A request for an abortion

How to manage to abortion request by a hypothetical 30-year old married woman who states the she fears a deformed child because of taking an antibiotic combination, cotrimoxazole, containing trimethoprim is discussed by 3 physicians. The 1st doctor would confirm pregnancy with an exam and a laboratory test, schedule another consultation for counseling, and schedule a pelvic ultrasound if she decides to carry the pregnancy. If she wants an abortion, the physician would counsel her at length about her marriage and the emotional consequences of abortion. The 2nd physician would advise her that fetal abnormality from trimethoprim has not been reported in women. Since this doctor is personally opposed to abortion, she would refer the patient to another doctor to make the arrangements, and counsel her again afterward. The 3rd physician added the advice that 1-2% of all U.K. births are abnormal in some way. He would take steps to establish the precise gestational date, recommend an ultrasound scan at 18 weeks to cover himself legally and suggest that the patient's husband join in the counseling session to help bring out feelings about the marriage and the pregnancy.     

An autopsy of an ethical dilemma

An ethical dilemma was created for the intensive care unit staff following a physician's "No Code (Do Not Resuscitate)" telephone order. The author, the Director of Nursing involved, analyzes the short- and long-term outcomes of the situation. She applies a deontological framework, or duty-oriented ethical decision-making methodology, to help other administrators solve similar problems.     

Enhancing medical student consultation request skills in an academic emergency department

The purpose of this study was to develop an educational protocol to enhance the communication skills of medical students when requesting specialty consultation. A protocol consisting of a worksheet and oral instructions was created to teach nine criteria of effective consultation requests, derived from the existing literature. Consultation requests made by senior medical students using the protocol were evaluated and compared to consultation requests made by Emergency Medicine residents who did not complete the educational protocol. Forty-two medical student consultation requests and 50 Emergency Medicine resident consultation requests were evaluated. The students included five of the nine criteria in their consultation requests significantly more often than the residents. The median number of criteria included by the students was eight, while the median number of criteria included by the residents was six. This study shows that senior medical students can be taught to communicate effectively with specialists when requesting consultations.     

Secondary renal neoplasms: an autopsy study.

The records of 11,328 autopsies performed on patients who died of malignant disease between March 1944 and August 1974 were reviewed, and 816 cases (7.2%) demonstrated renal metastases. The most common primary tumors in decreasing order of frequency were lung, breast, skin (melanoma), and tumors of the genitourinary, gastrointestinal, and gynecologic tracts, respectively. Generally metastases were hematogenous, multiple, bilateral, less than 3 cm in diameter, and located throughout the renal parenchyma. Associated metastases were usually present in many other organs. Because methods to detect renal lesions depend upon their size, clinical recognition of renal metastases will be largely limited to that 10% which are greater than 3 cm in diameter.     

胎婴儿成红细胞增多症4例尸检分析

目的 观察成红细胞增多症胎婴儿的临床病理特点,并对其发生机制进行分析.方法 对4例成红细胞增多症胎婴儿的临床表现、外形、内脏结构以及胎盘形态进行观察分析.结果 4例成红细胞增多症均伴有胎儿水肿和腹腔积液,胎婴儿肝、脾、肺或肾中可见有核红细胞,胎盘绒毛肿大和水肿,胎盘血管中可见幼稚红细胞.结论 胎婴儿成红细胞增多症的主要病理改变为全身脏器血管内可见大小不一、幼稚不成熟的有核红细胞,其发生与母婴血型不合有密切关系.     

Design and preliminary evaluation of an expert system for platelet request evaluation

In spite of growing awareness of the potential risks associated with transfusion, the number of platelet units transfused in the United States continues to increase each year. There is a growing interest in ensuring that all transfusions are administered for appropriate reasons. Prospective review of requests for transfusions has been used to accomplish this goal. Although successful in reducing the number of inappropriate transfusions, this review method requires great time commitments by blood bank personnel and physicians. A knowledge-based system (ESPRE) that aids hospital blood bank personnel in the review of requests for platelet transfusions has been developed. The system automatically obtains most of the required patient data via a direct link to the hospital's main laboratory computers. The system generates a printed report that includes a list of patient-specific data, a list of the conditions for which a transfusion would be appropriate for the particular patient (given the clinical condition), and the conclusions drawn by the system. During a preliminary clinical evaluation of ESPRE, 73 randomly selected platelet transfusion requests were evaluated for approval by laboratory personnel and ESPRE. Overall, ESPRE would have approved 71 of the requests and laboratory staff would have approved 72. Forty-four percent of the requests would have been approved for the same reasons given by the staff. There were only three disagreements on final approval between ESPRE and blood bank personnel. This computerized expert system is a promising approach to the prospective review of all platelet transfusions.     

Using drugs to end life without an explicit request of the patient

A small proportion of deaths result from the use of drugs with the intention to hasten death without an explicit request of the patient. Additional insight into its characteristics is needed for evaluating this practice. In the Netherlands in 2001, questionnaires were mailed to physicians that addressed the decision making that preceded their patient's death. Cases of ending life without an explicit request of the patient were compared with similar cases from 1995 and with cases from Belgium, Denmark, and Switzerland. In the Netherlands in 2001, patients receiving life-ending drugs without their explicit request were most often 80+ years old and had cancer. Most of them were incompetent patients nearing death. Characteristics of this practice in 1995 were quite comparable, as were characteristics of this practice in Belgium, Denmark, and Switzerland. The use of drugs with the intention to hasten death without an explicit request of the patient is part of medical end-of-life practice in the studied countries, regardless of their legal framework, and it occurs in similar fashion.     

A request for benzodiazepines

A benzodiazepine-dependent patient may evoked a feeling of guilt in his or her GP. Most doctors now feel that withdrawal, however difficult, should be attempted. In an unmotivated patient this can be a particularly time-consuming and sometimes frustrating, exercise.     

How--and when--to obtain consent for do-not-resuscitate orders. Clinical guidelines and strategies for resolving conflicts

Consider a do-not-resuscitate (DNR) order when a patient's presumed consent for cardiopulmonary resuscitation (CPR) is in question, the patient has an illness that is terminal or severe and irreversible, or he or she is permanently unconscious or likely to have cardiac or respiratory arrest. The patient with decisional capacity has the right to give or withhold consent for a DNR order. State law may limit a surrogate's authority to request that CPR be withheld. Remember, a DNR order does not restrict a patient's access to intensive care. Nurses, patient advocates, social workers, and clergy members may help mediate disputes. If necessary, seek advice from an ethics committee on how to resolve the conflict.     

Rib structure and bending strength: an autopsy study.

Mechanical rib testing and geometric analysis were explored as means of evaluating metabolic bone disease. Seventy-nine male patients were examined postmortem. Displacement rate at the loading point and patient age were important variables for which results had to be corrected. Like long bones, ribs apparently undergo progressive circumendosteal resorption with advancing age but unlike long bones, they show no evidence of continued subperiosteal apposition. Effects of selected individual diseases and of all diseases grouped by major organ system were analyzed. Most produced no discernible modification of rib volume, geometry or bending strength as quantified by modulus of rupture. Exceptions were myeloma and arthritis, where the bony material was weakened without remodeling or loss in volume.