State insurance commissioner actions against health maintenance organizations for denial of emergency care

OBJECTIVE

Concerns have emerged from two west coast communities that health maintenance organizations (HMOs) may deter their members from calling 911. One means of influence is retrospective denial of emergency department (ED) or emergency medical services (EMS) claims. The study objective was to systematically assess legal action taken to contest HMO denial of claims.

METHODS

Telephone survey of all state insurance commissioners (SICs). The specific question asked was: "What actions, if any, have been taken by the Office of Insurance Commissioner since 1990 against HMOs for denying claims for emergency department care or care provided by paramedics after a person has called 911?" Each office was contacted at least three times.

RESULTS

Representatives from 49 states were interviewed. Three states (6%, Oregon, Texas, and Virginia) have taken formal action since 1990. Oregon fined two HMOs a total of $25,000 for inappropriate systematic claim denial of ED care. Texas fined one HMO $1,000,000 for similar practices. Virginia, with no authority to fine, has issued citations. No action had been taken for denying EMS claims. Thirty-eight states (78%) reported no formal actions. Eight (16%) state SICs could not easily retrieve these data and did not report. Fourteen (29%) representatives reported receiving these complaints. Most of these complaints were resolved without formal SIC action.

CONCLUSIONS

Three health plans in two states received financial penalties for systematic denial of ED claims. A fourth was cited. This may underrepresent the true incidence of appealed ED and EMS claim denials. While complaints occurred in 29% of states, recent actions by SICs are relatively rare (6% of states). These results speak more to the extent systematic claim denials are discovered by SICs than to the true incidence of this practice.

The stiffness of lumbar spinal motion segments with a high-intensity zone in the anulus fibrosus

STUDY DESIGN

Biomechanical and anatomic study of human cadaveric spinal motion segments.

OBJECTIVES

To measure the stiffness of spinal motion segments by disc type and by load type (flexion, extension, axial rotation, or lateral bending). To compare stiffness in motion segments with and without a high-intensity zone or radial tear in the anulus fibrosus.

SUMMARY OF BACKGROUND DATA

The high-intensity zone, that is a linear zone of high-intensity on T2-weighted magnetic resonance images corresponding to a radial tear in the anulus fibrosus, is a marker for a painful disc at discography. The high-intensity zone is hypothetically associated with diminished stiffness of the motion segment.

METHODS

Human cadaveric lumbar spinal motion segments with normal disc morphology or a high-intensity zone of the anulus fibrosus were selected on the basis of magnetic resonance imaging. The motion segments were subjected to incremental flexion, extension, rotation, and lateral bending torques. Rotation was measured with a kinematic system. Torque-rotation curves and stiffness were calculated for each motion segment and for each torque. The motion segments were sectioned on a cryomicrotome to verify the disc morphology as normal or as that of a radial tear.

RESULTS

In four motion segments with normal discs, stiffness was greater in axial rotation (8.4 Nm/degree) than in lateral bending (2.3 Nm/degree), flexion (1.8 Nm/degree), or extension (2.6 Nm/degree). In 16 motion segments with a high-intensity zone, stiffness was 2.4 Nm/degree in axial rotation, and less severely reduced in lateral bending, flexion, and extension. Stiffness in motion segments with a high-intensity zone was significantly less with smaller than with larger axial rotation loads.

CONCLUSIONS

The presence of a high-intensity zone in the intervertebral disc is associated with reduced stiffness of motion segments. The reduction is greater in axial rotation than in other torques. The reduction is more in smaller than in larger axial torques.

Oregon emergency medical technicians' attitudes toward physician-assisted suicide

OBJECTIVES

To determine Oregon intermediate and advanced emergency medical technicians' (EMTs') attitudes toward physician-assisted suicide (PAS) and factors associated with those attitudes.

METHODS

An anonymous survey was sent to a random sample of 498 EMTs registered in Oregon.

