Gregory P. Moore

PEARLS, PITFALLS, AND UPDATES FOR PAIN MANAGEMENT

Pain management is one of the most challenging areas we encounter as emergency physicians. However, many of us fail to adequately meet this challenge. This article discusses frequently encountered pain syndromes and pain management options.

Risk Acceptance and Desire for Shared Decision Making in Pediatric Computed Tomography Scans: A Survey of 350.

Objective The dual goals of this study were to assess the level of radiation risk parents are comfortable with and also whether they expect a shared decision making conversation. Methods A convenience sample of adult patients in the emergency department was surveyed. Participants were educated regarding the associated radiation risk with computed tomography (CT) scans. They were then surveyed about their willingness to accept the risk of radiation exposure to their children given varying degrees of pretest probability of a clinically significant finding. Additionally, participants were surveyed regarding whether a physician should provide shared decision making. Results A total of 350 surveys were collected. For low, moderate, and high pretest probability of a positive finding on CT, the proportion of participants who would want a CT for their child was 37% (95% confidence interval [95% CI], 32–43%), 70% (95% CI, 65–75%), and 89% (95% CI, 85–92%), respectively. If the likelihood of a positive CT scan was very low (<5%), 24% (95% CI, 20–29%) were willing to have the study performed on their child. Participants would not want a CT for their child regardless of the probability of finding significant pathology in 9% of those surveyed (28/315). Participants wanted a physician to counsel them before ordering a potentially dangerous test in 93% of the surveys. In a test with an estimated 1:1000 risk of cancer, 91% of participants felt that a doctor should always discuss the risk before ordering the study. Conclusions Parents are less willing to accept the risk of radiation from CT scan on their child as the likelihood of positive findings decrease. Parents overwhelmingly want an informed discussion before getting a potentially dangerous test.

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

Abstract : 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. The authors, who have significant medical legal experience, selectively chose illustrative legal cases to discuss caveats of assessment of acute psychiatric emergencies. We selected representative cases after reviewing legal journals and publications. Cases involving restraint and sedation were excluded as they were covered in a prior manuscript. Psychosis is a relatively common syndrome affecting 3% to 5% of the population at some point in life. Encountering undiagnosed psychiatric conditions, such as psychosis or bipolar disorder, is commonplace for the emergency physician (EP). The following case illustrates the challenge and importance of the assessment of new onset psychiatric disorders.

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

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. If restraints are placed, the physician has a duty to protect the patient and should fill out all appropriate paperwork as they have decided to take away the patient’s liberty. Use of restraints may precipitate issues of battery and false imprisonment. Finally, prior to discharge, the physician has a duty to determine if there have been any direct threats made regarding a third party and if there is a duty to warn. These medico-legal issues will be illustrated using actual court cases. The purpose of this paper is to educate practicing emergency physicians (EP) on high-risk legal issues concerning the agitated patient, so that liability can be avoided.

EYE, EAR, NOSE, AND THROAT*

Patients present to the emergency department with a number of eye, ear, nose, and throat (ENT) problems. This article updates some very common problems; identifies a few pearls on nasal foreign body removal, ophthalmologic medication, and epistaxis; and reviews a few pitfalls in identifying malignancies and sore throats.

Patient with a Subarachnoid Headache

Subarachnoid hemorrhage (SAH) is a life-threatening cause of headache. The diagnostic approach to this entity continues to evolve with a recent questioning of the classic workup of computed tomography and lumbar puncture. We report a risk management case of a patient with a missed SAH resulting in a fatal outcome. When there are multiple diagnostic strategies, the patient may be involved with shared decision-making. Some of the medical and legal implications of the diagnosis of SAH will be discussed.

Pacemaker limitation of tachycardia in hypovolemic shock.

A 49-year-old white man was admitted to the emergency department with nausea and diarrhea of 11 hours duration. He had experienced crampy abdominal pain as well. He reported that his stools had been dark and malodorous. He had no prior history of gastrointestinal disorders, nor travel, unusual oral or liquid intake. There was a remote history of alcohol abuse, but no hepatitis or cirrhosis. Recent alcohol intake was denied by the patient. He had no medical allergies. His past medical history was pertinent for a history of hypertension, congestive heart failure, and a dual chamber pacemaker insertion. There was no history of diabetes mellitus, smoking, or myocardial infarction. Medications included lisinopril, a small dose of aspirin daily, and thyroid supplement. Family history was negative for cardiomyopathy, sudden cardiac death, gastric or duodenal ulcers, colon cancer, or any congenital abnormalities.