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Ethical and Legal Issues

Optimizing the Use of a Precious Resource: The Role of Emergency Physicians in a Humanitarian Crisis

Parveen K. Parmar, MD, MPH, et al.

Emergency physicians (EP) are uniquely suited to provide care in crises as a result of their broad training, ability to work quickly and effectively in high-pressure, austere settings, and their inherent flexibility. While emergency medicine training is helpful to support the needs of crisis-affected and displaced populations, it is not in itself sufficient. In this article we review what an EP should carefully consider prior to deployment.

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Ethical and Legal Issues

Emergency Physicians as Good Samaritans: Survey of Frequency, Locations, Supplies and Medications

Volume 17, Issue 1, January 2015.
Taylor W. Burkholder, MD, MPH, et al.

Introduction: Little is known about the frequency and locations in which emergency physicians
(EPs) are bystanders to an accident or emergency; equally uncertain is which contents of an
“emergency kit” may be useful during such events. The aim of this study was to describe the
frequency and locations of Good Samaritan acts by EPs and also determine which emergency kit
supplies and medications were most commonly used by Good Samaritans.
Methods: We conducted an electronic survey among a convenience sample of EPs in Colorado.
Results: Respondents reported a median frequency of 2.0 Good Samaritan acts per five years of
practice, with the most common locations being sports and entertainment events (25%), road traffic
accidents (21%), and wilderness settings (19%). Of those who had acted as Good Samaritans, 86%
reported that at least one supply would have been useful during the most recent event, and 66%
reported at least one medication would have been useful. The most useful supplies were gloves
(54%), dressings (34%), and a stethoscope (20%), while the most useful medications were oxygen
(19%), intravenous fluids (17%), and epinephrine (14%).
Conclusion: The majority of EPs can expect to provide Good Samaritan care during their careers
and would be better prepared by carrying a kit with common supplies and medications where they
are most likely to use them.

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Ethical and Legal Issues

Epidemiology of Advance Directives in Extended Care Facility Patients Presenting to the Emergency Department

Volume 16, Issue 7, December 2015.
Jessica Wall, MD, MPH, et al.

Introduction: We conducted an epidemiologic evaluation of advance directives and do-notresuscitate
(DNR) prevalence among residents of extended care facilities (ECF) presenting to the
emergency department (ED).

Methods: We performed a retrospective medical record review on ED patients originating from an
ECF. Data were collected on age, sex, race, triage acuity, ED disposition, DNR status, power-of
attorney (POA) status, and living will (LW) status. We generated descriptive statistics, and used
logistic regression to evaluate predictors of DNR status.

Results: A total of 754 patients over 20 months met inclusion criteria; 533 (70.7%) were white, 351
(46.6%) were male, and the median age was 66 years (IQR 54-78). DNR orders were found in 124
(16.4%, 95% CI [13.9-19.1%]) patients. In univariate analysis, there was a significant difference in
DNR by gender (10.5% female vs. 6.0% male with DNR, p=0.013), race (13.4% white vs. 3.1% nonwhite
with DNR, p=0.005), and age (4.0% <65 years; 2.9% 65-74 years, p=0.101; 3.3% 75-84 years,
p=0.001; 6.2% >84 years, p<0.001). Using multivariate logistic regression, we found that factors
associated with DNR status were gender (OR 1.477, p=0.358, note interaction term), POA status
(OR 6.612, p<0.001), LW (18.032, p<0.001), age (65-74 years OR 1.261, p=0.478; 75-84 years OR
1.737, p=0.091, >84 years OR 5.258, P<0.001), with interactions between POA and gender (OR
0.294, P=0.016) and between POA and LW (OR 0.227, p<0.005). Secondary analysis demonstrated
that DNR orders were not significantly associated with death during admission (p=0.084).

Conclusion: Age, gender, POA, and LW use are predictors of ECF patient DNR use. Further, DNR
presence is not a predictor of death in the hospital.

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Ethical and Legal Issues

Do Emergency Physicians and Medical Students Find It Unethical to ‘Look up’ Their Patients on Facebook or Google?

Volume 16, Issue 2, March 2015
Maxim Ben-Yakov, MD et al.

The use of search engines and online social media (OSM) websites by healthcare providers is increasing and may even be used to search for patient information. This raises several ethical issues. The objective of this study is to evaluate the prevalence of OSM and web-searching for patient information and to explore attitudes towards the ethical appropriateness of these practices by physicians and trainees in the emergency department (ED).

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Ethical and Legal Issues

Effects of a Dedicated Regional Psychiatric Emergency Service on Boarding of Psychiatric Patients in Area Emergency Departments

Volume XV, Issue 1, February 2014
Scott Zeller, MD et al.

This study sought to assess the effects of a regional dedicated emergency psychiatric facility design known at the “Alameda Model” on boarding times and hospitalization rates for psychiatric patients in area EDs.

