Challenging situations

Principles of a good death (Smith)

• To know when death is coming and understand what can be expected
• To be able to retain control
• To be afforded dignity and privacy
• To have control over pain and symptom relief
• To have choice and control over where death occurs
• To have access to necessary information and expertise
• To have access to required spiritual and emotional support
• To have access to hospice care in any location
• To have control over who is present and who shares the end
• To be able to issue advance directives that are respected
• To have time to say goodbye and control over timing
• To be able to leave when it is time to go and not have life prolonged pointlessly

Family presence in resuscitation

• Senior support person should be available throughout
• Family members can be encouraged to be involved in decision to cease resuscitation
• Improves the grieving process
• Quality management of grief states can prevent significant morbidity
• ED physicians have a duty of care to surviving family members
• All loved ones need time to accept the message of death, and this may need to be repeated

Breaking bad news

• Private room, refreshments available
• Greet family by name, confirm the relationship and shake hands or touch shoulders of each person
• All should be seated
• What do they know?
• Brief unambiguous summary
• If dead, use this term early
• Anxiolytics are contraindicated in early grieving
• Offers of follow-up are important

Viewing the body

• Assists the grieving process
• Inform of police involvement if the matter will be referred to coroner
• Allow to continue as long as desired
• Families will often assist in determining culturally appropriate handling and disposal of bodies +- ATSI liaison officers

Bereavement counselling

• Referral should be arranged prior to departure if not already made contact
• Ministers of religion should be available for all major denominations
• Inform GP’s promptly as are a great source of support for the family
• Social workers are experts at arranging this

Debrief

• Unclear if team debrief improves psychological outcome but can help foster reflective practice around teamwork in crisis situations

Sexual assault

• Stabilize the patient as appropriate – 5% of victims require hospitalization secondary to severe injury^5,8,9
• Understand your options and do what’s in the best interest of the patient:
  • Call the patient advocate (state attorney’s offices will provide a list of resources if needed)
  • Refer as appropriate:
    • If the patient may be better served by an institution with a SANE program, then transfer
  • Provide pregnancy prophylaxis as appropriate
  • Provide STI prophylaxis
  • Provide Hepatitis B vaccination if un-immunized
  • Discuss risk factors for HIV transmission and the risks/benefits of prophylaxis
  • Involve a rape crisis counselor EARLY
    • Many patients experience PTSD, depression, and suicidal ideation post assault¹³
  • Stress the importance of follow-up for STI monitoring, PEP evaluation as indicated, and continued emotional support

• 1/5 women globally suffer rape or attempted rape in their lifetime
• 19% of victims in Australia report sexual assault to police
• 1.3% of Australian women suffer sexual assault annually
• 0.6% of Australian men suffer sexual assault annually
• 17% of Australian women over 15 had experienced sexual assault vs. 4.8% of men
• For females
  • 39% by family member or friend
  • 32% by another known person
  • 22% assaulted by stranger
  • 21% by previous partner
• For males
  • 33% assaulted by stranger

Barriers to care

• ¼ perpetrators are charged once police involved by only 50% found guilty
• 12.5% of women do not report to police due to shame and embarrassment
• Consent must be obtained for forensic examination and release of information the the police
• The consent must be informed, freely given and specific. 
• The consent must be witnessed
• The capacity of the victim to give consent has to be carefully confirmed
• A forensic register must be kept for all items of evidence in a dedicated secure storage facility

Medical evaluation of the victim

• Medical needs
  • Physical injury
    • 50% have some form of physical injury although <5% require admission for this
    • Non-genital injury in 46% and genital injury in 22% in Australia
    • Attempted strangulation, blunt traumatic and penetrating injury may all occur
    • Attempted strangulation warrants high index of suspicion of underlying associated injuries and period of observation
  • Toxicological issues
  • Risk of infection and/or pregnancy

