- Email: [email protected]
Self-administered electroshock
CORRESPONDENCE
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and the quality of health care provided to patients can be appropriately addressed by analyzing the questions raised above. PAUL J. LEO, DO JOSEPH BORE, MD
Department of Emergency Medicine New York Methodist Hospital Brooklyn, NY
References 1. Thompson DR, Pohl JEF, Sutton TW: Acute myocardial infarction and day of the week. Am J Cardiol 1992;69:266-267 2. Williams BT: Admission to hospital and the day of the week. Public Health (London) 1979;93:173-176 3. Maldonado G, Kraus JF: Variations in suicide occurrence by time of day, day of the week, month, and lunar phase. Suicide Life Threat Behav 1991;21:174-187
SELF-ADMINISTEREDELECTROSHOCK To the Editor:--We recently encountered a case of a patient who volitionally applied a defibrillator charge to his chest. This case brought out issues related to this patient's care, and other aspects of such injuries. A 25-year-old man was brought to the emergency department (ED) by paramedics, having been placed on a 72-hour psychiatric hold after a suicide attempt. He had a prior history of depression, having made four previous suicide attempts. The patient was awake and alert, and cooperated with ED personnel. Because the room usually reserved for such patients was occupied at the time of his arrival, this patient was placed in a cardiac room for observation. A few minutes after his arrival, he indicated the need to urinate. Consequently, he was provided with a urinal, and the curtain around the gurney was drawn closed. Shortly thereafter, a loud noise was heard, and the patient was observed to fall to the floor. ED personnel immediately rushed into the room and found the patient lying on the floor with the paddles of a Zoll model 1200 defibrillator/pacemaker (ZMI Corporation, Woburn, MA) next to him. There were areas of erythema on his right anterior and left lateral chest corresponding in size and shape to the defibrillator paddles. The automatic readout recording of the defibrillator indicated that a 300-joule electrical discharge had occurred. The patient was awake and alert. Vital signs were as follows: blood pressure, 148/52 mm Hg; heart rate, 99 beats/rain; respirations, 16 breaths/rain; temperature, 37°C. Aside from the burns to the thorax, the physical examination was unremarkable. A 12-1ead electrocardiogram showed no abnormalities. The patient was observed in the ED and thereafter in the hospital with continuous electrocardiographic monitoring for 72 hours. He experienced no dysrhythmias. Follow-up electrocardiograms and serum creatine kinase determinations were within normal limits. The patient was subsequently transferred to the psychiatric service. One noteworthy aspect of this case involves the effects of application of electric current to this patient. He appeared to exhibit no adverse effects from his self-administered electroshock except for the cutaneous burns sustained. There was no subsequent indication of cardiac irritability or of myocardial damage having been sustained. Myocardial damage has been documented experimentally following direct current countershock. 1,2 However, it has been postulated that cardiac isoenzyme levels are not sufficiently reliable as markers of myocardial damage in such settings because technical limitations restrict their sensitivity in detecting minor damage to the heart. 3,4 In the only other reported instance of suicide attempt by electrocution involving a defibrillator,5 the patient applied the maximum charge of 400 joules to his head. Although suffering a
2-minute period of unconsciousness following the electrical shock, the patient awoke thereafter, and appeared to experience no significant medical sequelae. The author reporting that case probed the specific significance of the use of electricity as the chosen method of suicide, proposing among other possibilities the view that electroshock therapy "like an ancient magical treatment," connoted a death and rebirth. We are in no position to draw similar conclusions from our case. Rather, it seemed to us that this suicidal patient, when presented with the chance to injure himself with what appeared a lethal piece of machinery, simply availed himself of the opportunity. It seems clear in retrospect that allowing this patient to remain unobserved and unrestrained--even for a brief period--was a mistake. Moreover, it is clearly ideal to confine such patients in designated rooms particularly suited for the purpose of minimizing self-injurious behavior. However, such facilities are not necessarily available in all EDs and, even if present, may be occupied at the time they are needed. In such instances, alternate accommodation will be required. Another noteworthy aspect seemed to us to be this patient's rather dexterous use of the defibrillator. Despite having been in the room only a few moments, he nonetheless managed during this time to grasp the dangerous potential of the instrument, charge the machine, apply the paddles (in