Expert Opinion: Luis Vargas – ED Overcrowding

EMERGENCY DEPARTMENT OVERCROWDING

Dear students, emergency departments are suffering overcrowding since long time. There are various causes of this situation as well as solutions. It is better to know about ED overcrowding before your first shift. Dr. Luis Vargas from Colombia summarizes his lecture presented in 30th Emergency Medicine Congress of Mexican Society in Cancun.

ED Overcrowding - English

Manejo y consecuencias del sobrecupo en urgencias

Airway Tips by Manrique Umana

Dr. Manrique Umana from Costa Rica presented a fantastic lecture during the 30th Emergency Medicine Conference of Mexican Society in Cancun/Mexico. Every emergency physician should know the airway tips he gave in the talk. Moreover, medical students and interns should also be aware of these clues. Therefore, we asked him to summarize his speech for iEM. You will find English and Spanish version of the summary on the below videos. Enjoy!

Airway Tips

This video includes a summary of “physiologically difficult airway” presentation given by Dr. Manrique Umana from Costa Rica.

Consejos de la vía aérea

Este video incluye un resumen de la presentación de la “vía aérea fisiológicamente difícil” realizada por el Dr. Manrique Umana de Costa Rica.

Against Medical Advice and Elopement

In certain circumstances, patients may request to leave prior to completion of their medical evaluation and treatment. In this situation, it is essential for the last health care professional caring for the patient to document clearly why the patient left and attested that the patient had the mental capacity to make such a decision at that time (Henry, 2013). While some electronic documentation systems have templates in place to assist with this documentation, Table 2 provides basic information for against medical advice (AMA) discharge documentation that can be used to create a uniform template (Henry, 2013; Siff, 2011; Levy, 2012; Devitt, 2000).

What to do?

Interventions in the ED Discharge Process

DomainIntervention
ContentStandardize approach
DeliveryVerbal instructions (language and culture appropriate)
Written instructions (literary levels)
Basic Instructions (including return precautions)
Media, visual cues or adjuncts
ComprehensionConfirm comprehension (teach-back method)
ImplementationResource connections (Rx, appointment, durable medical supplies, follow-up)
Medication review

An attempt should be made to provide the patient with appropriate discharge instructions, even if a complete diagnosis may not yet be determined. Include advice for the patient to follow up with his physician, strict return precautions, and concerning symptoms that should prompt the patient to seek further care. It should also be made clear that leaving against medical advice does not prevent the patient from returning to the emergency department for further evaluation if his symptoms worsen, or if he changes his mind. Despite a common notion to the contrary, simply leaving against medical advice does not automatically imply that physicians are immune to potential medical liability (Levy, 2012; Devitt, 2000). If a patient lacks decision-making capacity to be able to adequately understand the rationale and consequences of leaving AMA and his condition places him at risk for imminent harm, involuntary hospitalization is warranted. In unclear circumstances and if available, psychiatry can assist in determining capacity, especially in the case of patients with mental health conditions.

Elopement is a similar process where patients disappear during the care process. While it is difficult to provide discharge paperwork for these patients, documenting the actions taken to find the patient is essential (e.g., searching the ED, having security check the surrounding areas). In addition, attempt to reach the patient by phone to discuss his elopement and any additional care issues or concerns. Documentation of these attempts or any additional conversation is very important (Henry, 2013; Siff, 2011).

To Know More About It?

References

  • Brooten J, Nicks B. Discharge Communications. In: Cevik AA, Quek LS, Noureldin A, Cakal ED (eds) iEmergency Medicine for Medical Students and Interns – 2018. Retrieved February 27, 2019, from https://iem-student.org/discharge-communications/
  • Henry GL, Gupta G. (2013). Medical-Legal Issues in Emergency Medicine. In Adams (Ed.), Emergency Medicine Clinical Essentials, 2nd Ed; 1759-65. Philadelphia, PA: Elsevier.
  • Siff JE. (2011). Legal Issues in Emergency Medicine. In Tintinalli’s (Ed.), Emergency Medicine, 7th Ed; 2021-31. McGraw-Hill.
  • Levy F, Mareiniss DP, Lacovelli C. The Importance of a Proper Against-Medical-Advice (AMA) Discharge. How Signing Out AMA May Create Significant Liability Protection for Providers. J Emerg Med. 2012;43(3):516-520.
  • Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51:899-902.

