Avoiding Common Errors in the Emergency Department - Book 2

patient population. The most recent update to the American Heart
Association guidelines for prevention of IE does not mention antibiotic
prophylaxis for wounds that have no signs of infection. Similarly, the
American Academy of Orthopedic Surgeons (AAOS) has no
recommendation for wound prophylaxis to prevent prosthetic joint infections
(PJI). The AAOS has recommended against antibiotic prophylaxis for dental
procedures, as there is no evidence it prevents PJI (Table 347.1).

TABLE 347.1 ANTIBIOTIC PROPHYLAXIS SUMMARY

aG+, gram-positive; G−, gram-negative; A, anaerobes.
bProphylactic courses range from 3 to 5 days, no optimal duration has been determined.

KEY POINTS

Antibiotic prophylaxis is no substitute for good wound care.
Healthy patients with clean, simple wounds do not benefit from
prophylactic antibiotics.
Consider patient and wound factors when determining the need for
prophylactic antibiotics.
Wounds associated with fractures require urgent antibiotic
prophylaxis.

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Prophylaxis for IE is not beneficial for simple wounds.

SUGGESTED READINGS

Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds:
A meta-analysis of randomized studies. Am J Emerg Med. 1995;13(4):396–400.

Hoff WS, Bonadies JA, Cachecho R, et al. East Practice Management Guidelines
Work Group: Update to practice management guidelines for prophylactic
antibiotic use in open fractures. J Trauma. 2011;70(3):751–754.

Mark DG, Granquist EJ. Are prophylactic oral antibiotics indicated for the
treatment of intraoral wounds? Ann Emerg Med. 2008;52(4):368–372.

Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane
Database Syst Rev. 2001;(2):CD001738.

Raz R, Miron D. Oral ciprofloxacin for treatment of infection following nail
puncture wounds of the foot. Clin Infect Dis. 1995;21(1):194–195.

1449

348

DO NOT MISS A FOREIGN BODY IN
A WOUND

JASON W. WILSON, MD, MA AND CONSTANTINO DIAZ,
MD

Wounds account for ~5% of all emergency department (ED) visits. These
injuries are at high risk of contamination and retained foreign body. Retained
foreign bodies predispose to infection and can migrate and cause injury to
nearby critical structures. It is crucial to identify and remove, if possible, a
foreign body in order to improve patient outcome. Importantly, improper
wound care and the failure to identify a foreign body account for a
substantial number of legal claims against emergency physicians (EPs). A
recent review of closed medical malpractice claims demonstrated that
retained foreign bodies and contaminated wounds represented 11% to 20% of
successful litigation against EPs.

The most common foreign bodies found in wounds are glass, wood,
bone, teeth, bullets, metal, gravel, shell, rock, and plastic. Each object has
properties that affect the ability to detect them using various imaging
modalities. Often, foreign bodies are defined as radiopaque or radiolucent.
However, recent literature has shown that these are relative terms and depend
on the depth of the foreign body within the wound.

Imaging modalities used for the detection of foreign bodies include plain
films (XR), ultrasound (US), computed tomography (CT), and magnetic
resonance imaging (MRI). Recently, MRI has been shown to have decreased
sensitivity in the detection of foreign bodies due to artifact created by the
foreign material. A common theme in successfully litigated cases of missed
wound foreign bodies is the failure to obtain diagnostic imaging during the
initial ED visit.

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An XR should be obtained in any patient when a foreign body is
suspected, especially glass. Glass is often apparent on an XR. Be sure to
order multiple views of the wound area. When multiple views are obtained,
XR can detect a glass fragment >2 mm over 99% of the time. Most metals,
bone, and select plastic materials are also detectable on XR. Thin pieces of
aluminum, however, may be missed by XR since the anatomic number is
close to that of the surrounding tissues. CT should be considered when a
foreign body is suspected but not seen on XR. CT should also be considered
when the foreign body is deep, close to critical anatomic structures, or when
surgery is planned for removal.

US is a noninvasive and cost-efficient approach for the detection and
removal of foreign bodies. In fact, US is very sensitive for the identification
of wood fragments that are larger than 5 mm. If a patient presents soon after
injury, wood can appear bright and echogenic on US. If a patient presents
more than 24 hours after injury, a hypoechoic rim is typically seen around
the wood fragment. Glass and metal foreign bodies can also be detected
using US and appear as echogenic structures with reverberation artifact. Use
the high-frequency linear US transducer (10 Hz) in an “in-plane” orientation
to achieve the highest likelihood for foreign body detection. The local
administration of lidocaine may also enhance the appearance of the foreign
body. In addition, the use of a water bath can improve sound wave
conduction and help identify soft tissue foreign bodies.

In some patients, a foreign body might be highly suspected but not
visualized on diagnostic imaging or direct visualization of the wound. In
addition, a foreign body may be located in a precarious position where the
risks of removal might outweigh the benefit. In these situations, the patient
should be counseled regarding the possibility of a infection and asked to
return within 48 hours for a wound check or sooner if fever, erythema,
purulent discharge, and worsening pain develops. While antibiotics are not
prescribed for patients with a simple laceration, those with retained foreign
bodies are at higher risk of infection and may warrant prophylactic antibiotic
therapy.

KEY POINTS

A retained foreign body can lead to poor patient outcomes and
represents a high medicolegal risk for the provider.
An XR with multiple views should be ordered when there is concern
for a retained foreign body.

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XRs readily identify retained glass if the fragment is >2 mm in size.
CT and US are additional diagnostic imaging modalities that can be
used to evaluate the presence of a foreign body.
Antibiotic prophylaxis may be indicated in patients with retained
foreign bodies when the object cannot be removed.

SUGGESTED READINGS

Halverson M, Servaes S. Foreign bodies: Radiopaque compared to what? Pediatr
Radiol. 2013;43:1103–1107.

Ingraham CR, Mannelli L, Robinson JD, et al. Radiology of foreign bodies: How
do we image them? Emerg Radiol. 2015;22:425–430.

Jarraya M, Hayashi D, de Villiers RV, et al. Multimodality imaging of foreign
bodies of the musculoskeletal system. AJR. 2014;203:W92–W102.

Kaiser CW, Slowick T, Spurling KP, et al. Retained foreign bodies. J Trauma.
1997;43:107–111.

Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: What are the risks for
infection and has the golden period of laceration care disappeared. Emerg Med
J. 2014;31:96–100.

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349

KNOW HOW TO TREAT
MAMMALIAN BITES

CHRISTOPHER I. DOTY, MD, FAAEM, FACEP

Patients seeking treatment for a mammalian bite is a common occurrence in
the emergency department (ED) and is estimated to account for 1 million ED
visits each year in the United States. The true incidence of mammalian bites
is unknown, as many patients do not seek treatment for injuries sustained
from known animals (i.e., pets and neighborhood animals). In addition, many
states do not have mandatory reporting of mammalian bites. It is estimated
that only 50% of patients suffering a mammalian bite present to the ED for
treatment.

The vast majority of bites seen in the ED are from canines. Feline bites
account for <10% of visits. It is believed that feline bites are significantly
underreported because most of these bites are from the patient’s pet. Canine
and feline injuries are often bites to the hands or arms and rarely cause
significant tissue destruction. Larger breeds, particularly large terrier breeds
and canines trained as law enforcement animals, can cause extensive soft
tissue destruction, fractures, and crush injuries. Feline bites are more likely to
cause puncture wounds, while only a third of canine bites are puncture
wounds. A puncture wound should prompt the provider to increase the
amount of fluid used for wound irrigation.

Infection is nearly universal with mammalian bites, as the mammal’s
mouth is teeming with bacteria. However, most of these infections heal well
without antibiotics or debridement. Studies have shown a wide variation in
infection rates ranging from 1.44% to 30%. It is important to remember that
most ED patients present due to bites from a stray canine, bites with
significant soft tissue injury, or bites that are already clinically infected. Cat
bites that present to the ED are more likely to be infected upon presentation.

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Talen et al. showed that both canine and feline bites are polymicrobial, with
staphylococcus, streptococcus, and pasteurella being the most predominant
organisms.

Not all mammalian bites require treatment with antibiotics. However,
recent meta-analyses and systematic reviews have demonstrated that
prophylactic antibiotics do show benefit in select circumstances. Mammalian
bites to the distal extremities, particularly the hand, show a significant
reduction in clinically relevant infections if treated with a proper antibiotic
regimen. Furthermore, bites sustained from humans showed a decreased risk
of clinically relevant infection if treated with antibiotics as well. One study
demonstrated a strong trend for decreased infections in feline bite wounds if
treated with antibiotics, but the data did not reach statistical significance. It is
critical to remember that all of these meta-analyses and systematic reviews
are based on several small, flawed studies. Better evidence for the utility of
antibiotics in these patients does not presently exist. The most recent
evidence supports treating all mammalian bites to the distal extremities and
all bites from humans. Patients with select clinical characteristics of high-risk
wounds should also be considered for antibiotics. These characteristics are
listed in Table 349.1. Importantly, antibiotics should cover β-lactamase–
producing bacteria.

