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A physician on the staff of Omega Hospital calls the Omega emergency department and speaks to one of the nurses. He says that a patient of his is coming in with a migraine headache, and he wants the nurse to give the patient 100 mg of Demeral intramuscularly (a normal adult dose). The nurse knows that verbal orders for narcotics are not permitted.
A registered nurse working in a busy emergency department receives a call from a mother whose two-year-old child has diarrhea and is vomiting. The mother wants to know what to do. At the same time, the physician on duty gets a call from a physician's assistant at an outlying hospital, asking for advice in managing a difficult emergency case. What are their responsibilities regarding telephone requests for help by patients and other health care providers?
A 24-year-old man arrives in the small community emergency department in the middle of the night with epistaxis (nosebleed). The nursing staff are the only ones present in the hospital. (This situation is common in many small communities in the United States.) The senior nurse applies direct pressure to the nose, but after five minutes the bleeding has not stopped, so she contacts the physician-on-call.
An 18-year-old asthmatic with an acute exacerbation of her condition arrives in the emergency department. The examining physician asks the nurse to give the patient 0.3 cc of epinephrine, 1:10,000 dilution. (The normal dose is 0.3 cc of epinephrine, 1:1,000 dilution.) The nurse questions the order, but the physician is adamant. The nurse is aware that in this case the drug will not cause any ill effect to the patient.
A 24-year-old woman arrives in the emergency department complaining that she has felt dizzy for the past month. On this occasion, she was in town shopping when she felt dizzy, and her mother brought her in. She had seen her family doctor previously because of the dizziness, but he was unable to help. She reported that she originally sought this physician's help for a heart problem and that he had prescribed a number of medications.
A 20-year-old woman is brought to St. Agnes Hospital emergency department after being raped. Medical treatment, begun immediately by emergency department personnel, includes psychological support, a general physical examination, and the standard me­dicolegal rape examination. No significant physical injury is found, and the patient is discharged on antibiotics to prevent possible venereal disease, with instructions to follow up with the rape crisis counselor.
Paramedics were summoned to aid a 70-year-old woman in cardiac arrest. They attempted to resuscitate her, but on arrival at the emergency department the patient was still unresponsive and was pronounced dead. The patient's husband and daughter are waiting for news regarding the outcome of the resuscitation procedure.
A community physician on staff at Alpha Hospital calls the emergency department there and informs the physician on duty that a patient of his, a 43-year-old woman, is going to arrive in extremis from "terminal" breast carcinoma. He says that she may be in cardiac arrest when she arrives or, if not, may be close to it and that he does not want anyone to try to resuscitate her. He says that he has been taking care of her for the past year and has all of her records.
One of Alpha Hospital's emergency physicians has an opportunity to go on a four-day raft trip, a vacation he has been looking forward to for a long time. In order to take the trip, however, he must switch a shift, and this means that he would work 24 hours continuously. Alpha Hospital has a very busy emergency department and often receives more than 100 patient visits in 24 hours.
A 14-week-old infant is brought to the emergency department at 3 a.m. by his mother, who explains that he has been irritable all night and not sleeping well. On exam, the patient has a temperature of 37.9°C. He is irritable while being examined but is comforted by his mother. He has a good cry and suck. Exam is otherwise unremarkable.
An 8-year-old child with a minor head injury is brought in to the emergency department and is judged by the physician to be completely normal. The parents say that a sibling had a skull fracture under similar circumstances and that they would sleep much better if a skull x-ray were taken. The physician realizes that in cases like this, practically the only significant finding — that is, one that would change care — is relatively rare (namely, a depressed skull fracture).
A two-year-old child with a rectal temperature of 102°F is brought into the emer­gency department at 2:00 a.m. by his parents because of the fever. He is fussy and is pulling at his left ear. The patient belongs to a health maintenance organization (HMO) (prepaid health plan). His physician is contacted but refuses permission (refuses to pay) for the child's treatment. He suggests that the parents bring the child to the clinic at 9:00 a.m.
A 24-year-old unemployed man presents to the emergency department with a complaint of a sore knee which has not been injured recently but occasionally gives way (most likely, a chronic injury of the cartilage of the knee joint). He wants an evaluation and something for the pain. Prior to treatment, he is questioned concerning his ability to pay and method of payment, and he responds that he will pay his bill personally.
