In this issue of The Journal of Emergency Medicine, Drs. Venkat, Baker, and Schears express concern over the ethical and professional appropriateness of emergency physicians' involvement in the referral of potential organ donors to organ procurement organizations (OPO) ( 1 Venkat A. Baker E. Schears R.M. Ethical controversies surrounding the management of potential organ donors in the emergency department. J Emerg Med. 2014; 47: 232-236 Abstract Full Text Full Text PDF Scopus (12) Google Scholar ). We agree with the overarching goal of the authors, to ensure that emergency physicians remain free to exercise their best professional judgment and to practice ethically and clinically appropriate care. However, we believe that their understanding and presentation of the legal and ethical guidelines at play are flawed. In their analysis, the authors conjure a scenario in which emergency physicians are forced to render aggressive treatments to unsalvageable, dying patients without the family's consent or possibly against the family members' wishes while waiting hours for an OPO representative to arrive. In reality, many facets of this scenario are inaccurate. Ethical Controversies Surrounding the Management of Potential Organ Donors in the Emergency DepartmentJournal of Emergency MedicineVol. 47Issue 2PreviewOn a daily basis, emergency physicians are confronted by patients with devastating neurological injuries and insults. Some of these patients, despite our best efforts, will not survive. However, from these tragedies, there may be benefit given to others who are awaiting organ transplantation. Steps taken in the emergency department (ED) can be critical to preserving the option of organ donation in patients whose neurologic insult places them on a potential path to declaration of brain death. Much of the literature on this subject has focused on the utilitarian value of clinical interventions in the potential organ donor to optimize the likelihood of effective organ procurement. Full-Text PDF

Objective: To determine the accuracy of do-not-resuscitate/do-not-intubate (DNR/DNI) orders in representing patient preferences regarding cardiopulmonary resuscitation (CPR) and intubation.Patients and Methods: We conducted a prospective survey study of patients with documented DNR/DNI code status at an urban academic tertiary care center that serves approximately 250,000 patients per year. From October 1, 2010, to October 1, 2011, research staff enrolled a convenience sample of patients from the inpatient medical service, providing them with a series of emergency scenarios for which they related their treatment preference. We used the Kendall tau rank correlation coefficient to examine correlation between degree of illness reversibility and willingness to be resuscitated. Using bivariate statistical analysis and multivariate logistic regression analysis, we examined predictors of discrepancies between code status and patient preferences. Our main outcome measure was the percentage of patients with DNR/DNI orders wanting CPR and/or intubation in each scenario. We hypothesized that patients with DNR/DNI orders would frequently want CPR and/or intubation.Results: We enrolled 100 patients (mean +/- SD age, 78 +/- 13.7 years). A total of 58% (95% CI, 48%-67%) wanted intubation for angioedema, 28% (95% CI, 20%-3.07%) wanted intubation for severe pneumonia, and 20% (95% CI, 13%-29%) wanted a trial resuscitation for cardiac arrest. The desire for intubation decreased as potential reversibility of the acute disease process decreased (Kendall tau correlation coefficient, 0.45; P<.0002).Conclusion: Most patients with DNR/DNI orders want CPR and/or intubation in hypothetical clinical scenarios, directly conflicting with their documented DNR/DNI status. Further research is needed to better understand the discrepancy and limitations of DNR/DNI orders. (c) 2013 Mayo Foundation for Medical Education and Research

The expanding role of emergency medicine in the care of potential organ donors presents unique ethical challenges. This chapter introduces emergency providers to the ethical challenges of organ donation, including issues of patient autonomy and consent, public perception and trust, goals of care, and the determination of death.

Seizure is one of the most common complaints encountered in the prehospital setting. In this review the authors discuss the prehospital management of seizures and review the evidence for specific treatment approaches. Specific attention is devoted to prehospital care of the pediatric seizure patient. Topics of interest to Emergency Medical Services directors such as patient refusal, resource allocation, and dispatch priority are also addressed.

Central line-associated bloodstream infections (CLABSIs) pose a significant threat to patient safety. CLABSIs have an attributable mortality of 12-25%, increase health care costs by $30,000 per infection, and increase hospital length of stay by an average of 7 days. Hospital-level CLABSI data are now published by CMS as a publicly available quality measure, and CLABSI prevention is a specific patient safety goal of both the CDC and the Joint Commission. The majority of CLABSIs can be prevented through the use of established CLABSI reduction techniques.

