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Geiderman JM, Moskop JC, Marco CA, Schears RM, Derse AR. Civility in Health Care: A Moral Imperative. HEC Forum 2024; 36:245-257. [PMID: 36547791 PMCID: PMC11070391 DOI: 10.1007/s10730-022-09501-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 12/24/2022]
Abstract
Civility is an essential feature of health care, as it is in so many other areas of human interaction. The article examines the meaning of civility, reviews its origins, and provides reasons for its moral significance in health care. It describes common types of uncivil behavior by health care professionals, patients, and visitors in hospitals and other health care settings, and it suggests strategies to prevent and respond to uncivil behavior, including institutional codes of conduct and disciplinary procedures. The article concludes that uncivil behavior toward health care professionals, patients, and others subverts the moral goals of health care and is therefore unacceptable. Civility is a basic professional duty that health care professionals should embrace, model, and teach.
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Affiliation(s)
- Joel M Geiderman
- Ruth and Harry Roman Emergency Department, Department of Emergency Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - John C Moskop
- Department of Internal Medicine, Medical Center Blvd, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA.
- General Internal Medicine, Wake Forest University School of Medicine, Medical Center Boulevard Winston-Salem, Winston-Salem, NC, 27157, USA.
| | - Catherine A Marco
- Department of Emergency Medicine, Penn State Health - Milton S. Hershey Medical Center,, Penn State College of Medicine, 500 University Drive, Hershey, PA, 17033, USA
| | - Raquel M Schears
- Department of Emergency Medicine, College of Medicine, University of Central Florida, 6850 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Arthur R Derse
- Department of Emergency Medicine, Center for Bioethics and Medical Humanities, Medical College of Wisconsin, Kern Institute for the Transformation of Medical Education, M1100, 8701 Watertown Plank Road, Milwaukee, WI, 53226-3548, USA
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2
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Kadaster AK, Schears MR, Schears RM. Difficult Patients: Malingerers, Feigners, Chronic Complainers, and Real Imposters. Emerg Med Clin North Am 2024; 42:181-195. [PMID: 37977749 DOI: 10.1016/j.emc.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Malingering is the intentional production of false or grossly exaggerated symptoms motivated by internal and external incentives. The true incidence of malingering in the emergency department is unknown because of the difficulty of identifying whether patients are fabricating their symptoms. Malingering is considered a diagnosis of exclusion; a differential diagnosis framework is described to guide emergency physicians. Several case studies are presented and analyzed from a medical ethics perspective. Practical recommendations include use of the NEAL (neutral, empathetic, and avoid labeling) strategy when caring for patients suspected of malingering.
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Affiliation(s)
| | - Markayle R Schears
- University of Wisconsin School of Medicine and Public Health, 750 Highland Avenue, Madison, WI 53705, USA.
| | - Raquel M Schears
- University of Central Florida, 400 Central Florida Boulevard, Orlando, FL 32816, USA
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Iserson KV, Schears RM, Padela AI, Baker EF, Moskop JC. Increasing Solid Organ Donation: A Role for Emergency Physicians. J Emerg Med 2022; 63:702-708. [PMID: 36372592 DOI: 10.1016/j.jemermed.2022.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/15/2022] [Accepted: 10/11/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND More than 100,000 Americans with failing organs await transplantation, mostly from dead donors. Yet only a fraction of patients declared dead by neurological criteria (DNC) become organ donors. DISCUSSION Emergency physicians (EPs) can improve solid organ donation in the following ways: providing perimortem critical care support to potential organ donors, promptly notifying organ procurement organizations (OPOs), asking neurocritical care specialists to evaluate selected emergency department patients for death based on established neurologic criteria, participating in research to advance these developments, implementing automatic OPO notification technologies, and educating the professional and lay communities about organ donation and transplantation, including exploration of opt-out (presumed consent) organ recovery policies. CONCLUSION With future improvements in organ preservation and DNC assessment, EPs may become even more involved in the donation process. EPs should support and engage in efforts to promote organ donation and transplantation.
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Affiliation(s)
- Kenneth V Iserson
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Raquel M Schears
- Department of Emergency Medicine, University of Central Florida College of Medicine, Orlando, Florida
| | - Aasim I Padela
- Department of Emergency Medicine and Center for Bioethics and Medical Humanities, Medical College of Wisconsin, Medical College of Wisconsin Hub for Collaborative Medicine, Milwaukee, Wisconsin
| | | | - John C Moskop
- Biomedical Ethics, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Farhadfar N, Ahn KW, Bo-Subait S, Logan B, Stefanski HE, Hsu JW, Panch S, Confer D, Liu H, Badawy SM, Beitinjaneh A, Diaz MA, Hildebrandt GC, Kelkar AH, Lazarus HM, Murthy HS, Preussler JM, Schears RM, Sharma A, van der Poel M, Bruce JG, Pulsipher MA, Shaw BE, Wingard JR, Switzer GE. The Impact of Pre-Apheresis Health Related Quality of Life on Peripheral Blood Progenitor Cell Yield and Donor's Health and Outcome: Secondary Analysis of Patient-Reported Outcome Data from the RDSafe and BMT CTN 0201 Clinical Trials. Transplant Cell Ther 2022; 28:603.e1-603.e7. [PMID: 35688325 PMCID: PMC9427696 DOI: 10.1016/j.jtct.2022.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/06/2022] [Accepted: 05/30/2022] [Indexed: 10/18/2022]
Abstract
There is a lack of evidence about how health-related quality of life (HRQoL), including psychosocial factors, might affect donation-related experiences and clinical markers in the context of hematopoietic stem cell donation. The broader literature suggests that psychological factors, including anxiety and depression, are associated with higher levels of inflammatory burden leading to poorer postprocedural outcomes including longer hospital stays and increased pain perception. In this study, we aimed to evaluate whether predonation HRQoL markers predict toxicity profile and stem cell yield after peripheral blood stem cell (PBSC) donation in healthy donors. The study population comprised adult granulocyte colony-stimulating factor mobilized PBSC-related donors (RD) (n = 157) and unrelated donors (URD) (n = 179) enrolled in the related donor safety study (RDSafe) and Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 0201 clinical trials. Pre-donation HRQoL was assessed using the Short-Form-12 (SF-12) in RDSafe and SF-8 questionnaire in BMT CTN 0201 (higher score is better). The aims of this study were to (a) determine the impact of pre-donation HRQoL on peri-collection pain and acute toxicities experienced and (b) to investigate the pre-procedural HRQoL indicators on stem cells yield. URDs were younger than RDs (median age 35 versus 63). A higher proportion of RDs were female (50% versus 40%) and obese (41% versus 35%). A higher proportion of RD PBSC donations required 2 days or more of apheresis (44% versus 21%). More RD collections were lower volume procedures (<18L, 16% versus 28%), and required a central line (28% versus 11%). RDs were more likely to report pre-donation grade 1-2 pain (27% versus 8%) and other toxicities (16% versus 6%). Among RDs, a lower pre-donation physical component summary (PCS) score was associated with significantly more grade 2-4 pain at 1 month (P = .004) and at 1-year after donation (P = .0099) in univariable analyses. In multivariable analysis, pre-donation PCS remained significantly associated with grade 2-4 pain 1 month after donation (P = .0098). More specifically, RDs with predonation PCS scores in the highest quartile were less likely to report pain compared with donors with PCS scores in the lowest quartile (odds ratio 0.1; 95% confidence interval 0.01-0.83; P = .005). There was also a trend toward higher grade 2-4 pain at 1-year post-donation among RDs with lower predonation PCS score (P = .018). Among URDs, neither PCS nor mental component summary (MCS) scores were associated with pain or toxicities at any time point after donation based on the univariable analysis. Because of low rates of postdonation grade 2-4 pain and toxicities, multivariable analysis was not performed in the URD setting. Moreover, there was no correlation between preapheresis HRQoL score (PCS or MCS) and PBSC collection yield in either the RD or URD setting. Our study demonstrates that pre-donation HRQoL scores are significantly associated with the toxicity profile after PBSC donation in the RD setting, with adult RDs with lower predonation physical HRQoL experiencing higher levels of pain at 1 month and persisting up to 12 months after a PBSC collection procedure. There were no such associations found in URD. Our findings can help clinicians identify donors at higher risk of pain with donation, and lead to personalized information and interventions for specific donors. Lack of correlation between predonation HRQoL and stem cell yield may be due to a small sample size and warrants further evaluation.