The emergency physician began his shift an hour ago and has already seen five patients, all with the viral syndrome that is going around. None of these patients have insurance, so the physician bills them at a minimal rate for his services. A sixth patient arrives with the same syndrome, but this patient has Saguaro Mutual insurance, and the physician is tempted to bill him a bit more for his services.
A 28-year-old female executive was jogging on her lunch hour and twisted her ankle. Although the soft tissues are swollen, and some support for the ankle is indicated, no fracture is evident on x-ray. A plaster posterior splint might be slightly more com­fortable for the patient than an elastic bandage. In addition, the physician will be significantly better off financially if he applies the splint, since that special procedure is very well rewarded by the insurance company.
A "wino" with pneumonia and septic shock arrives in an emergency department, obviously requiring admission to an ICU bed, but the hospital has no available beds. The emergency physician calls a private hospital about five miles away and asks them to accept the patient in their ICU; he makes it clear that the patient is completely destitute.
Two patients in the emergency department require admission to the intensive care unit (ICU). At this time only one bed is open, so one of the patients must be transferred to another hospital. The first patient, who is on the hospital's board of directors, came to the emergency department complaining of chest pains. He is now in an apparently stable condition with no indications of myocardial infarction, although he continues to require intensive care monitoring facilities.
A 40-year-old man walks into a freestanding emergency clinic with a bloody bandage on his head. He explains that he had been in a fight earlier in the evening and is still bleeding; he thinks he probably needs stitches in his head. The admitting clerk asks if he has insurance or money. When he replies that he does not, the clerk refers him to the municipal hospital downtown.
A 30-year-old man collapses in the downtown area of a large city. He is thin and looks chronically ill. A friend is with him and asks people passing by if they know CPR. When they approach, he tells them that his friend has AIDS and has been battling an infection for the last several months. People offer to call 911 for paramedics and an ambulance, but nobody wishes to initiate CPR.
You are driving to work when you come upon a two-car motor vehicle accident which has obviously just occurred. It appears that a number of people may be injured. You have had a significant degree of medical training, but you are on your way to an important meeting and cannot afford to be late — it could cost you your job.
Two paramedics are called to the home of a 60-year-old man (Mr. Smith) suffering from chest pain. Vital signs reveal a blood pressure of 90/60, a pulse of 50 and irregular, and respirations of 24. The ECG shows multiple PVCs (which means that he is at high risk of suffering a cardiac arrest). Smith requests to be transported to St. Mary's Hospital where his doctor and records are located.
A 16-year-old single girl arrives in the emergency department with a gunshot wound to the head. The entrance wound is just above one ear, and the exit, with brain protruding, is above the other ear (generally a rapidly lethal injury). The patient is seven months pregnant. The fetal heart rate is 180 / minute (fast). The mother's heart stops. Should an emergency cesarean section be performed? What if the girl's mother is present and declares that no one in the family will take care of the child?
A 24-year-old man is involved in a motorcycle accident one block from the com­munity hospital. An empty ambulance passes by, scoops him up, and brings him into the emergency department. The patient, who initially has minimal vital signs (pulse 140 / minute and weak, blood pressure 40 palpable systolic) goes into cardiac arrest after about five minutes and resuscitative efforts begin.
A two-year-old child is brought into the emergency department on a warm summer day after having been found floating in a backyard swimming pool. The paramedics who deliver the child state that the child had no vital signs (blood pressure, pulse, respirations) when they arrived at the scene. After hooking the child to a monitor, they only got a flat line (isoelectric activity, indicating absence of any electrical and certainly absence of mechanical activity in the heart).
Seventy-year-old Morris Brook is brought into the emergency department by ambulance. His family explains that his breathing has been getting progressively worse over the past two days and that he has metastatic cancer of the prostate for which he has been receiving only palliative treatment. His private physician is out of town and unavailable for immediate consultation.