Medical students’ ultrasound training – SURVEY

There are many studies showing benefits of ultrasound training about understanding anatomy, pathologies and improving clinical decision making. Countries show different approaches to implementing ultrasound training at the medical school level. There are many obstacles such as staff, equipment, training manikins, dedicated time in curriculum design. International organizations are trying to find solutions for these obstacles and encouraging to implement ultrasound training into the medical school curriculum. Ultrasound can be a valuable diagnostic and procedural tool in many low resourced countries, especially where the CT scans and x-rays are not available. However, even in developed countries, medical students’ training on ultrasonography skills is still an infancy period.

We conducted a 1-minute survey to explore the global situation in order to understand current applications in medical schools. We hope you fill and share this survey with your professional contacts and students.

1 minute SURVEY

Mnemonic for Right Lower Quadrant Pain

Open fracture! Antibiotic choice.

ERic Motorcycle accident

A 20-year-old male presents to your ED with a 5 cm wound after he fell off his motorbike. On physical exam, the wound overlays a fractured left tibia but does not show extensive soft tissue damage nor any signs of periosteal stripping or vascular injury. 

Which antibiotic should you give to this patient?

To learn more about it, read chapters below.

Read "Scores" Chapter
Read "Lower Extremity Injuries" Chapter

Quick Read

Gustilo-Anderson Classification

Gustilo-Anderson classification is used for fractures with open wounds and antibiotic coverage.

Gustilo-Anderson Classification

TypeDefinition
Type IOpen fracture, clean wound, wound <1cm in length
Type IIOpen fracture, wound >1cm in length without extensive soft tissue damage, flaps, avulsions
Type IIIOpen fracture with extensive soft tissue laceration, damage, or loss or an open segmental fracture. This type also includes open fractures caused by farm injuries, fractures requiring vascular repair, or fractures that have been open for 8 hours prior to treatment.
Type III AType III fracture with adequate periosteal coverage of the fractured bone despite extensive soft tissue laceration or damage
Type III BType III fracture with extensive soft tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination. It will often need further soft tissue coverage procedure (i.e. free or rotational flap).
Type III CType III fracture associated with arterial injury requiring repair, irrespective of degree of soft tissue injury

According to the above classification, each class should receive the following antibiotics:

  • Type I: 1st generation cephalosporin
  • Type II: 1st generation Cephalosporin +/- Gentamycin
  • Type III: 1st generation Cephalosporin + Gentamycin +/- Penicillin

To learn more about it, read chapters below.

Read "Scores" Chapter
Read "Lower Extremity Injuries" Chapter

Shock Index

A 57-year-old male presented to the ED with severe abdominal pain for 1 day. No allergies or significant past medical history. His vitals are: Temp 37.6 Celsius, BP 100/55, HR 110/min, RR 20/min and O2 Saturation is 99% on room air. 

What level of care does this patient require?

To learn more about it, read chapters below.

Read "Shock" Chapter

Read "Scores" Chapter

Quick Read

Shock Index

SHOCK INDEX (SI) = Heart Rate / Systolic Blood Pressure

Application

SI can be used to identify patients needing a higher level of care despite vital signs that may not appear strikingly abnormal. This index is a sensitive indicator of left ventricular dysfunction and can become elevated following a reduction in left ventricular stroke work.

Interpretation

  • Normal SI = 0.5 to 0.7
  • If SI > 0.9 was helpful to identify patients in the ED requiring admission and/or intensive care despite apparently stable vital signs
  • Persistent high SI has been associated with poor outcome

The answer to the above clinical scenario: By applying the above equation, (110/100 = 1.1), this patient has a high shock index and requires a high level of care.

To learn more about it, read chapters below.

Read "Shock" Chapter

Read "Scores" Chapter

AEIOU TIPS Card

ALTERED MENTAL STSTUS

Action Plan

Creating Your Action Plan chapter written by Chew Keng Sheng from Malaysia is just uploaded to the Website!