Forensics

• Need clinicians trained in this to perform
• Post-menopausal women are significantly more likely to require surgical management of genital injuries than younger women
• The documentation of injuries increases the chance of successful prosecution
• DNA evidence left on or in the body of a victim, particularly in moist areas, degrades rapidly over 2-10 days
  • Thus forensic assessment should be performed as soon as possible
• Underpants or panty liners worn during or after the assault should be retained and stored in paper bags (to prevent growth of organisms)
• The likelihood of detecting semen from the vagina is very low by 72 hours
  • But in some circumstances can last longer from endocervical os or cervix
  • Detection from mouth or anus is possible but depends on actions since assault (should record this)
• DNA in saliva may give positive result for up to 2 days
• Skin swabs for epithelial cells are unhelpful after 12 hours
• Victim should undress over a drop sheet to catch any hairs/cells/fluids
• All measures to minimise DNA cross-contamination in the clinical setting should be adhered to e.g. gloves/gowns/masks and drapes throughout assessment

Toxicological issues

• Urine is the preferred specimen but blood should also be collected within 24 hours of assault and kept refrigerated
• Alcohol intake prior to assault is very common (77% of those reporting drug-facilitated sexual assault)
• 37% of all alleged sexual assault have ethanol present in samples with average concentration of 0.11%
• Covert drug administration for the purposes of sexual assault appears to be rare in Australia

Risk of infection

• 4-5% risk of STI
• 43% of victims have pre-existing infection
• Most experts discourage testing for STI in the ED unless symptomatic
• Baseline screening is recommended in follow-up (however, follow-up rates are low):
  • HIV antibody
  • HBsAg, HBcAb, anti-HBc, anti-HBs
  • RPR/Treponema pallidum haemagglutination assay (TPHA)
  • Chlamydia PCR endocervical swab, first void urine
  • Gonorrhoea PCR endocervical swab, first void urine
  • Trichomonas high vaginal swab MCS
• Antibiotic prophylaxis is not typically recommended unless the person committing the assault is known to be suffering from an STI or victim is thought unlikely to return for follow-up
  • Poor follow-up rates are the norm, so all patients should be offered prophylaxis in ED if urgent follow-up cannot be assured
    • IM Ceftriaxone 250mg + 1g Azithromycin PO + Metronidazole 2g PO or tinidazole 2g PO

• Given the low rate of syphilis prevalence, reasonable not to provide benzathine penicillin but to repeat syphilis serology at 3 months if follow-up can be assured
  • Consider prophylaxis if follow-up unlikely or areas/populations where syphilis is prevalent
• Hep B
  • Prophylaxis vaccination 1mL IM + HepB IG 400IU IM should be provided if assailant is known to be HepB positive or victim is at high risk of HepB
  • HepB vaccination alone is highly effective if assailant has chronic HepB
  • HBIG is required if assailant has acute HepB and prevents 75% of infections
  • Full HepB vaccination course should be initiated at this point unless reliable vaccination history and serological conversion history
• HIV
  • 0.1-0.2% transmission rate for consensual vaginal sex
  • 0.5-3.0% transmission rate for consensual receptive anal intercourse
  • Oral intercourse rate much lower
  • Increased risk of transmission in:
    • Anal penetration
    • Broken skin/mucosa
    • Genital lesions
    • Associated STI
    • Multiple assailants
    • Likelihood of assailant having HIV given local epidemiology
    • Whether assailant is MSM or IVDU or incarceration
  • Should offer PEP as soon as possible up to 72 hours after
  • National guidelines recommend two ARV’s increased to three-drug stavudine 40mg BD if risk exceeds 1/1000
  • Need full 28 day course with both regimes
  • Provide first 5 days and arrange follow-up
• Consider tetanus prophylaxis

Pregnancy prophylaxis

• 5% risk of pregnancy
• It is the responsibility of the treating clinician to ensure the patient knows of availability and has immediate access to emergency contraception
• Levonorgestrel 1.5mg PO can be given up to 5 days from time of intercourse
• If given within 72 hours, 85% reduction in pregnancy rate
• The earlier it is given, the more effective it is
• Arranging follow-up for pregnancy testing, STI repeat testing, Hep B vaccination regimes is crucial and must be provided in writing

Crisis intervention

• Devastating sense of loss with fear for survival and gross invasion of privacy
• Increased lifetime risk of PTSD (30%) and major depression (30%)
• Sexual assault counsellors must have input prior to discharge
• The greater support the doctor provides to the victim, the better the outcome
• Doctors are the least supportive health professionals in this setting

