What's with the lights?

This is might seem a little bit off topic, but I thought that I would get other people's perspectives (including those of you who have worked in pre-hospital EMS), and I will bring it back to an ethical issue.

Why do AMR rigs drive with lights and sirens on?

At least in Seattle, Medic One provides first responder care to patients. The premise of using lights and sirens is that rapid arrival on scene of an incident will help to decrease mortality in emergent situations (although even this premise is debated). Since telephone triage is not 100% effective, unless it is absolutely clear that there is not a life threatening situation, Seattle Fire responds with lights and sirens going. And when it is clear that a life hangs in the balance, Medic One comes along with similar displays to encourage the motorist (as well as pedestrian and bicyclist) to move out of the way. Once on scene it is determined that the patient does not need ACLS certified transportation to the hospital, AMR (a private company providing ambulance transport in Seattle) is summoned. At this point someone (a paramedic or firefighter, occasionally via telephone conversation with a physician) had determined that a life threatening emergency does not exist and that the patient does not need to be transported post-haste to the nearest emergency room. Yet, AMR will arrive on scene with lights and sirens going.

For anyone that has witnessed the number of near miss accidents of been in an emergency vehicle rushing through a busy city, it is apparent how dangerous it is for the operators of the emergency response vehicle, let alone the citizenry. Despite this, someone has decided that it's okay for AMR to drive as fast as possible to a non-emergent scene. How does one balance the ethics of this response with the danger it exposes everyone too?

Just as a clarification: this is not to say that certain AMR rigs do not transport critically ill patients. Indeed, AMR in Seattle has pediatric critical care and adult critical care vehicles that provide inter-hospital transport (and occasionally from the helipad at Harborview to another hospital). Usually this is done without use of lights and sirens, as even though the patient is sick, they are already receiving appropriate care.

I have some ideas behind this, but wanted others to weigh in first.

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?

Psychiatric Holds

In the next class, we will be talking about issues in autonomy and consent. One really big issue within these topics is how to approach dilemmas that involve patients with mental illness. You may know that the Harborview ER has its own psych ward and psychiatrist (plus a resident) in house 24 hours a day. Not every emergency department will have such a resource. In fact, few do. Emergency providers must be familiar with the law, or at least with hospital procedures relevant to detaining a person.

Dr. Cooper will be giving a lecture on Wednesday about what is needed to establish consent. Needless to say, the mentally ill fall short on several accounts. (Can you name which?) The interesting thing is that each state defines autonomy differently. "5150" for example, refers to California's involuntary detainment statutes. We live in a state that is among the most protective of individual autonomy. It is very difficult to detain someone in Washington.

There are three ways to learn about Washington's system.

1. Read the law. Start here and here, and focus on this section and the laws referenced. Make sure you are caffeinated.
   
2. Look at a description not written in legalese. (This description of Washington's Involuntary Treatment Act is published by Snohomish County)
   
3. Have someone explain it to you. We can go over it in class.

One or two of our cases on Wednesday may deal with this issue, so if you have a chance to read about it, you'll be one step ahead.

Class Resources

Hi there everyone,

The reading assignments have been posted and are available in .pdf format at the course website, as is a copy of Dr. Cooper's case discussion outline and her example of a three page case writeup. If you have not signed up for the blog yet, please do so before Wednesday. If you have questions, read this intro to the blog.

ALSO, We'll be posting the lecture outlines and supplemental material at an Ethics in the ER Catalyst Workspace. Up now are two handouts Dr. Fryer-Edwards made about the four box method and ethics frameworks. They will be good resources for you when you prepare your discussions and write your final assignment.

Have a great weekend.

Welcome to the Ethics in the ER Blog

Welcome to the course blog for MHE 597E: Ethics in the ER. We are requiring course participants to make one entry or comment a week. This may seem daunting for folks not used to blogs or blogging, but I think you will find it pretty easy. This post is meant to provide you with some basic instructions about making entries on this blog. (It will stay at the top of the queue for a week.)

Is This Blog Private?

You may have concerns about blogs as a public repository of ideas. Statements made on blogs, in social networking sites, or on personal websites have lives of their own. They persist, even after the site is deleted. As such, it is important to us that this be an environment where your comments are safe and freely offered. Using the Blogger program, you may select an an anonymous user name or may use your name (like I do). There are benefits to both options - the main one for me using my real name is that I want the credit and accountability for what I write. It's a good habit to get into thinking that what you post will be visable to all, but if you are on the fence at all, I recommend you choose an anonymous name. (Be sure to email me your name so that you get credit for your posts!) This blog will be publicly accessible, but only class participants will be able to post new entries.

Getting Started:

Blogger is owned by (surprise!) Google. This means that you will need a Google account to use the blog. If you already have a Gmail address, you can use that one, but be aware that your email may be linked to your user name. If you want to be fully anonymous, consider making a second Google account with a separate email address. (You can even use your u.washington.edu address. Your username can still be a pseudonym.) Set up your user name by following this link, or just follow the directions in the invitation email you received on 1/3. When you make your blogger profile, the name you use to post and your first and last name fields are each different. If you want to be anonymous, you do not have to use your real name.

Once you have an account, check out your dashboard. You have received an invitation to join the Ethics in the ER blog, and should see it here. If there is any step that doesn't work out, this will be the one. Email Thomas if you cannot get to this step, or we can sort it out on Wednesday after class. Every time you log in, you can use the dashboard to view the blog or make a new post.

Post Content:

You can reply to a comment by clicking on the "X Comments" link at the end of the post or make a new post by clicking "New Post" at the top of the screen.

So now that you have an account, what exactly do you post? For guidance, we make the following suggestion (from the syllabus):

Each week, instructors will post a vignette or news story relevant to emergency medicine or medical ethics. Students are asked to type one response to this topic or to the assigned reading. Entries may take many forms. We expect to receive entries similar to what is found on other blogs: reviews of the reading, ‘ah-ha’ moments, questions you are left with, rants about politics, an account of a relevant patient encounter, a poem, or links to other stories or internet resources. When possible, entries should include concepts learned from class.

One final note is that HIPPA compliance does not stop with blogging. It is important that you maintain confidentiality if you ever refer to anything associated with a patient encounter. For tips on how to do that, you can consult the Healthcare Blogger Code of Ethics. I (Thomas) will be your point person for questions about blogging or the blog, so feel free to send me an email at any time, or post a comment below.

Happy blogging!

Jan 7 Helpful Links

A couple of resources that will be very helpful to you through the class are available at the UW Ethics in Medicine page that is maintained by the Department of Bioethics and Humanities. I've linked the general resource page in the upper right of this blog, but you may want to bookmark it yourself.

In specific, check out the four links under the Clinical Ethics bullet. There is a link to the four box method and one example of how to write a simple case discussion. We will provide you with another in the near future.

See you in a few hours!

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.