roughly appropriate position for defibrillation) to his chest, and discharge the electrical current. This was a patient without prior medical background, and one who subsequently denied having previously received instruction in the use of a defibrillator. In the other case described, 5 the patient was a nurse with knowledge of the proper use of the instrument and access to it as a routine aspect of his job. In addition to the considerations noted above, the subject may be of importance in light of the fact that the use of defibrillators in the community has increased, and appears about to increase further. The American Heart Association Task Force on the Future of Cardiopulmonary Resuscitation, in its 1992 report, pronounced the availability of automatic external defibrillators "to large numbers of people" as being essential to increased survival of cardiac arrest. 6 The need for dissemination of automatic external defibrillators to individuals and groups outside organized emergency medical services systems has also been recognized. 7
GEORGESTERNBACH,MD Emergency Medicine Seton Medical Center Daly City, CA Emergency Medicine Service Stanford University Medical Center Stanford, CA JOSEPHVARON,MD
Department of Anesthesiology and Critical Care The University of Texas M.D. Anderson Cancer Center Houston, TX
References 1. Dahl CF, Ewy GA, Warner ED, et ah Myocardial necrosis from direct current countershock. Circulation 1974;50:956-961 2. Doherty PW, McLaughlin PR, Billingham M, et al: Cardiac damage produced by direct current countershock applied to the heart. Am J Cardiol 1979;43:225-232 3. Tacker WA, Van Vleet JF, Geddes LA: Electrocardiographic and serum enzymic alterations associated with cardiac alterations induced in dogs by single transthoracic damped sinusoidal defibrillator shocks of various strengths. Am Heart J 1979;98:185-193 4. Metcalfe MJ, Smith F, Jennings K: Does cardioversion of atrial fibrillation result in myocardial damage? BMJ 1988;296:1364 5. Grumet GW: Attempted suicide by electrocution. Bull Menninger Clin 1989;53:512-521
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 1 • January 1996
6. Cobb LA, Eliastam M, Kerber RE, et ai: Report of the American Heart Association Task Force on the Future of Cardiopuimonary Resuscitation. Circulation 1992;85:2346-2355 7. Haynes BE, Mendoza A, McNeil M, et al: A statewide defibrillation initiative including laypersons and outcome reporting. JAMA 1991 ;266:545-547
A SURVEY OF THE CONTRACT TERMS USED IN ACADEMIC EMERGENCY MEDICINE To the Editor:--A contract is a promise between two more or more parties for the performance of duties and a list of legal remedies should there be a breach of this promise. 1 Contracts may be written, oral, or "in-fact." "In-fact" contracts occur in situations in which a person is working without a written or verbal contract. Emergency medicine contracts are bilateral contracts with an emergency physician providing emergency services for the contract holder. The contract holder can be a contract management company, independent democratic group, hospital, medical group, or medical school. Physicians may have multiple contracts with these entities, depending on their employment versus independent contractor status, and specific duties and responsibilities with each entity. Academic emergency physicians have additional contractual responsibilities to educate emergency medicine residents. Although contracts are commonly used in emergency medicine, a Medline search of English literature for the past 10 years found no prior study of the terms of contracts used in Emergency Medicine or in Academic Emergency Medicine. The purpose of this study was to determine the terms used in Academic Emergency Medicine and their relationships to contract satisfaction. A 14-item survey tool was developed by the authors in consultation with a law firm with a national health care practice, Katten, Muchin, and Zavis (Table 1). The survey used yes/no, multiple choice, and graded scale questions. The initial section addressed hospital and emergency department (ED) characteristics, compensation, and benefits. The later part of the survey dealt with contract terms and physician satisfaction issues. The contract terms were defined as needed. The survey was mailed to all 95 program directors in Emergency Medicine listed in the American College of Graduate Medical Education Guide to Post-Graduate Training, 1993-4. The program directors were instructed to focus on the relationship between the full-time emergency physicians and the hospital or between the emergency physician and the medical group, not the service contract between the physician and the hospital. The survey envelopes were coded in case it was necessary to follow-up with the nonrespondents. The surveys were kept confidential. Information was collated and placed into a computer statistical program. Statistical correlations were performed using standard statistical analysis for means, medium, and norms, and the Chi-squared test for correlation analysis. The total number of