Article

The Emergency Medical Treatment and Active Labor Act (EMTALA): Assisting physicians to honor medical oaths

Emergency medical treatment and Acti”>Correspondence / American Journal of Emergency Medicine 37 (2019) 13621393 1391

IDSA, and not inappropriately covering MRSA can improve patient’s ex- periences and decrease their overall cost of care.

William David Boothe

Dayna Diven Dell Seton Medical Center, Department of Dermatology, 1701 Trinity St., Stop Z0900, Austin, TX 78712, United States of America

E-mail addresses: [email protected],

[email protected].

9 January 2019

https://doi.org/10.1016/j.ajem.2019.01.022

References

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    Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibi- otic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med 2013;126(12):1099-106 Epub 2013/11/23 https://doi.org/10. 1016/j.amjmed.2013.08.016. [PubMed PMID: 24262724; PubMed Central PMCID: PMCPMC4075054].

  3. Gunderson CG, Cherry BM, Fisher A. Do patients with cellulitis need to be hospital- ized? A systematic review and meta-analysis of mortality rates of inpatients with cel- lulitis. J Gen Intern Med 2018;33(9):1553-60 Epub 2018/07/20 https://doi.org/10. 1007/s11606-018-4546-z. [PubMed PMID: 30022408; PubMed Central PMCID: PMCPMC6108983].
  4. Jeng A, Beheshti M, Li J, Nathan R. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation. Medicine 2010;89(4): 217-26 Epub 2010/07/10 https://doi.org/10.1097/MD.0b013e3181e8d635. PubMed PMID: [20616661].

    The Emergency Medical Treatment and Active Labor Act (EMTALA): Assisting physicians to honor medical oaths

    Oath-taking in medical education is an integral part of becoming a physician. One hundred percent of medical schools confirm the practice of oath-taking amongst their medical students [1]. Central to these med- ical oaths is the principle of non-discrimination [2]. The value that all patients should be treated equally is fundamental to the practice of a physician. Emergency medicine is unique due to the passage of the Emergency Medical Treatment and Active Labor Act (EMTALA), that while protecting patients, can also assist physicians in upholding their non-discriminatory oath.

    There is no unified medical oath used by medical schools. However, many medical schools select The Declaration of Geneva, while some schools still use an unmodified translation of the Hippocratic Oath [1]. The Declaration of Geneva states that a physician swears to serve “hu- manity”, without “considerations of age, disease or disability, creed, eth- nic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor” [3]. As medical oaths elude to, discrimination embodies many forms, including race, immi- gration status, and sexual orientation. Discrimination based on financial status also exists, yet is a practice in medicine that is regularly employed by many specialties. Physicians and hospitals can limit or deny care to an individual based on insurance status or their ability to pay for their care.

    In 1986, EMTALA was passed in order to ensure that everyone within the borders of the United States had access to Emergency medical care, regardless of their ability to pay [4]. EMTALA was cre- ated in response to a practice called patient dumping, where

    Uninsured patients were transferred to public hospitals before as- sessment or stabilization [4]. EMTALA is based on the principle that it would be unethical to withhold life-saving care, based on ability to pay, when a patient presents to an ED with an acute, life- threatening condition. Moreover, the law intentionally uses the lan- guage “any individual” in order to eliminate any opportunity to dis- criminate [4]. As a result, the law essentially eliminated financial discrimination through denial of care.

    Working in an environment protected by EMTALA, emergency med- icine physicians treat patients without consideration of ability to pay. Patients at the very least must be assessed and stabilized before insur- ance status is confirmed. Effectively, EMTALA established universal ac- cess to emergency care, allowing emergency medicine physicians to practice medicine while upholding their non-discriminatory oath to their patients [4].

    Unfortunately, EMTALA does not apply to other medical specialties, where patients may be denied care if they are uninsured or unable to pay. Therefore, the evolution of healthcare financing and the business side of medicine may take higher precedence than the moral obligation to patients, as stated in medical oaths. Often physicians work within the constraints of institutions where healthcare administrators do not take similar oaths. The disparate moral obligations of those treating patients and those deciding who receives treatment potentially forces physicians into ethical dilemmas. As long as the moral obligations of healthcare ad- ministrators do not match those of physicians, we cannot expect physi- cians to act otherwise.