OBJECTIVESThis study sought to identify factors that are associated with successful organ retrieval among patients referred to organ procurement services for potential organ donation. Particular attention was paid to the frequency, patient characteristics, and outcomes of patients referred for donation from the emergency department (ED).METHODSFor this retrospective cohort study, data were collected on all solid-organ donor referrals made to a single organ procurement organization serving 78 hospitals over a 45-month period. Data retrieved included patient age, sex, race, referral site (ED vs. inpatient), and mechanism of injury. Outcome of referral (organs retrieved or not) was the primary outcome variable. Pearson chi-square and Student's t-tests were used for bivariate statistical analysis. Multiple logistic regression analysis was used to determine which variables remained associated with organ retrieval after controlling for potential confounders.RESULTSA total of 6,886 donor referrals were made in the study population. Of these, 155 were excluded due to incomplete data, leaving 6,731 subjects for analysis. Using bivariate statistical analysis, we found that successful organ retrieval was associated with younger age (donor mean age 40.8 years, 95% confidence interval [CI] = 39.1 to 42.5 vs. nondonor mean age 59.4, 95% CI = 58.9 to 59.9), mechanism of injury (p < 0.001), and referral from the ED (ED 15.5% retrieved, inpatient 5.9%, odds ratio [OR] = 2.92, 95% CI = 2.32 to 3.67). After controlling for potential confounders with multiple logistic regression, referral from the ED remained significantly associated with successful organ retrieval (OR = 1.52, 95% CI = 1.18 to 1.97), as did age (OR = 0.96, 95% CI = 0.96 to 0.97) and mechanism of injury (p < 0.001). On regression analysis, race emerged as a significant predictor of organ retrieval (p < 0.001). Medically suitable patients referred from the ED were significantly more likely on bivariate analysis to have consent for donation granted compared to patients referred from inpatient settings (OR = 1.48, 95% CI = 1.03 to 2.12), but this association was not found to be significant on regression analysis (OR = 1.37, 95% CI = 0.93 to 2.02).CONCLUSIONSReferral of potential organ donors from the ED is associated with an increased likelihood of successful organ retrieval. The authors conclude that further attention and resources should be directed toward the role of emergency medicine (EM) in the organ procurement process, owing to the relatively high likelihood of successful organ retrieval among patients referred from the ED.

Recently, emphasis has been placed on improving and expanding research in disaster response and the treatment of disaster-stricken populations. However, research in these settings presents unique ethical challenges with which the scientific and biomedical ethics communities continue to struggle. At the core of the controversy is the question of how best to balance the critical need for research with the equally important obligation to respect and protect the interests of research participants within the unique stress of a disaster. This concern stems from the potential of increased vulnerability of individuals stricken by disaster over and above their usual vulnerability to risk and exploitation as research subjects. Ethical principles that must be considered in these situations are the same as those that are important when conducting any human research: respect for persons, non-maleficence, beneficence, and justice. This paper explores the ethical challenges that accompany inadequate resources and personnel, the potential vulnerability of research participants, the dual role of physician-researcher, and the importance of the public's perception and trust are explored. It then proposes a number of potential avenues through which to conduct ethically justifiable research that could answer many of the pressing questions in disaster medicine and response.

Prior studies have found that > 50% of prehospital intravenous catheters (i.v.s) were unutilized for treatment; however, few data are available regarding which patients benefit. The objective of this study was to examine the association between i.v. utilization in the field, paramedic primary impression, and patient presentation. Prehospital records for 34,585 patients were evaluated for i.v. placement and utilization in the field. Logistic regression was used to evaluate the association of primary impression, systolic blood pressure, heart rate, respiratory rate, Glasgow Coma Scale score, skin sign color, and capillary refill with placement and utilization. Intravenous catheters were placed in 60% of patients, but only 17% of the total was utilized. Examples of primary impressions with frequent initiation and low utilization (n = number in group, % of total with i.v. placed, % of total used): post-seizure (n = 989, 72%, 9%); weakness/dizzy/nausea (n = 3092, 69%, 20%), syncope/near-syncope (n = 2034, 81%, 26%), and abdominal pain (n = 1554, 70%, 14%). Fifty-eight percent with normal vital signs received an i.v. and 28-30% were utilized; hypotension: 80% received i.v. (odds ratio [OR] 1.211, p = 0.012), 70% utilized; hypertension: 61% received i.v. (OR 1.060, p = 0.027), 28% utilized; bradycardia: 82% received i.v. (OR 1.588, p < 0.0001), 51% utilized; tachycardia: 66% received i.v. (OR 1.152, p = 0.001), 33% utilized; bradypnea: 93% received i.v. (OR 1.638, p = 0.051), 86% utilized; tachypnea: 70% (OR 1.120, p = 0.024), 33% utilized. A Glasgow Coma Scale score < 15: 76% received i.v. (OR 1.672, p < 0.0001), 32% utilized. Abnormal skin color: 79% received i.v. (OR 1.691, p < 0.0001), 42% utilized. Certain primary impressions are associated with high i.v. initiation rates but infrequent utilization. High utilization rates were associated with hypotension, bradycardia, bradypnea, and abnormal skin signs. Study of high-frequency, low-utilization groups could reduce unnecessary i.v. placement.