responses received was 62, representing a response rate of 62%. We found that one program director did not have a written contract. The responders with a contract were used to analyze the data concerning the terms of the contracts. Seventy-two percent of programs had 400 or more hospital beds. The most frequent teaching programs' primary hospital was a university hospital (22 out of 61), followed by a community hospital (18 out of 61). The average volume of the ED was greater than 40,000 patients per year and the average number of full-time faculty members was 13.3. The contract was most frequently found between the physician and the hospital (22 out of 61), followed by the physician and medical school (19 out of 61). Most of the groups' or physicians' service arrangement (85.2%) was an employment arrangement, followed by independent contractor status (9.8%). The most common compensation was salary (34 out of 61), followed by salary plus bonus (19 out of 61). The most frequent benefits
provided to the faculty were pension plan (85.2%) and health insurance (83.6%), followed by disability insurance (78.7%) and life insurance (75.6%). The majority of program directors surveyed included compensation and benefits in the contract (82.0%) (Table 2). Professional liability insurance (78.7%), outside practice (60.7%), and qualifications to work (54.1%) were also noted as common contract terms by the reporting program directors. On the other hand, substitution (who can work for the physician) (13.1%), physicians' acceptance (8.2%), non-compete clauses (14.8%), amendment process (18.0%), review of the professional fee schedule (19.7%), and managed care contract participation (24.6%) were mentioned less frequently as contract terms by the program directors. The most common length of the term of the contract was 1 year (25 of 61) and the least common was a 4-year contract (1 of 61). Eight program directors used some other type of term than the standard 1, 2, 3, 4, or 5 years in their contracts. Termination notice time was commonly 90 to 120 days (26.2%) and rarely 0 to 89 days (13.1%). The contract was most frequently drafted by the hospital (19.7%), the university (16.4%), or independent group (11.5%), and least by the physician (9.8%). Twenty-seven of 51 respondents had the contract reviewed by legal counsel (53%). On the average, the physicians had a satisfaction index of 7.8 on a 0 to 10 scale. Of those respondents dissatisfied with their contracts, physicians were most frequently dissatisfied with compensation (21.3%), whereas only a few were dissatisfied with their benefits (11.5%). The study attempted to determine if there were any correlations of factors that may influence physician satisfaction with the contract. This correlation was performed by lumping the degree of satisfaction into a low, medium, and high level and used the chi-squared test. There was no significant correlation between satisfaction and the contracting entity, type of contractual arrangement the physician had with the hospital, volume of the ED, review by legal counsel or drafting party to the contract. There was a significant correlation between contract satisfaction and the size of the primary hospital (P = .045), ie, the larger the hospital, more satisfied physicians were with their contract. Emergency physicians in the academic setting are most often employees of the hospital. In rare circumstances, they are employed by contract management companies. TheAmerican College of Emergency Physicians does not endorse or favor any one type of service or compensation arrangements for emergency physicians. 2 Most emergency physicians in the academic setting were perceived by program directors to be satisfied with their contracts. This finding appears to be confirmed by the limited response to the questions concerning areas of dissatisfaction. It is a common finding in medicine that academic physicians are compensated less than physicians in private practice (personal communication from the Society for Academic Emergency Medicine and Daniel Stern and Associates). This compensation is an understandable source of dissatisfaction. There were a number of interesting findings in this study: (1) A mechanism for dispute resolution was noted in fewer than half of the contracts. Many program directors believe that emergency physicians' contracts should contain provisions to resolve disputes. 3,4 Dispute resolution can take many forms, such as simple negotiation, in-house problem solving panels, or arbitration. It is better to have the dispute resolution process established up-front rather than to negotiate a mechanism when a dispute has already occurred. (2) Fifteen percent of the contracts were found to have non-compete clauses. The issue of non-compete clauses in the survey was defined as a restriction on the physician's ability to work within a certain radius of the hospital for a defined amount of time after the contract is terminated. This may apply to either termination of the individual physician's contract or the service contract with the group providing physicians to the hospital. There