RESULTS

Surveys were delivered to 498 EMTs and 343 completed surveys were returned, for a response rate of 69%. The mean age of the respondents was 37.5 years (+/-8.73) and 79% were male. 232 (68%) agreed that PAS should be legal, 263 (77%) agreed that terminally ill people have a right to decide to commit suicide, while 57 (17%) thought not attempting resuscitation would be immoral. 251 (73%) reported seeing attempted suicide in terminally ill patients at least once, with 117 (34%) experiencing such calls >5 times. Only 22 (6%) stated that they would be unable to work in a system that directed them to withhold resuscitation after a PAS attempt, and 277 (81%) agreed that treatment protocols should direct EMTs to withhold resuscitation. 105 (31%) thought EMTs should participate in the decision to withhold resuscitation. 206 (60%) thought the law should allow lethal injection for terminally ill patients. 201 (59%) agreed there were circumstances under which they might personally consider PAS. If PAS were legal, EMTs stated they would withhold treatment from a terminally ill patient following attempted suicide in the following circumstances: based on standing orders, 78%; with on-line medical direction, 67%; after speaking with the primary physician, 53%; if the patient had decision-making capacity, 45%; with written documentation from the patient's physician, 68%; and never, 6%.

CONCLUSIONS

A majority of Oregon EMTs responding to this survey expressed support for PAS, think treatment protocols should direct paramedics to withhold resuscitation in such cases, and would feel comfortable withholding resuscitation given appropriate protocols. Nearly 3 out of 4 Oregon EMTs report seeing at least 1 terminally ill patient who had attempted suicide.

Do patients refusing transport remember descriptions of risks after initial advanced life support assessment?

OBJECTIVE

To determine patient recall and understanding of instructions given to patients who refuse transport after initial paramedic assessment and medical treatment.

METHODS

Following patient consent, a phone interview was completed for consecutive persons living in a large urban area for whom 9-1-1 was contacted but who subsequently refused transport after advanced life support (ALS) assessment. Subjects were asked about their recall of explained risks and benefits of transport, their understanding of those risks at the time of assessment, and subsequent use of medical care, including hospitalization.

RESULTS

From October 1, 1996, to February 23, 1997, 324 people refused transport after ALS arrival. Sixty-eight people could not be contacted, providing a response rate of 79% (256/324). Six percent were subsequently admitted to the hospital for the same problem and an additional 59% sought care from a health care provider (66 ED visits, 63 personal physician, 16 urgent care, 5 other). There were no unexpected deaths. Ninety (35%) respondents were still experiencing symptoms at the time of phone contact. Despite the routine practice of providing a verbal explanation of risks and written instructions, only 141 (55%) recalled receiving written instructions and 56 (22%) recalled an explanation of risks. Twenty-six percent believed they did not fully understand their conditions or circumstances surrounding the 9-1-1 call when they refused transport and 18% would now take an ambulance if the same incident were to recur.

CONCLUSION

A substantial proportion of patients refusing transport do not recall receiving verbal or written instructions and would reconsider their transport decision, raising doubts about people's ability to make informed decisions at a time of great vulnerability. The majority of patients accessed health care after refusing transport and 6% were hospitalized.

Multiple options and unique pathways: a new direction for EMS?

The same forces transforming the health care delivery system also are reshaping EMS. The changing economic and organizational structures of the health services delivery system may predict how EMS systems will redesign themselves. We discuss one template for future EMS systems.

Lumbar facet joint tropism does not accelerate degeneration of the facet joints

PURPOSE

To study the relationship of lumbar facet joint tropism to degeneration of the cartilage and subcortical bone in the facet joints and the effect of tropism in intervertebral disk degeneration.

METHODS

The orientation of 104 cadaveric lumbar facet joints with respect to sagittal plane was measured on CT scans, and the joints were classified as having no tropism, mild tropism, or severe tropism. On MR images, the severity of cartilage degeneration and bony sclerosis was measured. The correlation between tropism and degeneration was calculated, as was the relationship among age, spinal level, and degeneration.

RESULTS

We identified four spinal levels with severe tropism, six with moderate tropism, and 94 without tropism. Cartilage degeneration was not significantly more severe in the joints with tropism than in the joints without. Sclerosis was slightly greater in the joints with tropism than in the joints without it. Sclerosis and cartilage degeneration were significantly related to age and spinal level.