This study sought to assess the effects of a regional dedicated emergency psychiatric facility design known at the “Alameda Model” on boarding times and hospitalization rates for psychiatric patients in area EDs.

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Ethical and Legal Issues

The Alameda Model: An Effort Worth Emulating

Volume XV, Issue 1, February 2014
Aimee Moulin, MD, et al.

In 2009 Alameda placed 11.0 involuntary holds per 1,000 population, while the next highest county in California only placed 6.4 per 1,000 population.5 This may suggest instead that some of Alameda’s mental health patients would not have been placed on an involuntary hold in other California counties in the first place, increasing the proportion of lower acuity psychiatric emergencies and thus accounting for the high discharge rate.

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Ethical and Legal Issues

Response to Moulin and Jones: “The Alameda Model: An Effort Worth Emulating”

Volume XV, Issue 1, February 2014
Scott Zeller, MD

As Moulin and Jones correctly indicate, there is no delineation of the relative acuity of the study patients to those seen in other emergency settings in California. However, we are unaware of any established metric to provide such a comparison for this patient population, and no such categorization was noted in any of the other boarding time studies cited in the article.

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Ethical and Legal Issues

Assessment of the Acute Psychiatric Patient in the Emergency Department: Legal Cases and Caveats

Volume 15, Issue 3, May 2014
Benjamin Good, MD et al.

Assessment of the acute psychiatric emergency is challenging and fraught with error. This paper, using legal cases, will discuss the assessment of new onset psychiatric illness, exacerbation of chronic psychiatric disease, and the suicidal patient. We will share diagnostic caveats, medical clearance, and suicide assessment tools.

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Ethical and Legal Issues

Informed Consent Documentation for Lumbar Puncture in the Emergency Department

Volume 15, Issue 3, May 2014
Pankaj B. Patel, MD et al.

Informed consent is a required process for procedures performed in the emergency department (ED), though it is not clear how often or adequately it is obtained by emergency physicians. Incomplete performance and documentation of informed consent can lead to patient complaints, medico-legal risk, and inadequate education for the patient/guardian about the procedure. We undertook this study to quantify the incidence of informed consent documentation in the ED setting for lumbar puncture (LP) and to compare rates between pediatric (<18 years) and adult patients.

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Ethical and Legal Issues

Increasing Suicide Rates Among Middle-age Persons and Interventions to Manage Patients with Psychiatric Complaints

Volume XV, Issue 1, February 2014
Bharath Chakravarthy, MD, MPH et al.

The Centers for Disease Control and Prevention (CDC) has published significant data and trends related to suicide rates in the United States (U.S.). Suicide is the 10th leading cause of death in U.S. adults, and rates are increasing across all geographic regions. There is a significant increase in the suicide rate among adults in the 35–64 age range. We present findings from the CDC’s Morbidity and Mortality Weekly Report (MMWR) with commentary on current resources and barriers to psychiatric care.

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Ethical and Legal Issues

Integrated Model of Palliative Care in the Emergency Department

An integrated model of palliative care in the emergency department (ED) of an inner city academic teaching center utilized existing hospital resources to reduce hospital length of stay (LOS) and reduce overall cost. Benefits related to resuscitation rates, intensity of care, and patient satisfaction are attributed to the ED-based palliative team’s ability to provide real time consults, and utilize InterQual criteria to admit to a less costly level of care or transfer directly to home or hospice.

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Ethical and Legal Issues

Medical-legal Issues in the Agitated Patient: Cases and Caveats

Volume 14, Issue 5, September 2013
Jessica Thomas, MD, et al.

More than any other area of emergency medicine, legal issues are paramount when caring for an agitated patient. It is imperative to have a clear understanding of these issues to avoid exposure to liability. These medico-legal issues can arise at the onset, during, and at discharge of care and create several duties. At the initiation of care, the doctor has a duty to evaluate for competence and the patient’s ability to consent. Once care has begun, patients may require restraint if they become combative or violent.

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Ethical and Legal Issues

When a Patient Declines Curative Care: Management of a Ruptured Aortic Aneurysm

Volume 14, Issue 5, September 2013
Sangeeta Lamba, MD, et al.

The management of major vascular emergencies in the emergency department (ED) involves rapid, aggressive resuscitation followed by emergent definitive surgery. However, for some patients this traditional approach may not be consistent with their goals and values. We explore the appropriate way to determine best treatment practices when patients elect to forego curative care in the ED, while reviewing such a case.

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WestJEM/ Department of Emergency Medicine
UC Irvine Health

333 The City Blvd. West, Rt 128-01
Suite 640
Orange, CA 92868, USA
Phone: 1-714-456-6389
Email: westjem@gmail.com

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WestJEM
ISSN: 1936-900X
e-ISSN: 1936-9018

CPC-EM
ISSN: 2474-252X

Our Philosophy

Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.