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Consultation in emergency medicine
CONSULTATIONS in emergency medicine George Podgorny, M D - editor Winston-Salem, North Carolina
Obligations and Conditions of Treating Minors Q
What obligation does the emergency physician • have to treat minors, and under what conditions is he able to treat without parental consent?
tives, of the court, of social service agencies, or of detention homes, or who are committed to psychiatric hospitals, should be dealt with as if those agencies or institutions were acting in loco parentis.
James E. George, MD, JD Woodbury, New Jersey
JFW, Detroit, Michigan The emergency physician has an obligation to • evaluate and treat, or arrange for evaluation and treatment, of all patients who present themselves to the emergency department, regardless of their age. This includes minors. The lack of parental consent may be a result of outright parental refusal of treatment, or it may b e due to the unavailability of the parents at that time. All 50 states, the District of Columbia, and Puerto Rico have their own statutes on this subject and any generalization must be evaluated against the specifics in each jurisdiction. However, we might offer a few guidelines. Treatment, when it is not critical and not greatly affected by time, should be delayed to make every effort to locate parents or adult relatives or someone acting in loco parentis (ie, in the place of the parent). When treatment must be administered promptly and the p a r e n t s are not available, get additional medical consultation concurring with your plan for treatment, its timing, and its necessity; proceed with necessary emergency treatment to minimize the loss of life or limb; and make complete and detailed entries in the medical records explaining the events and problems. If parental consent is withheld, notify the hospital administration; obtain additional medical consultation signifying the treatment; and, in most jurisdictions, it may be useful to notify the local social services authorities. At times it may be possible to assuage the feelings of the parents who have refused the definitive treatment by an offer of at least stabilization until further decisions are made. In certain states, treatment of minors can be provided without parental consent for sexually transmitted disease, drug abuse and birth control. Also, those minors who are married or who live away from their parents and support themselves can be considered emancipated and treated as adults. Previous blanket parental consent such as that customarily provided through schools and camps is usually satisfactory. Unusual cases of minors who may be wards of their rela-
George Podgorny, MD Annals Consultations Editor
A
10:1 (January) 1981
Rabies Prophylaxis Q
When is rabies prophylaxis indicated?
•
GDB, Portland, Oregon
A•
Any generalization about prophylaxis for rabies must be tempered by a need to look at each suspected case on its own merit. My policy states that there is indication for rabies prophylaxis when: 1. The animal involved is a wild carnivore or dog; 2. The attack was unprovoked (feeding and petting may provoke an attack); 3. The animal's saliva has entered the patient's body via biting, scratching, or licking of an open wound or of the mucous membrane; 4. The offending animal is not captured or killed nor is known to have been vaccinated for rabies; or 5. Examination of the animal's brain by fluorescent antibody confirms the presence of rabies. In such instances, the immunization should be u n d e r t a k e n quickly and should consist of the following: 1. Rabies immunoglobulin (human) - - the dosage is calculated at 20 IU/kg of weight. If this is not available, equine antirabies serum may be utilized, but is not recommended. 2. The human diploid cell vaccine in a dosage of 1 ml on days 0, 3, 7, 14, and 28 may be used. If this is not available, you may use duck embryo rabies vaccine, one dosage daily for 21 days to be followed by a s i n g l e dosage 10 days after determination of the vaccination. Should the offending a n i m a l be captured and killed or found dead and, after examination, found not to have rabies, the immunization should be terminated. Local health departments and the Center for Disease Control are useful sources of information, particularly in regard to questions of locale and the animal species. The common wild carnivores are coyotes,
Ann Emerg Med
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foxes, wolves, raccoons, skunks, and bats. Rodents, such as squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats and mice, and lagomorphs (rabbits and hares) are rarely found to be affected with rabies.
Recommended Reading: Podgorny G: Bites--human and animal, in Tintinalli JE (ed): A Study Guide in Emergency Medicine. Lansing, Michigan, American College of Emergency Physicians, 1979, pp 31-35.
George Podgorny, MD Winston-Salem, North Carolina
Center for Disease Control: Morbidity and Mortality Weekly Report 29;265-280, 1980.
