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At a time in which the integrity of the medical profession is perceptibly challenged, emergency physicians (EPs) have an opportunity to reaffirm their commitment to both their patients and their practice through acceptance of a virtue-based ethic. The virtue-based ethic transcends legalistic rule following and the blind application of principles. Instead, virtue honors the humanity of patients and the high standards of the profession. Recognizing historical roots that are relevant to the modern context, this article describes 10 core virtues important for EPs. In addition to the long-recognized virtues of prudence, courage, temperance, and justice, 6 additional virtues are offered unconditional positive regard, charity, compassion, trustworthiness, vigilance, and agility. These virtues might serve as ideals to which all EPs can strive. Through these, the honor of the profession will be maintained, the trust of patients will be preserved, and the integrity of the specialty will be promoted. are often linked to malpractice claims, outcome data, economic profiling, and, even more recently, the ability to follow practice guidelines. Although following rules and optimizing technical outcomes are important, they say little about the physician's character. Character, or virtue, is an ancient concept that is often not well articulated in our modern conception of the complete emergency physician (EP). We assert that virtue is central to the practice of emergency medicine (EM) and that there are specific, identifiable virtues that the practitioner should possess. CHARACTER AND VIRTUEEthike, the Greek word for ''character,'' forms the etymological root and philosophical basis of the classical Western notion of ethics. For the ancients, character and virtue were inextricably intertwined. Homer's Iliad contains an early depiction of character (ethike) and virtue (arete). In it, the heroes of the Trojan War are animated by their quest for virtue, or attempts to achieve perfection. Homer used the Greek word arete to describe not only virtue, but all characteristics that enable an individual to achieve excellence in the performance of their duties.The ancient Greek notion of character and virtue was most highly developed by Aristotle around 330 BC. In The Nichomachean Ethics, Aristotle states that the exercise of virtue is necessary to live a good and happy life.1 Virtues are dispositions to be good. They include not only good actions, but also good thoughts and good feelings. Aristotle further described virtue or character as the golden mean between deficiency and excess. Courage, e.g., was described as the mean between foolhardiness and cowardice. Like Socrates and Plato before him, Aristotle regarded courage, justice, prudence, and temperance to be the four cardinal virtues. The struggle for optimal balance in one's life was the struggle for virtue. His concept was that virtue must be practiced to find the balance; it must be cultivated for moral behavior to become a habit. 2,3Virtue-based ethical concepts remained i...
Objective: This study aimed to identify the patient characteristics, history factors, physical examination findings, and sonographic findings, which contribute to a higher risk of the appendix not being visualized on ultrasound evaluation (ie, nondiagnostic or equivocal study) in patients being evaluated for appendicitis. Secondarily, this study assessed the utility of an equivocal ultrasound, specifically in the ability to predict the absence of appendicitis.Methods: A retrospective case review was performed, of children (age, 0-18 years) presenting to a pediatric emergency department with clinical suspicion for appendicitis, who underwent sonographic studies during the 12-month study period.Results: Five hundred forty-three cases were reviewed, of which 75 (14%) were diagnosed with appendicitis. The sensitivity of ultrasound diagnosis of appendicitis was 62.7% and specificity was 79.1%. The appendix was not visualized in 398 (73%) cases. Of the cases where the appendix was not visualized, 370 did not have appendicitis (negative predictive value, 93%). In cases where the appendix was not visualized and the white blood cell count was less than 10,000, the negative predictive value rose to 97%. The patient's age (odds ratio [OR], 1.049), weight (OR, 1.015), presence of appendicolith (OR, 0.426), presence of right lower quadrant fat stranding on sonography (OR, 0.081), and presence of hyperemia on sonography (OR, 0.094) were found to be significant in affecting the visualization of the appendix on ultrasound.Conclusions: Increasing patient's age and weight leads to increased likelihood that the appendix will not be visualized on ultrasound, whereas the presence of an appendicolith, right lower quadrant fat stranding or hyperemia will increase the likelihood of visualization. The sensitivity and specificity of ultrasound for the diagnosis of appendicitis are moderate but the negative predictive value of an equivocal study is high. Clinicians can use supporting clinical examination and laboratory findings, in conjunction with a nondiagnostic ultrasound evaluation of the appendix to exclude the diagnosis of appendicitis, without the need for further imaging.
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