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Affiliation(s)
- Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Kwang Woo Ahn
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin; CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Stephanie Bo-Subait
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Brent Logan
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin; CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Heather E Stefanski
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Jack W Hsu
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Sandhya Panch
- NIH-Experimental Transplantation and Immunology Branch, National Cancer Institute - NIH, NIH Clinical Center, Department of Transfusion Medicine, Bethesda, Maryland
| | - Dennis Confer
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Hien Liu
- H. Lee Moffitt Cancer and Research Center, Tampa, Florida
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Miguel A Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
| | | | - Amar H Kelkar
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Hemant S Murthy
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida
| | - Jaime M Preussler
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Raquel M Schears
- Department of Emergency Medicine, University of Central Florida, Orlando, Florida
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Marjolein van der Poel
- Department of Internal Medicine, Division of Hematology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Jessica G Bruce
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael A Pulsipher
- Division of Hematology and Oncology, Intermountain Primary Children's Medical Center, Huntsman Cancer Institute at the Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Bronwen E Shaw
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - John R Wingard
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Galen E Switzer
- Departments of Medicine, Psychiatry, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, Pennsylvania
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Marco CA, Schears RM, Geiderman JM, Derse AR, Moskop JC. Disruptive behavior among emergency department patients. Am J Emerg Med 2022; 59:176-177. [DOI: 10.1016/j.ajem.2022.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 11/28/2022] Open
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Takakuwa KM, Schears RM. Emergency Medicine Physicians Would Prefer Using Cannabis Over Opioids for First-Line Treatment of a Medical Condition if Provided With Medical Evidence: A National Survey. Cureus 2021; 13:e19641. [PMID: 34926086 PMCID: PMC8673685 DOI: 10.7759/cureus.19641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: To determine emergency medicine (EM) physicians’ preferences for using medical cannabis versus opioids if medical cannabis was legalized. Methods: We surveyed US physicians at the largest national EM conference (American College of Emergency Physicians’ Annual Conference) held in San Diego, CA from October 1 to 4, 2018. Of the thousands of conference participants approached, 539 US physicians completed the anonymous written survey, which represented 15.2% of the US physicians attending the conference. Results: The mean age of the participants was 39.6 ± 10.9 years, men composed 57.5% of the participants, and whites made up 72.8% of the respondents. Participants practicing in medically legal (54.8%) and medically plus adult-use legal cannabis states (23.1%) totaled 77.9%. A majority (70.7%) of the participants believed that cannabis has medical value. EM physicians preferred cannabis over opioids as a first-line treatment addressing a medical condition provided that medical studies found that cannabis was equally effective (p < 0.001, X2 = 36.8 [95% CI 2, 415]), and overwhelmingly preferred cannabis over opioids if it were more effective (p < 0.001, X2 = 90.8 [95% CI 2, 415]). Physicians appeared to prefer opioids over cannabis if medical studies found that cannabis was less effective though it was not significant (p > 0.05). Subgroup analyses showed that belief in the medical value of cannabis significantly increased the odds ratio of choosing cannabis over opioids if cannabis was equally or more effective than opioids. Conclusion: Our study shows that EM physicians believe cannabis has medical value and would prefer using cannabis over opioids if provided with equivalent findings. We believe our findings reflect EM physicians’ experience of the opioid epidemic and suggest the need for further study of this potential therapeutic.
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Affiliation(s)
- Kevin M Takakuwa
- Emergency Medicine, Society of Cannabis Clinicians, Sebastopol, USA
| | - Raquel M Schears
- College of Medicine, University of Central Florida, Orlando, USA
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Takakuwa KM, Schears RM. The emergency department care of the cannabis and synthetic cannabinoid patient: a narrative review. Int J Emerg Med 2021; 14:10. [PMID: 33568074 PMCID: PMC7874647 DOI: 10.1186/s12245-021-00330-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/05/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cannabis is the most prevalent illegal drug used and the second most common cause of ED drug-related complaints in the USA. Recently, newer more potent strains, concentrated THC products, and consumption methods have become available. OBJECTIVE Our first objective was to define cannabis use in the USA and provide a summary background on its current preparations, pharmacokinetics, vital sign and physical exam findings, adverse effects, and laboratory testing. Our second objective, using the aforementioned summary as relevant background information, was to present and summarize the care and treatment of the most commonly reported cannabis-related topics relevant to ED physicians. METHODS We first performed an extensive literature search of peer-reviewed publications using New PubMed and Cochrane Central Register of Controlled Trials to identify the most commonly reported cannabis-related topics in emergency care. Once the six topic areas were identified, we undertook an extensive narrative literature review for each section of this paper using New PubMed and Cochrane Central Register of Controlled Trials from the inception of the databases to September 30, 2020. RESULTS The six subject areas that were most frequently reported in the medical literature relevant to cannabis-related ED care were acute intoxication/overdose, pediatric exposure, cannabinoid hyperemesis syndrome, cannabis withdrawal, e-cigarette or vaping product use-associated lung injury (EVALI), and synthetic cannabinoids. CONCLUSION As cannabis becomes more widely available with the adoption of state medical cannabis laws, ED-related cannabis visits will likely rise. While cannabis has historically been considered a relatively safe drug, increased legal and illegal access to newer formulations of higher potency products and consumption methods have altered the management and approach to ED patient care and forced physicians to become more vigilant about recognizing and treating some new cannabis-related life-threatening conditions.