CALL FOR ABSTRACTS FOR 1981 ACEP SCIENTIFIC ASSEMBLY The ACEP Scientific Meetings Committee has issued a call for abstracts of original scientific papers to be considered for presentation at the 1981 Scientific Assembly in New Orleans, Louisiana, September 14-17, 1981. George Podgorny, MD, chairman of the Scientific Meetings Committee, has set April 15, 1981 as the deadline for submission of abstracts. Final papers must be in the Committee's hands no later than August 15, 1981. Submit five copies of the abstract. The abstract should be between 250 and 500 words in length. The presentation format will be as follows: 1. Presentation of the paper by the principal author or investigator or by a participant of the team of authors and investigators (surrogates are not acceptable). Presentations will be limited to 12 minutes. 2. Discussion of the paper by a discussant of the author's choice. Arrangements should be made ahead of time and the name of the discussant provided to the Committee by August 15, 1981. The discussant will have six minutes. 3. General open discussion and questioning, with participation of the audience, will be limited to six minutes. 4. Papers submitted must be original, unpublished work of the author and must be related directly to some aspect of emergency medicine. Papers will be considered for publication in Annals of Emergency Medicine, the Journal of the American College of Emergency Physicians and the University Association for Emergency Medicine. Papers must be submitted in a form suitable for publication 30 days prior to the Assembly. Papers not received will not be presented. Annals reserves the right of first refusal on all scientific papers presented at the 1981 Scientific Assembly. If the editors do not notify authors, in writing, of an intent to publish by December 18, 1981, authors reserve the right to submit papers to other publications. Abstracts should be submitted to Harvey W. Meislin, MD, Scientific Meetings Committee, ACEP, PO Box 61911, Dallas, Texas 75261.
SUGGESTIONS FOR WRITING ABSTRACTS An abstract should be factual, clearly conveying the reason for the work, the methods, the results, and their significance. To make your abstract more readable, follow these guidelines: 1. A brief introduction stating why the work was done. 2. The methods used stated clearly, as well as whatever limitations the methods may have. 3. The results clearly stated in numerical or tabular form. Has statistical significance been achieved? 4. Brief discussion of what the results indicate. 5. Conclusion, stating the relevance of these particular findings to emergency medicine. Be sure to present the data in the abstracts. Avoid generalities such as "the significance of these results will be discussed," or "the management will be outlined." Clearly state the authors, the presenter (who must be one of the authors), the institution, and the mailing address. All papers submitted will be judged on their originality, content and informational value, and the one judged best will receive an appropriate citation.
Check appropriate category: [ ] Gastrointestinal [ ] Cardiovascular [ ] EMS [ ] Trauma [ ] Methods and Techniques E3 Infections [ ] ED Administration [ ] Psychosocial [ ] Respiratory [ ] Burns [ ] Prehospital Care
Presenter: Mailing Address of Principal Author From (Institution)
86/63
Ann Emerg Med
10:1 (January) 1981
Obligations and Conditions of Treating Minors Q
What obligation does the emergency physician • have to treat minors, and under what conditions is he able to treat without parental consent?
tives, of the court, of social service agencies, or of detention homes, or who are committed to psychiatric hospitals, should be dealt with as if those agencies or institutions were acting in loco parentis.
James E. George, MD, JD Woodbury, New Jersey
JFW, Detroit, Michigan The emergency physician has an obligation to • evaluate and treat, or arrange for evaluation and treatment, of all patients who present themselves to the emergency department, regardless of their age. This includes minors. The lack of parental consent may be a result of outright parental refusal of treatment, or it may b e due to the unavailability of the parents at that time. All 50 states, the District of Columbia, and Puerto Rico have their own statutes on this subject and any generalization must be evaluated against the specifics in each jurisdiction. However, we might offer a few guidelines. Treatment, when it is not critical and not greatly affected by time, should be delayed to make every effort to locate parents or adult relatives or someone acting in loco parentis (ie, in the place of the parent). When treatment must be administered promptly and the p a r e n t s are not available, get additional medical consultation concurring with your plan for treatment, its timing, and its necessity; proceed with necessary emergency treatment to minimize the loss of life or limb; and make complete and detailed entries in the medical records explaining the events and problems. If parental consent is withheld, notify the hospital administration; obtain additional medical consultation signifying the treatment; and, in most jurisdictions, it may be useful to notify the local social services authorities. At times it may be possible to assuage the feelings of the parents who have refused the definitive treatment by an offer of at least stabilization until further decisions are made. In certain states, treatment of minors can be provided without parental consent for sexually transmitted disease, drug abuse and birth control. Also, those minors who are married or who live away from their parents and support themselves can be considered emancipated and treated as adults. Previous blanket parental consent such as that customarily provided through schools and camps is usually satisfactory. Unusual cases of minors who may be wards of their rela-
George Podgorny, MD Annals Consultations Editor
A
10:1 (January) 1981
Rabies Prophylaxis Q
When is rabies prophylaxis indicated?
