Med On The Go episode 19: Informed Consent/Discharge

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Consent (as applicable in Canada)

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Medico-legal issues are such “downers” to talk about, but in this day and age it really needs to be discussed because we all want outcomes that are safe and fair for all parties involved. Since I’m hoping to practice medicine in a different country than the one I was trained in, it’s especially important for me to learn about the laws and regulations in Canada.

According the Canadian Medical Protective Association (CMPA) three criteria required for informed consent:

1.     Patient must have the mental capacity to understand the nature and possible consequences of the procedure/treatment.

2.     The patient must be fully informed about the procedure/treatment.

a.     The physician should disclose the diagnosis.

b.     The physician should disclose the nature of the proposed investigation/treatment.

c.      The physician should disclose the expected consequences for forgoing the proposed investigation/treatment.

d.     The physician should disclose reasonable alternatives to the proposed investigation/treatment.

e.     The physician should disclose any material risks of the proposed investigation/treatment and answer questions posed by the patient.

                                               i.     Not every possible complication needs to be conveyed to the patient.

                                              ii.     Complications that occur frequently should be disclosed.

                                            iii.     Complications, however rare, with significant consequences for the patient (e.g. death, paralysis) need to be disclosed.

                                            iv.     Risks that a reasonable person in the patient’s position would consider significant should also be disclosed.

3.     The consent must be given voluntarily

The consent form itself does not equal real consent. The explanation given by the physician and the dialogue between physician and patient about the proposed procedure/treatment is the all-important element of the consent process (no explanatory pamphlet/video can replace this, but if supplementary material was provided it should also be documented). A signed form will be of relatively little value later if the patient can convince a court that the explanations were inadequate or absent. A summary of the consent discussion entered into the medical record at the time is the best defense against an allegation of lack of informed consent; the documentation of the consent discussion need not be lengthy or detailed. The physician can delegate the responsibility of obtaining consent to a colleague, medical trainee, or nurse who has the knowledge and experience to provide information tailored to the requirements of the patient and circumstances.

In witnessing a signature, the witness simply confirms the identity of the patient who signed the document and that the person’s mental state at the time appeared to allow for an understanding of what was signed. The witness has no obligation to provide pre-treatment explanations and is in no way attesting to the adequacy of the explanations given by the physician.

If a surgeon at a teaching hospital delegates certain surgical procedures to his/her trainees, he should disclose to patients the involvement of trainees in these procedures.

Battery in the medico-legal context is when a physician carries out an investigation/treatment in the absence of valid consent or when treatment went beyond or deviated significantly from that for which consent was given. Assault and battery may also apply when consent was obtained by way of serious misrepresentation.

In the emergency department, however, consent is not needed when a patient is at imminent risk of serious injury AND obtaining consent is either not possible or would increase risk to the patient. This rule assumes that most people would want to be saved in an emergency. However, a capable and informed patient can refuse treatment or part of treatment (even if it is life-saving); and emergency treatment CANNOT be initiated if a competent patient has previously refused the same or similar treatment (for same problem) and there’s no evidence to suggest he has changed his mind or an advanced directive (such as DNR) is available. Refusal of help in a suicide situation still warrants treatment. When in doubt, initiate treatment; it can be withdrawn at a later time.

Children presenting to the ER are treated in the same way: treat immediately if the patient is at imminent risk. The patient does NOT have to reach age of majority to give a valid informed consent. However, if the patient in question is obviously not capable to make a decision (like a baby or toddler), parents/guardians have the right to make treatment decisions; if they refuse treatment that is life-saving or will potentially alter the child’s quality of life, Children’s Aid Society (CAS—there is one in every hospital) must be contacted, in which case the consent of CAS is needed to treat.

Common issues needing consent include HIV testing and administration of blood products. Jehovah’s Witnesses are the most common group who will have issues with latter; they may refuse all blood products (even autologous), in which case treatment needs to provide the highest possible quality of care with out the use of blood products (e.g. crystalloids for volume expansion like hydroxyethyl starch). They will generally sign hospital forms releasing medical staff from liability.

An extension of informed consent is the topic of informed discharge. During informed consent, patients are informed of what can potentially go wrong; during informed discharge, patients are informed of the symptoms and signs that would indicate something wrong may be happening. They should also be given a sense of urgency of the response required and where best to seek medical attention. The information should be tailored to each patient and clinical situation.

In the emergency room setting, for many patients there are diagnostic uncertainty on an initial/subsequent visits. These patients should be made aware of this uncertainty—what is known and what is unknown—so that any continuation, escalation, or change in symptoms may prompt reevaluation. Just like informed consent, a discussion between physician and patient is warranted; any detailed explanatory pamphlet or video would not suffice. Documentation of the advice provided on discharge should be documented in the medical records.

Med On The Go episode 18

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Altered Level Of Consciousness

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Altered mental status is a collective, non-specific term referring to change in cognitive function, behavior, or attentiveness. It includes delirium, dementia, lethargy (state of decreased awareness and alertness i.e. patient may appear wakeful), stupor (unresponsive but rousable), and coma (sleep-like state, not rousable to consciousness).

Possible causes of coma (AEIOU TIPS)

Acidosis/alcohol

Epilepsy

Infection

Oxygen (hypoxia)/opiates

Uremia

Temperature/trauma (esp. to head)

Insulin (too little or too much)

Psychogenic/poisoning

Stroke

Remember “GCS < 8 intubate!” Ability to protect airway is first priority.

History

·      Obtain collateral from family, friends, police, paramedics, old charts, or Medic Alert bracelets etc.

