The principal physician in emergency medicine

The implementation of an experienced pre-hospital care emergency physician as an on the-scene medical command officer (MCO) within the emergency medical service (EMS) is an essential prerequisite to guarantee qualified medical supervision during mass-casuality incidents (MCI). The MCO has four basic functions. Within the administration of the EMS system, he is responsible for the medical aspects of strategic planning for the MCI response. During the MCI the MCO is responsible for the overall assessment of the situation, triage, and supervision of medical treatment by physician and non-physician providers. Aside from extensive personal experience in pre-hospital care, the MCO needs special training to be qualified for this position. State EMS laws provide the legal basis for the MCO within the EMS system.     

The work of the American emergency physician

OBJECTIVE: To compare gestational age (GA) calculated from oocyte retrieval and from ultrasound measurements in pregnancies after in vitro fertilization (IVF). DESIGN: In a retrospective study of 253 women with singleton and 84 women with twin pregnancies conceived from IVF, GA calculated from the day of oocyte retrieval was compared with GA calculated in the second trimester of pregnancy from ultrasound measurements of biparietal diameter (BPD) and femur length (FL). RESULTS: For singletons, the mean GA calculated from ultrasound measurements was significantly shorter than the mean GA estimated from the day of oocyte retrieval. The mean difference was 1.9 days (SD 3.3; 95% CI 1.5-2.4) if only BPD was used and 2.1 days (SD 2.1; 95% CI 1.6-2.5) if BPD and FL were combined. For twins, the mean GA calculated from ultrasound measurements was also significantly shorter than the mean GA calculated from the day of oocyte retrieval. The mean difference was 1.4 days (SD 2.7; 95% CI 1.0-1.8) if BPD was used and 1.6 days (SD 2.5; 95% CI 1.2-2.0) if BPD and FL were combined. CONCLUSIONS: In IVF pregnancies, term prediction using ultrasound in the second trimester is reliable and may reduce the number of pregnancies subsequently classified as post-term, thus avoiding unnecessary obstetric interventions.     

The emergency physician and patient confidentiality: a review

Confidentiality is a promise rooted in tradition, law, and medical ethics. Emergency physicians treat a variety of patients to whom confidentiality is of vital importance: employees, celebrities, victims of violence or disaster, minors, students, criminals, drug abusers, and patients with STDs. EDs should develop methods of ensuring confidentiality for all patients. Although confidentiality is an important principle that should be respected and guarded, it is not absolute. Various laws mandate disclosure of certain patient information; in addition, an overriding moral duty may occasionally require a breach of confidentiality. As Beauchamp and Childress noted, "the therapeutic role may sometimes have to yield to one's role as citizen and as protector of the interests of others." In general, however, circumstances requiring a breach of confidentiality are rare.     

The physician and accidents. Legal and medical problems

German law requires that any physician at a place of accident is obliged to help according to his training and ability. As an emergency doctor on duty he works in a warrantee position. In cases with multiple accident victims triage may be necessary, corresponding to the priority of medical care. In criminal procedures against a physician due to omitted help, there is no probative charge against the accused. On the other hand, civil law sets up an objective standard: attention as required in communication. In giving initial medical assistance for unconscious patients or injured children, rules of "authorized management without commission" become valid. Basic first aid measures involve: securing, saving and rescue. Life-threatening situations such as severe bleeding, airway obstruction and cardiac arrest must be dealt with immediately. Following this, such measures as proper positioning, clearing of the respiratory tract, removal of dental prostheses, evaluation of multiple injuries, avoidance of hypothermia and initiating infusions are mandatory. The orientating examination of the accident victim is described, as is the "ABCD Rule" for treating respiratory insufficiency or circulatory arrest and shock, using heart massage and artificial respiration. Finally, medical first aid is described for special injuries, such as cerebral or thoracic trauma, fractures and burns. The psychological situation affecting the physician at the place of an accident is characterized.     

The emergency management of trauma

For effective care, the severely injured patient may require the cooperative effort of many physicians and paramedical personnel. In the individual with isolated maxillofacial injury, adequate management may be provided by one or several specialists. In any event, there should be a plan for emergency, semiurgent, and delayed treatment. It is also important for each individual caring for the patient to understand and appreciate the problems within and outside his area of expertise. There is a logical progression of evaluation, with particular attention to the more severe and significant area of trauma. Hemmorrhage, shock, and airway problems take priority. Often the definitive treatment, from a cosmetic and functional standpoint, is delayed.     

The physician perspective of health psychologists in medical settings.

Examined physician attitudes and utilization of psychologists in medical settings by administering a 15-item questionnaire to 397 26–78 yr old physicians (84% male) practicing family/general practice, surgery, internal medicine, or miscellaneous clinical medicine. Although differences in attitudes were associated with age, sex, and specialty, generally favorable attitudes toward psychologists were found among Ss. Results show a recognition by the majority of Ss of the role that psychological factors play in medical disease and an appreciation of clinical psychological skills by a large majority. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of medical training factors on physician utilization behavior

The purpose of this study is to determine the influence of medical school, teaching hospital, and specialization on physicians' use of clinical and technical resources. The universe of the study consists of 34 internists practicing in the prepaid gorup practice setting of Kaiser in Portland, Oregon. The data reported here show that physicians trained in medical schools and hospitals with a scientific medical orientation generally use fewer such resources than other physicians. However, under conditions of uncertainty, that is, when diagnosis is unknown, they tend to use more services. In other words, these physicians are conservative in theri use of resourses when ambiguity is low, and liveral when ambiguity increases. Graduates of the more scientifically oriented institutions seem therefore more flexible in adjusting to the demands of the disease situation.     