CONCLUSION

Age, spinal level, and overall facet joint angle are more important factors in facet joint degeneration than is tropism.

K+ supplementation increases muscle [Na+-K+-ATPase] and improves extrarenal K+ homeostasis in rats

Effects of K+ supplementation (approximately 200 mmol KCl/100 g chow) on plasma K+, K+ content, and Na+-K+-adeonsinetriphosphatase (ATPase) concentration ([Na+-K+-ATPase]) in skeletal muscles as well as on extrarenal K+ clearance were evaluated in rats. After 2 days of K+ supplementation, hyperkalemia prevailed (K+-supplemented vs. weight-matched control animals) [5.1 +/- 0.2 (SE) vs. 3.2 +/- 0.1 mmol/l, P < 0.05, n = 5-6], and after 4 days a significant increase in K+ content was observed in gastrocnemius muscle (104 +/- 2 vs. 97 +/- 1 micromol/g wet wt, P < 0.05, n = 5-6). After 7 days of K+ supplementation, a significant increase in [3H] ouabain binding site concentration (344 +/- 5 vs. 239 +/- 8 pmol/g wet wt, P < 0.05, n = 4) was observed in gastrocnemius muscle. After 2 wk, increases in plasma K+, K+ content, and [3H]ouabain binding site concentration in gastrocnemius muscle amounted to 40, 8, and 68% (P < 0.05) above values observed in weight-matched control animals, respectively. The latter change was confirmed by K+-dependent p-nitrophenyl phosphatase activity measurements. Fasting for 1 day reduced plasma K+ and K+ content in gastrocnemius muscle in rats that had been K+ supplemented for 2 wk by 3.1 +/- 0.3 mmol/l (P < 0.05, n = 5) and 15 +/- 2 micromol/g wet wt (P < 0.05, n = 5), respectively. After induction of anesthesia, arterial plasma K+ was measured during intravenous KCl infusion (0.75 mmol KCl x 100 g body wt(-1) x h(-1)). The K+-supplemented fasted group demonstrated a 42% (P < 0.05) lower plasma K+ rise, associated with a significantly higher increase in K+ content in gastrocnemius muscle of 7 micromol/g wet wt (P < 0.05, n = 5) compared with their control animals. In conclusion, K+ supplementation increases plasma K+, K+ content, and [Na+-K+-ATPase] in skeletal muscles and improves extrarenal K+ clearance capacity.

Reduced concentration of myocardial Na+,K(+)-ATPase in human aortic valve disease as well as of Na+,K(+)- and Ca(2+)-ATPase in rodents with hypertrophy

Myocardial Na+,K(+)-ATPase was studied in patients with aortic valve disease, and myocardial Na+,K(+)- and Ca(2+)-ATPase were assessed in spontaneously hypertensive rats (SHR) and hereditary cardiomyopathic hamsters using methods ensuring high enzyme recovery. Na+,K(+)-ATPase was quantified by [3H]ouabain binding to intact myocardial biopsies from patients with aortic valve disease. Aortic stenosis, regurgitation and a combination hereof were compared with normal human heart and were associated with reductions of left ventricular [3H]ouabain binding site concentration (pmol/g wet weight) of 56, 46 and 60%, respectively (p < 0.01). Na+,K(+)- and Ca(2+)-ATPases were quantified by K(+)- and Ca(2+)-dependent p-nitrophenyl phosphatase (pNPPase) activity determinations in crude myocardial homogenates from SHR and hereditary cardiomyopathic hamsters. When SHR were compared to age-matched Wistar Kyoto (WKY) rats an increase in heart-body weight ratio of 75% (p < 0.001) was associated with reductions of K(+)- and Ca(2+)-dependent pNPPase activities (mumol/min/g wet weight) of 42 (p < 0.01) and 27% (p < 0.05), respectively. When hereditary cardiomyopathic hamsters were compared to age-matched Syrian hamsters an increase in heart-body weight ratio of 69% (p < 0.001) was found to be associated with reductions in K(+)- and Ca(2+)-dependent pNPPase activities of 50 (p < 0.001) and 26% (p = 0.05), respectively. The reductions in Na+,K(+)- and Ca(2+)-ATPases were selective in relation to overall protein content and were not merely the outcome of increased myocardial mass relative to Na+,K(+)- and Ca(2+)-pumps. In conclusion, myocardial hypertrophy is in patients associated with reduced Na+,K(+)-ATPase concentration and in rodents with reduced Na+,K(+)- and Ca(2+)-ATPase concentrations. This may be of importance for development of heart failure and arrhythmia in hypertrophic heart disease.