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Affiliation(s)
- Kevin M Takakuwa
- Society of Cannabis Clinicians, PO Box 27574, San Francisco, CA, 94127, USA.
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8
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Takakuwa KM, Shofer FS, Schears RM. Letter to the Editor: A National Survey of U.S. Emergency Medicine Physicians on Their Knowledge Regarding State and Federal Cannabis Laws. Cannabis Cannabinoid Res 2021; 5:337-339. [PMID: 33381647 DOI: 10.1089/can.2019.0073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Frances S Shofer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raquel M Schears
- Department of Emergency Medicine, University of Central Florida, Orlando, Florida, USA
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Takakuwa KM, Hergenrather JY, Shofer FS, Schears RM. The Impact of Medical Cannabis on Intermittent and Chronic Opioid Users with Back Pain: How Cannabis Diminished Prescription Opioid Usage. Cannabis Cannabinoid Res 2020; 5:263-270. [PMID: 32923663 DOI: 10.1089/can.2019.0039] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: To determine if cannabis may be used as an alternative or adjunct treatment for intermittent and chronic prescription opioid users. Design: Retrospective cohort study. Setting: A single-center cannabis medical practice site in California. Patients: A total of 180 patients who had a chief complaint of low back pain were identified (International Classification of Diseases, 10th Revision, code M54.5). Sixty-one patients who used prescription opioids were analyzed. Interventions: Cannabis recommendations were provided to patients as a way to mitigate their low back pain. Outcome Measures: Number of patients who stopped opioids and change in morphine equivalents. Results: There were no between-group differences based on demographic, experiential, or attitudinal variables. We found that 50.8% were able to stop all opioid usage, which took a median of 6.4 years (IQR=1.75-11 years) after excluding two patients who transitioned off opioids by utilizing opioid agonists. For those 29 patients (47.5%) who did not stop opioids, 9 (31%) were able to reduce opioid use, 3 (10%) held the same baseline, and 17 (59%) increased their usage. Forty-eight percent of patients subjectively felt like cannabis helped them mitigate their opioid intake but this sentiment did not predict who actually stopped opioid usage. There were no variables that predicted who stopped opioids, except that those who used higher doses of cannabis were more likely to stop, which suggests that some patients might be able to stop opioids by using cannabis, particularly those who are dosed at higher levels. Conclusions: In this long-term observational study, cannabis use worked as an alternative to prescription opioids in just over half of patients with low back pain and as an adjunct to diminish use in some chronic opioid users.
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Affiliation(s)
| | | | - Frances S Shofer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raquel M Schears
- Department of Emergency Medicine, University of Central Florida, Orlando, Florida
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10
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Takakuwa KM, Schears RM. Indications and preference considerations for using medical Cannabis in an emergency department: A National Survey. Am J Emerg Med 2020; 45:513-515. [PMID: 32682602 DOI: 10.1016/j.ajem.2020.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/01/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Kevin M Takakuwa
- Society of Cannabis Clinicians, Sebastopol, California (Dr Takakuwa); University of Central Florida, Orlando, FL (Dr Schears), United States of America.
| | - Raquel M Schears
- Society of Cannabis Clinicians, Sebastopol, California (Dr Takakuwa); University of Central Florida, Orlando, FL (Dr Schears), United States of America
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Brenner JM, Marco CA, Kluesner NH, Schears RM, Martin DR. Assessing psychiatric safety in suicidal emergency department patients. J Am Coll Emerg Physicians Open 2020; 1:30-37. [PMID: 33000011 PMCID: PMC7493483 DOI: 10.1002/emp2.12017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/20/2019] [Accepted: 12/31/2019] [Indexed: 11/06/2022] Open
Abstract
We provide a review of the assessment of suicidal emergency department patients and includes a legal and ethical perspective. Screening tools and psychiatric consultation are important adjuncts to the ED evaluation of potentially suicidal patients. Suicide risk should be assessed, and if positive, an appropriate and safe disposition should be arranged. The aim of this article is to review these assessment tools and consider ethical issues, such as patient autonomy, accountability of the emergency physician, and consultant to Emergency Medical Treatment and Labor Act (EMTALA) as well as confidentiality, privacy, and social issues.
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Affiliation(s)
- Jay M Brenner
- Department of Emergency Medicine SUNY-Upstate Medical University Syracuse New York
| | | | | | - Raquel M Schears
- Department of Emergency Medicine University of Central Florida Orlando Florida
| | - Daniel R Martin
- Department of Emergency Medicine The Ohio State University Columbus Ohio
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12
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Takakuwa KM, Shofer FS, Schears RM. The practical knowledge, experience and beliefs of US emergency medicine physicians regarding medical Cannabis: A national survey. Am J Emerg Med 2020; 38:1952-1954. [PMID: 32067838 DOI: 10.1016/j.ajem.2020.01.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 10/25/2022] Open
Affiliation(s)
- Kevin M Takakuwa
- Society of Cannabis Clinicians, Sebastopol, CA, United States of America.
| | - Frances S Shofer
- University of Pennsylvania, Philadelphia, PA, United States of America
| | - Raquel M Schears
- University of Central Florida, Orlando, FL, United States of America
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13
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Takakuwa KM, Schears RM. A History of the US Medical Cannabis Movement and Its Importance to Pediatricians: Science Versus Politics in Medicine's Greatest Catch-22. Clin Pediatr (Phila) 2019; 58:1473-1477. [PMID: 31538822 DOI: 10.1177/0009922819875550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Marco CA, Geiderman JM, Schears RM, Derse AR. Emergency Medicine in the #MeToo Era. Acad Emerg Med 2019; 26:1245-1254. [PMID: 31166061 DOI: 10.1111/acem.13814] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 11/26/2022]
Abstract
Sexual harassment is a serious threat to a safe and productive workplace. The emergency department (ED) environment poses unique threats, including stress, time constraints, working in close physical proximity, and frequent personal contacts with staff, colleagues, consultants, and difficult patients. Sexual harassment must be recognized and addressed in individual cases, in policy and in law, to protect staff members and patients. This article addresses the scope of the problem of sexual harassment known to date. It describes the ED environment and culture and why they may be conducive to harassment or abusive behavior. The authors examine relationships among staff, legal and regulatory issues, and strategies for prevention and remediation of inappropriate behavior. The article ends with a call for future research.