TABLE 349.1 CLINICAL CHARACTERISTICS OF HIGHER-RISK BITE
WOUNDS

All mammalian bites should receive analgesia, copious irrigation, assessment
for tetanus prophylaxis, and potential rabies treatment. Complex wounds
should receive higher amounts of irrigation. It is recommended that
mammalian bite wounds should not be closed primarily, but this is
sometimes impractical with large or cosmetically highly visible wounds.

FIGHT BITES

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It is critical for emergency physicians to realize that tooth injuries to the
metacarpal phalangeal (MCP) joint or “fight bites” should be treated more
aggressively than other human bites. These injuries occur when the patient
strikes another person in the mouth with a closed fist. The clinical concern is
the inoculation of the superficial tendon and sheath as it passes over the
dorsal, extensor surface of the MCP joint. A closed fist has the extensor
tendons at maximal length. The damaged and contaminated tendon then
retracts up the sheath carrying saliva and bacteria with it. A small MCP skin
laceration can appear innocuous but a significant infection may be evolving.
A suggestive history in the presence of even a small MCP skin defect should
prompt a thorough evaluation. “Fight bites” have an infection rate up to 75%.
Approximately 60% have deep structure involvement including tendon
injury, joint involvement, and fractures. These injuries should be washed out
in the ED or in the operating room and should be seen by a hand surgeon
emergently.

KEY POINTS

The more complex the wound, the more it should be irrigated.
Antibiotics should be reserved for bite wounds that occur on the distal
extremities and any bites by humans.
All lacerations at the MCP joint should be considered a “fight bite.”
Consider rabies prophylaxis in all mammalian bites.
Proper antibiotic coverage for mammalian bites should include
medications to cover β-lactamase–producing bacteria.

SUGGESTED READINGS

Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites (Cochrane
Review). The Cochrane Library. 2001;2.

Nakamura Y, Daya M. Use of appropriate antimicrobials in wound management.
Emerg Med Clin North Am. 2007;25(1):159–176.

Phair IC, Quinton DN. Clenched fist human bite injuries. J Hand Surg Br.
1989;14(1):86–87.

Shewring DJ, Trickett RW, Subramanian KN, et al. The management of clenched
fist ‘fight bite’ injuries of the hand. J Hand Surg Eur. 2015;40(8):819–824.

Talan DA, Abrahamian FM, Morgan GJ, et al.; Emergency Medicine Human Bite
Infection Study Group. Clinical presentation and bacteriologic analysis of
infected human bites in patients presenting to emergency departments. Clin
Infect Dis. 2003;37(11):1481–1489.

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350

IS THAT SKIN LESION AN
INFECTION OR AN ENVENOMATION?

SPENCER GREENE, MD, MS, FACEP, FACMT AND
VERONICA TUCCI, MD, JD, FAAEM

Patients frequently present to the emergency department (ED) with a chief
complaint of “spider bite.” The likelihood that a skin lesion is due to a spider
often depends on where the patient lives. The majority of lesions attributed to
spiders are actually cutaneous abscesses, cellulitis, or other soft tissue
conditions such as vasculitis, neoplasms, chemical burns, and venous stasis
ulcers. The challenge for the emergency provider (EP) is to recognize the
patient with a true spider bite, as the management is very different from the
treatment of more common soft tissue conditions.

There are an estimated 4,000 spider species in the United States (US).
Importantly, only several species cause clinically significant reactions in
humans. The most important are Latrodectus mactans, the black widow
spider, and Loxosceles reclusa, the brown recluse spider. The black widow
spider is found throughout the US. Envenomation produces systemic toxicity
rather than significant cutaneous findings. As a result, it is uncommon for the
EP to confuse skin infections with black widow envenomation. In contrast,
Loxosceles envenomation often produces significant cutaneous
manifestations with or without systemic involvement. The remainder of this
chapter will focus on the brown recluse spider bite.

Distinguishing a brown recluse spider bite from a cutaneous infection
can be challenging. Brown recluse spiders are found in the south central US,
especially in Arkansas, Missouri, and Kansas. Less common recluse species
(i.e., L. deserta, L. arizonica, L. blanda, L. apachea, L. devia) are confined to
the southwest. Patients living outside of these endemic areas are unlikely to

1456

have a brown recluse bite. For patients who live in endemic regions, it is
important to accurately identify the spider, if possible. L. reclusa vary in
size; however, the body is usually 2 to 3 cm long. The eight legs may each
extend up to 20 mm. The distinguishing feature of a brown recluse spider is
the violin-shaped marking on the dorsal cephalothorax. Brown recluse
spiders also possess six eyes, whereas most other spiders have eight eyes. It
is important to remember, however, that proximity to a brown recluse spider
does not mean that the spider is responsible for the patient’s signs and
symptoms.

Brown recluse spider bites present with local findings that follow a
predictable course. The bite itself causes little to no pain. A nonpurulent
blister soon appears, followed by surrounding erythema that spreads in a
gravitational pattern. Over the next 2 to 3 days, wound discomfort,
induration, and edema develop. An area of central necrosis appears in ~50%
of patients between days 2 and 4. Concentric rings of ischemia and erythema,
resulting in a “red, white, and blue” appearance, often surround the necrotic
area. Over the next few days, an eschar develops over the necrotic area,
which typically heals over a period of weeks. Lymphangitis and purulent
drainage are not characteristic of brown recluse bites. Importantly, incision
or excision of a brown recluse bite is associated with increased pain, delayed
wound healing, and a higher incidence of infection.

In contrast to a brown recluse spider bite, cellulitis is erythematous and
often exquisitely tender. Lymphangitis may also be seen. Cutaneous
abscesses are generally fluctuant and may spontaneously drain purulent
material. Ultrasound is useful for distinguishing and abscess from cellulitis.
Severe soft tissue infections may appear violaceous, have gas or crepitus in
the subcutaneous tissue, and have signs of systemic toxicity.

On occasion, brown recluse envenomation may cause systemic
manifestations such as fever, myalgias, nausea, and vomiting. Systemic
loxoscelism is characterized by a rapidly progressive scarlatiniform rash,
abdominal pain and tenderness, and hemolysis. Children are especially
susceptible to the effects of this hemolysis, which can lead to profound
anemia, cardiovascular collapse, and death. Systemic loxoscelism must be
treated aggressively.

Laboratory tests are not helpful in confirming the diagnosis of a brown
recluse bite. In cases of systemic loxoscelism, anemia, thrombocytopenia,
increased urinary hemoglobin, decreased haptoglobin, renal dysfunction,
hepatic dysfunction, and coagulation abnormalities may be noted.

It is essential for the EP to be able to identify a brown recluse spider bite.
While most bite wounds will heal spontaneously, 15% to 20% may require

1457

skin grafting several weeks after the envenomation. Antibiotics are
unnecessary for a brown recluse bite. Evidence for the use of the dapsone in
brown recluse envenomation is scant. In addition, dapsone has significant
side effects that include methemoglobinemia, cholestatic jaundice, and
hypersensitivity reactions.

KEY POINTS

Brown recluse spider bites are restricted to select geographical regions
of the United States.
A brown recluse spider bite presents with a small, nonpurulent blister,
which develops into a central area of necrosis surrounded by
concentric rings of ischemia and erythema.
The area of central necrosis forms an eschar within the first week and
typically heals spontaneously over the ensuing weeks.
Brown recluse spider bites do not produce fluctuant, purulent lesions.
Systemic loxoscelism is characterized by a rapidly progressive rash,
abdominal pain, and hemolysis.

SUGGESTED READINGS

Rogers KM, Klotz CR, Jack M, et al. Systemic loxoscelism in the age of
community-acquired methicillin-resistant Staphylococcus aureus. Ann Emerg
Med. 2011;57(2):138–140.

Swanson DL, Vetter RS. Bites of brown recluse spiders and suspected necrotic
arachnidism. N Engl J Med. 2005;352(7):700–707.

Vetter RS. Arachnids submitted as suspected brown recluse spiders (Araneae:
Sicariidae): Loxosceles spiders are virtually restricted to their known
distributions but are perceived to exist throughout the United States. J Med
Entomol. 2005;42(4):512–521.

Wasserman GS, Siegel C. Loxoscelism (Brown Recluse Spider Bites): A review of
the literature. Clin Toxicol. 1979;14:353–358.

Wright SW, Wrenn KD, Murray L, et al. Clinical presentation and outcome of
brown recluse spider bite. Ann Emerg Med. 1997;30(1):28–32.

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351

KNOW HOW TO TREAT SNAKE
BITES

FREDERICK C. BLUM, MD, FACEP, FAAP, FIFEM
AND SHABNAM NOURPARVAR, MD

There are ~9,000 snakebites annually in the United States (US). Although
snakebites are an uncommon emergency department (ED) complaint, it is
imperative to know how to properly treat snakebite victims to avoid
unnecessary morbidity and mortality.

