Can J Emerg Med
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Unique ethical issues arise in the practice of emergency medicine, and common ethical problems are often more difficult to address in the emergency department than in other medical settings. This article is Part 2 of the Series "Ethics in the Trenches" and it presents and analyses 2 cases--each dealing with an ethical challenge that emergency physicians are likely to encounter. The first case deals with patient refusal of care. ⋯ The second case deals with patient involvement in criminal activities. Emergency physicians often encounter patients who have engaged in illegal activities. Although certain activities must be reported, physicians should be mindful of their responsibility to protect patient privacy and confidentiality.
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A previously healthy 73-year-old woman presented to hospital with acute atrial fibrillation. After intravenous procainamide failed to restore sinus rhythm, she was treated with 300 mg of oral propafenone and discharged with a prescription for propafenone and propranolol. Six hours later she took 150 mg of propafenone as prescribed. ⋯ Hypertonic sodium bicarbonate (HCO3) was administered and, shortly thereafter, her blood pressure increased, her QRS duration normalized and her clinical status improved dramatically. In this case of severe refractory propafenone-related cardiac toxicity, intravenous HCO3 led to a profound clinical improvement. Emergency physicians should be familiar with the syndrome of sodium-channel blocker poisoning and recognize the potentially important role of bicarbonate in its treatment.
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Non-urgent visits comprise a significant proportion of visits to most emergency departments (EDs). Given the severe overcrowding issues faced by many EDs, the use of the Canadian Emergency Department Triage and Acuity Scale (CTAS) to identify patients who could be managed elsewhere seems to be an obvious way to reduce the pressure on the ED and "solve" the overcrowding problem. ⋯ Non-urgent patients consume a small fraction of the ED stretchers and acute-care resources; therefore, strategies aimed at diverting non-urgent patients are unlikely to improve access for more urgent patients. Using the CTAS to identify patients for diversion away from the ED is measurably unsafe and will lead to inappropriate refusal of care for many patients requiring hospital treatment.