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Affiliation(s)
| | - Joel M. Geiderman
- Ruth and Harry Roman Emergency Department Department of Emergency Medicine Cedars‐Sinai Medical Center Los Angeles CA
| | - Raquel M. Schears
- Department of Emergency Medicine University of Central Florida College of Medicine Orlando FL
| | - Arthur R. Derse
- Center for Bioethics and Medical Humanities and Department of Emergency Medicine Medical College of Wisconsin Milwaukee WI
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15
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Affiliation(s)
| | - Raquel M Schears
- Emergency Medicine, College of Medicine, University of Central Florida, Orlando
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16
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Schears RM, Fischer AC, Hodge WA. Medical Cannabis and AASM Position Statement: The Don't Ask, Don't Tell Wishing Well. J Clin Sleep Med 2018; 14:1811. [PMID: 30353820 DOI: 10.5664/jcsm.7408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/22/2018] [Indexed: 11/13/2022]
Affiliation(s)
- Raquel M Schears
- Osceola Regional Hospital, Kissimmee, Florida.,University of Central Florida, Orlando, Florida
| | - Anne C Fischer
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - W Andrew Hodge
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
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Abstract
BACKGROUND The actual baseline of radiation exposure used in evaluating pediatric trauma is not known and has relied on estimates in the literature that may not reflect clinical reality. Our objectives were to determine the baseline amount of radiation delivered in a pediatric trauma evaluation and correlate radiation exposure with trauma activation status to identify the cohort most at risk. METHODS We retrospectively evaluated trauma patients (N = 1050) at an independent Level I children's hospital for each level of trauma activation (consults, alerts, stats) from June 2010 to January 2011. Those patients with full dosimetry (N = 215) were analyzed for demographics, mechanism of injury, Injury Severity Score, imaging modalities, and total effective radiation dosages during the full trauma assessment from the time of injury to discharge. RESULTS Demographics included gender (143 males, 72 females) and average age (5.5 years [range < 1-16]). The most radiation was conferred from CTs and greatest in trauma stats, followed by alerts, then consults (p < 0.001 for stat and alert doses compared to consults). Repeated imaging was common: 35% of stats had 2-3 CTs and 40% had 4-10 CTs (range 0-10 CTs). The average non-accidental trauma consult utilized four times as many CTs as the average consult (p = 0.002). Most outside hospital CTs (66%) delivered more radiation: 50.0% were at least double the standard pediatric dosage. CONCLUSIONS This study is the first to identify the actual baseline of radiation exposure for one trauma evaluation and correlate radiation exposure with trauma activation status. Factors associated with highest radiation include stat activations, suspected non-accidental traumas (NAT), and outside hospital system imaging.
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Affiliation(s)
- Raquel M. Schears
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA
| | - Zainab Farzal
- Department of Otolaryngology, University North Carolina, Children’s Hospital, 101 Manning Drive, Chapel Hill, NC USA
| | - Zehra Farzal
- Department of Neurology, MedStar Georgetown University Hospital, Reservoir Rd NW, Washington, DC, 3800 USA
| | - Anne C. Fischer
- Florida Atlantic University/St. Mary’s Medical Center, 927 45th Street, Suite 301, West Palm Beach, FL 33407 USA
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El-Jawahri A, Chen YB, Brazauskas R, He N, Lee SJ, Knight JM, Majhail N, Buchbinder D, Schears RM, Wirk BM, Wood WA, Ahmed I, Aljurf M, Szer J, Beattie SM, Battiwalla M, Dandoy C, Diaz MA, D'Souza A, Freytes CO, Gajewski J, Gergis U, Hashmi SK, Jakubowski A, Kamble RT, Kindwall-Keller T, Lazarus HM, Malone AK, Marks DI, Meehan K, Savani BN, Olsson RF, Rizzieri D, Steinberg A, Speckhart D, Szwajcer D, Schoemans H, Seo S, Ustun C, Atsuta Y, Dalal J, Sales-Bonfim C, Khera N, Hahn T, Saber W. Impact of pre-transplant depression on outcomes of allogeneic and autologous hematopoietic stem cell transplantation. Cancer 2017; 123:1828-1838. [PMID: 28102896 DOI: 10.1002/cncr.30546] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 11/23/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND To evaluate the impact of depression before autologous and allogeneic hematopoietic cell transplantation (HCT) on clinical outcomes post-transplantation. METHODS We analyzed data from the Center for International Blood and Marrow Transplant Research to compare outcomes after autologous (n = 3786) or allogeneic (n = 7433) HCT for adult patients with hematologic malignancies with an existing diagnosis of pre-HCT depression requiring treatment versus those without pre-HCT depression. Using Cox regression models, we compared overall survival (OS) between patients with or without depression. We compared the number of days alive and out of the hospital in the first 100 days post-HCT using Poisson models. We also compared the incidence of grade 2-4 acute and chronic graft-versus-host disease (GVHD) in allogeneic HCT. RESULTS The study included 1116 (15%) patients with pre-transplant depression and 6317 (85%) without depression who underwent allogeneic HCT between 2008 and 2012. Pre-transplant depression was associated with lower OS (hazard ratio [HR], 1.13; 95% confidence interval [CI], 1.04-1.23; P = 0.004) and a higher incidence of grade 2-4 acute GVHD (HR, 1.25; 95% CI, 1.14-1.37; P < 0.0001), but similar incidence of chronic GVHD. Pre-transplant depression was associated with fewer days-alive-and-out-of-the hospital (means ratio [MR] = 0.97; 95% CI, 0.95-0.99; P = 0.004). There were 512 (13.5%) patients with Pre-transplant depression and 3274 (86.5%) without depression who underwent autologous HCT. Pre-transplant depression in autologous HCT was not associated with OS (HR, 1.15; 95% CI, 0.98-1.34; P = 0.096) but was associated with fewer days alive and out of the hospital (MR, 0.98; 95% CI, 0.97-0.99; P = 0.002). CONCLUSION Pre-transplant depression was associated with lower OS and higher risk of acute GVHD among allogeneic HCT recipients and fewer days alive and out of the hospital during the first 100 days after autologous and allogeneic HCT. Patients with pre-transplant depression represent a population that is at risk for post-transplant complications. Cancer 2017;123:1828-1838. © 2017 American Cancer Society.