    This also brings into question the relevance of medical oath-taking, if financial discrimination is not only acceptable, but commonly practiced. When surveyed, only one in four practicing physicians reported medical oaths taken during medical school as having a strong influence on their practice, instead relying heavily on their own sense of right and wrong [5]. Rather than providing ethical standards for practicing physicians, it may be that oath-taking is merely an expression of tradition and that there exists gaps in the application of medical oaths after medical school [1].

    Whether intentional or happenstance, EMTALA assists emer- gency medicine physicians to honor the medical oath they likely re- cited in medical school, specifically pertaining to non- discrimination. Expecting physicians of specialties that EMTALA does not reach to provide care for all people is ignoring the for- profit nature of our healthcare system. There needs to be a legal framework, mirroring the implementation of EMTALA, that allows not only emergency medicine physicians, but all physicians, to up- hold their moral obligations.

    Funding

    This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

    Conflicts of interest

    None [AB], none [JJ].

    IRB approval

    Not applicable — perspective article.

    Prior poster/abstract presentations

    None.

    1392 Correspondence / American Journal of Emergency Medicine 37 (2019) 13621393

    Prior online publication

    None.

    Kimberly Gressick Jennifer S. Jackson MD*

    Berkshire, UK); Ambu(R) AuraGain(TM) Disposable Laryngeal Mask (Ambu A/S, Kopenhagen, Denmark); (4) Intubating laryngeal tube iLTS-D (iLTS-D; VBM Medizintechnik GmbH, Sulz, Germany);

    (5) EasyTube (Rusch, Kenen, Germany). After the theoretical training, they completed a questionnaire, in which they assessed the preferences and ease of performing airway management in the case of various

    University of Miami Miller School of Medicine, Department of Medicine, Division of Emergency Medicine, Miami, FL 33136, United States of America

    *Corresponding author at: Division of Emergency Medicine, Depart- ment of Medicine, Soffer Bldg, Box # C235 (R-760), 1120 NW 14th Street, Miami, FL 33136, United States of America.

    E-mail address: [email protected].

    9 January 2019

    https://doi.org/10.1016/j.ajem.2019.01.023

    References

    Crawshaw R, Foster B, Iles-Shih M, Stull J. The uses of medical oaths in the twenty-first century. Pharos Alpha Omega Alpha Honor Med Soc 2016;79(2):20-5 PMID: 27328533.

  5. Scheinman SJ, Fleming P, Niotis K. Oath taking at U.S. and Canadian medical school ceremonies: historical perspectives, current practices, and future considerations. Acad Med 2017. https://doi.org/10.1097/ACM.0000000000002097 Epub ahead of print. PMID: 29239902.
  6. World Medical Association Declaration of Geneva. https://www.wma.net/policies- post/wma-declaration-of-geneva/. Updated 2006. Accessed February 21, 2018.
  7. Zibulewsky J. The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physicians. Proc (Bayl Univ Med Cent) 2001;14(4): 339-46 PMID: 16369643. PMCID: PMC1305897.
  8. Antiel R, Curlin F, Hook C, Tilburt J. The impact of medical school oaths and other pro- fessional codes of ethics: results of a National physician survey. Arch Intern Med 2011; 171(5):469-71 PMID: 21403046. PMCID: PMC3951008 https://doi.org/10.1001/

    archinternmed.2011.47.

    Attitudes of firefighters towards the use of Supraglottic airways devices

    To the Editor,

    In the article “advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis” by White et al. published in The American Journal of Emergency Medicine, the authors indicate that the overall heterogeneous benefit in survival with ETT was not replicated in the low risk randomized controlled trials, with no significant difference in survival or neurological outcome [1]. It is worth noting that endotra- cheal intubation is a highly specialized procedure, requiring from the per- son performing it a lot of knowledge and skills in its use. As Buis et al. indicate, the learning curve for direct laryngoscopy is about 50 intuba- tions [2]. In the case of videolaryngoscopy it is much lower [3-5]. After all, because of the cost of videolaryngoscopes, they are relatively rarely used in pre-hospital settings. An alternative to them can be supraglottic airway devices, which in present times are used not only in pre-hospital settings [6,7], but also under operating theatre conditions [8].