Child sexual assault

• Usually chronic abuse vs. stranger
• Typically male in position of trust
• Physical injury is much less common (unless stranger)

Family violence

• Includes physical and sexual abuse, threats, psychological/emotional/social abuse and financial deprivation
• 30% of women and 15% of men report lifetime history of family violence
• 20% of women and 8% of men report family violence during adult life
• 15% of women experienced physical or sexual violence by a previous partner and 2.1% by a current partner since age of 15
  • Vs. 4.9% and 0.9% of men
• 61% of women who suffered family violence had children in their care at the time and 31% of these children had witnessed the violence
• 59% of women were pregnant during the relationship and 36% reported violence during pregnancy
• 17% of women reported the first episode of family violence occurring during pregnancy
• Women have 4x risk of family violence
• Individuals who have been victims of child abuse have 6x risk of family violence
• Men and women report similar incidence of child abuse of 7%
• 2% of women presenting to ED have suffered family violence in the preceding 24 hours
  • 10% if psychological abuse is included

Vulnerable groups

• Indigenous communities
  • 14% of homicide victims are ATSI and 68% of these victims died in a family homicide incident
• CALD
  • Culture values and beliefs alter norms, behaviour and response to violence
  • May encounter greater difficulty obtaining assistance and support due to lack of awareness of legal rights/protections/assistance, concerns of bringing dishonour to the family, fear of authority figures, communication barriers and marginalisation
• Disability
  • Have greater difficulty accessing mainstream support services due to communication barriers, lack of transport/accommodation options, reliance on perpetrator and limited recognition of victim status
• Elderly
  • Social isolation, undetected abuse and physical/cognitive limitations enhance vulnerability

Risk factor identification

• Individual
  • Male alcohol abuse, drug use, low education, unemployment and being former vs. current partner
  • Pregnancy and new birth
  • Perpetrator depression and psychosis
• Relationship
  • Hx of abusive and violent behaviour is strongest predictor of future violence
  • Separation of intention to separate
  • Separated or divorced women are 4x more likely to suffer violence than women have never married, are married or are widowed
  • Men who are abused are often assaulted by the women they abuse
• Social
  • Gender inequality supported by societal norms and economic/social policies that create or sustain inequalities

Outcomes

• Physical
  • Hx inconsistent with injury
  • Injuries of variable temporal stages
  • Unreasonable delay in presentation
  • NAI often central vs. peripheral
  • Injuries to defensive areas or back of body
  • Injuries inflicted on females typically include contusions, abrasions, lacerations, fractures and dislocations
  • Women are more likely to be choked, beaten or sexually abused
  • Men have greater risk of objects thrown at them or weapons used against them
  • Injury pattern is overall of low positive predictive value despite above
• Sexual
  • Abuse before, during or after pregnancy represents a threat to mother and baby
  • 40% of women who are physically abused are forced into non-consensual sex at some stage
    • High rates of STI, unintended pregnancy and termination of pregnancy
  • Complex link between family violence and preterm labour, LBW babies and postnatal depression
• Interference with accessing healthcare seen in 17%
• 38% of homicide victims are due to family violence
• Psychological
  • Women who suffer family violence have 11-fold increase in dissociative disorders, 6x risk of somatisation disorders, 5x higher risk of anxiety and 3x risk of depression, phobias and drug dependence
  • Associated with PTSD
  • 2x the rate of hazardous alcohol consumption and dependence
  • If abuse occurs in childhood and adulthood, get further increases in above risks
• Impact on children
  • Victimisation, witnessing violence, separations, foster care, future mental illness and increased potential to perpetrate violence in the future
  • 15x more likely to be a victim of abuse or neglect themselves
  • Increased risk of being perpetrator of homicidine in the pre-teenage group
  • 1/3 of the population risk of mental illness is attributable to family violence
• Social
  • Isolation, prevention from paid employment and inhibited contact with medical practitioners
  • Financial dependence
  • Dependence on perpetrator
  • Children or elderly may be institutionalised by authorities or carers
  • Male victims feel less trapped/controlled/fearful and are generally less financially dependent on the perpetrators
• Economic cost
  • Pain, suffering and premature mortality
  • Health costs
  • Production-related costs
  • Consumption –related costs (property replacement)
  • Second-generation costs (childcare, child protection)
  • Administration legal and forensic costs
  • Transfer costs (income support and lost taxes)