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Affiliation(s)
| | - Yi-Bin Chen
- Massachusetts General Hospital, Boston, Massachusetts
| | - Ruta Brazauskas
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin.,Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Naya He
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Jennifer M Knight
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | | | | | | | - William A Wood
- University of North Carolina, Chapel Hill, North Carolina
| | - Ibrahim Ahmed
- The Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Jeff Szer
- Royal Melbourne Hospital, Victoria, Australia
| | | | | | | | | | - Anita D'Souza
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cesar O Freytes
- University of Texas Health Science Center San Antonio, San Antonio, Texas
| | | | - Usama Gergis
- New York Presbyterian Hospital, New York, New York
| | | | - Ann Jakubowski
- Memorial Sloan-Kettering Cancer Center, New York, New York
| | | | | | | | | | - David I Marks
- University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Kenneth Meehan
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Bipin N Savani
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard F Olsson
- Karolinska Institute, Stockholm, Sweden.,Uppsala University, Uppsala, Sweden
| | | | | | | | | | | | | | | | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan.,Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jignesh Dalal
- The Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | | | | | - Theresa Hahn
- Roswell Park Cancer Institute, Buffalo, New York
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
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19
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Vrooman L, Millard H, Brazauskas R, Majhail NS, Battiwalla M, Flowers ME, Savani BN, Akpek G, Aljurf MD, Bajwa R, Baker KS, Beitinjaneh A, Bitan M, Buchbinder D, Dandoy CE, Gale RP, Hayashi RJ, Hematti P, Kamble RT, Kasow KA, Kletzel M, Lazarus HM, Malone AK, O'Brien T, Olsson R, Reddy V, Willert JR, Ringden O, Schears RM, Seo S, Steinberg A, Yu LC, Shaw BE, Duncan C. Survival and Late Effects of Children Undergoing Myeloablative Allogeneic HCT at Less Than Three Years of Age: A Report from the Center for International Blood and Marrow Transplant Research. Biol Blood Marrow Transplant 2016. [DOI: 10.1016/j.bbmt.2015.11.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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20
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Hsu JW, Wingard JR, Logan BR, Chitphakdithai P, Akpek G, Anderlini P, Artz AS, Bredeson C, Goldstein S, Hale G, Hematti P, Joshi S, Kamble RT, Lazarus HM, O'Donnell PV, Pulsipher MA, Savani BN, Schears RM, Shaw BE, Confer DL. Race and ethnicity influences collection of granulocyte colony-stimulating factor-mobilized peripheral blood progenitor cells from unrelated donors, a Center for International Blood and Marrow Transplant Research analysis. Biol Blood Marrow Transplant 2014; 21:165-71. [PMID: 25316111 DOI: 10.1016/j.bbmt.2014.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 10/07/2014] [Indexed: 11/27/2022]
Abstract
Little information exists on the effect of race and ethnicity on collection of peripheral blood stem cells (PBSC) for allogeneic transplantation. We studied 10,776 donors from the National Marrow Donor Program who underwent PBSC collection from 2006 to 2012. Self-reported donor race/ethnic information included Caucasian, Hispanic, Black/African American (AA), Asian/Pacific Islander (API), and Native American (NA). All donors were mobilized with subcutaneous filgrastim at an approximate dose of 10 μg/kg/day for 5 days. Overall, AA donors had the highest median yields of mononuclear cells per liter and CD34(+) cells per liter of blood processed (3.1 × 10(9) and 44 × 10(6), respectively), whereas Caucasians had the lowest median yields at 2.8 × 10(9) and 33.7 × 10(6), respectively. Multivariate analysis of CD34(+) per liter mobilization yields using Caucasians as the comparator and controlling for age, gender, body mass index, and year of apheresis revealed increased yields in overweight and obese AA and API donors. In Hispanic donors, only male obese donors had higher CD34(+) per liter mobilization yields compared with Caucasian donors. No differences in CD34(+) per liter yields were seen between Caucasian and NA donors. Characterization of these differences may allow optimization of mobilization regimens to allow enhancement of mobilization yields without compromising donor safety.
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Affiliation(s)
- Jack W Hsu
- University of Florida Shands Cancer Center, Gainesville, Florida.
| | - John R Wingard
- University of Florida Shands Cancer Center, Gainesville, Florida
| | - Brent R Logan
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pintip Chitphakdithai
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Gorgun Akpek
- Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Paolo Anderlini
- University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | | | - Chris Bredeson
- Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, Ontario, Canada
| | | | - Gregory Hale
- All Children's Hospital, St. Petersburg, Florida
| | - Peiman Hematti
- University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | | | - Rammurti T Kamble
- Baylor College of Medicine Center for Cell and Gene Therapy, Houston, Texas
| | - Hillard M Lazarus
- University Hospitals Case Medical Center, Seidman Cancer Center, Cleveland, Ohio
| | | | - Michael A Pulsipher
- University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | - Bipin N Savani
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Bronwen E Shaw
- Anthony Nolan Research Institute, London, United Kingdom
| | - Dennis L Confer
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota; National Marrow Donor Program, Minneapolis, Minnesota
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21
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Jain A, Jain M, Bellolio MF, Schears RM, Rabinstein AA, Ganti L. Is early DNR a self-fulfilling prophecy for patients with spontaneous intracerebral hemorrhage? Neurocrit Care 2014; 19:342-6. [PMID: 23884512 DOI: 10.1007/s12028-013-9878-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND To investigate differences in outcome of patients with intracerebral hemorrhage (ICH) based on institution of do-not-resuscitate (DNR) order within first 24 h of admission. METHODS A prospective registry of patients presenting with ICH from Jan 2006 to Dec 2008 was created. Patients with and without DNR orders instituted within 24 h of admission were classified as cases and controls respectively and were matched based on age and stroke severity. Demographics, intracerebral volume of hematoma, intraventricular extension of hemorrhage (IVH), invasive treatments, and outcomes at discharge were collected. All patients were followed up at least for 1 year, to determine mortality outcomes. RESULTS Of a total of 245 subjects, 18 % had DNR order instituted within 24 h of admission. After matching, a total of 69 controls were available for 44 cases. There was no difference in demographics, IVH extension, volume of hemorrhage, and length of stay among cases and controls. Higher proportions of controls had surgical evacuation of the hematoma (p = 0.0125) and mechanical ventilation (p = 0.0001). There was no significant difference in functional outcome and survival rates among cases and controls at the end of 1 week, 1 month, and 1 year. CONCLUSIONS DNR institution and restriction of resuscitation was not associated with poor outcome or difference in survival within 1 year after ICH. This indicates an early DNR probably does not lead to a self-fulfilling prophecy in this population, and might be explained by our practice, were DNR orders do not impact the level of supportive medical care we provide.
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Affiliation(s)
- A Jain
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
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22
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Simon JR, Schears RM, Padela AI. Donation after cardiac death and the emergency department: ethical issues. Acad Emerg Med 2014; 21:79-86. [PMID: 24552527 DOI: 10.1111/acem.12284] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 07/04/2013] [Accepted: 07/17/2013] [Indexed: 11/29/2022]
Abstract
Organ donation after cardiac death (DCD) is increasingly considered as an option to address the shortage of organs available for transplantation, both in the United States and worldwide. The procedures for DCD differ from procedures for donation after brain death and are likely less familiar to emergency physicians (EPs), even as this process is increasingly involving emergency departments (EDs). This article explores the ED operational and ethical issues surrounding this procedure.
