* What are the benefits?
* Who can use an AED? What is the survival rate?
* Wide what?

A
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37
Q

Unstable Angina
* Paramedics administer what? What do you need to check before?

A
  • Paramedics administer nitroglycerin and aspirin (4 baby chew and swallow)
    – Check patient Rx before giving: Viagra etc because it will cause hypotension/tank them
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38
Q

Unstable Angina
* Pre-hospital drug therapy does what?

A

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

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39
Q

AMI/Cardiac Alert
* What is the phase?
* EMS systems perform what? What does it do?

A

“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

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40
Q

AMI/Cardiac Alert
* What is the alert? What happens?

A

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

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41
Q

Adult Medical Care
* EMS control of what is life saving? Give examples
* Pre-hospital ALS improves what?

A
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42
Q

What is the 1st sign of airway obstruction?

A

stidor

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43
Q

Adult Medical Care
* COPD/ASTHMA: what is safe and effective?
* What do you need to give to altered mental status?

A

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

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44
Q

Adult Medical Care: Seizures
* What do you need to give?
* What do you aviod?
* What an example of benzo?
* What is the reversal of benzo?

A

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.

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45
Q

Pediatric Care
* What are the most common emergencies?

A

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

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46
Q

Pediatric Care
* What is the intubation ET size equation?
* What should happen regardless of age?
* Children are not what?

A
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47
Q

Rural EMS
* What are some unique challenges?

A
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48
Q

What are the Resuscitation Equipment?

A

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

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49
Q

What are the areas of law?

A

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

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50
Q

What is administerative law?

A

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

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51
Q

What is civil law?
* Apologizes for what?

A

– 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

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52
Q

Civil Law
* How is this different criminal law?
* Litigants have to prove what?

A
  • 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)
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53
Q

Malpractice applies not just to medicine, explain

A

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

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54
Q

What is inevitable, explain?

A

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

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55
Q

4 Elements that MUST be met for a lawsuit to be filed

A

Duty

Standard of Care
* Breach of Duty

Causation
* Cause in Fact
* Proximate Cause

Damages

The plaintiff has the burden of proof to show all elements of the cause of action

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56
Q

Duty
* Determined by who?
* Legal obligation owed by who?
* Duty is always owed in what? What are the exceptation?

A
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57
Q

Duty
* If the patient is what?
* What patients has no duty?
* If no duty is found, then what?

A
  • If the patient is established, duty is owed
  • Outpatient NEW patient=noduty
  • If no duty is found, then no case exists
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58
Q

Standard of Care
* Liability flows when?
* What type of standard? Expand on this?
* Failure to meet the bar =
* Who decides?

A
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59
Q

What are the Failure to meet standard of care examples?

A
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60
Q

Foreseeability rule
* What is this?

A

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

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61
Q

Which one is applies foreseeability rule and now?
* Giving someone Valium and discharging home via own car, same day patient causes a fatal car accident
* Giving someone Ketorolac (Toradol) for ankle sprain in ER, later same day patient commits suicide at home and attorney alleges lack of pain control as the cause of suicide – too remote of a cause

A
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62
Q

Breach can be measured by what? Give an example

A

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.

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63
Q

Causation:
* There must be what?
* What are the two types?

A
  • There must be a causal connection between patient’s injury and provider’s breech
  • Two types: Cause in fact (substantial factor) and proximal cause
64
Q

What is Cause in Fact (Substantial Factor) and Proximal Cause

A

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)

65
Q

Damages:
* Must have what? What are the types?
* What does not count?

A
66
Q

In Florida, injury cases have to be filed when?

A

within 2 years from the date of injury/death

67
Q
  • Litigation can last last how long?
  • When does the injury cases filed within 2 years not apply?
A

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)

68
Q

What happens in VA cases?

A

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

69
Q

What are some issues that could come up from this? What legal issues at play?

A
70
Q

What loophole does FL have?

A

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

71
Q

What is the “free-kill” loophole?

A

– 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

72
Q

Vicarious Liability
* Who may be liable for negligent conduct of the PA?
* Only applies in what?

A
73
Q

HIPAA
* What is this? What does it not apply to?