Barriers to detection

• Only 10% of those that present with acute family violence-related injuries or issues will be asked about the violence issue
• Documentation of violence is rare
• Barriers to detection
  • System: Inadequate privacy
  • Practitioner lack of time and education 
  • Health practitioner attitudes
  • Social and gender issues
• Barriers to disclosure
  • Fear, shame, anxiety re; medicloegal processes, familial/cultural/religious pressures
  • May not perceive themselves as victims
  • Indigenous women rarely report violence
    • Historical forcible removal of children, high rates of Indigenous death in custody, lack of culturally appropriate legal processes
  • Elderly may fear institutionalisation, further abuse or neglect

Screening

• Detection rates increase from 0.4% to 14% with direct questioning
• Do you feel safe at home? – May be all that is required as an effective screening question
• 20% of family violence perpetrators have presented to ED in 6 months prior
• No evidence exists that screening improves outcomes for victims but may improve detection and referral rates

Management

• Leaving a violent relationship is a complex process not an event
• Understanding
  • Pre-contemplative: Victim not consciously aware of or in denial
  • Contemplative: Abuse identified by victim unable to decide on leaving
  • Preparation: Steps taken in preparation to leave
  • Action phase: Leaving the relationship with episodes of return
  • Maintenance phase: Period of 6 months without return to relationship
• Referral to services
• Safety
  • Emergency accommodation or hospital admission may be required to ensure immediate safety
  • Greatest risk of injury occurs while leaving the relationship
  • 70% of homicides occur as woman leaves or has left the home
  • Continued contact due to custody issues makes the risk of abuse a continuing one
• Reporting
  • No mandatory reporting except in NT
• Documentation
  • Objective and accurate
  • Direct quotes and descriptions of behaviours and appearances improve objectivity
  • Body maps and photographs assist

The homeless patient

• Primary homelessness: Sleeping rough
• Secondary homelessness: Staying with friends/relatives, no fixed address or in homeless shelter
• Tertiary homelessness: Boarding houses or caravan parks with no secure lease and no private facilities, both short and long-term
• Indigenous homelessness
  • Living in public places
  • At risk of losing their house
  • Spiritually homeless

• Present to the ED 10x as frequently
• Re-presentation rates within one month constitute 50% of all re-presentation episodes
• 23% of patients who re-present to the ED are homeless
• Predictors of re-presentation
  • Age <65, receiving government pension
  • Case management, discharge at own risk
  • Primary psychiatric presentations, complex medical history, high number of prescribed medications
  • Non-urgent triage in 91% of cases
• Common presentations
  • Infectious diseases e.g. TB, HIV
  • Penetrating trauma
  • Depression
  • Schizophrenia
  • Ethanol and drug abuse

• 2x rate of completed suicide
• Management
  • Multidisciplinary approach
  • Link to community services, assistance with discharge planning and assistance with emergency accommodation
  • SSU admission is common and may assist with improved outcomes of illness and other social parameters
  • Compassionate approach reduces re-presentation rates (dispels myth)

The prisoner

• Security issues
  • Perceived threat to safety of staff and other patients
  • Potential for violent incidents
  • Presence of non-hospital security staff
  • Weapons in the ED
• Patient care issues
  • Clinical management of complex illness
  • Medial/psychiatric/addiction comorbidities
  • Maintenance of confidentiality
  • Discharge planning
• 25% of prisoners report hospitalisation in the prior 12 months

• Presentations
  • Injury
    • 1/3 self-inflicted injury; 1/3 accidental; 1/3 due to assault
    • Tend to be more severe than general population
  • Mental health issues
  • Substance withdrawal (9% of presentations and 6% of admissions)
• Risk factors for incarceration in those with mental health issues
  • Prior incarceration
  • Substance-related diagnoses
  • Schizophrenia
  • Bipolar
  • Male gender

• Risk factors for suicide in prisoners
  • Isolation
  • Punitive sanctions
  • Severely restricted living conditions
  • Acquisition of new charges
  • Imposition of an unexpected sentence
• High risk of substance overdose upon release
• High rates of admission (36-49%) due to higher acuity of illness and practical/logistical difficulties
• Have reduced LOS in ED compared to non-prisoner controls

