A Model for Emergency Department End‐of‐life Communications After Acute Devastating Events—Part II: Moving From Resuscitative to End‐of‐life or Palliative Treatment

The model for emergency department (ED) end‐of‐life communications after acute devastating events addresses decision‐making capacity, surrogates, and advance directives, including legal definitions and application of these steps. Part II concerns communications moving from resuscitative to palliative and end‐of‐life treatments. After completing the steps involved in determining decision‐making, emergency physicians (EPs) should consider starting palliative measures versus continuing resuscitative treatment. As communications related to these end‐of‐life decisions increasingly fall within the scope of emergency medicine (EM) practice, we need to become educated about and comfortable with them.     

Cutaneous squamous cell carcinoma of the scalp extending to the skull: A case report and review of the literature

Squamous cell carcinoma (SCC) of the scalp has increased prevalence in older patients and often presents later in life. Mohs micrographic surgery remains the most effective treatment in most cases. Delayed presentation may result in localized bony invasion or distant metastases. We present a case of an elderly woman presenting with extension of SCC into the parietal bone of the skull.     

Nontransient third-degree heart block and persistent respiratory findings as sequelae of acute occupational exposure to pyrethroids insecticide

We present the case of a worker with occupational exposure to a pyrethroid insecticide who acutely developed nontransient third-degree heart block. In 2000, a 57-year-old male truck driver on his delivery route was accidentally exposed to pyrethroid insecticide being sprayed for West Nile virus containment. Both the driver and his vehicle were coated with the spray. The exposure was prolonged because he did not change his clothes until after his shift ended and he used the same contaminated truck for a week. Within days, he presented with a third-degree heart block, for which he was emergently treated, and a pacemaker was placed. He had no past history of arrhythmias. In the weeks thereafter, he also developed reactive airway dysfunction syndrome (RADS). In the second decade following the exposure, the patient replaced his pacemaker, confirming the permanent nature of his heart block. In addition to the persistence of his exposure-related RADS, he developed restrictive lung disease and was diagnosed with pulmonary interstitial fibrosis in the absence of established risk factors. The patient died in October 2019 from respiratory illness. Most previous reports of pyrethroid-related disorders are limited to acute exposures, in which transient symptoms predominate. To our knowledge, this is the first report of an exposed worker experiencing permanent third-degree heart block, as well as persistent respiratory findings, as possible short- and long-term sequelae of pyrethroid exposure.     

Public health ethics

Viewing public health as a political and social undertaking as well as a goal of this activity, the authors develop some key elements in a framework for public health ethics, with particular attention to the formation of public health policies and to decisions by public health officials that are not fully determined by established public policies. They concentrate on ways to approach ethical conflicts about public health interventions. These conflicts arise because, in addition to the value of public health, societies have a wide range of other values that sometimes constrain the selection of means to achieve public health goals. The authors analyze three approaches for resolving these conflicts (absolutist, contextualist, and presumptivist), argue for the superiority of the presumptivist approach, and briefly explicate five conditions for rebutting presumptions in a process of public justification. In a liberal, pluralistic, democratic society, a presumptivist approach that engages the public in the context of a variety of relationships can provide a foundation for public trust, which is essential to public health as a political and social practice as well as to achieving public health goals.