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Affiliation(s)
- Jeremy R. Simon
- The Department of Medicine and Center for Bioethics; Columbia University; New York NY
| | - Raquel M. Schears
- The Department of Emergency Medicine; Mayo Clinic College of Medicine; Rochester MN
| | - Aasim I. Padela
- The Department of Medicine, Initiative on Islam and Medicine; Program on Medicine and Religion and Maclean Center for Clinical Medical Ethics; The University of Chicago; Chicago IL
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23
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Abstract
The recent enactment of the Patient Protection and Affordable Care Act (ACA) of 2010, and the ongoing debate over reform of the U.S. health care system, raise numerous important ethical issues. This article reviews basic provisions of the ACA; examines underlying moral and policy issues in the U.S. health care reform debate; and addresses health care reform's likely effects on access to care, emergency department (ED) crowding, and end-of-life care. The article concludes with several suggested actions that emergency physicians (EPs) should take to contribute to the success of health care reform in America.
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24
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Moskop JC, Iserson KV, Aswegan AL, Larkin GL, Schears RM. Gifts to Physicians From Industry: The Debate Evolves. Ann Emerg Med 2012; 59:89-97. [DOI: 10.1016/j.annemergmed.2011.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 07/27/2011] [Accepted: 08/02/2011] [Indexed: 10/17/2022]
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Abstract
Trust in the doctor-patient or investigator-subject relationship is vital to the practice of medicine and advancement through biomedical research. Individual and environmental factors can make this trust more difficult to establish in the emergency department (ED). To perform research ethically and maintain this trust, it is important to minimize and manage conflicts of interest in human subjects research. While principle-based ethics are an important starting point, the virtue of the individual investigator is required to assure that the interests and safety of research participants are prioritized over the interests of the investigator or the medical community at large. SAEM Ethics Committee 2009-2010 Objective 4: "Based on the results of the didactic session presented at the annual meeting, develop a guide to assist SAEM members in the recognition of potential conflicts of interest in the practice of academic emergency medicine".
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Affiliation(s)
- Shellie L Asher
- Department of Emergency Medicine, Albany Medical College, Albany, NY, USA.
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26
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Rao RL, Schears RM. Prescription use and survival among nonagenarians presenting to the ED. Am J Emerg Med 2010; 28:348-53. [DOI: 10.1016/j.ajem.2008.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 12/10/2008] [Accepted: 12/17/2008] [Indexed: 10/19/2022] Open
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27
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Baren J, Campbell CF, Schears RM, Shofer FS, Datner EM, Hollander JE. Observed Behaviors of Subjects During Informed Consent for an Emergency Department Study. Ann Emerg Med 2010; 55:9-14. [DOI: 10.1016/j.annemergmed.2009.09.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 08/24/2009] [Accepted: 09/16/2009] [Indexed: 11/29/2022]
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Crow S, Fischer AC, Schears RM. Extracorporeal life support: utilization, cost, controversy, and ethics of trying to save lives. Semin Cardiothorac Vasc Anesth 2009; 13:183-91. [PMID: 19713206 DOI: 10.1177/1089253209347385] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Since the first successful application of extracorporeal membrane oxygenation (ECMO) in 1972, ECMO's role in the management of respiratory and circulatory collapse continues to be refined and debated. Randomized clinical trials aimed at establishing efficacy and patient selection criteria have been fraught with ethical challenges. Growing concerns over rising health care costs require that careful evaluations of cost, utilization, and ethical issues surrounding heroic life-saving interventions such as ECMO are undertaken. Continued analyses of ECMO's place in the medical management of respiratory and circulatory failure will help ensure that ECMO is used for not only prolonging life but also for providing a chance for "quality of life" following recovery from near-fatal illnesses.
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Affiliation(s)
- Sheri Crow
- Mayo Clinic, Rochester, Minnesota 55905, USA.
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29
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Chen HH, Martin FL, Gibbons RJ, Schirger JA, Wright RS, Schears RM, Redfield MM, Simari RD, Lerman A, Cataliotti A, Burnett JC. Low-dose nesiritide in human anterior myocardial infarction suppresses aldosterone and preserves ventricular function and structure: a proof of concept study. Heart 2009; 95:1315-9. [PMID: 19447837 DOI: 10.1136/hrt.2008.153916] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND B-type natriuretic peptide (BNP, nesiritide) has anti-fibrotic, anti-hypertrophic, anti-inflammatory, vasodilating, lusitropic and aldosterone-inhibiting properties but conventional doses of BNP cause hypotension, limiting its use in heart failure. OBJECTIVE To determine whether infusion of low-dose BNP within 24 h of successful reperfusion for anterior acute myocardial infarction (AMI) would prevent adverse left ventricular (LV) remodelling and suppress aldosterone. METHODS A translational proof-of-concept study was carried out to determine tolerability and biological activity of intravenous BNP at 0.003 and 0.006 microg/kg/min, without bolus started within 24 h of successful reperfusion for anterior AMI. 24 patients with first anterior wall ST elevation AMI and successful revascularisation were randomly assigned to receive 0.003 (n = 12) or 0.006 (n = 12) microg/kg/min of IV BNP for 72 h in addition to standard care during hospitalisation for anterior AMI. RESULTS Baseline characteristics, drugs and peak cardiac biomarkers for myocardial damage were similar between both groups. Infusion of BNP at 0.006 microg/kg/min resulted in greater biological activity than infusion at 0.003 microg/kg/min as measured by higher mean (SEM) plasma cGMP levels (8.6 (1) vs 5.5 (1) pmol/ml, p<0.05) and suppression of plasma aldosterone (8.0 (2) to 4.6 (1) ng/dl, p<0.05), which was not seen in the 0.003 microg/kg/min group. LV ejection fraction (LVEF) improved significantly from baseline to 1 month (40 (4)% to 54 (5)%, p<0.05) in the 0.006 group but not in the 0.003 group. Infusion of BNP at 0.006 microg/kg/min was associated with a decrease of LV end-systolic volume index (61 (9) to 43 (8) ml/m(2), p<0.05) at 1 month, which was not seen in the 0.003 group. No drug-related serious adverse events occurred in either group. CONCLUSIONS 72 h infusion of low BNP at the time of anterior AMI is well tolerated and biologically active. Patients treated with low-dose BNP had improved LVEF and smaller LV end-systolic volume at 1 month.
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Affiliation(s)
- H H Chen
- Cardiorenal Research Laboratory, Mayo Clinic, Rochester, MN 55904, USA.