115
and the quality of health care provided to patients can be appropriately addressed by analyzing the questions raised above. PAUL J. LEO, DO JOSEPH BORE, MD
Department of Emergency Medicine New York Methodist Hospital Brooklyn, NY
References 1. Thompson DR, Pohl JEF, Sutton TW: Acute myocardial infarction and day of the week. Am J Cardiol 1992;69:266-267 2. Williams BT: Admission to hospital and the day of the week. Public Health (London) 1979;93:173-176 3. Maldonado G, Kraus JF: Variations in suicide occurrence by time of day, day of the week, month, and lunar phase. Suicide Life Threat Behav 1991;21:174-187
SELF-ADMINISTEREDELECTROSHOCK To the Editor:--We recently encountered a case of a patient who volitionally applied a defibrillator charge to his chest. This case brought out issues related to this patient's care, and other aspects of such injuries. A 25-year-old man was brought to the emergency department (ED) by paramedics, having been placed on a 72-hour psychiatric hold after a suicide attempt. He had a prior history of depression, having made four previous suicide attempts. The patient was awake and alert, and cooperated with ED personnel. Because the room usually reserved for such patients was occupied at the time of his arrival, this patient was placed in a cardiac room for observation. A few minutes after his arrival, he indicated the need to urinate. Consequently, he was provided with a urinal, and the curtain around the gurney was drawn closed. Shortly thereafter, a loud noise was heard, and the patient was observed to fall to the floor. ED personnel immediately rushed into the room and found the patient lying on the floor with the paddles of a Zoll model 1200 defibrillator/pacemaker (ZMI Corporation, Woburn, MA) next to him. There were areas of erythema on his right anterior and left lateral chest corresponding in size and shape to the defibrillator paddles. The automatic readout recording of the defibrillator indicated that a 300-joule electrical discharge had occurred. The patient was awake and alert. Vital signs were as follows: blood pressure, 148/52 mm Hg; heart rate, 99 beats/rain; respirations, 16 breaths/rain; temperature, 37°C. Aside from the burns to the thorax, the physical examination was unremarkable. A 12-1ead electrocardiogram showed no abnormalities. The patient was observed in the ED and thereafter in the hospital with continuous electrocardiographic monitoring for 72 hours. He experienced no dysrhythmias. Follow-up electrocardiograms and serum creatine kinase determinations were within normal limits. The patient was subsequently transferred to the psychiatric service. One noteworthy aspect of this case involves the effects of application of electric current to this patient. He appeared to exhibit no adverse effects from his self-administered electroshock except for the cutaneous burns sustained. There was no subsequent indication of cardiac irritability or of myocardial damage having been sustained. Myocardial damage has been documented experimentally following direct current countershock. 1,2 However, it has been postulated that cardiac isoenzyme levels are not sufficiently reliable as markers of myocardial damage in such settings because technical limitations restrict their sensitivity in detecting minor damage to the heart. 3,4 In the only other reported instance of suicide attempt by electrocution involving a defibrillator,5 the patient applied the maximum charge of 400 joules to his head. Although suffering a
2-minute period of unconsciousness following the electrical shock, the patient awoke thereafter, and appeared to experience no significant medical sequelae. The author reporting that case probed the specific significance of the use of electricity as the chosen method of suicide, proposing among other possibilities the view that electroshock therapy "like an ancient magical treatment," connoted a death and rebirth. We are in no position to draw similar conclusions from our case. Rather, it seemed to us that this suicidal patient, when presented with the chance to injure himself with what appeared a lethal piece of machinery, simply availed himself of the opportunity. It seems clear in retrospect that allowing this patient to remain unobserved and unrestrained--even for a brief period--was a mistake. Moreover, it is clearly ideal to confine such patients in designated rooms particularly suited for the purpose of minimizing self-injurious behavior. However, such facilities are not necessarily available in all EDs and, even if present, may be occupied at the time they are needed. In such instances, alternate accommodation will be required. Another noteworthy aspect seemed to us to be this patient's rather dexterous use of the defibrillator. Despite having been in the room only a few moments, he nonetheless managed during this time to grasp the dangerous potential of the instrument, charge the machine, apply the paddles (in roughly appropriate position for defibrillation) to his chest, and