Reduction of cerebral cortical [3H]ouabain binding site (Na+,K(+)-ATPase) density in dementia as evaluated in fresh human cerebral cortical biopsies

Na+,K(+)-ATPase density in human cerebral cortex was for the first time studied by vanadate facilitated [3H]ouabain binding to intact samples. Fresh human cerebral cortical biopsies were obtained as a result of diagnostic frontal lobe biopsy from patients with normal pressure hydrocephalus (NPH) syndrome and associated dementia. For control measurements post-mortem samples were obtained from patients without clinically observed dementia. [3H]ouabain binding kinetics were evaluated: when incubating samples in 1 microM [3H]ouabain binding equilibrium was obtained after 6 h of incubation, non-specific uptake and retention amounted to only 2.3% of total uptake and retention of [3H]ouabain and release of specifically bound [3H]ouabain during washout in the cold occurred only slowly (T1/2 = 37 h). Evaluation of receptor affinity for ouabain was in agreement with a heterogeneous population of [3H]ouabain binding sites. [3H]Ouabain binding was significantly reduced after frozen storage of samples before measurements. Post-mortem degradation of cerebral [3H]ouabain binding sites occurred only slowly (T1/2 = 75 h). No significant variation in [3H]ouabain binding site density was observed between the cerebral lobes with occipital, parietal and temporal values (means +/- S.E.M., n = 5) amounting to 10281 +/- 649, 11267 +/- 1011 and 9263 +/- 615 pmol/g wet wt., respectively. [3H]Ouabain binding measured in frontal cortical samples gave values of (means +/- S.E.M., n = 5) 4274 +/- 1020 and 11397 +/- 976 pmol/g wet wt. delta % = 62; P < 0.05) in patients with dementia and controls, respectively. Human cerebral cortical capacity for active K+ uptake was around 37- and 16-fold greater than in skeletal muscular and myocardial tissue, respectively.

Oregon emergency physicians' experiences with, attitudes toward, and concerns about physician-assisted suicide

OBJECTIVE

To determine emergency physicians' (EPs') attitudes toward physician-assisted suicide (PAS), factors associated with those attitudes, current experiences with attempted suicides in terminally ill persons, and concerns about the impact of legalizing PAS on emergency medicine practice.

METHODS

A cross-sectional, anonymous mailed survey was taken of EPs in the state of Oregon.

RESULTS

Of 356 eligible physicians, 248 (70%) returned the survey. Of the respondents, 69% indicated that PAS should be legal, 65% considered PAS consistent with the physician's role, and 19% believed that it is immoral. The respondents were concerned that patients might feel pressure if they perceived themselves to be either a care burden on others (82%) or a financial stress to others (69%). Only 37% indicated that the Oregon initiative has enough safeguards to protect vulnerable persons. Support for legalization was not associated with gender, age, or practice location. Respondents with no religious affiliation were most supportive of PAS (p < 0.001), and Catholic respondents were least suppportive (p = 0.03). A majority (58%) had treated at least 1 terminally ill patient after an apparent overdose. Most respondents (97%) indicated at least 1 circumstance for which they would sometimes be willing to let a terminally ill patient die without resuscitation after PAS if the Oregon initiative becomes law: if verified with an advance directive from the patient (81%), with documentation in writing from the physician (73%), after speaking to the primary physician (64%), if a competent patient verbally confirmed intent (60%), or if the family verbally confirmed intent (52%).