There are more than 100 species of snakes indigenous to the US.
Thankfully, only about 20 species are venomous snakes. Most of these
venomous snakes belong to the Viperidae (sub-family Crotalinae) or
Elapidae family. Crotaline snakes (i.e., rattlesnake, copperhead, moccasin)
are commonly called “pit vipers” and account for nearly all the venomous
snakebites in the US. Pit vipers have a triangular head, elliptical pupils, and a
pair of small, heat-sensing pits between each eye and nostril. Up to 25% of
pit viper bites do not result in envenomation, commonly referred to as a
“dry” bite. Coral snakes are the most well-known member of the Elapidae
family of venomous snakes. These are brightly colored with black, yellow,
and red rings. The phrase “red on yellow, kill a fellow; red on black, venom
lack” is often used to differentiate coral snakes from the nonvenomous king
snake. There are no venomous snakes indigenous to Alaska, Hawaii, or
Maine.

The majority of snakebites are limited to the subcutaneous tissues. Only
rarely does a bite reach deeper tissues. When venom is injected, it travels
along the lymphatic system and superficial veins to reach the central
circulation. Rapidly fatal envenomation can occur if venom is injected
directly into a vessel. Crotaline venom causes direct cell damage, capillary

1459

leak, a consumptive coagulopathy and, to a lesser extent, neurotoxicity.
Clinical symptoms range from local symptoms to life-threatening systemic
reactions. Local symptoms include pain, erythema, edema, or ecchymosis at
the bite site. Systemic symptoms include nausea, vomiting, lethargy,
weakness, and perioral and extremity paresthesias. Hypotension, tachypnea,
respiratory distress, tachycardia, altered mental status, renal failure, and
death may also be seen in severe reactions. Rattlesnake bites often result in a
consumptive coagulopathy, as manifested by elevations in the international
normalized ratio (INR), prothrombin time, and fibrin degradation products.
Thrombocytopenia (<20,000 cells/mm3) is also characteristic.

Coral snake venom is an α-neurotoxin. This toxin blocks postsynaptic
nicotinic acetylcholine receptors at the neuromuscular junction. Fang marks
are often difficult to see, and there are often minimal local findings.
Immediate symptoms may include numbness at the bite site. Cranial nerve
abnormalities can be seen and include ptosis, dysarthria, and dysphagia.
Respiratory paralysis can also develop. Systemic symptoms can be delayed
for up to 12 hours but are difficult to reverse once present.

Prehospital treatment of the snakebite victim includes immobilization of
the affected body part, avoidance of excessive activity, and transportation to
a local hospital. The affected limb should be maintained at the level of the
heart. All jewelry and constrictive clothing should be removed. Arterial
tourniquets, aggressive wound incisions, and ice are no longer recommended.
A wide band proximal to the bite site compressing only superficial vessels
may be applied and left in place until the patient reaches definitive medical
care. Immobilization and compression have been shown to be helpful in
Elapidae snakebites but remain unproven in pit viper envenomation. The use
of a venom extractor has been shown to increase local tissue damage and is
not recommended.

In the ED, wound care should be performed, with tetanus updated if
applicable. Patients should undergo an evaluation for hematologic,
neurologic, renal, and cardiovascular abnormalities. Blood work should be
drawn from an unaffected limb and sent for a complete blood count,
coagulation studies, electrolytes, blood urea nitrogen, serum creatinine, and
creatine phosphokinase. Additional blood work may include a type and
cross-match, fibrinogen, fibrin split products, and bleeding time. A urinalysis
and electrocardiogram should also be obtained. Poison center consultation
should also be obtained. An x-ray can be obtained if there is concern over a
retained fang. Prophylactic antibiotics are not recommended.

Patients with pit viper bites should be observed for approximately 8 to 12
hours. If there are no signs of envenomation, the patient may be discharged

1460

home. When envenomation does occur, the edge of the swelling should be
demarcated with a pen, and the circumference of the extremity should be
measured every 15 to 30 minutes. If there is no progression of swelling and
no coagulopathy develops on serial lab values, the patient can be discharged
home.

In contrast to pit viper bites, patients with coral snake bites should be
observed for at least 24 hours, even without definitive signs of
envenomation. If envenomation is suspected, they should be treated
immediately with antivenin, since symptoms are irreversible.

The antivenin Crotalidae Polyvalent Immune Fab (Ovine) (CroFab; BTG
International, West Conshohocken, PA) has supplanted the older horse-
derived Antivenin (Crotalidae) Polyvalent (ACP) for the treatment of
crotaline envenomation. The Ovine formulation is as effective as the horse-
derived antivenom, but with a reduced risk of allergic reaction. Antivenin
should ideally be administered within 4 hours of envenomation but can be
effective for up to 24 hours following the bite. Indications for antivenin
include progressive swelling, a coagulation abnormality, or development of
systemic effects. The initial dose of antivenin is 4 to 6 vials given over 1
hour. If symptoms are controlled, the patient should receive two vials at
times 6, 12, and 18 hours. If initial control is not achieved, the patient should
receive an additional 4 to 6 vials. Be prepared to treat anaphylaxis in any
patient receiving antivenin.

For any coral snake bite, regardless of symptoms, Micrurus fulvius
antivenin (equine) is recommended. This antivenin has no activity against the
Sonoran, Arizona, coral snake. Supplies of this antivenom will soon be
exhausted, as the manufacturer stopped production in 2003. There is
currently a study of a F(ab′)2 antivenom in Phase 3 clinical trials. If an exotic
snakebite occurs, local zoo or poison center experts should be contacted.

KEY POINTS

Monitor patients closely for systemic and hematologic effects.
“Red on yellow, kill a fellow; red on black, venom lack” can be used
to differentiate a coral snake from a king snake.
Coral snake bites require antivenin even without signs of
envenomation.
Antivenin may need to be readministered several times until there is
control of symptoms.
Have epinephrine and antihistamine ready when administering

1461

antivenin in case of an anaphylactic reaction.

SUGGESTED READINGS

Gold BS, Barish RA, Dart RC. North American snake envenomation: Diagnosis,
treatment, and management. Emerg Med Clin North Am. 2004;22(2):423–443.

Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med.
2002;347(5): 347–356.

Juckett G, Hancox JG. Venomous snakebites in the United States: Management
review and update. Am Fam Physician. 2002;65(7):1367–1374.

Lavonas, EJ, et al. Unified treatment algorithm for the management of crotaline
snakebite in the United States: Results of an evidence-informed consensus
workshop. BMC Emerg Med. 2011;11:2.

Sullivan JB. Bites and envenomations. In: Harwood-Nuss’ Clinical Practice of
Emergency Medicine. 5th ed. 2010:1624–1628.

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352

EYELID LACERATIONS: WHEN TO
REPAIR AND WHEN TO REFER

ERIN SETZER, MD

It is important for the emergency provider (EP) to know how to manage an
eyelid laceration. Poorly managed lid lacerations often lead to eyelid and tear
duct dysfunction, a source of significant patient discomfort as well as
liability for the EP.

The eyelid is composed of several layers including the skin, orbicularis
muscle, and the orbicularis septum. The orbicularis septum is a fibrous
material that separates the superficial eyelid structures from the deeper
structures. Orbital fat and the levator palpebrae muscle lie beneath the
orbicularis septum. The levator muscle is important for eyelid function and
inserts at the tarsal plate along the eyelid margin. Puncta are located in the
medial eyelid margins and connect via canaliculi to the lacrimal duct system.

Eyelid laceration repair should occur only after the eye has been
thoroughly evaluated for injury. Document the visual acuity and complete a
thorough eye exam. If globe rupture is suspected, laceration repair should not
be performed, as increased pressure on the globe can cause additional injury.
The history of the incident is important in assessing the complexity of the
laceration. Important historical features include the mechanism of injury (i.e.,
blunt vs. penetrating), time of injury, presence of foreign bodies, and any
prior ocular history. Retained foreign bodies can lead to infection and
discomfort. Plain radiographs, ultrasound, or computed tomography should
be obtained if there is concern for a retained foreign body. Importantly, the
eyelid is highly vascular, and laceration repair can be deferred up to 36 hours
if needed.

It is important to determine whether the eyelid laceration is simple or

1463

complex. Features that determine simple or complex include location, depth,
and size.

1) Location. Any laceration that involves the lid margin or communicates
with the lacrimal duct system is complex and should be referred to a
specialist for repair. Placing a drop of fluorescein into the eye and then
examining the laceration with the blue light can evaluate the lacrimal
duct system. If fluorescein is detected within the wound, then it
communicates with the lacrimal duct system.

2) Depth. The presence of fat within an eyelid laceration indicates that
deeper structures, like the levator muscle, may be injured. Ptosis is
another key exam finding to suggest that the levator muscle is
compromised. These lacerations should be considered complex and
referred to a specialist for repair.

3) Size. Avulsion injuries should be considered complex lacerations and
referred for repair, as improper repair can cause wound tension that
affects lid function. Small lacerations that are superficial and less that
25% of the lid width can be left to heal by secondary intention. Tissue
adhesive is an option for small lacerations, but care should be taken to
prevent the adhesive from entering the eye.