Communication between treating physician and occupational physician in the management of absenteeism

In case of an employee's absenteeism, both the treating physician and the company doctor possess relevant medical information. With a view to reducing absenteeism, exchange of data is considered important. Provision of data requires the consent of the patient/employee. If the latter is informed of the purpose for which the data are requested and of how they will be used, medical professional secrecy is not violated. In order to enhance the exchange of data between treating physician and company doctor, without bypassing the requirement of consent or cancelling the division between treatment and checking, the treating physician should be permitted to provide more information than just the data asked for in specific questions. This however requires the development of guidelines for careful consultation.     

The medical management of stroke

The management of stroke, so long a 'Cinderella' condition, is changing rapidly as new developments appear for acute treatment, rehabilitation and secondary prevention. Most patients with acute stroke now need rapid assessment at hospital following the onset of symptoms. Those needing admission should be managed on an acute stroke unit for stabilisation, CT scanning and other investigation, and diagnosis, and then referred, as appropriate, to a specialist stroke rehabilitation unit. Aspirin is now the recognised treatment for acute ischaemic stroke (once primary intracerebral haemorrhage has been excluded), and can be continued for secondary prevention. Attention should be paid to risk factors to prevent recurrence, especially treatment of hypertension, atrial fibrillation, and severe ipsilateral carotid stenosis. Patients with mild cerebrovascular disease should be managed in a specialist stroke/TIA clinic. Stroke is no longer an untreatable or unpreventable condition, and it is vital that hospitals design appropriate systems to manage patients in an interdisciplinary environment.     

The role of protocols and professional judgement in emergency medical dispatching

The task of evaluating incoming calls to Emergency Medical Services (EMS) systems in order to determine the most appropriate response is performed in many different ways in current EMS systems. At one end of the spectrum, the process is entirely dependent on the judgement of professionals, while at the other end protocols specify the exact questions to be asked and corresponding decisions. This case study describes the experience of the Montreal EMS system, Urgences santé, where professional telephone evaluation performed by nurses since 1981 was replaced by a protocolized system in 1992. During the professional era, there were many attempts to formalize the nurses' decision-making process. These first revealed that professional judgement tended to override decision-support tools that did not allow a flexible processing of the information spontaneously provided by callers. Second, the choice of a single protocol for each call was unnatural for professionals who could spontaneously integrate multiple aspects of a problem in parallel. Third, when protocols were used by professionals, it was a posteriori in order to document their decisions rather than actually support them. Fourth, the use of Artificial Intelligence (AI) methods in order to formalize professional judgement revealed its great complexity, which was confirmed by cognitive analyses of the nurses' decision-making processes. In particular, decisions of not sending EMS resources seemed to be the most difficult. These unsuccessful attempts at formalizing professional judgement led to an evaluation of its performance in terms of results, i.e. to which extent actual decisions minimized errors (both false positives and false negatives) and decision times. A random sample of 1006 calls was collected and the ideal decision was determined by concensus of experts for each call based on the patient's clinical condition. This theoretical decision was considered as a goal standard to which actual decisions were compared. Data analysis revealed that sensitivity of telephone triage (i.e. decision to send EMS resources or not) was almost perfect and specificity was 0.55. The necessary compromise between sensitivity and specificity varied with the types of decisions. Decision times were related to the urgency of the situations, more urgent calls being processed more rapidly. These results were interpreted as representing sophisticated optimization processes in professional judgement. The professional system was replaced by a non-professional protocolized system in 1992. This new system has not yet been formally evaluated in terms of results, but many sources of evidence suggest that it was accompanied by a deterioration of performance. Many contextual factors influence the organization of telephone assessment in EMS systems. This case study suggests that professional judgement may be most useful in contexts where the demand for EMS services often exceeds the availability of resources. On the other hand, protocolized systems may be more appropriate in the absence of such constraints, and where the litigation context prohibits the occurrence of any false negative.     

Patient-reported medical outcomes according to physician type and region

The purpose of the present study was to determine whether patients with common foot disorders have different medical outcomes depending on whether podiatrists, orthopedic surgeons, or other physicians provided their medical care in rural or urban areas. A validated medical effectiveness score was formulated using indirect standardization of risk-adjusted morbidity, based on patient reports from a national random household interview survey of 3,270 subjects. Patients in rural and urban areas did not differ significantly in medical outcomes across provider types, but there was a trend for patients in rural areas to have poorer outcomes. The medical effectiveness score of podiatrists was 3.9 times higher (indicating more beneficial outcomes) than that of orthopedic surgeons or other physicians (p < 0.01). Patients that visited podiatrists for common foot problems reported significantly more beneficial outcomes than those who visited other types of health care providers.     

Organization of emergency medical service

A total of 552 strains of Pseudomonas aeruginosa were obtained in 1970-1975 from different hospitals; the strains were isolated from various sources. Serotyping of these cultures was carried out with the aid of a set of agglutinating sera (20 in all) prepared by the author, and 97.5% of these cultures were typed. A high percentage of the strains belonging to the II, III, and IV serological groups and to the serotype 011 pointed to the epidemiological significance of these serological groups. The results obtained showed the expediency of introduction of the method of serological typing of the Ps. aeruginosa cultures into the public health practice for the purpose of epidemiological analysis.     

A minimum medical emergency kit

Medical emergency preparedness in dentistry has become too complicated with far too many drugs, devices, and diagnostic/therapeutic routines being recommended by various authors. This review will target practicality in the real world of clinical practice. Only four drugs or devices are recommended for the general practitioner by this author.     

Medical express ... physician practice management

There's a hot new acronym in town, and investors from Wall Street to your street are paying attention. Physician management companies--better known as PMCs--are the newest force in the health care market. But is this bigger-is-better approach alienating more people than it's attracting? And how long before the boom goes burst?