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30
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Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ. Emergency Department Crowding, Part 2—Barriers to Reform and Strategies to Overcome Them. Ann Emerg Med 2009; 53:612-7. [DOI: 10.1016/j.annemergmed.2008.09.024] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Revised: 09/10/2008] [Accepted: 09/23/2008] [Indexed: 11/26/2022]
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Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ. Emergency Department Crowding, Part 1—Concept, Causes, and Moral Consequences. Ann Emerg Med 2009; 53:605-11. [DOI: 10.1016/j.annemergmed.2008.09.019] [Citation(s) in RCA: 305] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Revised: 09/10/2008] [Accepted: 09/22/2008] [Indexed: 11/29/2022]
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Affiliation(s)
- Anjali Bhagra
- Department of Internal Medicine, Mayo Clinic College of Medicine, Generose G-410, 200 First Street SW, Rochester, MN 55905 USA
| | - Smitha Suravaram
- Department of Emergency Medicine, Mayo Clinic College of Medicine, Generose G-410, 200 First Street SW, Rochester, MN 55905 USA
| | - Raquel M. Schears
- Department of Emergency Medicine, Mayo Clinic College of Medicine, Generose G-410, 200 First Street SW, Rochester, MN 55905 USA
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33
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Griffin MD, Koenig BA, Schears RM. Topics in transplant ethics. Transplant Rev (Orlando) 2008; 22:151-3. [PMID: 18631868 DOI: 10.1016/j.trre.2008.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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34
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Schears RM, Hess JM. Sats in the 60s. Int J Emerg Med 2008; 1:51. [PMID: 19384502 PMCID: PMC2536182 DOI: 10.1007/s12245-008-0001-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2008] [Accepted: 01/29/2008] [Indexed: 11/20/2022] Open
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35
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Stead LG, Vaidyanathan L, Schears RM, Gilmore RM, Vedula KC, Behera SR, Bellolio MF, Gau GT, Decker WW. Electrocardiographic intervals in the healthy geriatric population--what are the "normals"? Am J Geriatr Cardiol 2008; 17:87-91. [PMID: 18326954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The authors compared the average electrocardiographic (ECG) intervals in a population of patients 80 years and older with published "normal" values. The medical records of patients who presented to the Mayo Clinic for health maintenance examinations and who had a routine ECG performed (N=702) were selected. Age; sex; rhythm; PR, QRS, and QTc intervals; incidence of cardiac disease; and presence of interval-prolonging medication were recorded. Reference ranges were estimated from the data and compared with standard cutoffs for prolonged intervals. Interval values were significantly higher in men. Reference ranges were established separately for both sexes based on the subset of 578 patients without a history of cardiac disease and not taking interval-prolonging medication. In all instances, the ranges were higher than the recommended cutoffs. The upper limits for prolonged PR, QRS, and QTc intervals were found to be significantly higher in a population of patients older than 80 years.
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Affiliation(s)
- Latha G Stead
- Department of Emergency Medicine Mayo Clinic, Rochester, MN 55905, USA.
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36
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Affiliation(s)
- Catherine A Marco
- Clinical professor at the University of Toledo and attending physician at St. Vincent Mercy Medical Center in Toledo, Ohio
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Schears RM, Watters A, Schmidt TA, Marco CA, Larkin GL, Marshall JP, Mason JD, McBeth BD, Mello MJ. The Society for Academic Emergency Medicine position on ethical relationships with the biomedical industry. Acad Emerg Med 2007; 14:179-81. [PMID: 17185294 DOI: 10.1197/j.aem.2006.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Raquel M Schears
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA.
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Abstract
Issues regarding patient care near the end of life can be challenging and rewarding for emergency physicians. Knowledge of the patient's wishes is essential, and may be accomplished by advance directives or communication with patients and surrogates. Resuscitative efforts are appropriate for many patients, but inappropriate for others. The goals of medicine remain the following: providing optimal health care, provision of the best possible symptom control, communication, empathy, and caring. As death approaches, provision of the best possible medical care, in accordance with the patient's wishes, can be rewarding for patients, families, and health care providers.
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Affiliation(s)
- Catherine A Marco
- Department of Emergency Medicine, Acute Care Services, St Vincent Mercy Medical Center, Toledo, OH 43608-2691, USA.
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Olson LJ, Schears RM, Clavell AL, Seid KR, Santrach PJ, Bailey KR, Long KH. Economic Impact of Brain Natriuretic Peptide Measurement for Evaluation of Dyspneic Patients in the Emergency Department: A Randomized, Controlled Study. J Card Fail 2006. [DOI: 10.1016/j.cardfail.2006.06.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kumar G, Vaidyanathan L, Bhagra A, Varadachari CJ, Decker WW, Schears RM, Stead LG. Correlation of Electrocardiographic Data with Duration of Hospitalization and In-Hospital Mortality in Patients with Congestive Heart Failure. J Card Fail 2006. [DOI: 10.1016/j.cardfail.2006.06.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Schears RM. Ethics of surrogate consent for living organ donation. JAMA 2004; 292:1684-5; author reply 1685. [PMID: 15479930 DOI: 10.1001/jama.292.14.1684-c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Schmidt TA, Salo D, Hughes JA, Abbott JT, Geiderman JM, Johnson CX, McClure KB, McKay MP, Razzak JA, Schears RM, Solomon RC. Confronting the ethical challenges to informed consent in emergency medicine research. Acad Emerg Med 2004; 11:1082-9. [PMID: 15466152 DOI: 10.1197/j.aem.2004.05.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The Society for Academic Emergency Medicine believes that protection of human subjects is vital in emergency medicine research and that, whenever feasible, informed consent is at the heart of that protection. At the same time, the emergency setting presents unique barriers to informed consent both because of the time frame in which the research is performed and because patients in the emergency department are a vulnerable population. This report reviews the concept of informed consent, empirical data on patients' cognitive abilities during an emergency, the federal rules allowing exemption from consent under certain circumstances, issues surrounding consent forms, and the new Health Insurance Portability and Accountability Act regulations as they relate to research. The authors conclude that, in many circumstances, informed consent is possible if the researcher is diligent and takes time to adequately explain the study to the potential subject. In cases in which it is possible to obtain consent, precautions must be taken to ensure that subjects have decision-making capacity and are offered time to have their questions answered and their needs met. Sometimes resuscitation and other emergency medicine research must be conducted without the ability to obtain consent. In these cases, special protections of subjects under the exception from consent guidelines must be followed. Protection of research subjects is the responsibility of every researcher in emergency medicine.
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Affiliation(s)
- Terri A Schmidt
- Department of Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97235, USA.