A

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)

74
Q

HIPAA
* Disclosures are subject to what?
* Incidental Disclosures could lead to what?

A
  • 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
75
Q
A
76
Q

FS §381.004(5)(b), states that breaching the confidentiality unintentionally, can result in what?

A

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

77
Q
A
78
Q

What are the HIPAA Exclusions?

A
79
Q

Cures Act Update
* What is it?
* Pay attention to what? Why?

A
80
Q

What is EMTALA? When was it enacted and regulated?

A
  • Emergency Medical Treatment and Active Labor Act
  • Enacted in 1986, regulated in 1994 (42 CFR section 489.24)
81
Q

EMTALA
* What does it stem from?
* What did the studies show on transfers?
* Most patients had the lack of what?
* What was the delay?

A

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

82
Q

EMTALA
* What does it require hosptial to do?

A

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.

83
Q

EMTALA
* EMTALA is not a substitute (statute) for what?
* EMTALA does not define what?
* Triage may or may not satisfy what?

A
  • 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)
84
Q

EMTALA
* Most frequently scrutinized issue is what? Explain

A

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

85
Q

EMTALA
* The definition of emergency is what?

A
  • The definition of emergency is subjective, not objective
86
Q

EMTALA
* Flexible definition of “sufficient severity”, including what?
* According to 42 USC §1395dd(e)(1), an emergency medical condition means what?

A

– 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.

87
Q

What is stable definition?

A

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.

88
Q

EMTALA
* Violations can range from what?
* EMTALA does not apply to what?

A
89
Q

EMTALA
* Specialists that are on ER call are what?
* What type of rule is there? Explain
* EMTALA obligations end when ?

A
  • 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)
90
Q
A
91
Q

Each hospital is required under EMTALA to provide what?

A

provide emergency care to stabilize a patient

92
Q

Transfer (42 U.S.C. §1395dd)
* What are the different reasons to transfer?
* What needs to accompany the patient

A

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

93
Q

Advance Directives
* What are they?

A

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

94
Q

Healthcare Surrogate/Proxy, NOT POA
* Who are they/

A
  • 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)
95
Q

Living Will
* What is this?

A

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

96
Q

DNR (golden ticket)/DNI/Artificial Nutrition/CMO
* What is this?
* What does not qualify?
*

A
  • 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
97
Q

What If There is NO Advance Directives?

A
  • Next of Kin
98
Q

What is next of kin?

A

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.

99
Q

What are the exceptions of next of kin?

A
100
Q

Fraud
* What is it?

A

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

101
Q

Waste
* what is it?

A

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

102
Q

What is hc abuse?

A

Medically unnecessary services beyond defensive medicine (“Shotgun orders”)

103
Q

What are FHPs?

A

Federal Healthcare Programs

104
Q

Healthcare Fraud: kickbacks
* Prohibits what?
* What type of charge?
* What is it?
* Careful with who?

A
  • Prohibits the exchange of anything of value for referral for services that are payable by a federal program
  • Is a FELONY under42 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
105
Q

Healthcare Fraud: False Claims Act
* What is this?

A

Willful acceptance of referrals from someone conspiring to bill federal programs

106
Q

Healthcare Fraud: Stark Law
* What is this?
* Applies to who?

A
  • 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
107
Q
A
108
Q

What is The Americans with Disabilities Act (ADA)?

A

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

109
Q

ADA
* What are the limitations?

A
110
Q

Ethical Principles: Respect for Autonomy
* What does that mean?

A

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

111
Q

Ethical Principles: Beneficence and Nonmaleficence
* What does that mean?

A

– 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

112
Q

Ethical Principles: Justice
* What is this?

A

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

113
Q

Informed Consent
* What is the goal?
* Requires what?

A
  • 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
114
Q

Informed Consent
1. Treatment with underinformed consent is what?
2. Treatment without consent is what?

A
  1. Negligence
  2. battery
115
Q

What is Informed Consent?

A

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

116
Q

Successful suit will usually undermine IC if what?

A

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

117
Q

Special Circumstances IC?

A
  • ETOH intoxication
  • Police/DLE custody
  • Minors
  • Psychiatric problems
  • Narcotic abusers
118
Q

Special Circumstances IC
* ETOH intox?
* police custody?

