Decreased Glasgow Coma Scale Score Does Not Mandate Endotracheal Intubation in the Emergency Department

From ScienceDirect:


Background: Decreased consciousness is a common reason for presentation to the emergency department (ED) and admission to acute hospital beds. In trauma, a Glasgow Coma Scale score (GCS) of 8 or less indicates a need for endotracheal intubation. Some advocate a similar approach for other causes of decreased consciousness, however, the loss of airway reflexes and risk of aspiration cannot be reliably predicted using the GCS alone. Study Objective: A survey of all poisoned patients with a decreased GCS who were admitted to an ED short-stay ward staffed by experienced emergency physicians, to establish the incidence of clinically significant aspiration or other morbidities and endotracheal intubation. Methods: A prospective, observational study was conducted of all patients admitted to the ED short-stay ward with a decreased level of consciousness (GCS < 15). Results: The study included 73 patients with decreased consciousness as a result of drug or alcohol intoxication. The GCS ranged from 3 to 14, and 12 patients had a GCS of 8 or less. No patient with a GCS of 8 or less aspirated or required intubation. There was one patient who required intubation; this patient had a GCS of 12 on admission to the ward. Conclusions: This study suggests that it can be safe to observe poisoned patients with decreased consciousness, even if they have a GCS of 8 or less, in the ED.

Christian doctors’ group protests rolling back ‘conscience’ rule


An organization of Christian physicians argued Wednesday against an impending rollback of a federal rule allowing health care workers to refuse to provide certain reproductive services, saying it’s discriminatory.

The Bush White House proposed the rule in August, and it was enacted January 20, the day President Obama took office. It expanded on a 30-year-old law establishing a “conscience clause” for health care professionals who don’t want to perform abortions.

Under the rule, workers in health care settings — from doctors to janitors — can refuse to provide services, information or advice to patients on subjects such as contraception, family planning, blood transfusions and even vaccine counseling if they are morally against it.

The Obama administration is expected to reverse the rule shortly, touching off a new wave of heated debate over what remains one of the most sensitive and emotional hot-button issues in American politics.

Epi-Injectors May Need Redesign to Prevent Accidents

From MedPage Today:

Unintentional sticks with epinephrine autoinjectors appear to be increasing and may indicate a need to redesign the lifesaving devices, researchers said.

There are no hard statistics on misfired epinephrine injectors, but a literature review identified 69 cases in the past 20 years — more than two-thirds of which occurred since 2002, according to F. Estelle Simons, M.D., of the University of Manitoba in Winnipeg, and colleagues.

Details were often scant, but it appeared that most incidents involved patients who tried to inject themselves but stuck their fingers instead of their thighs as intended, the researchers wrote in the April Annals Of Allergy, Asthma & Immunology.

In about 10% of the cases, accidental self-injections involved health professionals, Dr. Simons’ group foun

Illegal Immigrant Used Stolen Identity to Get Hospital Care

From the Wall Street Journal Health Blog:

Mariana de la Torre crossed into the U.S. from Mexico in the trunk of a car soon after her boyfriend beat her and threatened to kill her. Several months arriving in the U.S., she was diagnosed with cervical cancer. She used an ID purchased on the black market to get roughly $530,000 worth of hospital care, some of which was paid for by Medicaid.

The Chicago Tribune told her story in a recent front-page article last month, and ran her obit this morning. She died back in Mexico at age 28.

Her story illustrated how medical identity theft works: de la Torre took the name and Social Security number of a person who is serving a three-year prison term in Texas for robbery, the Trib said. She then used that information to get care at Trinity Medical Center, University of Chicago Medical Center and St. Francis Medical Center, all in Illinois.

Miles to Go on E-Health Records

From the NY Times (editorial):

President Obama is counting on electronic health records to help modernize the nation’s dysfunctional health care system, improve the quality of care and reduce its cost. His stimulus package will provide $19 billion over the next two years to promote the adoption and use of health information technology, and he has pledged to spend some $50 billion in all over five years.

There is a long way to go. A new study reveals that American hospitals have been appallingly slow to adopt electronic records, just as previous studies have shown that American physicians have been very slow to computerize their operations. By contrast, a vast majority of doctors in four other industrialized nations have adopted electronic records, although hospitals are thought to be lagging.

Appeals court says lawsuit against Mich. hospital can proceed

From Modern Healthcare:

A federal appeals court has revived a lawsuit alleging a Detroit-area hospital violated the Emergency Medical Treatment and Active Labor Act when it discharged a psychotic patient who murdered his wife 10 days later. In an opinion delivered Monday, the 6th U.S. Circuit Court of Appeals reversed a judge’s ruling granting summary judgment in favor of the hospital, 453-bed Providence Hospital in Southfield, Mich.

The lawsuit was filed by the estate of the victim, who brought her husband, Christopher Howard, to the emergency room in 2002. Howard was admitted and evaluated, and six days later he was sent home with a diagnosis of “atypical psychosis (with) delusional disorder.” It was noted that his wife continued to fear him.

Sixth Circuit Court Judge Eric Clay wrote that the victim’s estate was free to sue under EMTALA even if Congress intended it only to cover harm suffered by the person denied care. Clay also rejected the hospital’s argument that its obligations under EMTALA ended when Howard was admitted.

Providence Hospital parent St. John Health, a division of Ascension Health, declined to comment.

U.S. District Court Judge Anna Diggs Taylor in 2007 granted summary judgment to the hospital, concluding EMTALA wasn’t intended to “establish guidelines for patient care or to provide a suit for medical negligence or malpractice.” The hospital did not turn the patient away but rather screened and admitted him as required under the law, Diggs Taylor said from the bench, as transcribed in the 6th Circuit opinion

Patient-Safety Expert: ‘Our Current Approach … Is Nuts’

From the Wall Street Journal Health Blog:

Some big players in patient safety are looking to emulate the aviation industry in a quest to reduce medical errors. Here’s a Health Affairs paper explaining the project.

“Our current approach to solving these mistakes is nuts,” Peter Pronovost, the Johns Hopkins patient safety guru who is the man behind the plan, told the Health Blog. Basically, he said, it’s common for a hospital to identify a safety problem — and attempt to solve it by telling doctors and nurses to be more careful, an approach Pronovost called “neither efficient nor effective.”

As an example, Pronovost pointed out that the catheters used for epidurals are sometimes accidentally attached to patients’ IV lines — a dangerous situation that can harm the patient. Hospitals often respond by reminding doctors and nurses not to do this, or by affixing stickers that say the epidural catheters are for epidural use only, Pronovost said. But a more effective solution might be persuading manufacturers to redesign epidural catheters so that they cannot be attached to an IV line.

The paper cites as a model something called the Commercial Aviation Safety Team (CAST), which includes, among others, the FAA, airline groups, manufacturers and pilots’ associations.

Pronovost proposes bringing together key people from organizations such as big health systems, the FDA, the Joint Commission (which accredits hospitals) and AHRQ (a federal health research agency) to identify common safety problems and come up with new systems to prevent them from happening.