•
GDB, Portland, Oregon
A•
Any generalization about prophylaxis for rabies must be tempered by a need to look at each suspected case on its own merit. My policy states that there is indication for rabies prophylaxis when: 1. The animal involved is a wild carnivore or dog; 2. The attack was unprovoked (feeding and petting may provoke an attack); 3. The animal's saliva has entered the patient's body via biting, scratching, or licking of an open wound or of the mucous membrane; 4. The offending animal is not captured or killed nor is known to have been vaccinated for rabies; or 5. Examination of the animal's brain by fluorescent antibody confirms the presence of rabies. In such instances, the immunization should be u n d e r t a k e n quickly and should consist of the following: 1. Rabies immunoglobulin (human) - - the dosage is calculated at 20 IU/kg of weight. If this is not available, equine antirabies serum may be utilized, but is not recommended. 2. The human diploid cell vaccine in a dosage of 1 ml on days 0, 3, 7, 14, and 28 may be used. If this is not available, you may use duck embryo rabies vaccine, one dosage daily for 21 days to be followed by a s i n g l e dosage 10 days after determination of the vaccination. Should the offending a n i m a l be captured and killed or found dead and, after examination, found not to have rabies, the immunization should be terminated. Local health departments and the Center for Disease Control are useful sources of information, particularly in regard to questions of locale and the animal species. The common wild carnivores are coyotes,
Ann Emerg Med
62/85
foxes, wolves, raccoons, skunks, and bats. Rodents, such as squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats and mice, and lagomorphs (rabbits and hares) are rarely found to be affected with rabies.
Recommended Reading: Podgorny G: Bites--human and animal, in Tintinalli JE (ed): A Study Guide in Emergency Medicine. Lansing, Michigan, American College of Emergency Physicians, 1979, pp 31-35.
George Podgorny, MD Winston-Salem, North Carolina
Center for Disease Control: Morbidity and Mortality Weekly Report 29;265-280, 1980.
CALL FOR ABSTRACTS FOR 1981 ACEP SCIENTIFIC ASSEMBLY The ACEP Scientific Meetings Committee has issued a call for abstracts of original scientific papers to be considered for presentation at the 1981 Scientific Assembly in New Orleans, Louisiana, September 14-17, 1981. George Podgorny, MD, chairman of the Scientific Meetings Committee, has set April 15, 1981 as the deadline for submission of abstracts. Final papers must be in the Committee's hands no later than August 15, 1981. Submit five copies of the abstract. The abstract should be between 250 and 500 words in length. The presentation format will be as follows: 1. Presentation of the paper by the principal author or investigator or by a participant of the team of authors and investigators (surrogates are not acceptable). Presentations will be limited to 12 minutes. 2. Discussion of the paper by a discussant of the author's choice. Arrangements should be made ahead of time and the name of the discussant provided to the Committee by August 15, 1981. The discussant will have six minutes. 3. General open discussion and questioning, with participation of the audience, will be limited to six minutes. 4. Papers submitted must be original, unpublished work of the author and must be related directly to some aspect of emergency medicine. Papers will be considered for publication in Annals of Emergency Medicine, the Journal of the American College of Emergency Physicians and the University Association for Emergency Medicine. Papers must be submitted in a form suitable for publication 30 days prior to the Assembly. Papers not received will not be presented. Annals reserves the right of first refusal on all scientific papers presented at the 1981 Scientific Assembly. If the editors do not notify authors, in writing, of an intent to publish by December 18, 1981, authors reserve the right to submit papers to other publications. Abstracts should be submitted to Harvey W. Meislin, MD, Scientific Meetings Committee, ACEP, PO Box 61911, Dallas, Texas 75261.
SUGGESTIONS FOR WRITING ABSTRACTS An abstract should be factual, clearly conveying the reason for the work, the methods, the results, and their significance. To make your abstract more readable, follow these guidelines: 1. A brief introduction stating why the work was done. 2. The methods used stated clearly, as well as whatever limitations the methods may have. 3. The results clearly stated in numerical or tabular form. Has statistical significance been achieved? 4. Brief discussion of what the results indicate. 5. Conclusion, stating the relevance of these particular findings to emergency medicine. Be sure to present the data in the abstracts. Avoid generalities such as "the significance of these results will be discussed," or "the management will be outlined." Clearly state the authors, the presenter (who must be one of the authors), the institution, and the mailing address. All papers submitted will be judged on their originality, content and informational value, and the one judged best will receive an appropriate citation.
Check appropriate category: [ ] Gastrointestinal [ ] Cardiovascular [ ] EMS [ ] Trauma [ ] Methods and Techniques E3 Infections [ ] ED Administration [ ] Psychosocial [ ] Respiratory [ ] Burns [ ] Prehospital Care
Presenter: Mailing Address of Principal Author From (Institution)
86/63
Ann Emerg Med
10:1 (January) 1981