We present four medicolegal cases involving medication errors, which led to patient harm and subsequent settlements or jury awards to patients. These cases each involved scenarios in which a medication was inappropriately prescribed and/or inappropriately dispensed. In such cases, it is often not obvious whether the physician or pharmacist is at fault. These cases highlight the importance of understanding the roles and responsibilities of the physician and pharmacist in medication prescription and dispensation.
Study Objectives: Awake intubations are commonly performed in the OR for high-risk airways and include the use of topical anesthesia often augmented by lowerdose sedative agents. The rate of use of "awake" techniques, indications, devices employed, and outcomes are not known in ED populations. We sought to describe the current spectrum of awake intubation practices in the ED setting and report success rates, devices used, and rescue techniques in this population.Methods: We analyzed data from the National Emergency Airway Registry (NEAR), a multicenter prospective observational registry of 25 community and academic emergency departments. Patients with an awake intubation attempt, defined by use of topical airway anesthesia, between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with clusteradjusted 95% confidence intervals (CIs).Results: Of 19,071 discrete patient encounters, an awake technique was used on first attempt in 82 (0.4%) patients. The median patient age was 59 years (IQR 46-67) and 27 (33%) were female. Angioedema (32%) and non-angioedema airway obstruction (31%) were the most common indications. Emergency physicians performed 90% of first attempts. The most common initial devices were a flexible endoscope (78%) followed by the GlideScope video laryngoscope (7%). A nasal route was used in 56 (68%) cases. A combination of sedative and topical medications were used in 42 (51%) cases, while topical anesthesia alone was used in 40 (49%) cases. The most common sedative used was ketamine (41%). The first-attempt success rate for all awake intubations was 85% (95% CI [76%-95%]). Nasal first attempts were successful in 91% (95% CI [80%-97%]) versus 73% of oral first attempts (95% CI [52%-88%]). Success with flexible endoscopes via nasal and oral routes was 93% (95% CI ) and 50%, (95% CI [19%-81%]), respectively. Rigid video laryngoscopes via oral route were successful in 8 of 9 patients (89%, 95% CI [45%-100%]). First-attempt success among those receiving only topical agents was 90% (95% CI [70%-98%]); among those with topical plus sedative agent use first-attempt success was 81% (95% CI [64%-92%]). The most common device used for rescue technique was a flexible endoscope, which was used in 5 of 12 cases (47%). Hypoxia was the most common adverse event and occurred in 10 cases (12%). One patient required a rescue surgical airway. Ultimate success was 100%.Conclusion: Awake intubations in the ED are uncommon and are done most often in patients with airway swelling or obstruction. Emergency physicians performed the majority of first intubation attempts with high first-attempt success. Nasal and oral routes with flexible and rigid video laryngoscopic equipment were used. Rescue cricothyroidotomy was performed once.
Introduction Social determinants of health (SDoH) are known to impact the health and well-being of patients. However, information regarding them is not always collected in healthcare interactions, and healthcare professionals are not always well-trained or equipped to address them. Emergency medical services (EMS) professionals are uniquely positioned to observe and attend to SDoH because of their presence in patients’ environments; however, the transmission of that information may be lost during transitions of care. Documentation of SDoH in EMS records may be helpful in identifying and addressing patients’ insecurities and improving their health outcomes. Our objective in this study was to determine the presence of SDoH information in adult EMS records and understand how such information is referenced, appraised, and linked to other determinants by EMS personnel. Methods Using EMS records for adult patients in the 2019 ESO Data Collaborative public-use research dataset using a natural language processing (NLP) algorithm, we identified free-text narratives containing documentation of at least one SDoH from categories associated with food, housing, employment, insurance, financial, and social support insecurities. From the NLP corpus, we randomly selected 100 records from each of the SDoH categories for qualitative content analysis using grounded theory. Results Of the 5,665,229 records analyzed by the NLP algorithm, 175,378 (3.1%) were identified as containing at least one reference to SDoH. References to those SDoH were centered around the social topics of accessibility, mental health, physical health, and substance use. There were infrequent explicit references to other SDoH in the EMS records, but some relationships between categories could be inferred from contexts. Appraisals of patients’ employment, food, and housing insecurities were mostly negative. Narratives including social support and financial insecurities were less negatively appraised, while those regarding insurance insecurities were mostly neutral and related to EMS operations and procedures. Conclusion The social determinants of health are infrequently documented in EMS records. When they are included, they are infrequently explicitly linked to other SDoH categories and are often negatively appraised by EMS professionals. Given their unique position to observe and share patients’ SDoH information, EMS professionals should be trained to understand, document, and address SDoH in their practice.
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