The problems of emergency department (ED) crowding, ambulance diversion, and increasing health care costs have been widely documented in the medical literature. A common factor contributing to all these problems is the increasing number of patients being transported to EDs by ambulance. In this study we sought to quantify the proportion of patients arriving at the ED by ambulance who have non-emergent conditions. We then conducted a simple cost-analysis to estimate the economic burden of unnecessary ambulance utilization.

The problems of emergency department (ED) crowding and ambulance diversion have been widely documented in the medical literature. A common factor contributing to both these problems is the increasing number of patients being transported to EDs by ambulance. In this study we sought to quantify the proportion of patients arriving at the ED by ambulance that have non-emergent conditions. We further sought to identify patient characteristics that were associated with utilizing ambulances for non-emergent conditions.

Objectives: The goal of this study was to examine the effect of socioeconomic factors, such as ethnicity, income, age, and sex, on the administration of analgesia for isolated extremity injuries in the prehospital setting.Methods: For this retrospective study, the electronic medical record of a large ground-based emergency medical services agency was reviewed and all isolated extremity injuries occurring during the year 2005 were extracted. A total of 1009 cases met the inclusion criteria. Of these cases, 56 were excluded because of incomplete records, leaving 953 cases for analysis. Basic univariate analysis as well as logistic regression analysis were used to examine the relationship between analgesia administration and patient age, ethnicity, sex, income, subjective pain severity, and time under prehospital care.Results: A total of 279 patients (29%) received morphine. Both univariate and logistic regression analysis revealed significant differences in analgesia administration based on sex (proportion of men receiving analgesia, 32.8%; women, 26.7%), initial pain severity, and time under prehospital care. Although no category of income was itself significant, a significant trend emerged in which increasing income was associated with increasing likelihood of receiving analgesia. There was no significant difference in analgesia based on patient age or ethnicity.Conclusion: This study suggests that women are less likely than men to receive prehospital analgesia for isolated extremity injuries. Patients with higher pain severity and longer duration of prehospital care are more likely to receive prehospital analgesia. Increasing levels of income were associated with increased rates of analgesia. The overall rate of prehospital analgesia administration for isolated extremity injuries in this population is higher than has been reported for other emergency medical services systems (29% vs 2%-18% in other recent studies), but there remains considerable room for improvement in the provision of prehospital analgesia. Further inquiry is needed to determine why certain populations such as women receive disproportionately less analgesia, (C) 2007 Elsevier Inc. All rights reserved.

BACKGROUND:Computer-aided dispatch systems are used to assess the severity of a 9-1-1 caller's complaint and then assign an appropriate level of emergency medical services (EMS) response.OBJECTIVE:To evaluate a group of low-acuity codes (defined as requiring advanced life support [ALS] intervention in fewer than 10% of cases) that has been derived and validated in one community.METHODS:All of the 9-1-1 medical calls assigned to these predetermined emergency medical dispatch codes between January 1, 2004, and July 1, 2004, were analyzed. ALS care was defined as receiving one or more of the following: pulse oximetry measurement, blood glucose measurement, cardiac defibrillation, administration of any medication, airway maneuvers, or the placement of an intravenous (IV) catheter. A more restrictive definition of ALS care (use of IV fluid bolus, medication administration, intubation, or defibrillation) was also calculated.RESULTS:A total of 1,799 calls were assigned low-acuity dispatch codes, and 1,597 met inclusion criteria. None of the 26 dispatch codes were found to be low-acuity by the study definition. Fifty-six percent of these patients received ALS care. Placement of an IV-catheter was the ALS intervention used most frequently (45% of cases), followed by pulse oximetry measurement (32%), glucose measurement (22%), medication administration (11%), intubation (0.13%), and defibrillation (0%). The medication administered most frequent was morphine. When using the more restrictive definition of acuity, patients in 19 of the 28 categories received ALS intervention less than 10% of the time. Patients in the other seven categories were considered high-acuity 13% to 36% of the time.CONCLUSION:Dispatch codes that had previously been determined to be low-acuity were found not to be so in this community. The variation in clinical practice is likely explained by a more precautionary approach to care in this EMS system and the increased use of analgesics. This study demonstrates the need to define the optimal subset of prehospital patients who would benefit from these treatments.