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REICHMAN’S

EMERGENCY
MEDICINE PROCEDURES
THIRD EDITION

Eric F. Reichman
 Reichman’s Emergency Medicine
Procedures

Reichman_FM_pi-xxx.indd 1 13/08/18 6:28 PM

 NOTICE
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required. The authors and the publisher of
this work have checked with sources believed to be reliable in their efforts to provide information
that is complete and generally in accord with the standards accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences, neither the
editors nor the publisher nor any other party who has been involved in the preparation or pub-
lication of this work warrants that the information contained herein is in every respect accurate
or complete, and they disclaim all responsibility for any errors or omissions or for the results
obtained from use of the information contained in this work. Readers are encouraged to confirm
the information contained herein with other sources. For example and in particular, readers are
advised to check the product information sheet included in the package of each drug they plan to
administer to be certain that the information contained in this work is accurate and that changes
have not been made in the recommended dose or in the contraindications for administration. This
recommendation is of particular importance in connection with new or infrequently used drugs.

Reichman_FM_pi-xxx.indd 2 13/08/18 6:28 PM

 Reichman’s Emergency Medicine
Procedures
Third Edition

Eric F. Reichman, PhD, MD, FAAEM, FACEP, NBPAS

Clinical Associate Professor of Emergency Medicine
Attending Physician, Department of Emergency Medicine
UT-Health
McGovern Medical School
University of Texas Health Science Center at Houston-Medical School
Voluntary Attending Physician, Emergency Department
Memorial Hermann Hospital-Texas Medical Center
Houston, Texas

New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto

Reichman_FM_pi-xxx.indd 3 13/08/18 6:28 PM

 Reichman’s Emergency Medicine Procedures, Third Edition
Copyright © 2019 by Eric F. Reichman, PhD, MD. All rights reserved. Printed in China. Except as permitted under the United States
Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base
or retrieval system, without the prior written permission of the editor.

1 2 3 4 5 6 7 8 9 DSS 23 22 21 20 19 18

ISBN 978-1-259-86192-5
MHID 1-259-86192-9

This book was set in Minion Pro by Cenveo Publisher Services.

The editors were Amanda Fielding and Kim J. Davis.
The production supervisor was Catherine Saggese.
Project management was provided by Shivani Salhotra and Neha Bhargava, Cenveo Publisher Services.
The illustrations were done by Susan Gilbert, CMI.

This book is printed on acid-free paper.

Library of Congress Cataloging-in-Publication Data

Names: Reichman, Eric F., editor.
Title: Reichman’s emergency medicine procedures / [edited by] Eric F.
Reichman.
Other titles: Emergency medicine procedures.
Description: Third edition. | New York : McGraw-Hill Education, [2019] |
Preceded by Emergency medicine procedures / [edited by] Eric F. Reichman.
2nd. ed. c2013. | Includes bibliographical references and index.
Identifiers: LCCN 2018024915 (print) | LCCN 2018025655 (ebook) | ISBN
9781259861932 (ebook) | ISBN 1259861937 (ebook) | ISBN 9781259861925
(hardback : alk. paper) | ISBN 1259861929 (hardback : alk. paper)
Subjects: | MESH: Emergency Medicine—methods
Classification: LCC RC86.7 (ebook) | LCC RC86.7 (print) | NLM WB 105 | DDC
616.02/5—dc23
LC record available at https://lccn.loc.gov/2018024915

McGraw-Hill Education Professional books are available at special quantity discounts to use as premiums and sales promotions, or for use
in corporate training programs. To contact a representative, please visit the Contact Us pages at www.mhprofessional.com.

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 To my wife, Kristi. Thanks for your patience and help.
I appreciate your tolerance with the mess from all the papers and files and
your trips for printer paper. Thanks for your support and understanding.
Thanks to Phoebe, Joey, Ken, Russ, Rick, Kobi, and Freya
for the help and entertaining me each day.

Reichman_FM_pi-xxx.indd 5 13/08/18 6:28 PM

Reichman_FM_pi-xxx.indd 6 13/08/18 6:28 PM
 Contents

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 19 Confirmation of Endotracheal Intubation. . . . . . . . . . . . 139