• May have reduced incidence of violence compared to non-prisoner population
• Prioritisation of prisoners is reasonable to expedite management and reduce LOS in ED
• Confidentiality
  • Presence of guards vs. safety risk of being left alone with patient must be weighed up
  • Advice from custodial staff on suitability for leaving cubical or removing restraints should be sought
  • History obtained in presence of guards may be inaccurate
• Mental health issues not resourced in ED in most hospitals of Australia
• Follow-up within the prison or return to outpatients is often logistically demanding or impossible so often investigated more thoroughly in ED
• Need low threshold for admission
• Need clear written discharge instructions and dispensing instructions for prescribed medications
• Liaison with prison nurse or medical officer should establish whether the facility can provide the expected management

• Prisoners have no right to:
  • Determine their location
  • Know dates/times of follow-up
  • Refuse any security requirements
  • Notify next of kin
  • Have any belongings
  • Make or receive phone calls
  • Access any form of communication device
  • Receive unapproved visitors
  • Receive discharge information
  • Receive sought after medications

The behaviourly disturbed patient

• Unarmed threat to others characterised by aggression, violence and irrational/altered behaviour
• 0.3-2.0% incidence rate
• 50% have acute flare of mental illness; 40-50% intoxicated
• Small number have organic illness
• 65% male and most under 40yo
• 20% brought to ED in police custody
• 58-80% require chemical or physical restraint

• Should be assessed in quiet, private and secure rooms as standard
• Respectful and clear communication with lowered voice, eye contact and non-threatening body language may establish rapport to prevent escalation
• Explanation of treatment decisions, bargaining and rewarding compliance can diffuse tension
• Allowing semblance of autonomy and control, while setting clear behavioural limits, is recommended

• Clinical features
  • Diagnosis – Aetiology
  • Risk assessment – Can the patients autonomy be overridden?
  • Arousal assessment – Does the patient require containment and/or sedation and how quickly?
• Cognitive abilities should guide mental health assessment rather than presence of drugs or alcohol
• Clinical features suggestive of high risk:
  • Threats or actual self-harm
  • Suicidal behaviour or ideation
  • Threats or actual violence to others
  • Altered conscious state due to illness, injury or intoxication
  • Incompletence
  • Pre-hospital retraint usually necessitates ongoing restraint
  • Physical agitation, sweating, pacing, restlessness, loss of rational thinking, increased voice, foul language, eye widening and pupil dilatation

• Legal and ethical considerations
  • Lawfully protected in emergency situations, committal under legislation, suicide prevention, necessity or in best interests and for incompetent patients
  • A compassionate approach that maintains human dignity and recognises medical due to of care is appropriate and lawful
• Management
  • Need minimum 6 people
  • Smaller hospitals may have to utilise police but not ideally
  • Police should be involved if weapon is present or person is not a patient
  • Chemical restraint
    • If rapid tranquilisation desired, IV approach is preferred but depends on access as onset of action is 5 minutes vs. 15-20 for IM drugs
    • IV midaolam alone causes more adverse events related to airway and oversedation and more likely to require re-sedation within one hour

• Physical restraint
  • Five point hold recommended
  • Oxygen mask or loose towel over face can be used if spitting
  • Shackles
    • Safe in supine positioning
    • Soft fabric securing patient to trolley is recommended at wrists and ankles
    • Concomitant chemical sedation is advised
    • Prolonged shackling risks musculoskeletal injury, respiratory compromise and psychological trauma
    • Need regular review of necessity and safety
  • Can utilise seclusion rooms instead

• Patient perspective
  • Benzodiazepines preferred
  • Seclusion rooms preferred over shackles
  • Chemical sedation preferred over physical restraint
• Disposition
  • Patient must be alert, have stable vital signs and not require further monitoring prior to transfer to inpatient setting as deaths have occurred
  • Multidisciplinary care-coordination approach optimises safe discharge for the acutely intoxicated and disturbed patient
  • If normal clinical and investigative findings, absence of ongoing intoxication and exclusion of mental illness – do not need ED care
  • Can discharge to care of police if ongoing risk to self or others
  • Must document all decisions and reasoning behind each intervention