The EP can repair simple lacerations. A small, 6-0 or 7-0 nylon suture, or
rapidly absorbing suture, may be used with a simple interrupted technique.
The ends of the suture should be cut short to avoid irritating the eye. If the
wound is near the lid margin, then the sutures most proximal to the margin
should be buried. An alternative is to leave the ends of the proximal suture
long and incorporate them into the next suture tie, effectively tying them
down and keeping them away from the eye. Puncturing the eye with the
suture needle can occur. One technique to avoid globe injury is to leave the
first suture ends long. The provider then uses the ends to gently pull traction
and lift the lid away from the globe. Another trick is to insert an ocular
anesthetic and then a Morgan’s lens, which can act to shield the globe during
repair.

Eyelid lacerations are a common problem facing the EP. The first step is
to evaluate the eye globe injury. Complex lacerations involving the eyelid
margin, lacrimal duct, or levator muscle should be referred to a specialist for
repair. Repair can be delayed up to 36 hours. Simple wounds can be repaired
using a small suture with an interrupted technique. Care must be taken to
avoid iatrogenic globe injury.

1464

KEY POINTS

Document a visual acuity and perform a thorough eye exam prior to
lid laceration repair.
The presence of fat in the laceration indicates penetration of the
orbicularis septum.
Any laceration that involves the lid margin or lacrimal system should
be referred for repair.
If fluorescein appears in the wound after placing in the eye, it suggests
violation of the lacrimal system.
A Morgan lens can be used to protect the globe from iatrogenic injury
during laceration repair.

SUGGESTED READINGS

Chang EL, Rubin PA. Management of complex eyelid lacerations. Int Ophthalmol
Clin. 2002;42:187.

Nelson CC. Management of eyelid trauma. Aust N Z J Ophthalmol. 1991;19:357.

WEB SITES

http://lacerationrepair.com/special-situations/lacerations-around-the-eye/

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353

EAR INJURIES AND LACERATIONS

ANAS SAWAS, MD, MPH, MS AND ERIC J. MORLEY,
MD, MS, FAAEM

Ear injuries generally occur as a result of blunt trauma or mammalian bites.
Appropriate management of these injuries is critical to prevent serious
complications. The irregular contour of the ear, blood supply, and underlying
cartilaginous structures can make these injuries difficult to manage.
Unfortunately, randomized-controlled trials are lacking to guide the care of
these injuries in the emergency department (ED).

One of the first steps in evaluating an ear injury is to determine whether
the cartilage has been injured or exposed. When cartilage is involved,
injuries should be classified as complete or incomplete avulsions. Plastic
surgery or otolaryngology (ENT) should be consulted emergently for
complete avulsion injuries. Avulsed tissue should be reattached as quickly as
possible. Detached tissue can be cleaned in cold saline, but this is best done
in consultation with the specialist. Consultation should also occur for partial
avulsion injuries with very small pedicles of tissue.

The decision to repair external ear injuries in the ED is dependent on the
extent of tissue loss, the time elapsed since the injury, and any associated
injuries. Proper repair of ear injuries and lacerations requires appropriate
anesthesia. Small lacerations can be anesthetized with local infiltration of
lidocaine. It has been traditionally taught to avoid the use of epinephrine in
this region. However, hemostasis is important for repair and prevention of an
auricular hematoma. There is an evidence that epinephrine does not lead to
complications when used for repair of ear injuries. A regional auricular block
may be required for large or complicated lacerations. Children and
uncooperative patients may require procedural sedation for proper repair.

The emergency provider (EP) can consider primary closure if the injured

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portion of the ear is on a wide pedicle and demonstrates good distal capillary
refill. The perichondrium and subcutaneous layers should be sutured closed
with absorbable sutures. The skin should be approximated with 5-0 or 6-0
nonabsorbable sutures (i.e., nylon or polypropylene). Rapid absorbing 5-0 or
6-0 sutures may be acceptable in children when there is concern for difficult
removal. Use the contralateral ear for comparison to help guide the repair of
the affected ear. Patients should receive specialist follow-up after primary
closure, as the repair can be revised if the cosmetic outcome is not
satisfactory.

Allowing ear wounds to heal by secondary intention may be appropriate
in select patients, namely diabetic patients, immunocompromised patients, or
those with heavily contaminated wounds. Small wounds to the concave
portions of the auricle (conchal bowl and antihelix) heal particularly well by
secondary intention, provided the surrounding ear is intact to provide
structural support. The wound requires copious irrigation even when primary
closure is not performed. Additionally, the wound should be covered with
antibacterial ointment and any crusting removed. Exposed cartilage should
be avoided, as the overlying skin provides its vascular supply. Patients who
do not have their wounds closed in the ED should be referred for follow-up
within 1 to 2 days with an ENT or plastic surgeon.

The primary complications of ear injuries are infection, auricular
hematoma, and poor cosmetic appearance. Consider antibiotics for patients
with diabetes, immunocompromising conditions, those receiving
chemotherapy or corticosteroids, or if the patient sustained their injury from
a human or animal bite. The EP should also consider antibiotics for
contaminated or macerated injuries. Auricular hematomas are usually the
result of blunt trauma to the auricle. The skin adheres to the perichondrium,
which supplies blood to the cartilage, and the unique anatomy of the ear does
not allow for significant expansion of the subcutaneous tissue. Blood
accumulates in the subperichondrial space and disrupts blood supply to the
underlying cartilage. To prevent formation of an auricular hematoma,
consider placing a pressure dressing after wound closure and give patients
strict instructions to return for any signs of swelling. Auricular hematomas
should be drained as soon as possible to prevent the development of
fibrocartilaginous overgrowth and deformity of the ear. Two approaches
have been described in the literature to aid with the drainage of these
hematomas. Generally, smaller hematomas can be drained with needle
aspiration, whereas larger hematomas should be drained with incision and
drainage. Following drainage, patients should be regularly followed for at
least 1 week to ensure there is no recurrence. Hematomas more than 7 days
old should be referred to a specialist.

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KEY POINTS

Consult ENT or plastic surgery emergently for complete avulsion
injuries.
Ensure all cartilage is covered with a wet-to-dry dressing following
repair. These dressings should be changed daily until follow-up with a
specialist.
Many small lacerations to the concave portions of the ear can be
allowed to close by secondary intention provided the supporting
peripheral structure of the ear is intact.
Antibiotics are recommended in bite wounds and should be strongly
considered in immunocompromised patients.
All patients with ear lacerations closed in the ED should be referred to
ENT or plastic surgery for follow-up.

SUGGESTED READINGS

Brickman K, Adams DZ, Akpunonu P, et al. Acute management of auricular
hematoma: A novel approach and retrospective review. Clin J Sport Med.
2013;23(4):321–323.

Giles WC, Iverson KC, King JD, et al. Incision and drainage followed by mattress
suture repair of auricular hematoma. Laryngoscope. 2007;117(12):2097–2099.

Hafner HM, Rocken M, Breuninger H. Epinephrine-supplemented local anesthetics
for ear and nose surgery: Clinical use without complications in more than
10,000 surgical procedures. J Dtsch Dermatol Ges. 2005;3(3):195–199.

Lavasani L, Leventhal D, Constantinides M, et al. Management of acute soft tissue
injury to the auricle. Facial Plast Surg. 2010;26(6):445–450.

Mudry A, Pirsig W. Auricular hematoma and cauliflower deformation of the ear:
From art to medicine. Otol Neurotol. 2009;30(1):116–120.

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354

KNOW WHICH WOUNDS TO
CLOSE…AND WHICH ONES TO

LEAVE OPEN

RAYMOND BEYDA, MD AND MARK SILVERBERG, MD,
MMB, FACEP

Several million patients present annually to the emergency department (ED)
with an acute wound. For these patients, the emergency provider (EP) must
decide between primary closure, delayed closure, or allow the wound to heal
by secondary intention. Both patient and wound factors are critical in making
this decision. In addition, it is important to assess patient concerns, such as
functional outcome, the potential for painful procedures, and the final
cosmetic appearance. For the EP, it is important to prevent the loss of
function, decrease the risk of infection, and achieve acceptable cosmetic
outcomes. The fundamentals of ED wound management include an accurate
history of present illness (HPI), assessment of patient comorbidities,
allergies, and tetanus status and a thorough wound assessment that includes
debridement of devitalized tissue and removal of foreign bodies.

An important element of the HPI is a determination of the amount of
time that has elapsed since the injury. This time frame has classically been
referred to as the “golden period,” after which the rate of infection
significantly increases. In 1898, Paul Leopold Friedrich was the first to
describe a 6-hour “golden period” for wound closure, based on the data
derived from a guinea pig model. At present, there is a no high-quality data
to suggest an ideal time for primary closure, beyond which there is an
increased risk of infection. Another important component in the assessment
of wound infection is location. Wounds above the clavicles generally have a

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lower risk of infection compared with extremity wounds. A history of
diabetes, immunosuppression, increased age, large wounds, and the presence
of contamination or a foreign body increase the risk for infection. Thus, a
clean facial wound can often be closed primarily, even up to a day or more
from the time of injury. In contrast, a contaminated foot laceration in an
elderly diabetic patient is likely a poor choice for primary closure, even just a
few hours following the injury.