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Schmidt TA, Abbott JT, Geiderman JM, Hughes JA, Johnson CX, McClure KB, McKay MP, Razzak JA, Salo D, Schears RM, Solomon RC. Ethics seminars: the ethical debate on practicing procedures on the newly dead. Acad Emerg Med 2004; 11:962-6. [PMID: 15347547 DOI: 10.1197/j.aem.2004.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Emergency medicine and its academic teaching programs face an ethical dilemma surrounding the question of practicing procedures on the newly dead. For many years, procedures have been practiced on the newly dead, but few institutions have had policies addressing the practice. This article considers the ethical arguments both for and against practicing procedures on the newly dead without consent, reviews the empirical studies on the subject, and presents the positions of other professional societies, before concluding with the position of the Society for Academic Emergency Medicine (SAEM). SAEM strongly encourages all emergency medicine training programs to develop a policy and make that policy available to the institution, educators, trainees, and the public. The practice should not occur behind closed doors or on an ad hoc basis without clearly articulated guidelines. With improvements in technology, including patient simulation and virtual reality, the need for the practice may decrease, but there is no current evidence that is compelling regarding the best methods of teaching procedural skills. Given the importance of protecting trust in the profession of medicine and the existing evidence that the public would expect that consent be obtained, SAEM recommends that families be asked for consent prior to practicing procedures on the newly dead.
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Affiliation(s)
- Terri A Schmidt
- Department of Emergency Medicine CDW-EM, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97201.
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Schmidt TA, Abbott JT, Geiderman JM, Hughes JA, Johnson CX, McClure KB, McKay MP, Razzak JA, Salo D, Schears RM, Solomon RC. Ethics Seminars: The Ethical Debate on Practicing Procedures on the Newly Dead. Acad Emerg Med 2004. [DOI: 10.1111/j.1553-2712.2004.tb00789.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Datner EM, O'Malley M, Schears RM, Shofer FS, Baren J, Hollander JE. Universal screening for interpersonal violence: inability to prove universal screening improves provision of services. Eur J Emerg Med 2004; 11:35-8. [PMID: 15167191 DOI: 10.1097/00063110-200402000-00007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Universal screening for interpersonal violence is recommended despite a lack of confirmed efficacy. We hypothesized that the detection of violence via universal screening would result in high intervention rates for victims. METHODS Women aged 18-65 years presenting to an emergency department were screened using a standard protocol. Medical and social work records were reviewed for positively screened patients. Outcomes included whether victims received counseling/referral services. Secondary outcomes were the documentation of services offered and safety assessment performed. RESULTS A total of 1732 patients were evaluated; 615 (35.5%) responded positively to at least one query. Patients had a mean age of 34.7+/-12 years, 79% were non-white, 19% were married, and 76% had completed high school. Twenty-five out of 606 victims (4%) had documentation of violence. Residents were more likely than faculty or nurses to document domestic violence [3.3% (95% confidence interval 1.8-4.8%) versus 2.1 (0.9-3.4) versus 0.7 (0.0-1.4)]. The documentation of police contact, suicide/homicide risk, weapon presence, safety assessment and outside resource referrals occurred in less than 2% of charts. Only two victims were referred to social work (0.3%; 0-0.9%). CONCLUSION Even in an institution with a heavy emphasis and training on interpersonal violence and alternative mechanisms for universal screening we could not prove that the identification of victims resulted in counseling/referral being offered in the emergency department.
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Affiliation(s)
- Elizabeth M Datner
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Chen HH, Schirger JA, Wright R, Schears RM, Cataliotti A, Reeder GS, Gibbons RJ, Burnett JC. Pilot study assessing dose and tolerability of BNP (nesiritide) infusion post anterior myocardial infarction to prevent adverse left ventricular remodeling and heart failure. J Card Fail 2004. [DOI: 10.1016/j.cardfail.2004.06.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Numerous factors affect decision making in the prehospital provision of resuscitative care. This study was undertaken to determine current practices involved in the initiation, continuation and termination of resuscitative efforts, and the impact of advance directives, in the prehospital resuscitation setting. This cross-sectional mailed questionnaire surveyed 3807 members of the National Association of Emergency Medical Technicians. The study instrument included questions regarding the termination and withholding of resuscitative efforts in the prehospital setting, as well as survival rates, local protocols and compliance with advance directives. Of 1546 respondents (41% response rate), with a mean 9.0 years of experience, most (89%) indicated that they would withhold resuscitative efforts in the presence of an official state-approved advance directive. However, very few providers would withhold resuscitative efforts if only an unofficial document (4%) or verbal report of an advance directive (10%) were available. Providers with more than 10 years experience were more likely to withhold resuscitation attempts in the presence of only a verbal report of an advance directive (p = 0.02, Chi-square), and were more likely to withhold resuscitation attempts in situations they considered futile (p = 0.001, Chi-square). Most (77%) respondents have local EMS guidelines for termination of resuscitation in the prehospital setting, but 23% of those consider existing guidelines to be inadequate. The majority of prehospital providers stated that they honor official state-approved advance directives, but do not follow directives from unofficial documents or verbal reports of advance directives. More experienced providers stated that they withhold resuscitative efforts more often in futile situations, or in the presence of unofficial advance directives. Advance directives should be utilized more uniformly among patients who wish to forgo resuscitative efforts in the event of cardiac arrest. Because many local protocols are judged to be inadequate, we support the institution of improved clinical guidelines regarding the prehospital termination of resuscitative efforts.
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Affiliation(s)
- Catherine A Marco
- Acute Care Services, St Vincent Mercy Medical Center, Toledo, Ohio 43608-2691, USA
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Abstract
Resuscitative measures are traditionally undertaken for most patients with cardiac arrest, unless an advance directive exists. This long-standing default presumption of patients' wishes to undergo resuscitation has never been proven. This study was undertaken to determine societal preferences of the general public regarding resuscitation. A cross-sectional survey was administered at community events to 724 volunteer participants over a 16-month period. For 6 hypothetical clinical scenarios (previously piloted and validated), respondents indicated personal preferences regarding resuscitation attempts for themselves. Most respondents indicated preferences for resuscitative efforts in a scenario depicting a young, healthy patient (96%), whereas few would desire resuscitative efforts for an elderly, debilitated patient (27%) (P <.01, Fisher's exact test). Nearly all (98%) respondents showed a trend (by scalogram analysis) toward refusal of resuscitative efforts in scenarios depicting more elderly, debilitated patients. Respondents had inaccurate perceptions of survival rates after cardiac arrest; the mean estimated survival rate was 50% (range 0%-100%). Although the majority of respondents had a personal physician (82%), only 10% of respondents had ever discussed death or resuscitation with their physicians. This study shows a trend in personal opinion among the general public toward refusal of resuscitative efforts in clinical scenarios with poor prognoses. Because so few patients have completed advance directives, physician awareness of such public opinions may be useful in decision-making in end-of-life care, particularly when caring for patients without advance directives. These public opinions support the feasibility of establishing societal consensus regarding resuscitation preferences, which may be useful in the development of federal and local guidelines and policies.
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Affiliation(s)
- Catherine A Marco
- Department of Emergency Medicine, St. Vincent Mercy Medical Center, Toledo, OH 43608-2691, USA.
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