CONCLUSIONS

Although the majority of Oregon EPs favor the concept of legalization of PAS, most have concerns that safeguards in the Oregon initiative are inadequate to protect vulnerable patients. These physicians would consider not resuscitating terminally ill patients who have attempted suicide under the law's provisions, only in the setting of documentation of the patient's intent.

Occult lumbar lateral spinal stenosis in neural foramina subjected to physiologic loading

PURPOSE

To measure the effect of extension, flexion, lateral bending, and axial rotation loads applied to the spine on the anatomic relationship of the spinal nerves in the neural foramen to the ligamentum flavum and the intervertebral disk, anc to determine the effect of disk degeneration on the response to loading.

METHODS

Cadaveric lumbar motion segments were examined with CT and MR imaging, loaded with pure moment forces, frozen in situ, reexamined with CT, and sectioned with a cryomicrotome. The morphology of the intervertebral disks was classified on the basis of the appearance of the cryomicrotome sections. The neural foramina were classified as having no evident stenosis, as being stenotic, as having occult stenosis, or as showing resolved stenosis on the basis of the images and sections before and after loading. The stenotic and nonstenotic foramina were stratified by disk level, intervertebral disk classification, and type of loading applied. The effect of spinal level, disk type, and load type on the prevalence of stenosis was studied.

RESULTS

On average, extension, flexion, lateral bending, and axial rotation resulted in the ligamentum flavum or intervertebral disk contacting or compressing the spinal nerve in 18% of the neural foramina. Extension loading produced the most cases of nerve root contact, and lateral bending produced the fewest cases. Each of the loading types resulted also in diminished contact between the spinal nerve and the intervertebral disk or ligamentum flavum in some cases. Disk degeneration significantly increased the prevalence of spinal stenosis. All foramina associated with advanced disk degeneration and half of the foramina associated with disks having radial tears of the annulus fibrosus either developed occult stenosis or were stenotic before loading.

CONCLUSIONS

The study supports the concept of dynamic spinal stenosis; that is, intermittent stenosis of the neural foramina. Flexion, extension, lateral bending, and axial rotation significantly changed the anatomic relationships of the ligamentum flavum and intervertebral disk to the spinal nerve roots.

Advanced life support in the wilderness: 5-year experience of the Reach and Treat team

Increasing recreation in the wilderness raises questions about the value of providing advanced life support (ALS) care in the backcountry. Since 1989 the Reach and Treat (RAT) team has provided ALS care in the wilderness area that surrounds Mount Hood, Oregon. The purpose of our study was to describe patient demographics, terrain, injuries, and ALS treatment in the wilderness environment. We utilized a retrospective, observational analysis of RAT missions from 1989 to 1994 based on data sheets maintained by the RAT team, prehospital run sheets, and hospital charts. Of the 114 missions analyzed, the median time of missions was 3 h, 9 min (range, 44 min-76 h) and 20% required technical climbing skills. Of the 74 patients treated, 55 (90%) received ALS care: 8 were intubated, 52 had intravenous lines established, and 24 received morphine for pain. Twenty patients were entered into the local trauma system. The most common injuries were extremity injuries (58), head injuries (18), and hypothermia (15). Mean time from arrival to return to staging area was 95 min. No injuries to RAT team members occurred during these missions, although two minor injuries occurred during training and testing. We found that wilderness-trained paramedics safely provided ALS care in a backcountry environment. This care may improve patient comfort during long extrication and speeds the arrival of potentially life-saving interventions such as advanced airway management.

A method to communicate patient preferences about medically indicated life-sustaining treatment in the out-of-hospital setting

OBJECTIVE

Patient preferences for life-sustaining treatment are frequently unknown at critical moments, which often results in clinicians providing treatment that is not medically indicated and/or may not be consistent with patient desires. A consortium of Oregon health care professionals developed the Medical Treatment Coversheet (MTC) to standardize documentation of patient preferences in the out-of-hospital setting by having corresponding physician orders available at the patient's location. We describe a unique process of development, evaluation, and implementation of the MTC.