Mammalian bite wounds have a higher risk of wound infection compared
to nonbite wounds. Dogs, cats, and humans most commonly cause bite
wounds. Wound characteristics vary with the type of bite. Dog bites are more
likely to result in lacerations, avulsions, and crush injuries, with or without
fractures, due to the force generated during the bite. Cats create deep,
penetrating puncture wounds that can deliver infectious inoculum deep into
subcutaneous tissues. Human bites often involve the fourth or fifth
metacarpophalangeal joint of the hand with possible tendon injury. The
location of bite wounds is also critical. High-risk wounds involve the
extremities, overly joints, or demonstrate deep tissue damage. Human or cat
bites that involve the hands or feet have a high risk of infection and should
be left open. Facial bite wounds, however, may be closed primarily as the
cosmetic benefit often outweighs the risk of infection.

In general, EPs should identify risk factors for wound infection on a
case-by-case basis, as wounds at high risk of infection should be considered
for delayed closure. These include human and cat bites to areas of the body
except the face. Dog bite wounds can be closed primarily, except in the case
of hand wounds and a delayed presentation from the time of injury. The
decision to close or leave open nonbite wounds should consider host and
wound factors such as time since wounding, medical comorbidities such as
diabetes, immunocompromised states, peripheral vascular disease, increased
age, wound contamination, presence of foreign body, anatomic location, and
wound size. Grossly contaminated wounds with significant amounts of
devitalized tissue should be left open. Regardless of the closure strategy,
each wound should be copiously irrigated to decrease the risk of infection.
As always, the risks and benefits of pursuing primary versus delayed closure
techniques should be discussed with the patient and appropriately
documented so that an informed and shared decision can be made. With no
clear guidelines, clinical judgment is the key in weighing the benefits of
wound closure against the risks of infection.

KEY POINTS

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The history and physical examination should be directed toward an
assessment of the overall risk for infection.
Important elements to the HPI include time since injury, patient
comorbidities, anatomic location, wound dimensions, and the
presence of foreign material, gross contamination, or devitalized
tissue.
Facial bite wounds can often be closed primarily, as the cosmetic
benefit outweighs the risk of infection.
All wounds should be copiously irrigated.
Discuss the risks and benefits of wound closure with each patient and
appropriately document the conversation.

SUGGESTED READINGS

Garcia-Gubern CF, Colon-Rolon L, Bond MC. Essential concepts of wound
management. Emerg Med Clin North Am. 2010;28:951–967.

Nicks BA, Ayello EA, Woo K, et al. Acute wound management: Revisiting the
approach to assessment, irrigation, and closure considerations. Int J Emerg
Med. 2010;3:399–407.

Philipsen TE, Molderez C, Gys T. Cat and dog bites. What to do? Guidelines for
the treatment of cat and dog bites in humans. Acta Chir Belg.
2006;106(6):692–695.

Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: What are the risks for
infection and has the ‘golden period’ of laceration care disappeared? Emerg
Med J. 2014;31:96–100.

Zehtabchi S, Tan A, Yadav K, et al. The impact of wound age on the infection rate
of simple lacerations repaired in the emergency department. Injury.
2012;43:1793–1798.

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SECTION XXIV
CLINICAL PRACTICE
AND LEGAL ISSUES

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355

CONSULT COMMUNICATIONS:
OPTIMAL COMMUNICATIONS WITH

CONSULTANTS

HUGH F. HILL III, MD, JD, FACEP, FCLM

Ask why we request consultations, ask what are the common elements of
consults, and you will know how to avoid common errors. In other words,
break it down!

We call consultants for:

Help with diagnosis
Workup and treatment advice
Specific procedural (medical and administrative) assistance
To assure family and patients of our thoroughness and accuracy
To coordinate and share responsibility for care

Once the need or perhaps opportunity for consultation is realized, the
linguistic elements of every consultation align in consistent order:

Contact
Communication about the patient
The question(s) or action requested
Assent
Response and report
The requestor’s closure

HELP WITH DIAGNOSIS

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Our requests are less often for another specialist’s thoughts about a diagnosis
than those requested in the office outpatient or in-hospital setting. But we
still use our colleagues’ help occasionally in this way, for example, what’s
this rash, could I be missing any other reasons for this persistent
hypotension? These requests require more complete information inclusion.
We avoid bias in the presentation of that information; the consultant is less
likely to pick up something we missed if we lead her too much.

WORKUP AND TREATMENT ADVICE

We often ask for comments about preadmission studies or choice of imaging.
While these communications can be brief, we profit from disciplining
ourselves to think of them as requests for consultation. Talking with the team
that will be caring for the patient after admission can only help. It is not an
abrogation of professional autonomy or status for us to modify our work to
better fit with what will happen next, when we no longer have control, where
it’s reasonable.

SPECIFIC PROCEDURAL (MEDICAL AND
ADMINISTRATIVE) ASSISTANCE

We know what must be done, so we call the right specialist to do it.
Nonetheless, it behooves us to acknowledge their independent judgment.
Good hospital interstaff relations and ultimately patient care depend on
smooth interactions. It’s rare that we have to go to the extreme of calling a
second same-specialty consultant because the first is making a dangerous
choice. Our non-EM colleagues usually don’t have a call list: they call
whoever they want. If our patients are not getting the support they need from
a consultant on the call list, we have to address it through staff mechanisms.

TO ASSURE FAMILY AND PATIENTS OF OUR

THOROUGHNESS AND ACCURACY

In some EDs, sophisticated and resource-enabled patients and families are
accustomed to self-referring to specialists. They may not even have a
primary care generalist. Even if all you do is talk with their choice for
follow-up, they can be reassured. But continue to think of it as a consult,
requiring elements of communication, specificity, and loop closing.

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TO COORDINATE AND SHARE RESPONSIBILITY
FOR CARE

Although not usually recognized as a consultation, calling the primary care
provider before the patient leaves the ED can be. For example, imagine that
she says, “I know this patient and this is atypical. Please admit him.” Even if
you don’t admit, your documentation burden just escalated. The most likely
source of criticism of your care in the ED remains the next provider to see
your patient. Most do not, but even a raised eyebrow can start a patient or
family thinking about litigation. The follow-up doctor who has “bought into”
your care plan is much less likely to point a finger or even question your
care.

Once you’ve decided you need a consult, a formulaic approach can help.
(Please note: Starting the process of seeking consultation establishes the
necessity of completing it. If the physician you are calling doesn’t respond,
you can be said to have a responsibility to persevere or call someone else.
Desisting requires documentation of why.)

THE ELEMENTS OF CONSULTATION

Contact

If during office hours, be respectful of your consultant’s other
responsibilities. If time allows, ask her staff to call you back. If the
consultant is not working, either make the call yourself or be very available if
the unit secretary or other personnel make the call. Introduce yourself, say
where you are calling from, and try to confirm you are talking to the right
person. A respectful, “I have you on call tonight; is that correct?” can turn
away wrath.

Communication about the Patient

The range and content of your presentation will alter with circumstances of
the case and what you are asking. Don’t edit the information beyond what
you would want to know if the situation was reversed. Explain why the
datum that doesn’t fit should be discounted, but reveal it.

The Question(s) or Action Requested

This requires clarity. We need to articulate specifically what we want from

1475

the consultant.

Response and Report

This is what the consultant does. If she doesn’t immediately put in a note,
then we have to record what we understood the response to be. When the
consultant takes responsibility—“Yes. Admit to my service.”—it’s obvious.
(Note: we still have to judge the reasonableness of the consultant’s
communicated immediate intentions. Further, our continued responsibility is
clearer until the consultant sees the patient.)

The Requestor’s Closure

As with any sequential charting, we risk conflicting statements if the
consultant enters documentation after we have put our note in. In some
situations, we may to read the subsequent entry and add a properly timed
addendum after.

Finally, many authors urge that we abstain from “curbside” consults. If
you do informally talk with another specialist, play fair. Don’t record what
you are told as if it were the result of the formal process. If you set up
another physician for untoward responsibility, you and your EM colleagues
will have more problems than conflict with that one doctor. If you want to
chart something, consider, “Called Dr. X and he will F/U.”

KEY POINTS

Be clear in your own mind why you are calling a consultant.
Communicate what you want from the consultant clearly.
Avoid bias in your presentation to the consultant.
Document the time you call and the time of response.
Close the loop and note the results of the consultation.

SUGGESTED READINGS

Guertler AT, Cortazzo JM, Rice MM. Referral and consultation in emergency
medicine practice. Acad Emerg Med. 1994;1(6):565–571.

Habermas J. The Theory of Communicative Action. Boston, MA: Beacon Press,
1981.

Kessler CS, et al. The 5C’s of consultation: Training medical students to

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communicate effectively in the emergency department. J Emerg Med.
2015;49:713–721.
Lee T. Consultation guidelines for primary care providers. Forum (The Risk
Management Foundation of the Harvard Medical Institutions), 2000:20.
Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the
effectiveness of medical consultations. Am J Med. 1983;74(1):106–112.