DORM study – 2010

• Droperidol vs. midazolam vs. Combination for IM sedation in acute behavioural disturbance
• 10mg/10mg/5+5mg
• Primary outcome was time security staff were required
• Secondary outcomes
  • Time until additional sedation administered
  • Staff and patient injuries
  • Further episodes of violence/behavioural disturbance
  • Drug-related adverse effects
• Results
  • 91 patients included out of 223 ED patients with acute behavioural disturbance
  • No difference in primary outcome
  • More additional sedation with midazolam
  • More oversedation with midazolam
  • No evidence of QT prolongation with droperidol vs. midazolam

DORM-II (2016)

• Efficacy and safety of ketamine as rescue treatment for acute behavioural disturbance
• Primary outcome was number of patients who failed to sedate within 120 minutes of ketamine or requiring further sedation within 1 hour
• 49 patients over 27 months
• Vast majority received 10mg + 10mg droperidol prior to ketamine
• Median dose of ketamine 300mg IM (50-500mg)
• Median time to sedation post-ketamine 20min
• No obvious harms noted 
• Doses less than 200mg associated with treatment failure

ED violence

• Under-reported, poorly documented and limited formal hospital support for those exposed
• Strategic approach
  • Environment (appropriate, safety)
    • Comfortable, clear visibility, security cameras, visible security staff, restricted access areas, minimising access to potential weapons, widely dispersed duress alarms
  • Staff (education, training, teamwork)
  • Systems (reporting, follow-up, peer support)
    • Debriefing and support
    • OHS framework follow-up

The frequent attender

• Frequent attender >3 times per year and make up 8% of all attendances
• Characteristics
  • Poverty
  • Homelessness
  • Chronic and complex medical illness
  • Psychiatric illness
  • Drug and alcohol abuse
  • Higher mortality, increased risk of sudden death from violent causes e.g. suicide and substance misuse
  • Typically male, older and socially isolated
• Availability and engagement with primary healthcare providers DOES NOT alter ED use by frequent attenders

• Patterns of attendance
  • Primarily psychosocial or substance misuse sustaining consistent attendance over years
  • Primarily chronic medical illness sustain consistent attendance for 1-2 years only
• Natural attrition occurs over time but studies around the world show high mortality in this group
• Compared to whole population, more likely to:
  • Present out of hours
  • Have serious or urgent illness
  • More often require admission
  • More likely to self-discharge
  • Less suitable for primary care diversion than other patients (despite assumptions)

• Management
  • Standard medical care procedures
  • Collateral from primary care providers, other health services and family
  • Development and wide dissemination of acute treatment plans to streamline assessment and management
  • ED-based multidisciplinary services for care coordination benefits the care of the frequent attender
    • Increases ED utilisation but improves psychosocial factors
  • Education of patients and acute care plans do not reduce frequency of ED attendance
  • ED may be the best place for management of these complex patients

The drug-seeker

• Features that raise suspicion
  • Previous suspicion in medical record
  • Inconsistent hx and examination
  • Requests for specific drugs
  • Higher than expected analgesia requirements
  • Demanding or aggressive behaviour
  • Complaints of lost or stolen prescriptions or medications
  • Letters from remote medical practices
  • Presentations that are possible to feign including migraine or ureteric calculus
  • Past history of drug dependence, mental health or self-harm
• 20% of patients deemed to exhibit drug-seeking behaviour are admitted to hospital for underlying illness and 17% self-discharge against medical advice so risk is high of missing organic illness
• Only 11% have documented discussion around drug dependence in the ED and only 23% are referred to addiction, psychiatric or chronic pain services

• Management
  • Develop rapport
  • Ensure new organic pathology does not exist
  • Determine that genuine pain has been adequately treated
  • Once degree of certainty attained, set clear limits regarding medications requested
  • Consider open discussion with patient regarding their behaviour if appropriate
  • Consider referral to appropriate services for ongoing care
  • Develop management protocols for particular patients if frequent attendance or threatening behaviours develop
  • Hospital or department-wide protocols on prescription of controlled drugs after hours and dispensing can assist in limit setting