DESIGN

First, we conducted focus groups of providers to help draft the MTC. Second, the accuracy of MTC interpretation was determined by cohorts of acute and long-term care providers by indicating their treatment approach to three hypothetical written scenarios. They responded to the same scenarios twice, with and without the MTC. Responses were compared with each other and with ideal responses (most medically appropriate and in agreement with patient preferences) as defined by an expert panel. Finally, we are instituting pilot projects and developing a plan for statewide voluntary implementation of the MTC.

SETTING

Urban and rural long-term care facilities and emergency medical service systems in Oregon.

PARTICIPANTS

Focus groups included 28 general internists practicing in urban and rural settings and five nurses working in a long-term care facility. In addition, 87 providers (19 primary care physicians, 20 emergency physicians, 26 paramedics, and 22 long-term care nurses) participated in the evaluation of the form by responding to hypothetical scenarios. Providers in long-term care facilities in both an urban and rural area helped with pilot implementation of the MTC. Use of the MTC in noninstitutional settings was not evaluated.

MAIN OUTCOME MEASURES

Suggestions from focus groups were incorporated into the form. For the hypothetical scenario responses, ideal appropriateness scores were analyzed, with a total possible score of 30 for each acute care provider and 15 for each long-term care provider. Statistically significant differences were determined using a paired t test. We report the experience of providers who helped with the pilot implementation of the form.

RESULTS

Focus groups would use the MTC and believed it would be useful for their patients. Comparing responses to the hypothetical scenarios without the MTC to those with the MTC, 37% of treatment decisions changed for acute care and 29% changed for long-term care providers. Changes were attributable overwhelmingly to withholding treatments consistent with patient preferences. Compared with the ideal, decisions were more appropriate for all specific treatments across all scenarios and clinician groups with the MTC, with one exception: some advanced emergency treatments were withheld inappropriately by 18% of acute care providers with the MTC, (chi-square = 15.94, P < .0001). For all scenarios combined, appropriateness scores increased significantly with the MTC for both acute care (16.4 to 22.3, P < .0001) and long-term care providers (8.8 to 12.2, P < .0001). Overall, providers helping with the pilot implementation were satisfied with the document, organizational endorsements, and available informational resources.

CONCLUSION

We describe our process for development, initial evaluation, and implementation of the MTC. In clinical scenarios overall, the MTC improves the appropriateness of clinicians' decisions about life-sustaining treatments. We are planning statewide implementation of the MTC after appropriate education of clinicians.

Legalizing assisted suicide--views of physicians in Oregon

BACKGROUND

Since the Oregon Death with Dignity Act was passed in November 1994, physicians in Oregon have faced the prospect of legalized physician-assisted suicide. We studied the attitudes and current practices of Oregon physicians in relation to assisted suicide.

METHODS

From March to June 1995, we conducted a cross-sectional mailed survey of all physicians who might be eligible to prescribe a lethal dose of medication if the Oregon law is upheld. Physicians were asked to complete and return a confidential 56-item questionnaire.

RESULTS

Of the 3944 eligible physicians who received the questionnaire, 2761 (70 percent) responded. Sixty percent of the respondents thought physician-assisted suicide should be legal in some cases, and nearly half (46 percent) might be willing to prescribe a lethal dose of medication if it were legal to do so; 31 percent of the respondents would be unwilling to do so on moral grounds. Twenty-one percent of the respondents have previously received requests for assisted suicide, and 7 percent have complied. Half the respondents were not sure what to prescribe for this purpose, and 83 percent cited financial pressure as a possible reason for such requests. The respondents also expressed concern about complications of suicide attempts and doubts about their ability to predict survival at six months accurately.

CONCLUSIONS

Oregon physicians have a more favorable attitude toward legalized physician-assisted suicide, are more willing to participate, and are currently participating in greater numbers than other surveyed groups of physicians in the United States. A sizable minority of physicians in Oregon objects to legalization and participation on moral grounds. Regardless of their attitudes, physicians had a number of reservations about the practical applications of the act.

Family response to out-of-hospital death

OBJECTIVE

To better understand the perceptions, needs, and responses of family members after an out-of-hospital death.