·      Onset and progression

o   Antecedent trauma, seizure activity, fever

o   Abrupt onset suggests CNS hemorrhage/ischemia or cardiac cause

o   Progression over hours to days suggests progressive CNS lesion or toxic/metabolic cause

·      Determine patient’s baseline level of consciousness

·      Past medical history, paying attention to similar episodes, overdose, or concurrent psychiatric disorders (e.g. depression).

Physical examination

·      Vital signs including temperature

·      Cardiac, respiratory, and abdominal exams

·      Complete neurological exam

o   Pupil size and reactivity

o   GCS

Investigations

·      Blood work—rapid blood sugar, CBC, electrolytes, creatinine, BUN, liver function test, glucose, serum osmolality, venous blood gas, coagulation studies, troponins

·      Imaging—CXR, CT head

·      Other tests—ECG, urine analysis, urine toxicology

Diagnosis

·      Administer appropriate universal antidotes

o   Thiamine 100mg IV if history of alcoholism or patient looks malnourished

o   One ampule D50W IV if low blood sugar

o   Naloxone 0.4~2mg IV or IM if opiate overdose is suspected

·      Distinguish between structural and toxic-metabolic coma

o   Structural coma

§  Pupils, extra-ocular movements, and motor findings are usually asymmetrical

§  Look for focal or lateralizing abnormalities

o   Toxic-metabolic coma

§  Dysfunction at lower levels of the brainstem (e.g. caloric unresponsiveness)

§  Respiratory depression in association with an intact upper brainstem (e.g. equal reactive pupils)

§  Extra-ocular movements and motor findings are symmetrical or absent

·      Essential to re-examine frequently because status can change rapidly

·      Diagnosis may become apparent only with the passage of time. Delayed deficit after head trauma suggestive of epidural hematoma (characteristic “lucid interval”).

Disposition

·      Admission if ongoing decreased level of consciousness

·      Discharge if altered level of consciousness is readily reversible; ensure adequate follow-up care

Genitourinary Tract Injuries

Welcome back to Med On The Go! This week we discuss genitourinary tract injuries commonly seen in the emergency room setting. Before we start, I'd like to invite you to visit our Facebook page www.facebook.com/drolimedonthego/ and help us by pressing "like". As usual, this blog post is also available in podcast form; subscribe to Med On The Go With Dr. Oli on iTunes, Google Play, or Podbean to make sure you never miss an episode. If you'd like to further support us, please visit www.patron.podbean.com/medonthego for more details.

Now let's dive into this week's topic:

Genitourinary tract injury secondary to trauma can occur any where within the genitourinary tract by a variety of mechanisms.

·      Blunt trauma—often associated with pelvic fractures

o   Upper tract

§  Renal

·      Contusions (minor injury—parenchymal ecchymoses with intact renal capsule)

·      Parenchymal tears/lacerations—non-communicating (hematoma), communicating (urine extravasation, hematuria)

§  Ureter: rare, at uretero-pelvic junction

o   Lower tract

§  Bladder—gross hematuria usually suggests bladder injury

·      Extraperitoneal rupture of bladder from pelvic fracture fragments

·      Intraperitoneal rupture of bladder from trauma and full bladder

§  Urethra

·      Posterior urethral injuries: MVCs, falls, pelvic fractures

·      Anterior urethral injuries: blunt trauma to perineum, straddle injuries/direct strike

o   External genitalia

·      Penetrating trauma—damage to kidney, bladder, ureter (rare), external genitalia

·      Acceleration/deceleration injury—renal pedicle injury—high mortality rate (laceration and thrombosis of renal artery, renal vein, and their branches).

·      Iatrogenic injury—ureter and urethra damage secondary to instrumentation

History

·      Mechanism of injury

·      Hematuria (microscopic or gross), any blood on underwear

·      Dysuria, urinary retention

·      History of hypotension

Physical examination

·      Abdominal pain, flank pain, CVA tenderness, upper quadrant mass, perineal lacerations

·      DRE: sphincter tone, position of prostate, presence of blood

·      Scrotum: ecchymoses, lacerations, testicular disruption, hematomas

·      Bimanual exam, speculum exam

·      Extraperitoneal bladder rupture: pelvic instability, suprapubic tenderness of mass of urine or extravasated blood

·      Intraperitoneal bladder rupture: acute abdomen

·      Urethral injury: perineal ecchymosis, scrotal hematoma, blood at penile meatus, high riding prostate, pelvic fractures

Investigations—in gross hematuria, the GU system is investigated from distal to proximal (i.e. urethrogram, cystogram… etc.)

·      Urethra: retrograde urethrography

·      Bladder: urinary analysis, CT scan, urethrogram +/- retrograde cystoscopy +/- cystogram (distended bladder and post-voiding)

·      Ureter: retrograde ureterogram

·      Renal: CT scan (best, if hemodynamically stable), intravenous pyelogram

Management

·      Urology consultation

·      Renal injury

o   Minor injuries—conservative management such as bed rest, hydration, analgesia, antibiotics

o   Major injuries—admit

§  Conservative management with frequent reassessments, serial urine analysis +/- re-imaging

§  Surgical repair (exploration, nephrectomy) for hemodynamically unstable patients or those who continue to bleed > 48hrs, major urine extravasation, renal pedicle injury, all penetrating wounds and major lacerations, infections, renal artery thrombosis

·      Ureter injury—ureterouretostomy

·      Bladder injury

o   Extraperitoneal

§  Minor rupture—Foley drainage for 10~14 days

§  Major rupture—surgical repair

o   Intraperitoneal—drain abdomen and surgical repair

·      Urethral injury

o   Anterior—conservative treatment, consider Foley catheter or suprapubic cystostomy and antibiotics for those who cannot void

o   Posterior—suprapubic cystostomy (AVOID CATHERIZATION) +/- surgical repair