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxix Tarlan Hedayati
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxx 20 Video Assisted Orotracheal Intubation Devices . . . . . . . . . 147
Pholaphat Charles Inboriboon and Curtis Blake Buchanan
SECTION 1 Introductory Chapters . . . . . . . . . . . . . . . . . . 1 21 Fiberoptic-Assisted Endotracheal Intubation Devices . . . . . 163
1 Informed Consent . . . . . . . . . . . . . . . . . . . .......1 Igor V. Kolesnikov, Gennadiy G. Voronov, and Ned F. Nasr
Eric Isaacs 22 Endotracheal Tube Intubating Introducers and Bougies . . . . 170
2 Against Medical Advice . . . . . . . . . . . . . . . . .......8 Marco Mikhael, Gennadiy G. Voronov, and Ned F. Nasr
Ryan P. Kirby, Jessica J. Kirby, and Richard Dean Robinson 23 Digital (Tactile) Orotracheal Intubation. . . . . . . . . . . . . 178
3 Family Presence . . . . . . . . . . . . . . . . . . . . . . . . . . 15 James A. Heilman, Beech S. Burns, and O. John Ma
Yanina Purim-Shem-Tov and Louis G. Hondros 24 Lighted Stylet Intubation . . . . . . . . . . . . . . . . . . . . 181
4 Procedures on Recently Deceased . . . . . . . . . . . . . . . . 18 Jaroslav Tymouch, Gennadiy G. Voronov, and Ned F. Nasr
Bryan Darger and Eric Isaacs 25 Supraglottic Airway Devices . . . . . . . . . . . . . . . . . . 187
5 Aseptic Technique . . . . . . . . . . . . . . . . . . . . . . . . . 20 Fred A. Severyn
John S. Rose 26 Laryngeal Mask Airways . . . . . . . . . . . . . . . . . . . . 193
6 Basic Principles of Ultrasonography . . . . . . . . . . . . . . . 28 Ned F. Nasr, Gennadiy G. Voronov, and Luis Sequera-Ramos
Basem F. Khishfe 27 Double Lumen Airway Tube Intubation . . . . . . . . . . . . . 211
7 Ultrasound Assisted Procedures . . . . . . . . . . . . . . . . . 41 Joseph M. Weber and Katie Tataris
Jehangir Meer and Brian Euerle 28 Fiberoptic Endoscopic Intubation . . . . . . . . . . . . . . . . 217
8 Trauma Ultrasound: The FAST and EFAST Scans . . . . . . . . . . 45 Ruth E. Moncayo, Alia Safi, and Ned F. Nasr
Wesley Zeger 29 Nasotracheal Intubation . . . . . . . . . . . . . . . . . . . . 228
Ned F. Nasr, Abed Rahman, and Isam F. Nasr
SECTION 2 Respiratory Procedures . . . . . . . . . . . . . . . . 55 30 Retrograde Guidewire Intubation. . . . . . . . . . . . . . . . 236
9 Essential Anatomy of the Airway . . . . . . . . . . . . . . . . . 55 Ned F. Nasr, Anna Tzonkov, and Gennadiy G. Voronov
Divya Karjala Chakkaravarthy, Serge G. Tyler, and Isam F. Nasr 31 Percutaneous Transtracheal Jet Ventilation . . . . . . . . . . . 240
10 Basic Airway Management . . . . . . . . . . . . . . . . . . . . 61 Gennadiy G. Voronov, Tamer Elattary, and Ned F. Nasr
Christopher J. Russo 32 Cricothyroidotomy . . . . . . . . . . . . . . . . . . . . . . . 247
11 Noninvasive Airway Management . . . . . . . . . . . . . . . . 72 Charles Boland, Ned F. Nasr, and Gennadiy G. Voronov
Gennadiy G. Voronov, Tamer Elattary, and Ned F. Nasr 33 Tracheostomy . . . . . . . . . . . . . . . . . . . . . . . . . . 264
12 Pharmacologic Adjuncts to Intubation . . . . . . . . . . . . . . 79 Eric S. Levy and Christopher J. Haines
Ned F. Nasr, David W. Boldt, and Isam F. Nasr 34 Tracheostomy Care . . . . . . . . . . . . . . . . . . . . . . . 275
13 Endotracheal Medication Administration. . . . . . . . . . . . . 92 H. Gene Hern Jr and Julie K. Oliva
Megan Johnson and Shoma Desai 35 Transtracheal Aspiration . . . . . . . . . . . . . . . . . . . . 284
14 Management of the Difficult Airway . . . . . . . . . . . . . . . 98 Joseph A. Salomone III
Konstantin Inozemtsev, Gennadiy G. Voronov, and Ned F. Nasr 36 Ventilator Management . . . . . . . . . . . . . . . . . . . . 288
15 Obese Airway . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Ahmad M. Abou Leila, Abayomi E. Akintorin, and Ned F. Nasr
Charles Boland, Piotr C. Al-Jindi, and Ned F. Nasr
16 Rapid Sequence Intubation . . . . . . . . . . . . . . . . . . . 111 SECTION 3 Cardiothoracic Procedures . . . . . . . . . . . . . . 301
Ned F. Nasr, Piotr C. Al-Jindi, and Isam F. Nasr 37 Cardiac Ultrasound . . . . . . . . . . . . . . . . . . . . . . . 301
17 Delayed Sequence Intubation . . . . . . . . . . . . . . . . . 118 Basem F. Khishfe
Kevin J. Donnelly, Gennadiy G. Voronov, and Ned F. Nasr 38 Chemical Cardioversion . . . . . . . . . . . . . . . . . . . . . 313
18 Orotracheal Intubation . . . . . . . . . . . . . . . . . . . . . 121 Paul Casey and Thomas Alcorn
Hyang won Paek, Gennadiy G. Voronov, and Ned F. Nasr

