Joel M. Geiderman

From hippocrates to HIPAA: Privacy and confidentiality in emergency medicine: Part II: Challenges in the emergency department

Part I of this article reviewed the concepts of privacy and confidentiality and described the moral and legal foundations and limits of these values in health care. Part II highlights specific privacy and confidentiality issues encountered in the emergency department (ED). Discussed first are physical privacy issues in the ED, including problems of ED design and crowding, issues of patient and staff safety, the presence of visitors, law enforcement officers, students, and other observers, and filming activities. The article then examines confidentiality issues in the ED, including protecting medical records, the duty to warn, reportable conditions, telephone inquiries, media requests, communication among health care professionals, habitual patient files, the use of patient images, electronic communication, and information about minor patients.

Rapid Identification of Group A Streptococcus as the Cause of Necrotizing Fasciitis

Group A beta-hemolytic Streptococcus pyogenes (GAS) causes a spectrum of highly aggressive, invasive infections. We report two cases of necrotizing fasciitis in which GAS was identified as the presumptive causative organism with the use of the standard rapid streptococcal diagnostic kit. We believe the rapid test kits may be a useful adjunct in the diagnosis and treatment of this catastrophic illness and may play a role in limiting the spread of infection.

Diversion of ALS ambulances: characteristics, causes, and effects in a large urban system.

Objective. To characterize the reasons for and effects of diversions of advanced life support (ALS) ambulances in a large urban area with a high concentration of receiving hospitals. Methods. A retrospective study was performed in a large urban region during a consecutive three-month period. Diversion was defined as the ALS transport of a patient to an emergency department (ED) other than the designated primary receiving facility. Case-matched concurrent cohorts of patients who were and were not diverted were studied to establish emergency medical services (EMS) time intervals, including total prehospital interval (TPI), on-scene interval (OSI), and patient transfer interval (PTI); age; gender; Glasgow Coma Score (GCS); ALS interventions; and insurance status. The reasons for diversion and the chief complaints of diverted patients were also studied. Results. During the study period, 2,534 ALS runs occurred, of which 147 (5.8%) were diverted. Twenty-four (16.3%) diversions had incomplete run times, leaving 123 (83.7%) for analysis. The most common chief complaints of diverted patients were shortness of breath (SOB), chest pain (CP), and altered mental status (AMS). The most common reason for diversion was special consideration (SC), defined as a diversion requested by a patient, family member, law enforcement officer, or private medical doctor. Diverted ambulances had significant increases in TPI, 36.4 [95% confidence interval (95% CI) 35.1–37.7] vs 33.4 [95% CI 32.13–34.7], and PTI, 10.3 [95% CI 9.4–11.2] vs 7.9 [95% CI 7.2–8.6], compared with nondiverted ambulances. Further analysis demonstrated that SC diversions accounted for all of the increases in TPI (p < 0.001) and PTI (p < 0.001) when compared with other types of diversions and nondiverted transports. Conclusion. “Special consideration” was the most common reason for diversion in this study. Special consideration diversions increased TPI and PTI, causing delays in arrival to the ED and decreased ALS ambulance availability.

Physician Orders for Life-Sustaining Treatment and Emergency Medicine: Ethical Considerations, Legal Issues, and Emerging Trends

Since its original development in Oregon in 1993, Physician Orders for Life-Sustaining Treatment (POLST) is quickly growing in popularity and prevalence as a method of communicating the end-of-life care preferences for the seriously ill and frail nationwide. Early evidence has suggested significant advantages over advance directives and do-not-resuscitate/do-not-intubate documents both in accuracy and penetration within relevant populations. POLST also may contribute to the quality of end-of-life care administered. Although it was designed to be as clear as possible, unexpected challenges in the interpretation and use of POLST in the emergency department do exist. In this article, we will discuss the history, ethical considerations, legal issues, and emerging trends in the use of POLST documents as they apply to emergency medicine.

Central nervous system disturbances following clarithromycin ingestion.

antimicrobial regimens based on local information rather than on reports from other institutions. Potent antipseudomonal coverage should be strongly considered in such situations, particularly in view of the fact that two large surveys of P. aeruginosa bacteremia in cancer patients at our institution have clearly demonstrated that inadequate initial antipseudomonal coverage and/or a delay in the administration of appropriate antibiotic therapy has an adverse effect on the outcome of such infections [5, 10].

Ethical issues in the response to Ebola virus disease in United States emergency departments: a position paper of the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine.

The 2014 outbreak of Ebola virus disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged U.S. emergency departments (EDs) to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to U.S. acute care facilities, ethical questions have been raised in both the press and medical literature as to how U.S. EDs, emergency physicians (EPs), emergency nurses, and other stakeholders in the health care system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to U.S. EPs, emergency nurses, and other stakeholders in the health care system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to U.S. EDs in how they approach preparation for and management of potential patients with EVD.

Acute Calcific Tendinitis of the Wrist

BACKGROUND Acute calcific tendinitis, a benign and self-limiting inflammatory condition commonly seen in the shoulder, is also described in many other tendons, including those in the hand and wrist. When involving the wrist, acute calcific tendinitis is often misdiagnosed and mistaken for infection. OBJECTIVE We present this case to increase familiarity with this condition to avoid errors in diagnosis resulting in inappropriate treatment with antibiotics or even surgery. CASE REPORT A 27-year-old man presented to the Emergency Department with a 2-week history of volar wrist pain, with sudden increase in pain associated with chills and new onset swelling and redness of the wrist. Plain radiographs showed characteristic soft-tissue calcification overlying the insertion of the flexor carpi ulnaris tendon into the wrist. Treatment with ibuprofen and splinting resulted in complete symptom resolution. CONCLUSION Acute calcific tendinitis is an important consideration in the differential diagnosis of acute wrist pain. Radiographs are helpful in confirming the diagnosis when symptoms and examination findings are characteristic.

Fracture of the penis

Fracture of the penis is an unusual injury which has been reported fewer than 70 times. The injury results from a sudden bending of the erect penis. Such a force ruptures the tunica albuginea, usually unilaterally, resulting in local bleeding and immediate deturgescence of the penis; the urethra may also be torn. Treatment has not been standardized, and is aimed at restoring normal function and preventing late sequelae. The physician also should be aware of possible psychiatric complications. We present a case diagnosed in our emergency department and treated surgically with good results.

Observers in the Medical Setting

&NA; Requests for observation experiences are common in the emergency department and other medical settings. There is little guidance in the literature or in professional societies’ polices about who should be granted this privilege. This article reviews the ethical and legal issues that should be taken into account when one decides whether to allow observers in the medical setting. At the heart of the issue is patient privacy. This article recommends that institutions have policies in place that address these activities and suggests content for such policies.

Law Enforcement and Emergency Medicine: An Ethical Analysis

Emergency physicians frequently interact with law enforcement officers and patients in their custody. As always, the emergency physicians primary professional responsibility is to promote patient welfare, and his or her first duty is to the patient. Emergency physicians should treat criminals, suspects, and prisoners with the same respect and attention they afford other patients while ensuring the safety of staff, visitors, and other patients. Respect for patient privacy and protection of confidentiality are of paramount importance to the patient-physician relationship. Simultaneously, emergency physicians should attempt to accommodate law enforcement personnel in a professional manner, enlisting their aid when necessary. Often this relates to the emergency physicians socially imposed duties, governed by state laws, to report infectious diseases, suspicion of abuse or neglect, and threats of harm. It is the emergency physicians duty to maintain patient confidentiality while complying with Health Insurance Portability and Accountability Act regulations and state law.