METHODS

Over an 18-month period, phone interviews were conducted using a structured interview schedule modified from a similar study of survivors of in-hospital death. Subjects included 31 survivors of urban out-of-hospital deaths attended by paramedics from one ambulance company. Subjects were eligible if paramedics had arrived and death had been determined at the scene without transport. Survivors were interviewed 11 to 15 months after the death (mean = 12 months) to evaluate how well they coped with their loss, how they managed the experience of their loved ones' out-of-hospital deaths, and their feelings and beliefs about their loved ones' not being transported to a hospital.

RESULTS

None of the survivors believed their loved ones should have been transported to a hospital, and only one believed that something more could have been done for the individual. Although many of the survivors had suspected their loved ones had died, 64% had been informed of the death by emergency medical technicians (EMTs) or firefighters. Most thought the EMTs had informed them in a professional (81%) and gentle/supportive manner (74%). Some (29%) still had unanswered questions about the death, but most (58%) were adjusting well and no one had a "poor" adjustment.

CONCLUSION

In this small sample, survivors of out-of-hospital death were generally satisfied with the care their loved ones had received. None of the survivors believed their loved ones should have been transported to the hospital. They also believed the paramedics had been supportive and met their needs at the time of death. It appears that paramedics may be able to meet the needs of a patient's survivors by terminating out-of-hospital resuscitation efforts on the patient.

Digoxin affects potassium homeostasis during exercise in patients with heart failure

OBJECTIVE

The aim was to evaluate whether digitalisation of heart failure patients affects extrarenal potassium handling during and following exercise, and to assess digoxin receptor occupancy in human skeletal muscle in vivo.

METHODS

In a paired study of before versus after digitalisation, 10 patients with congestive heart failure underwent identical exercise sessions consisting of three bouts of increasing work rates, 41-93 W, on a cycle ergometer. The final bouts were followed by exercise to exhaustion. The femoral vessels and brachial artery were catheterised. Arterial blood pressure, heart rate, leg blood flow, cardiac output, plasma potassium, haemoglobin, pH, and skeletal muscle receptor occupancy with digoxin in biopsies were determined.

RESULTS

Occupancy of skeletal muscle Na/K-ATPase with digoxin was 9% (P < 0.05). Following digitalisation femoral venous plasma potassium increased by 0.2-0.3 mmol.litre-1 (P < 0.05) at work rates of 69 W, 93 W, and at exhaustion, as well as during the first 3 min of recovery. Following digitalisation the femoral venoarterial difference in plasma potassium increased by 50-100% (P < 0.05) during exercise, and decreased by 66-75% (P < 0.05) during early recovery. Total loss of potassium from the leg increased by 138%. The effects of digitalisation on plasma potassium were not the outcome of changes in haemodynamics, because cardiac output and leg blood flow increased by up to 13% and 19% (P < 0.05), nor was it the outcome of changes in haemoconcentration or pH.

CONCLUSIONS

Extrarenal potassium handling is altered as a result of digoxin treatment. This is likely to reflect a reduced capacity of skeletal muscle Na/K-ATPase for active potassium uptake because of inhibition by digoxin, adding to the reduction of skeletal muscle Na/K-ATPase concentration induced by heart failure per se. In heart failure patients, improved haemodynamics induced by digoxin may, however, increase the capacity for physical conditioning. Thus the impairment of extrarenal potassium homeostasis by heart failure and digoxin treatment may be counterbalanced by training.

When public health competes with individual needs

A case of a homeless, alcoholic man with tuberculosis is presented. This case is used to illustrate the ethical dilemmas health care providers must face when the needs of society and the actions of the patient come into conflict. In addition to discussing historical cases of conflicts between individual rights and the needs of society, two models for solving the dilemma in the current case are considered.

Family abuse and neglect: a case-based ethics model

The ethical dilemma of caring for the patient from a multiproblem family with suspected domestic violence is discussed. An ethical decision making model that organizes patient data and encourages systematic analysis of the case is reviewed to address the responsibility of the emergency physician to intervene and the options available. The analysis explores specific issues related to mandatory reporting laws, discretionary reporting, and factors to be weighed in deciding the best action for protecting various members within a family when abuse is known or suspected.