A
119
Q

Special Circumstances IC
* Minors?
* Psych?
* Narcotic abusers?

A
120
Q

If patient is incompetent,what can be used?

A

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

121
Q

What is the issue with first aid to minors?

A
122
Q

Pelvic Exam Law Changes
What is required?

A

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.”

123
Q

Pelvic Exam Law Changes
* If it is purely a visual exam, then what type of consent? Touch?
* Both verbal and written consents for a “pelvic examination”must be what?

A
  • 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.”
124
Q

Pelvic examination may not be done on who without what?
* What does NOT require consent?

A
  • 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.
125
Q

Competency
* Determined by who?
* Permanent until?
* Is usually what?
* Person may not what?

A
  • 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
126
Q

Refusal of care/AMA
* What is the list to meet the criteria of capacity of patient to obtain Informed Refusal (Furrow et al., 2018, p. 77)?

A
127
Q

Capacity
* may do what?
* Mayber determined by who?
* Capacity restored when ?
* May depend on what?

A
  • Temporary or wax/wane
  • Maybe determined by any professional
  • Capacity restored when underlying cause resolved (ETOH, hypoglycemia)
  • May depend on the day (Alzheimer’s)
128
Q

Refusal of care/AMA
* What is the list the patient has to meet the criteria of capacity?

A
129
Q
A
130
Q
  • What is the Bartling v. Superior Court, 1984 case?
  • What is the first amendment?
A
  • 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
131
Q

What are Observation Stay (levels 0-1)? What is the two midnight rule?

A

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

132
Q
  • Observation patients are billed how?
  • Inpatient admissions are billed how?
  • Observation patients may have?
A
  • 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.
133
Q
  • What is Inpatient stay (levels 2-3)?
  • What is always inpatient?
A
134
Q

What level is ICU?
* What type of patients?
* What is the ratio?
* What is the interventions?

A
135
Q

What level is intermediate medical unit?
* What type of patients?
* What is the ratio?
* What is the interventions?

A
136
Q

What level is telemetry medical unit?
* What type of patients?
* What is the ratio?
* What is the interventions?

A
137
Q

What level is ward unit?
* What type of patients?
* What is the ratio?
* What is the interventions?

A
138
Q

For ICU, what are the priority levels? What are the patient types?

A
139
Q

For (intermediate) IMU, what are the priority levels? What are the patient types?

A
140
Q

For palliative care, what are the priority levels? What are the patient types?

A
141
Q

What is the definiation of ICU?

A

“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.”

142
Q

What is the Criteria for ICU Admission?

A
143
Q
A
144
Q
A
145
Q

Thanatology:
* What is irrelevant?
* Healthcare benefits and legal obligation to provide what?
* What act is present?
* What is whole brain death?

A
146
Q

UDDA:
* What are two criteria?

A
  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.
147
Q

How is Persistent Vegetative State different?

A

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

148
Q

How is clincal death different?

A

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.

149
Q

LACK of MIDBRAIN function confirmed by what? (4)

A
  • absence of pupillary light(pons)
  • AND no response to pain
  • AND no cranial nerve reflexes
  • AND no spontaneous respirations
150
Q

LACK of PONTINE function confirmed by what?

A
  • 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.
151
Q

LACK of MEDULLARY function confirmed by what?

A

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

152
Q

Documentation of irreversibility requires what?

A

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

153
Q

Status Post Brain Death Determination
* Asystole usually occurs when?
* What has not occurred?
* What results in terminal rhythms?
* Purely spinal motor movements may occur in what?

A
  • 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
154
Q

Accepted Medical Standards
* Determination of death needs to be made by who? What is the exception?
* Sequential testing is required for what?
* At least 24 hours in the setting of what?

A
155
Q

Accepted Medical Standards
* What are some supportive studies?
* What can PAs do in FL?

A

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

156
Q

Not Dead until Warm & Dead
* What is the deal with this?
* How do we fix this?

A
157
Q

Death Notification
* Typically done by who?
* If family arrives to ED, who notifyies the fam?
* Notify who?
* Do not remove what?
* Local jurisdiction determines what?

A

Speciality Medicine (12 decks)

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