vii

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 viii Contents

39 Automated External Defibrillation . . . . . . . . . . . . . . . 319 63 Central Venous Access . . . . . . . . . . . . . . . . . . . . . . 516

James Montoya and Molly Garcia Arun Nagdev, Craig Sisson, Benjamin Thomas, and Peter C. Wroe
40 Cardioversion and Defibrillation . . . . . . . . . . . . . . . . 324 64 Ultrasound-Guided Vascular Access. . . . . . . . . . . . . . . 541
Chirag N. Shah, Patrick J. Rogers, and Daniel S. Morrison Srikar Adhikari and Lori Stolz
41 Transcutaneous Cardiac Pacing . . . . . . . . . . . . . . . . . 330 65 Troubleshooting Indwelling Central Venous Lines . . . . . . . 559
Chirag N. Shah, Patrick J. Rogers, and Daniel S. Morrison James J. McCarthy
42 Transthoracic Cardiac Pacing . . . . . . . . . . . . . . . . . . 336 66 Accessing Indwelling Central Venous Lines . . . . . . . . . . . 563
Chirag N. Shah, Guillermo Ortega, and Daniel S. Morrison John Cruz and Chad Gorbatkin
43 Transvenous Cardiac Pacing . . . . . . . . . . . . . . . . . . . 339 67 Pulmonary Artery (Swan-Ganz) Catheterization . . . . . . . . 570
Myles C. McClelland, Thuy Tran T. Nguyen, and Alfred Coats III J. Elizabeth Neuman and Jessica Mann
44 Transesophageal Cardiac Pacing . . . . . . . . . . . . . . . . 348 68 Noninvasive and Minimally Invasive Cardiac
John Bass and Chad Gorbatkin Output Monitoring . . . . . . . . . . . . . . . . . . . . . . . 577
45 Pacemaker Assessment . . . . . . . . . . . . . . . . . . . . . 353 Caleb P. Canders, Daniel W. Weingrow, and Alan T. Chiem
Elizabeth Kwan 69 Peripheral Venous Cutdown. . . . . . . . . . . . . . . . . . . 586
46 Automatic Implantable Cardioverter-Defibrillator Jason M. Rotoli and Flavia Nobay
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 373 70 Intraosseous Infusion . . . . . . . . . . . . . . . . . . . . . . 599
Carlos J. Roldan Beech S. Burns, James A. Heilman, and O. John Ma
47 Left Ventricular Assist Device (LVAD) Assessment . . . . . . . 384 71 Umbilical Vessel Catheterization . . . . . . . . . . . . . . . . 615
Paulino A. Alvarez, Myles C. McClelland, and Ashrith Guha Jeanne A. Noble
48 Pericardiocentesis . . . . . . . . . . . . . . . . . . . . . . . . 394 72 Arterial Puncture and Cannulation . . . . . . . . . . . . . . . 623
Marianne Juarez and Jacqueline Nemer Justin Grisham and Jennifer L’Hommedieu Stankus
49 Intracardiac Injection . . . . . . . . . . . . . . . . . . . . . . 408 73 Extracorporeal Membrane Oxygenation . . . . . . . . . . . . 635
Tiffany Abramson and Shoma Desai Jean W. Hoffman and Jordan R. H. Hoffman
50 Needle Thoracostomy . . . . . . . . . . . . . . . . . . . . . . 410 74 Catheter-Based Hemorrhage Control . . . . . . . . . . . . . . 646
Michael Gottlieb Matthew Rosen and Andrew Grock
51 Tube Thoracostomy . . . . . . . . . . . . . . . . . . . . . . . 417
Kimberly T. Joseph and John C. Kubasiak SECTION 5 Gastrointestinal Procedures . . . . . . . . . . . . 657
52 Thoracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . 429 75 Nasogastric Intubation . . . . . . . . . . . . . . . . . . . . . 657
Marianne Juarez and Jacqueline Nemer Alex Koo and Ryan Walsh
53 Open Chest Wound Management. . . . . . . . . . . . . . . . 447 76 Activated Charcoal Administration . . . . . . . . . . . . . . . 665
Eric F. Reichman Jenny J. Lu
54 Emergency Department Thoracotomy . . . . . . . . . . . . . 452 77 Gastric Lavage . . . . . . . . . . . . . . . . . . . . . . . . . 669
Kenny Banh Jenny J. Lu and Rosaura Fernandez
55 Open Cardiac Massage . . . . . . . . . . . . . . . . . . . . . 458 78 Whole Bowel Irrigation . . . . . . . . . . . . . . . . . . . . . 673
Eric F. Reichman Henry D. Swoboda and Steven E. Aks
56 Cardiac Wound Repair. . . . . . . . . . . . . . . . . . . . . . 461 79 Video Capsule Endoscopy for Gastrointestinal Bleeding . . . . 676
Eric F. Reichman Eric S. Levy, Christopher J. Haines, and Grant Wei
57 Hilum and Great Vessel Wound Management . . . . . . . . . 468 80 Esophageal Foreign Body Removal . . . . . . . . . . . . . . . 684
Eric F. Reichman Bashar M. Attar
58 Thoracic Aortic Occlusion . . . . . . . . . . . . . . . . . . . . 471 81 Balloon Tamponade of Gastrointestinal Bleeding . . . . . . . 696
Eric F. Reichman Bashar M. Attar
82 Gastrostomy Tube Complications and Replacement . . . . . . 706
SECTION 4 Vascular Procedures . . . . . . . . . . . . . . . . . 475 Erika Flores Uribe and Erick A. Eiting
59 General Principles of Intravenous Access . . . . . . . . . . . . 475 83 Paracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 717
Daniel Belmont Alex Koo and Ryan Walsh
60 Heel Stick Blood Sampling . . . . . . . . . . . . . . . . . . . 492 84 Diagnostic Peritoneal Lavage . . . . . . . . . . . . . . . . . . 729
Kimberly Lynn Fugok and Christopher J. Russo Leann Mainis and René Ramirez
61 Venipuncture and Peripheral Intravenous Access . . . . . . . . 495 85 Anal Fissure Management . . . . . . . . . . . . . . . . . . . 738
Daniel Belmont Eric F. Reichman
62 Peripheral Inserted Central Catheter (PICC) Lines. . . . . . . . 508 86 External Hemorrhoid Management. . . . . . . . . . . . . . . 744
Elizabeth Barrall Werley Katherine Holmes, Michael Balkin, and Hao Wang