discharge the electrical current. This was a patient without prior medical background, and one who subsequently denied having previously received instruction in the use of a defibrillator. In the other case described, 5 the patient was a nurse with knowledge of the proper use of the instrument and access to it as a routine aspect of his job. In addition to the considerations noted above, the subject may be of importance in light of the fact that the use of defibrillators in the community has increased, and appears about to increase further. The American Heart Association Task Force on the Future of Cardiopulmonary Resuscitation, in its 1992 report, pronounced the availability of automatic external defibrillators "to large numbers of people" as being essential to increased survival of cardiac arrest. 6 The need for dissemination of automatic external defibrillators to individuals and groups outside organized emergency medical services systems has also been recognized. 7
GEORGESTERNBACH,MD Emergency Medicine Seton Medical Center Daly City, CA Emergency Medicine Service Stanford University Medical Center Stanford, CA JOSEPHVARON,MD
Department of Anesthesiology and Critical Care The University of Texas M.D. Anderson Cancer Center Houston, TX
References 1. Dahl CF, Ewy GA, Warner ED, et ah Myocardial necrosis from direct current countershock. Circulation 1974;50:956-961 2. Doherty PW, McLaughlin PR, Billingham M, et al: Cardiac damage produced by direct current countershock applied to the heart. Am J Cardiol 1979;43:225-232 3. Tacker WA, Van Vleet JF, Geddes LA: Electrocardiographic and serum enzymic alterations associated with cardiac alterations induced in dogs by single transthoracic damped sinusoidal defibrillator shocks of various strengths. Am Heart J 1979;98:185-193 4. Metcalfe MJ, Smith F, Jennings K: Does cardioversion of atrial fibrillation result in myocardial damage? BMJ 1988;296:1364 5. Grumet GW: Attempted suicide by electrocution. Bull Menninger Clin 1989;53:512-521
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 1 • January 1996
6. Cobb LA, Eliastam M, Kerber RE, et ai: Report of the American Heart Association Task Force on the Future of Cardiopuimonary Resuscitation. Circulation 1992;85:2346-2355 7. Haynes BE, Mendoza A, McNeil M, et al: A statewide defibrillation initiative including laypersons and outcome reporting. JAMA 1991 ;266:545-547
A SURVEY OF THE CONTRACT TERMS USED IN ACADEMIC EMERGENCY MEDICINE To the Editor:--A contract is a promise between two more or more parties for the performance of duties and a list of legal remedies should there be a breach of this promise. 1 Contracts may be written, oral, or "in-fact." "In-fact" contracts occur in situations in which a person is working without a written or verbal contract. Emergency medicine contracts are bilateral contracts with an emergency physician providing emergency services for the contract holder. The contract holder can be a contract management company, independent democratic group, hospital, medical group, or medical school. Physicians may have multiple contracts with these entities, depending on their employment versus independent contractor status, and specific duties and responsibilities with each entity. Academic emergency physicians have additional contractual responsibilities to educate emergency medicine residents. Although contracts are commonly used in emergency medicine, a Medline search of English literature for the past 10 years found no prior study of the terms of contracts used in Emergency Medicine or in Academic Emergency Medicine. The purpose of this study was to determine the terms used in Academic Emergency Medicine and their relationships to contract satisfaction. A 14-item survey tool was developed by the authors in consultation with a law firm with a national health care practice, Katten, Muchin, and Zavis (Table 1). The survey used yes/no, multiple choice, and graded scale questions. The initial section addressed hospital and emergency department (ED) characteristics, compensation, and benefits. The later part of the survey dealt with contract terms and physician satisfaction issues. The contract terms were defined as needed. The survey was mailed to all 95 program directors in Emergency Medicine listed in the American College of Graduate Medical Education Guide to Post-Graduate Training, 1993-4. The program directors were instructed to focus on the relationship between the full-time emergency physicians and the hospital or between the emergency physician and the medical group, not the service contract between the physician and the hospital. The survey envelopes were coded in case it was necessary to follow-up with the nonrespondents. The surveys were kept confidential. Information was collated and placed into a computer statistical program. Statistical correlations were performed using standard statistical analysis for means, medium, and norms, and the Chi-squared test for correlation analysis. The total number of responses received was 62, representing a response rate of 