Final Online Challenge

Your last challenge is to complete this course survey. It should take between 10 and 15 minutes to answer all of the questions, but I'd ask you to consider taking a little extra time to write more lengthy comments. My only compensation for teaching the course is the privilege of the experience. Think of your honest responses as the currency of my payment. We're looking for candid feedback so that future incarnations of the course will improve. The names of the participants will be kept separate from the answers, and your grade will not depend on your responses, except that we are asking that you complete the survey before we file your grades.

THANKS!

Week Nine Online Challenge

57 million Americans had trouble paying medical bills in 2007. This is up 33% from 2003. In four years, more than 14 million more people went into debt or were contacted by a collection agency about healthcare costs. Hundreds of hospitals nationwide are in the red. These seem like frightening statistics, but historically, numbers like these fail to make meaningful inroads in public policy. My opinion is that unless we link human stories to crises, our minds tend to neglect the seriousness of the problem. And unless concerned citizens (who are nurses, doctors and EMTs) contribute to the local and national conversations, health care reform will remain theoretical.

This week's challenge requires you to put on your activist hat. With emergency care in mind, post a comment that furthers the discussion of health care system reform. Your response could take a couple of forms.

• Write a case vignette that tugs at the heartstrings of a concerned populace.
• Respond to last week's news story from the University of Chicago. (A boy was reportedly sent home to follow up at another hospital after he was attacked by a pit bull.)
• Teach us about a part of the local health care safety net that we can plug patients into.
• Hypothesize about how the worsening economy may change emergency medicine.
• How has pre-hospital care been affected by the current health care crisis?
  

Keep in mind that you don't have to be a Democrat or Republican to be concerned about the health care system. There are plenty of ideas from both sides. In case you are wondering how this fits into a medical ethics class, try to think about your responses using the rights and justice terminology.

Week Eight Online Challenge

"Nobody's Perfect!"

So goes the saying to console friends and colleagues when we fall short of goals or expectations. Personally, I have the feeling that in medicine, not being perfect isn't good enough. For this week's challenge, we're inviting you to do one of two things:

1. Write an account of a mistake you made or observed in a clinical setting. You may simply describe the mistake or reflect upon it by listing implications, detailing feelings or citing the ethical principles at stake.
2. Answer this question: What is different about mistakes made by health care providers that makes us uncomfortable to admit to them?

My contribution requires you to go to a different website. Last July, I made a mistake in the ED that was an amazing learning experience. Read it here then find your way back to post your own comment.

Week Seven Online Challenge

This week's online challenge is more of an assignment. We haven't assigned much reading this week in the hope that you'll be able to read a little bit on line.

Visit ethnomed.org and read about one of the four following ethnic groups: Karen, Hmong, Somali, and Oromo. Choose a group you're not familiar with. Think about how family structure or culture-specific health issues might influence your interaction with such a patient. What would be different about your ED interaction with a patient from one of these groups? What additional resources would you need? Would your approach to care differ? If you can't think of a reply that is specific to the ED, post an interesting fact from what you read to educate the rest of us about a new culture.

Also, if you are not familiar with The Spirit Catches You and You Fall Down, by Anne Fadiman, here is a case (set in the ER) from that book that you will benefit from reading. (Click HERE!)

Finally, if you have time for some additional reading, consider following links to two other articles I found interesting during my own preparation for this week.

Conceptions of Pain Among Somali Women. Finnström B, Söderhamn O. J Adv Nurs. 2006 May;54(4):418-25.

Principlism vs. Narrative Ethics. McCarthy J. Med Humanit. 2003 Dec;29(2):65-71.

Week Six Online Challenge

This week's topic is Sexuality and STDs in the ED. There is no way that we will be able to cover all of the potential topics in our first hour's case and discussion. This is a topic that should not be new; I suspect that everyone in the class has either witnessed or discussed dilemmas related to gender, sexual health, terminations of pregnancy or harassment. This week's challenge is for you to practice setting up a dilemma.

In about 100 words, write a case related to STDs or sexuality. Be sure that all personal identifications are obscured, and give us a title that identifies your case.