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356

TREATING THE PATIENT AND NOT
THE DISEASE: TIPS FOR PATIENT

SATISFACTION

DYLAN SEAN KELLOGG, MD

We don’t think of emergency medicine as a customer service business. Our
patients arrive dying, we stop them from dying. There is some intangible
benefit from being compassionate and making patients happy but surely that
is not the goal of our profession. Moreover, we often worry about patients
who are drug seeking or demanding unreasonable tests.

The reality, of course, is that a large segment of our patient population is
not trying to die in front of us, the majority of our patients are not just
looking for narcotics, and all have concerns that go beyond a clinical
diagnosis. The way we are paid is often tied to satisfaction metrics. Studies
have shown that increased patient satisfaction is tied to decreased litigation.
In urban environments, where multiple emergency departments (EDs) are
within close proximity, having satisfied patients contributes to increased
volumes through word-of-mouth advertising and retention of existing
patients. More satisfied patients are more likely to be compliant with, and
respond to treatment, and are less likely to require follow-up ED visits.
Finally, happier patients create a more positive working environment and
happier staff.

Five variables make the biggest difference in patient satisfaction scores:
technical competence, timeliness of care, empathy, information dispensation,
and pain management. Committing to address these variables in your own
clinical practice and on a departmental level can make significant
improvements in patient satisfaction.

1478

Technical competence is a domain in which emergency physicians excel,
and in some studies, it is the most important variable in satisfaction scores.
Unfortunately, academic centers can lose satisfaction because of the need to
have inexperienced trainees perform technical skills on patients. This can be
mitigated by the use of scripting—training providers on how to approach
difficult conversations with patients, like trainees’ involvement in care.

Timeliness of care is one of the most commonly cited complaints about
ED visits, and boarding and overcrowding are unlikely to disappear any time
soon. While there will always be some form of waiting in EDs, there are
simple steps that can be taken to improve patient satisfaction. Patients want
to be seen by a doctor as soon as possible and the longer they have to wait to
do so, the more likely they are to leave. Arranging department flow to
decrease door-to-doctor time can have a significant effect on patient
satisfaction, and practices like bedside registration, and placing a provider in
triage can be effective. If possible, try to keep door-to-doctor times to under
30 minutes. Patients care more about perceived wait times than actual wait
times, so shortening perceived waiting also improves satisfaction. Having
waits that are shorter than expected, allowing for visitors, providing
information on how the department functions and what to expect, and
providing frequent updates on care can all improve perceived wait times.

It can take a single negative interaction with a staff member to make the
entire visit a poor experience. Dress professionally: patients respond
negatively to providers who are dressed casually or appear unkempt.
Wearing clean, professional attire is an important (and easy) step to enhance
patient satisfaction—providers should consider wearing white lab coats, as at
least half of patients respond favorably to them. All personnel should wear
prominently displayed ID badges, introduce themselves to patients and
family members, and explain their role in the patient’s care. Good bedside
manner that includes sitting and listening patiently is a must. Your
department should have interpretive resources in place for non–English-
speaking patients. Empathy can also be improved with scripting by preparing
staff for potentially difficult interactions with patients and family.

Since pain is one of the most common reasons for patients to come to the
ED, pain management is an important tool for satisfaction. Scripting and
setting realistic pain management expectations play important roles in patient
satisfaction. When possible, allow patients to participate in decision-making
regarding pain management and institute departmental policies that allow for
nurse-initiated pain management prior to patients seeing a provider.

Information dispensation is frequently overestimated by ED providers.
During a patient’s stay in the department, frequent updates help to keep

1479

patients informed about their progression (and decrease perceived wait
times). Consider instituting a system of ED rounding, wherein patients are
given regular timed updates on their care by staff members. The presence of
a patient advocate in the department can also help patients understand what is
happening. On discharge, provide clear instructions with follow-up and
return precautions. Provide patients with your business card so that they can
call with additional questions. Multiple studies have demonstrated that a
follow-up phone call or e-mail from the ED provider after discharge
significantly improves patient satisfaction.

Ultimately, doctors and nurses are in the business of making people feel
better. This is especially true in the ED where our average day at work is
often our patient’s worst day. Patient satisfaction should not be viewed as
separate from clinical care. Making our patients feel better by making them
feel more welcome in the department, better informed about their care, and
more satisfied when they are discharged is just good medicine.

KEY POINTS

Dress professionally: ideally wear a white lab coat.
Institute scripting for difficult situations.
Keep door-to-doctor time to <30 minutes.
Implement ED rounding.
Follow-up with patients after discharge (phone call or e-mail).

SUGGESTED READINGS

Boudreaux ED, O’Hea EL. Patient satisfaction in the emergency department: A
review of the literature and implications for practice. J Emerg Med.
2004;26:13–26.

The Disney Institute; Kinni T. Be Our Guest: Revised and Updated Edition:
Perfecting the Art of Customer Service (The Disney Institute Leadership
Series). New York: Disney Editions, 2011.

Patel PB, Vinson DR. Physician e-mail and telephone contact after emergency
department visit improves patient satisfaction: A crossover trial. Ann Emerg
Med. 2013;61(6):631–637.

Welch SJ. Twenty years of patient satisfaction research applied to the emergency
department: A qualitative review. Am J Med Qual. 2010;25:64–72.

Worthington K. Customer satisfaction in the emergency department. Emerg Med
Clin North Am. 2004;22:87–102.

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357

YOUR PATIENT HAS DIED, NOW
FOCUS ON THE FAMILY: HOW TO
DELIVER BAD NEWS TO FAMILY

MEMBERS

DYLAN SEAN KELLOGG, MD

It’s 2 am, you’ve spent the last 45 minutes attempting to resuscitate a middle-
aged man without success. You thank your team and prepare to fill out the
appropriate paperwork when one of the registration staff comes up to you.
“Doctor, the patient’s wife is here.”

Most of us had brief instruction on “how to break bad news” during
medical school that involved role-playing. This was often before we had any
actual clinical exposure and was almost certainly not specific to emergency
medicine. During residency, we were expected to start having these
conversations. They don’t get easier, and when every family reacts
differently, how can you tell if you’re doing a good job? Moreover, these
conversations are often viewed as an afterthought—we’ve taken care of the
patient, now let’s inform the family.

This is the wrong approach. Treating a bereaved family member with the
same care as you would a patient facilitates both parties in dealing with an
incredibly challenging situation and provides better long-term outcomes for
the family.

We are extremely systematic in how we approach patient encounters and
that same rigor should be used in interactions with family members. Two
mnemonics that have been studied as tools to help in bad news conversation
are SPIKES (Table 357.1) and GRIEV_ING (Table 357.2). The first was

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originally studied in oncology but has been applied successfully to the
emergency department, while the second is less well studied but was
designed for emergency department application. Both stress the importance
of preparing for the conversation, providing a private, nonclinical space,
making sure the appropriate people are present, determining how much is
known before you begin speaking, being direct yet empathetic in delivering
news, and providing opportunity for questions and follow-up.

TABLE 357.1 SPIKES

TABLE 357.2 GRIEV_ING

Some tactics bear emphasis. Check your appearance—make sure you aren’t
covered in blood. Have a support person present—it isn’t feasible for a
physician to remain with family during their visit, and it is inappropriate to
leave family alone, so having a chaplain, social worker, or nurse stay with
them is helpful. Verify your facts—know the deceased’s name and whom
you will be speaking with. Use clear terms, like “dead” or “died” rather than
euphemisms. Family members often want to view or sit with their deceased
relative, and this should be encouraged, though not forced. (Note:
occasionally, this may not be possible if the death is a criminal matter and

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law enforcement has not finished its investigation of the body.) Prep family
members ahead of time so that they know what to expect (are there visible
injuries or medical interventions that may be disturbing?), provide a chair,
allow them to touch or hold the deceased. If family wants a lock of hair,
clothing, or jewelry, they should be allowed to take it (again assuming it does
not interfere with law enforcement). If clothing was cut, provide an
explanation of this to the family.

One intervention that is worth considering is to allow family to be
present during resuscitation. There is a concern that it will be disturbing to
family or that family will interfere with resuscitative efforts. Studies have
shown that family do not compromise resuscitations and that witnessing the
resuscitation typically has positive impacts on psychological outcomes for
family. If this is to be implemented, a staff member should be delegated to
remain with loved ones during the resuscitation.

Finally, death in the emergency department is not just stressful for
family. Staff members can become distraught as well, especially during
pediatric resuscitations, bad traumas, or even from knowing the deceased.
Providing appropriate support services for staff is an important, though often
overlooked, part of bereavement. Proactively engaging in appropriate
treatment for family and staff affected by death is an important part of our
role in the emergency department. We are going to have unsuccessful
resuscitations. And when they occur, we need to remember that there are
more patients than the one on the gurney.