62%. We found that one program director did not have a written contract. The responders with a contract were used to analyze the data concerning the terms of the contracts. Seventy-two percent of programs had 400 or more hospital beds. The most frequent teaching programs' primary hospital was a university hospital (22 out of 61), followed by a community hospital (18 out of 61). The average volume of the ED was greater than 40,000 patients per year and the average number of full-time faculty members was 13.3. The contract was most frequently found between the physician and the hospital (22 out of 61), followed by the physician and medical school (19 out of 61). Most of the groups' or physicians' service arrangement (85.2%) was an employment arrangement, followed by independent contractor status (9.8%). The most common compensation was salary (34 out of 61), followed by salary plus bonus (19 out of 61). The most frequent benefits
provided to the faculty were pension plan (85.2%) and health insurance (83.6%), followed by disability insurance (78.7%) and life insurance (75.6%). The majority of program directors surveyed included compensation and benefits in the contract (82.0%) (Table 2). Professional liability insurance (78.7%), outside practice (60.7%), and qualifications to work (54.1%) were also noted as common contract terms by the reporting program directors. On the other hand, substitution (who can work for the physician) (13.1%), physicians' acceptance (8.2%), non-compete clauses (14.8%), amendment process (18.0%), review of the professional fee schedule (19.7%), and managed care contract participation (24.6%) were mentioned less frequently as contract terms by the program directors. The most common length of the term of the contract was 1 year (25 of 61) and the least common was a 4-year contract (1 of 61). Eight program directors used some other type of term than the standard 1, 2, 3, 4, or 5 years in their contracts. Termination notice time was commonly 90 to 120 days (26.2%) and rarely 0 to 89 days (13.1%). The contract was most frequently drafted by the hospital (19.7%), the university (16.4%), or independent group (11.5%), and least by the physician (9.8%). Twenty-seven of 51 respondents had the contract reviewed by legal counsel (53%). On the average, the physicians had a satisfaction index of 7.8 on a 0 to 10 scale. Of those respondents dissatisfied with their contracts, physicians were most frequently dissatisfied with compensation (21.3%), whereas only a few were dissatisfied with their benefits (11.5%). The study attempted to determine if there were any correlations of factors that may influence physician satisfaction with the contract. This correlation was performed by lumping the degree of satisfaction into a low, medium, and high level and used the chi-squared test. There was no significant correlation between satisfaction and the contracting entity, type of contractual arrangement the physician had with the hospital, volume of the ED, review by legal counsel or drafting party to the contract. There was a significant correlation between contract satisfaction and the size of the primary hospital (P = .045), ie, the larger the hospital, more satisfied physicians were with their contract. Emergency physicians in the academic setting are most often employees of the hospital. In rare circumstances, they are employed by contract management companies. TheAmerican College of Emergency Physicians does not endorse or favor any one type of service or compensation arrangements for emergency physicians. 2 Most emergency physicians in the academic setting were perceived by program directors to be satisfied with their contracts. This finding appears to be confirmed by the limited response to the questions concerning areas of dissatisfaction. It is a common finding in medicine that academic physicians are compensated less than physicians in private practice (personal communication from the Society for Academic Emergency Medicine and Daniel Stern and Associates). This compensation is an understandable source of dissatisfaction. There were a number of interesting findings in this study: (1) A mechanism for dispute resolution was noted in fewer than half of the contracts. Many program directors believe that emergency physicians' contracts should contain provisions to resolve disputes. 3,4 Dispute resolution can take many forms, such as simple negotiation, in-house problem solving panels, or arbitration. It is better to have the dispute resolution process established up-front rather than to negotiate a mechanism when a dispute has already occurred. (2) Fifteen percent of the contracts were found to have non-compete clauses. The issue of non-compete clauses in the survey was defined as a restriction on the physician's ability to work within a certain radius of the hospital for a defined amount of time after the contract is terminated. This may apply to either termination of the individual physician's contract or the service contract with the group providing physicians to the hospital. There