A 25-year-old man is involved in a motorcycle accident and suffers multisystem trauma. When the paramedics arrive on the scene, the patient has no blood pressure, pulse, or spontaneous respirations. They transport the patient to the emergency de­partment while performing cardiopulmonary resuscitation. The patient has been down at least ten minutes without vital signs.
Two paramedics radio to the hospital that they are bringing in a 54-year-old man with chronic lung disease. They state that he is on "10 or 20" medications, but he does not have them all with him, and he does not know what they are. He has been a patient at that hospital in the past, and his records are there. It will take the paramedics about 20 minutes to transport the patient to the hospital.
The emergency department in the hospital nearest a certain college campus has admitted four 22-year-old college seniors in the past half hour.
A 30-year-old man comes to the emergency department claiming that he has been shot. He states that he is willing to undergo emergency tests and treatment only if the physician agrees not to call the police and that he will leave the emergency department if the physician does not promise this.
The primary cause of mortality in children and young adults is trauma. Injuries from motor vehicle accidents, bicycle accidents, home injuries, and violent crime take a large toll of our young, otherwise healthy population. Improvements in the availability of prehospital care transport facilities as well as upgraded emergency and surgical care have allowed an increasing number of trauma victims to survive serious injury.
Researchers have shown, in an animal model, that alterations in the technique of cardiopulmonary resuscitation improve blood flow to vital organs and increase survival of animals in cardiac arrest. The investigators would like to determine whether this technique will have similar effects on humans.
The paramedic trainee has had three years of ambulance experience and eighty additional hours of classroom training in emergency care. He is currently enrolled in additional classes. In order to receive state certification as a paramedic, he must also work a specified number of hours in the emergency department. Tonight is his first shift. What should his role be in the emergency department?
A 23-year-old female drug abuser presents with a history of malaise, generalized weakness, and fevers for the past month. She uses heroin intravenously and several other drugs intermittently. She has a grade 3/6 holosystolic murmur at the right sternal border (a moderately loud heart murmur) and conjunctival petechiae.
An eight-year-old boy walks into the emergency department saying he was riding his bicycle home from school and fell on his wrist. He lives only two blocks away, and because his wrist hurts, he decided to stop by the emergency department to determine whether any treatment is needed. The admitting clerk attempts, but is unable, to reach his parents. The policy of this particular hospital is that if two physicians declare that it is an emergency, minors may be seen and treated, even without parental consent.
Paramedics are called to the scene of a possible drug overdose by a man who told them that his wife had taken 50 sleeping pills about 15 minutes earlier. When the paramedics arrive, they find the woman waiting for them in the living room. She denies her husband's allegations and states that he is trying to "lock her up" so he can run off with another woman. She refuses transport to the hospital. The paramedics call the emergency department to consult with their base station physician. What should he advise?
The next set of case studies, in which three patients with varying degrees of injury and different prognoses are described, is designed to raise the question of the role of the severity of the patient's injury in the determination of his competence.
A 50-year-old man is brought to the emergency department for evaluation of lethargy. The patient has alcohol on his breath. There were also some sleeping pills in his apartment when his friend found him. The patient is easily arousable and able to answer questions coherently. Is his consent for admission to the emergency department valid?
A two-car accident occurs in central Amityville. The driver of one car is taken to Amity General, where he is found to be severely injured. The driver of the other vehicle is taken in critical condition to the Crosstown emergency department (ED). The emer­gency physician at Amity General, Dr. Roy, is presented with a patient who is apneic (not breathing) and has obvious severe head and chest injuries. Despite aggressive therapy, the patient dies.
There is considerable difference of opinion and even confusion about what ethics is. Sometimes, the term "ethics" is used to refer to the conduct of a person or a group, as when it is said "His ethics are questionable."
Why have a legal introduction on ethical issues in emergency medicine? Certainly not because ethics and law are synonymous, even though attempts to discuss ethical choices are frequently reduced by the pressures of the moment to worries about legal obligations and risks. Nor because compliance with the law guarantees ethical behavior; after all, society permits much conduct in which one ought not to engage.
A basic thesis of this website is that ethical problems are common in the emergency department - much more common than is usually recognized. The difficult ethical di­lemmas of emergency medicine have not attracted the widespread attention enjoyed by other areas of medicine, however.