KEY POINTS

Allow family to witness resuscitations when possible.
Use a systematic approach for bereavement discussions.
Use clear terminology; avoid medical jargon and euphemisms.
Provide opportunities for viewing the body and for asking follow-up
questions later (e.g., give family members your business card).
Do not neglect care of staff involved in difficult/emotional
resuscitations.

SUGGESTED READINGS

Baile WF, Buckman R, Lenzi R, et al. SPIKES—A six-step protocol for delivering
bad news: Application to the patient with cancer. Oncologist. 2000;5:302–311.

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Hobgood C, et al. The educational intervention “GRIEV_ING” improves the death
notification skills of residents. Acad Emerg Med. 2005;12(4):296–301.

Kazimiera A, et al. Sudden unexpected death in the emergency department: Caring
for the survivors. Can Med Assoc J. 1993;149(10):1445–1451.

Marrow J. Telling relatives that a family member has died suddenly. Postgrad Med
J. 1996;72:413–418.

Oczkowski SJ, et al. The offering of family presence during resuscitation: A
systematic review and meta-analysis. J Intensive Care. 2015;3(41):1–11.

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358

DON’T BE AFRAID TO DISCUSS
END-OF-LIFE DECISIONS WITH THE

PATIENT AND FAMILY

EMILY STREYER CARLISLE, MD, MA

We see many patients near the end of their lives. By the nature of our
training and our role in the health care system, the restoration of full health is
our default goal. In many cases, however, a patient has come to the
emergency department (ED) with a baseline so deteriorated or an injury so
severe that full health is no longer a realistic or desirable goal, and the full
deployment of our arsenal is inadvisable, if not futile. Initiating discussion
about end-of-life care in such cases may spare the patient painful and
pointless procedures, aid downstream decision-making, and conserve
hospital resources.

The literature is unanimous that earlier discussion of end-of-life issues is
better, especially for patients with terminal illness. Ideally, a primary care
provider leads timely, unpressured discussions on end-of-life planning, and
the transition from curative to palliative goals occurs in the patient’s own
time. Palliative care programs have been shown to reduce ED visits, hospital
admissions, and aggressive care in the last month of life. In many cases, they
improve symptom control and can even prolong life.

In other cases, however, these decisions are abruptly thrust at patients
and their families by an unexpected or acute event. As emergency physicians
(EPs), we often see these patients in the acute phase of the crisis. Giving bad
news of any kind in the ED is challenging. We generally have no previously
established relationship with the patient or family. The ED environment is
often chaotic, loud, and anxiogenic. The urgency of the clinical encounter

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often asks a patient or surrogate to make a high-stakes decision, with limited
time for reflection, after receiving a bolus of new and often technical and at
times, bewildering information. Nonetheless, it may fall to the EP to initiate
these discussions. Furthermore, the ED encounter may be the last opportunity
to determine the patient’s wishes directly from the patient.

End-of-life discussions, as with all informed medical decision-making,
require the physician to explain the options and provide guidance. The first
step is to identify the patient and family’s current understanding of the
medical situation. They may not appreciate that an illness is terminal or that
death is imminent, obvious as it may be to the provider. Take the family from
old information to new, for example, “She has had trouble with her lungs for
a while, but now her lung function is worse. Have you ever discussed what
she would want in the event she could not breathe on her own?” Inquire
about advanced directives or physician orders for life-sustaining treatment
(POLST). At this point, discuss the options available in the ED and provide
insight, for example, the more aggressive option might prolong life but is
painful and imperiled with complications, whereas comfort measures
prioritize peacefulness but likely fail to address the acute issue. Families
might need help avoiding logically inconsistent preferences stemming from
incomplete understanding (e.g., wanting vasopressors, understood as
“medication to help blood pressure” but no central line).

As EPs, we routinely make life-and-death decisions in seconds, but for
patients and families, these decisions may require time. Arriving at the
decision to pursue comfort measures, especially when the event was
unanticipated, may take multiple conversations over several hours to days.
Patients and families may need time for adjustment, as well as the arrival of
out-of-town relatives, or discussion with other physicians or advisors. Even if
no decision is made, this first discussion in the ED may facilitate the later
discussions with the inpatient team and allow a transition to palliative care
that is both gentler and timelier. When time permits (e.g., need for intubation
is not immediate), step away to allow time for reflection but remain available
for questions. At this time, offer to call a palliative care team if available.
The members of this team can offer answers and support to the family when
the emergency nurses and providers often have so little time to spare.

Families may make the decision to pursue comfort measures starting in
the ED. The time to death can be unpredictable and may be anywhere from
minutes to hours to days. Unless death is obviously imminent (e.g., low
oxygen saturations and bradycardia), admit the patient, preferably to a
private, nonmonitored inpatient room, which allows family at the bedside
while nature completes its course. While the patient waits for an inpatient
bed, attempt to find a private room in a relatively quiet part of the ED. Call a

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palliative care consultation if available and not already activated. Remember
to address air hunger and pain to make patients as comfortable as possible.

KEY POINTS

Discuss end-of-life preferences whenever it seems appropriate.
Be prepared to provide multiple small bundles of information,
especially if the event leading to the ED was unanticipated.
Call the palliative care team if one is available.
If possible, try to move the patient and family to a quiet part of the
department.
Remember that the ED conversation will help the patient, family, and
providers upstairs even if no decision is made in the ED.

SUGGESTED READINGS

Lamba S, Nagurka R, Walther S, et al. Emergency-department-initiated palliative
care consults: A descriptive analysis. J Palliat Med. 2012;15:633–636.

Limehouse WE, Feeser VR, Bookman KJ, et al. A model for emergency
department end-of-life communications after acute devastating events—Part I:
Decision-making capacity, surrogates, and advance directives. Acad Emerg
Med. 2012;19:1068–1072.

Limehouse WE, Feeser VR, Bookman KJ, et al. A model for emergency
department end-of-life communications after acute devastating events—Part II:
Moving from resuscitative to end-of-life or palliative treatment. Acad Emerg
Med. 2012;19:1300–1308.

Müller-Engelmann M, Keller H, Donner-Banzhoff N, et al. Shared decision
making in medicine: The influence of situational treatment factors. Patient
Educ Couns. 2011;82:240–246.

Zakhour M, LaBrant L, Rimel BJ, et al. Too much, too late: Aggressive measures
and the timing of end of life care discussions in women with gynecologic
malignancies. Gynecol Oncol. 2015;138:383–387.

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359

TOO MANY AT ONE TIME?
EMERGENCY DEPARTMENT

OVERCROWDING

RYAN BROOKS, MBA AND ARJUN CHANMUGAM, MD,
MBA

Emergency departments (EDs) across the country are finding themselves
facing an increasingly more common situation—escalating demand of
emergency resources and limited inpatient bed capacity, resulting in
untenable overcrowding. For more than one decade, ED visit rates have
steadily risen, contributing to overcrowding. ED overcrowding has a number
of detrimental effects, including longer patient lengths of stay, increased
morbidity, increases in adverse and preventable error, delays in treatment,
and longer waits to be evaluated by caregivers. ED overcrowding leads to
crowded waiting rooms and negatively impacts the patient experience, which
also leads to decreased staff and provider morale (Figure 359.1).

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Figure 359.1 Emergency departments are tasked with caring for a
steadily increasing number of patients.

COMMON ERRORS IN OVERCROWDING

A number of strategies exist to combat the problem of ED overcrowding.
Success of each of these strategies depends on the degree of leadership
involvement across a health system. ED overcrowding is not a problem that
is owned exclusively by emergency medicine. In fact, the ED component of
overcrowding can be considered relatively small.

Recently, several publications have reported that the main cause of ED
overcrowding is the extended boarding of inpatients in the ED. The lack of
timely transfer of ED patients to appropriate inpatient beds is compounded
by limited inpatient capacity and aggravated by hospital process inefficiency.
When addressing this problem, leadership at all levels of the organization
need to recognize that solving this problem requires coordination of the
inpatient units, the ambulatory clinics, ancillary services, and even other
hospitals within the health system.

It is helpful to consider two basic domains of variables that affect ED
operations. The first domain includes the variables that are intrinsic to the
ED itself. ED operations have to be optimized to reduce unnecessary waits,
increase efficiency in throughput, and reduce dwell times for patients in
beds. Bed turnover rates have a critical impact on the number of patients that

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can be fully evaluated. Thus, improving bed turnover rates can help to
optimize capacity and mitigate overcrowding. The second domain has to do
with variables external to the ED, including efficiency of transfer of admitted
or observation patients to other units, specialty consultation times,
availability and accessibility of outpatient clinics, and ancillary services. The
availability of outpatient referral services, including primary and specialty
care clinic appointments, can have a significant impact on patients’ ED dwell
times. If clinic and outpatient resources are not readily available for referral
by the ED physicians, the result is that prolonged evaluations and
interventions will occur in the ED. This prolongs the ED evaluations, which
exacerbate the crowding problem.

Unfortunately, many EDs are often faced to solve the problem of
overcrowding in isolation of other hospital operations. A coordinated
approach to overcrowding is the only way to achieve solutions. These
solutions will be effective especially if there is integration of the ED services
with other hospital-based services. A previous strategy had been to allow
EDs to attempt to solve the problem independently of hospital operations, but
such a strategy only address the initial element in the hospital-based health
care continuum. Ignoring the other hospital services will only lead to longer
ED patient waits, unsafe conditions, and suboptimal care.

