Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Nov 2009
ReviewTriage, EMTALA, consultations, and prehospital medical control.
Medical control of prehospital emergency services, triage in the emergency department, and the dual duties within the Emergency Medical Treatment and Active Labor Act challenge emergency medicine physicians with both statutory obligations and liabilities. Each independently may seem to present a definable boundary of liability for the practitioner. Under the Emergency Medical Treatment and Active Labor Act, the sequential duties of the medical screening examination and subsequent stabilization or transfer are confounded by the potential for tremendous sanction for a mechanistic violation. Nevertheless, the true obligation is to provide appropriate care to all who present to the emergency department and not simply weigh the totality of risk to the emergency medicine physician.
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Patients presenting to the emergency department (ED) with behavioral disturbances account for approximately 6% of all ED visits. Emergency physicians are often responsible for the initial assessment of these patients' psychiatric complaints, which might include homicidal and suicidal behavior and acute psychosis. ⋯ The purpose of the medical screening is to identify medical conditions that might be causing or contributing to the psychiatric emergency or that might be dangerous or inappropriate to treat in a psychiatric facility. Appropriate treatment in the ED is essential to avoid morbidity and mortality resulting from misdiagnosis of medical conditions as psychiatric illnesses and from mismanagement of psychiatric illnesses.
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Emerg. Med. Clin. North Am. · Nov 2009
ReviewHigh-risk chief complaints I: chest pain--the big three.
Chest pain is one of the most frequently seen chief complaints in patients presenting to emergency departments, and is considered to be a "high-risk" chief complaint. The differential diagnosis for chest pain is broad, and potential causes range from the benign to the immediately life-threatening. ⋯ Several atraumatic "high-risk" causes of chest pain are discussed in this article, including myocardial infarction and ischemia, thoracic aortic dissection, and pulmonary embolism. Also included are brief discussions of tension pneumothorax, esophageal perforation, and cardiac tamponade.
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The combative or uncooperative patient is a growing problem in the emergency department. Restrained patients are at especially high risk of adverse outcomes. Particular attention has been given to de-escalation techniques to reduce the need for patient restraint. This article examines these techniques and the need for and risks of physical and chemical restraints in managing patients in the emergency department.