Don't analyze the case for us, but when you write a case, it's important to be aware of which principles, rules or laws are central to its analysis. The case need not be set in the ER, nor need it be based on a personal story. It could even be a few sentences. Consider writing about something you have experienced OR something inspired by any of the readings.

Week Five Online Challenge

Our next topic is confidentiality. Your first thought probably is of HIPAA - that is probably what should come to mind. This week's challenge asks you to write about your own experiences with confidential medical information - in the ED or elsewhere.

Write a personal vignette of a time when you or someone else on the care team breached or almost breached a patient's right to confidentiality. Some things to write about include: What was the situation? Did you or anyone else do anything about it? How might this be avoided in the future?

I'll start off with one of my own stories in the first comment.

Week Four Online Challenge

Last week we talked mostly about the difference between withdrawing and withholding life-sustaining treatments, and touched a bit on surrogate decision makers, the challenge of interacting with families and what to do when it becomes clear that some medical approaches are futile. These are each topics that could consume an entire class, if not a whole quarter. It's reasonable that you feel like there are some loose ends!

This week's challenge offers a chance for each of you to do a little teaching about some of these difficult issues.

How do you break bad news? Write about one strategy you use (or could use) to talk with patients or families about death or a terminal diagnosis.

Update Jan 27, 2009: If this is an issue you are particularly interested in, there's a good article available about grief in the ER available on eMedicine. You may need to register for a free login with MedScape to read it.

Week Three Online Challenge

This week, we will discuss the topic of withholding medical treatment at the end of life. The readings identify issues related to living wills, while a previous blog post here introduces "Death with Dignity." This week's online challenge focuses on a topic closer to home: the cost of life sustaining treatment.

Many ethicists (especially those familiar with emergency medicine) argue there is no difference between withholding and withdrawing treatment. The point being that taking someone off the ventilator is the same as not intubating the patient in the first place. (Recall last week's challenge though: intubating in the ED may be the option that buys us time to make a decision...) Frequently, within the conversation about whether or not to withhold treatment is a cost/benefit analysis. This brings us to this week's question:

What are the costs involved in starting life-sustaining treatment in the ER?

Think both of who incurs the costs and what specific costs are involved. If you're stumped or if someone already posted your idea, refer to the four box framework for inspiration.

Week Two Online Challenge

Here's an online challenge on a topic we will come back to later in the course. Last week we talked about the 4 box method as a way to work through complicated ethical dilemmas. How long did it take to do one case at our first class? An hour! Will we have that kind of time in the emergency department? Of course not. But our approach right now is important to help with learning the basics. So what's next?

Kenneth Iserson is an emergency physician and bioethicist who has been writing about ethics in the ER for several decades. He has outlined a rubric for making decisions that consists of two questions:

1. Is this dilemma a type of ethical problem for which you have already worked out a rule, or is it at least similar enough that the rule could be reasonably extended to cover the situation? (Yes? --> USE THE RULE! / No? --> Ask question #2)
2. Is there an option which will buy you time for deliberation without excessive risk to the patient? (Yes? --> TAKE THAT OPTION! / No? --> Use a reliable reasoning technique.)

If you haven't already guessed, a primary goal of this class is to start building a set of rules that will allow you to answer "Yes!" to question 1 more often. One thing I think we should all think about, however, is:

What kind of delay tactics might be appropriate in question #2?

Week One Online Challenge

Each week, I'll be posting an online challenge a few days before class to help us all prepare for the two hours we spend together in class. Responding with comments will be a regular way for you to participate in online discussions, but is neither required, nor is it the only way you contribute. You are also encouraged to make your own posts. We'll talk more about this in class on Wednesday. So on to this week's challenge:

You've signed up for a class titled, "Ethics in the ER."

The first part of the challenge is to think of 3 words or phrases relevant to medical ethics. It's okay to repeat a previous poster's words, but push yourself to think of new contributions.

The second part of the challenge is to think of one way that medical ethics might be different in the emergency room.

You can answer one or both parts here. We'll be discussing what you come up with in class.