Whatever strategy—or strategies—your organization decides to pursue,
the most important thing to remember is that the problem will not get
resolved without multidisciplinary intervention. Few EDs are resourced
adequately to manage overcrowding in isolation of the other hospital
services. Long-term ED planning must include an element of preparation for
the potential of ever increasing demand for urgent and emergency care.

KEY POINTS

Over the last 10 years, ED visit rates have increased while inpatient
bed availability has decreased, resulting in ED overcrowding.
A leading cause of ED overcrowding is the boarding of admitted
patients in the ED while they await inpatient beds.
Other variables that affect overcrowding fall into two basic categories:
factors that are intrinsic to ED operations and factors that have to do
with hospital operations.
Strategies to deal with ED overcrowding must be accomplished at the
hospital operations level.
Most EDs lack the required resources to solve the problems associated

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with overcrowding, especially since overcrowding is often more a
reflection of hospital operations rather than emergency operations.

SUGGESTED READINGS

Agency for Healthcare Research and Quality (Information on ED visits from the
HCUP Nationwide Emergency Department Sample [NEDS]
(http://hcupnet.ahrq.gov/)).

Coil CJ, Flood JD, Belyeu BM, et al. The effect of emergency department boarding
on order completion. Ann Emerg Med. 2016;67(6):730–736.e2.
doi:10.1016/j.annemergmed.2015.09.018.

Kayden S, Anderson PD, Freitas R, et al. Emergency Department Leadership and
Management: Best Principles and Practice. n.d.

Kelen G, Peterson S, Pronovost P. In the name of patient safety, let’s burden the
emergency department more. Ann Emerg Med. 2016;67(6):737–740.
doi:10.1016/j.annemergmed.2015.11.031.

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360

DISCHARGE DOCUMENTATION:
KEEP IT CLEAR, CONCISE, YET

COMPLETE

DAVID ROSE, MD

Every patient leaves the emergency department (ED) eventually; either they
are admitted or discharged. It is comforting when capable hands assume their
care in the hospital, but often unsettling when they are sent into the world
with only the advice we provide and a few pieces of paper.

Discharge instructions are a critical part of patient care and can alter the
patient’s course of illness. They provide essential information to the patient
and to follow-up providers, as well as serving as a medicolegal document.

AVOID COMMON ERRORS WHEN WRITING
DISCHARGE INSTRUCTIONS

Include all essential elements of discharge instructions (see Table 360.1).1

TABLE 360.1 ESSENTIAL ELEMENTS OF DISCHARGE INSTRUCTIONS

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Adapted from Taylor DM, Cameron PA. Discharge instructions for emergency

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department patients: What should we provide? J Accid Emerg Med. 2000;17:86–90.

Use Preformatted Templates and Instruction Sheets

Brief summaries of common conditions can help the provider construct
discharge instructions more efficiently. These are commonly available via
reputable medical sources online, or through your hospitals electronic
medical record (EMR) system.

Personalize Discharge Instructions

The less generic and more personalized discharge instructions are, the more
likely patients will actually comprehend and use them. Highlighting and
going through the discharge instructions with the patient will aid in their
understanding. Specific places to do this are in their “expected course” and
“aftercare instructions.”

Simplify Discharge Instructions

When creating discharge instructions, “less is more.” The shorter and simpler
the instructions are, the easier they are to follow. Furthermore, literacy in ED
patients has been shown to average from a 3rd to 10th grade reading level.1
This highlights the importance of the clear, simple language when
communicating with patients, both verbally and in writing.

Assuring Patients Demonstrate Understanding of Their
Discharge Instructions

ED patients frequently do not comprehend their discharge instructions.2
Engel showed about 80% of patients lacked understanding regarding their
home care instructions and return precautions.3 Horwitz et al. found that with
elderly patients who felt they understood their discharge instructions well,
over half could not recall accurate information concerning follow-up
appointments.4 When discussing discharge instructions, the “repeat back
method” or closed loop communication can be employed to assess
comprehension, increase retention, and lead to better health care outcomes.5
A brief discussion should complement the paperwork in order to make the
discharge process more effective.

Next time you are writing discharge instructions, think of the time a
patient came to your ED with a jumble of papers from an outside hospital

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with essentially nothing useful on them. Write discharge instructions as if
they were for one of your family members, as if you were the doctor at the
next follow-up, or as if they were to be read to a courtroom.

KEY POINTS

Include all essential elements of discharge instructions.
Preformed templates and instruction sheets help with efficiency and
completeness of the discharge process.
Personalize discharge instructions, and keep them simple in terms of
language and content.
Ensure patients demonstrate a clear understanding of their discharge
instructions.

REFERENCES

Taylor DM, Cameron PA. Discharge instructions for emergency department
patients: What should we provide? J Accid Emerg Med. 2000;17:86–90.

McCarthy DM, Engel KG, Buckley BA, et al. Emergency department discharge
instructions: Lessons learned through developing new patient education
materials. Emerg Med Int. 2012;306859:7.

Engel KG. Patient understanding of emergency department discharge instructions:
Where are knowledge deficits greatest? Acad Emerg Med.
2012;19(9):E1035–E1044.

Horwitz LI, et al. Quality of discharge practices and patient understanding at an
academic medical center. JAMA Intern Med. 2013;173(18):1715.

Schillinger D, et al. Closing the loop: Physician communication with diabetic
patients who have low health literacy. Arch Intern Med. 2003;163(1):83.

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361

RESIDENT AND ADVANCED
PRACTICE PROVIDER SUPERVISION

PATRICIA PETRELLA NOUHAN, MD, FACEP AND
ROBERT B. TAKLA, MD, MBA, FACEP

There is a balance between the ideal level of emergency medicine (EM)
attending supervision and autonomy for EM residents as well as advanced
practice providers (APPs; physician assistants and nurse practitioners). The
use of APPs in the emergency center setting is commonplace but has been
catalyzed by a number of factors including residency duty hour restrictions
and the limited number of EM physicians in some settings. In addition, EM
residency training programs require plans for graduated faculty supervision
in order to ensure adequate teaching and patient safety. Rural emergency
department (ED) settings may struggle to attract board-certified ED
physicians and rely on APP employees to fill shift gaps. How much
supervision of residents and APPs is needed, and what are the critical factors
to keep in mind when doing so?

In EM residency training, there is a graduated progression of autonomy
in practice from PGY1 to PGY2 and onward to more senior levels (PGY3, 4,
or 5 depending on the EM program). The Accreditation Council for Graduate
Medical Education (ACGME) requires PGY1 residents to receive direct
face-to-face supervision or indirect with immediate availability of direct
supervision at all times in the ED. As a resident progresses through their EM
training, greater patient care responsibilities are assigned to them by their
faculty and program director based on achieved skill level. They may
advance to the level of seeing multiple patients before review and patient
evaluation by the attending. Regardless of residency level, advanced
procedures (such as intubation, chest tube insertion, or thoracotomy) should
always be performed under direct faculty supervision. The ACGME

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guidelines require supervision that is flexible based on resident level,
resident skill, patient safety concerns, and available support services. The
faculty must be attuned to these factors as they direct residents in safe patient
care strategies and as they guide their learners to be future supervisors.

APPs do not have the same type of structured ED training as EM
residents do, where they progress from year to year in their training
specifically focused on EM. In addition, there is significant variability in
state law dictating the independent practice of APPs. Depending on the APP
school program, the student may be exposed to minimal EM. Instead, they
gain ED knowledge, specialized skills, and experience on the job. Because of
this variation, their level of required supervision and level of autonomy are
very APP dependent. An NP who was an ED nurse for 12 years prior to
completing her advanced training will require less supervision than one who
is fresh out of school and has little ED experience.

For supervision of APPs, one suggested method is to define by protocol
which types of encounters require that the patient be seen by the ED
physician. Additionally, that encounter with the attending should be
documented in the chart. For example, a repeat visit or high acuity patient
may suggest the patient be evaluated by the ED physician and not discussed
simply with a phone dialogue between the APP and the ED physician. These
guidelines should be developed and agreed to in advance and tailored to state
law, hospital bylaws, and departmental rules and regulations. A rural setting
ED may only have an APP without any ED physician on site; therefore, the
scope of practice and autonomy of that APP may be higher relative to an
APP in an urban teaching hospital ED setting where there are EM residents
and faculty.

What seems to be critical for optimal patient care and efficiency, as well
as continued education and skill development of residents and APPs is
honest open communication and feedback. If the APP or EM resident feels
uncomfortable with any aspect of patient care, they need to ask for assistance
and supervision without hesitation. Anything less jeopardizes patient care as
well as the integrity of the educational process for both types of learners.

KEY POINTS

There is a balance between the individualized autonomy given to each
EM resident and APP based on their skill set and experience coupled
with the supervising physician’s level of comfort with that particular
learner.

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