Ethical Considerations in Pre-Hospital Care with Dr. Selk

• Autonomy, beneficence, nonmaleficence, justice
• Capacity: ability to understand medical situation and make an informed decision about care after being advised of the risks and benefits of a particular course of action
• Competence: a legal determination.  If you are concerned that a patient is not competent, then you can refer for 
• Refusal of EMS care:  Patient must articulate reasoning for refusing and articulate ramifications regarding their decision.  This conversation should be documented and witnessed as well. 
• Death on Scene: non-traumatic cardiac arrest, unresponsive/apneic/pulseless/F&D pupils/ALS EKG with asystole in at least two leads.  Lividity, rigor mortis, presence of venous  pooling, destruction of body incompatible with life
• Law enforcement information gathering activities should not interfere with patient care.  Law enforcement video or audio recording should only be used with permission from all parties

Management of Variceal Bleeds with Dr. D. Thomas and Dr. D. Grace

• ABCs:  HOB up, preoxygenate, RSI with cardiostable sedative and high dose paralytic, have video and 2 suctions available.  Place tamponade tube PRN and call GI.
• Tamponade tube depends on the institution.  No matter what, inflate gastric tube and apply proximal traction. Start by placing 50cc air into balloon and shoot a CXR to confirm placement in stomach.  Once placement is confirmed, fully inflate balloon.  Gastric balloons can potentially migrate into the esophagus and will compress the trachea, causing high peak pressures.  If you see increased peak pressures, repeat CXR to check placement. 
  • Blakemore tube:  Gastric balloon (250mL) + esophageal balloon + gastric suction
  • Minnesota tube: Gastric balloon (500mL) + esophageal balloon + gastric suction + esophageal suction
  • Linton tube: Gastric balloon (750mL) 

Mushroom Toxicity with Dr. Webb

• Orellenine:  symptom onset 36hrs-17days, severe renal failure, frequently no other symptoms with insidious onset
• Amatoxin:  gradual onset over several days.  Initially emesis and diarrhea → elevated LFTs → GI bleeding, hepatic encephalopathy, renal failure → death.  Can treat early ingestion with charcoal and gastric decontamination.  Silbinin, NAC, benzathine penicillin have been proposed as potential treatments. 
• Ibotenic acid and mucimol:  Increases GABA And serotonin. Onset minutes but up to 3 hours → visual distortions and hallucinations.  Can see N/V, ataxia, and hypotension.  Very rarely cause coma, convulsions, and death.  Symptoms typically resolve within 24 hours. 
• Monomethylhydrazine:  Inhibits pyridoxine function in CNX. Most common presentation is N/V/D.  Can rarely cause jaundice, liver failure, and seizure. Treatment is typically symptomatic, but should give pyridoxine if patient develops seizures
• Muscarine: Sweating, salivation, lacrimation, miosis, bradycardia, wheezing.  Treatment typically symptomatic, but if severe, can use atropine. 
• Coprine: causes disulfiram-like reaction.  Don’t mix with alcohol.
• Chlorophyllum: most common mushroom poisoning in the US.  N/V/D.  Supportive treatment.  

Peds GI Emergencies with Dr. Stevenson

• Obstruction– atresia (esophageal, jejunoileal, anorectal), meconium ileus, webs/stenoses/duplication.  Typically present within early weeks of life.  Can see double bubble sign with duodenal atresia.  Call surgery. 
• Malrotation– First week or so of life, bilious emesis.  Call surgery. 
• Pyloric stenosis– First month of life.  Child appears hungry and fussy, but non-toxic.  Olive-shaped mass.  Diagnostic test of choice is ultrasound.  Call surgery. 
• Incarceration– hernia or torsion.  Associated with prematurity.  Reduce and call surgery.
• Intussusception– paroxysmal abd pain, vomiting, lethargy.  Can have positive hemoccult.   

Implicit Bias in ED with the Office of Diversity and Inclusion

• Implicit bias is an unconscious cognitive shortcut between previous experiences and current data input
• IAT as a tool to evaluate your implicit bias
• Snap judgements, elitist behaviors, negative stereotypes, positive stereotypes, cloning, wishful thinking
• Can impact our ability to effectively interact with patients and colleagues
• Can unintentionally reinforce historical social inequalities 
• How to mitigate individual biases:  develop the capacity to self-reflect, get feedback, practice “constructive uncertainty,” engage “others,” and explore awkwardness

discomfort.