    The aim of the study was to assess the attitudes of firefighters to- wards the use of Supraglottic airway devices.

    The survey involved 78 firefighters working in the State Fire Service in Poland and participating in rescue operations as part of their profes- sional work. All study participants took part in training in airway man- agement. After the theoretical training, they had the opportunity to practice the practical application of various supraglottic airway devices in the conditions of simulated airway management. For this purpose an adult airway management simulator was used (Sakamoto Airway Man- agement Trainer; SAKAMOTO MODEL CORPORATION; Osaka, Japan). The participants used the following devices: (1) standard Laryngeal Mask Airway (Skamex, Lodz, Poland); (2) iGEL mask (Intersugical Ltd.,

    supraglottic airway devices. The ease of airway management was assessed on a 100-degree scale, where ‘1’ meant a very easy procedure and ‘100’ a very difficult procedure.

    The average age of study participants was 33.5 +- 5.6 years. The study participants did not have medical education. During the training, all participants performed airway management using each method. The most preferred supraglottic airway devices indicated by the participants were iGEL, then iLTS-D, and the least preferred were the standard LMA. The ease with which airway management could be carried out using dif- ferent supraglottic airway devices varied and was adequate: 10 +- 8 points for iGEL, 17 +- 8 points for iLTS-D, 23 +- 10 points for EasyTube, 46 +- 13 points for AMBU, and 52 +- 23 points for standard LMA.

    As the above study indicates, there are differences in the use of dif- ferent supraglottic airway devices. The iGEL laryngeal mask is the most preferred type of supraglottic airway devices among the fire- fighters surveyed. The training of rescuers in the use of SADs can be a key element of rescue operations, even more so that these devices in comparison with endotracheal intubation do not require from the res- cuer high practical skills.

    Source of support

    No sources of financial and material support to be declared.

    Kurt Ruetzler

    Department of General Anesthesiology, Anesthesiology Institute, Cleveland

    Clinic, Cleveland, OH, USA Department of Outcome research, Anesthesiology Institute, Cleveland

    Clinic, Cleveland, OH, USA

    Agnieszka Madziala Marcin Madziala Michal Pruc Dominika Dunder*

    Lazarski University, Warsaw, Poland E-mail address: [email protected] (D. Dunder).

    13 January 2019

    https://doi.org/10.1016/j.ajem.2019.01.028

    References

    White L, Melhuish T, Holyoak R, et al. Advanced airway management in out of hospi- tal cardiac arrest: a systematic review and meta-analysis. Am J Emerg Med 2018;36 (12):2298-306. https://doi.org/10.1016/j.ajem.2018.09.045.

  9. Buis ML, Maissan IM, Hoeks SE, et al. Defining the learning curve for endotracheal in- tubation using direct laryngoscopy: a systematic review. Resuscitation 2016;99: 63-71. https://doi.org/10.1016/j.resuscitation.2015.11.005.
  10. Gawel W, Kaminska H, Wieczorek W. UESope as a method of endotracheal intubation of trauma patient. Disaster Emerg Med J 2017;2(4):175-6. https://doi.org/10.5603/ DEMJ.2017.0040.
  11. Ladny JR, Sierzantowicz R, Kedziora J, et al. Comparison of direct and optical laryngos- copy during simulated cardiopulmonary resuscitation. Am J Emerg Med 2017;35(3): 518-9. https://doi.org/10.1016/j.ajem.2016.12.026.
  12. Madziala M. The ETView tracheoscopic ventilation tube for trauma patient intubation. Disaster Emerg Med J 2018;3(2):69-70. https://doi.org/10.5603/DEMJ.2018.0016.
  13. Frass M, Robak O, Smereka J, et al. Securing the airway patency by firefighters with the use of CombiTube. A pilot data. Disaster Emerg Med J 2018;3(2):46-50. https:// doi.org/10.5603/DEMJ.2018.0011.

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