The VIP

• Medical issues
  • Must ensure standard clinical procedures are followed and avoid VIP syndrome
  • Ensure other patients receive normal treatment
  • Liaise with other physicians involved e.g. those travelling with heads of state
  • Lower than normal threshold for admission or observation is recommended
• Administrative issues
  • Security of VIP and hospital staff
  • Protection of privacy and confidentiality
  • Containment of press
  • Minimise entry of unnecessary people to the ED
  • Disclosure to media should be two-tiered:
    • Acknowledgement of presence and seeking medical attention after consent obtained
    • Graded release of medical information after consent obtained

Obesity

• Epidemiology
  • 63% of Australians over 18 are overweight or obese
    • 35% overweight
    • 28% obese
  • Only 35% of adults are normal weight
  • 25% of children are overweight or obese
    • 18% overweight
    • 7% obese
  • Truncal obesity correlates to increased mortality

• Ideal body weight
  • Height (cm) – 100 (males) OR – 105 (females)
  • Males
    • 50 +(0.91x Height (cm) – 152)
  • Females
    • 45.5 + (0.91xHeight (cm) – 152)

• Classification
  • Overweight
    • BMI 25-30
    • Waist circumference >80cm in women or >94cm in men
  • Obese
    • BMI >30
    • Class I (30-35); Class II (35-40); Class III (>40) = Morbid
    • Super obese >50
    • Waist circumference >102cm (men) or >88cm (female)
  • Bariatric
    • BMI > 40 or >150kg
    • Need bariatric bed

Patients who did not wait

• National average in Australia = 5.4%
• Factors associated with DNW
  • Prolonged waiting time
  • Low SES
  • Lack of private health insurance
  • Young adults
  • Parents with young children
  • ATS 4 or 5
  • ED overcrowding
  • ED attendance after hours

• Consequences
  • Patient dissatisfaction/anger
  • Delayed Dx/Rx
  • 2/3 access health care in week following (only small percentage re-attend ED)
  • 5% subsequent admission rate
  • Adverse outcomes rare

• High risk situations
  • Chest pain
  • Head injury
  • Headache
  • Fever/abnormal vitals
  • Paediatric/geriatric/pregnant
  • GP concern (letter/phone call)
  • Impaired patient judgement
  • Intoxication
  • Psychosis
• Document any involvement otherwise NO DEFENCE

The extent of medical care

• Referral to ICU
  • Age alone is an unreliable predictor of outcome in ICU – studies vary
  • If reversible cause, may be appropriate
  • Study of patients >65yo in ICU showed:
    • Declining demand for ICU beds
    • Improved hospital survival
    • No associated increase in LOS or residential care requirement
  • Crucial decision is ‘what is the patient prepared to sacrifice for potential survival?’
  • Only really suitable for a rapidly resolvable condition
    • NOT MALIGNANCY COMPLICATION, NOTMAJOR TRAUMA, NOT PNEUMONIA
    • Urosepsis is one particularly reversible condition and maybe after elective surgery

• Expectations
  • Most patients and families receiving ‘palliative chemotherapy’ do not understand that the treatment is not curative
• Surrogate decision making
  • Only ever discuss treatments that are non-futile, on the table and could possibly be of benefit to the patient
  • Try to determine what things are important to the patient e.g. independence, quantity vs. quality
  • Give your opinion as you are the expert
  • Imagine patient sitting opposite you

• Do not
  • Rush the decision
    • Give family time alone to discuss situation
    • Let them know when a decision will be required 
    • Keep family informed of new information
  • Talk about withdrawing or ceasing care
    • Talk about changing focus towards comfort and symptom control
    • Talk about withholding/withdrawing life-sustaining measures NOT care
    • Good comfort care is an active process not a withdrawal

Organ donation

• Common suitable donors
  • Isolated head injury or neurological catastrophy
  • Sudden non-infectious death
• Contraindications to organ donation
  • Age >80
  • Death from infectious disease, cancer, or certain toxic exposures
• Only 45% of families of possible donors are approached
• Need to discuss with relatives after having viewed the body and notify DonateLife
• Best to bring up in separate conversation but must be considered early in the case of brain death or DCD due to time constraints

Last Updated on October 6, 2021 by Andrew Crofton