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 Contents ix

87 Prolapsed Rectum Reduction . . . . . . . . . . . . . . . . . . 748 110 Knee Joint Dislocation Reduction . . . . . . . . . . . . . . . . 928
Jamil D. Bayram and Eric F. Reichman Michael Gottlieb
88 Anoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 752 111 Ankle Joint Dislocation Reduction . . . . . . . . . . . . . . . 933
Charles Huggins, Claudia Kim, and Hao Wang Crystal Ives Tallman
89 Rigid Rectosigmoidoscopy . . . . . . . . . . . . . . . . . . . 757 112 Common Fracture Reduction . . . . . . . . . . . . . . . . . . 938
Hao Wang, Nicole Remish, and Nestor Zenarosa Christopher A. Gee
90 Rectal Foreign Body Extraction . . . . . . . . . . . . . . . . . 762 113 Casts and Splints . . . . . . . . . . . . . . . . . . . . . . . . 951
Chad Holmes, Jon Wolfshohl, and Hao Wang Eric F. Reichman
91 Proctoclysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 769
Hao Wang, Tyson Jay Higgins, and Richard Dean Robinson SECTION 7 Skin and Soft Tissue Procedures . . . . . . . . . . 971
114 General Principles of Wound Management . . . . . . . . . . . 971
SECTION 6 Orthopedic and Musculoskeletal Ivette Motola and John E. Sullivan
Procedures . . . . . . . . . . . . . . . . . . . . . . . 775 115 Burn Wound Management . . . . . . . . . . . . . . . . . . . 988
92 Bursitis and Tendonitis Therapy . . . . . . . . . . . . . . . . . 775 Stephen Sandelich and Christopher J. Russo
Dedra R. Tolson, Brandon M. Fetterolf, and Elaine H. Situ-LaCasse 116 Basic Wound Closure Techniques . . . . . . . . . . . . . . . . 994
93 Compartment Pressure Measurement . . . . . . . . . . . . . 788 Eric F. Reichman
Danielle D. Campagne and Scott T. Owens 117 Tissue Adhesives for Wound Repair . . . . . . . . . . . . . . 1018
94 Fasciotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 797 Hagop M. Afarian
Andrew Rotando and Justin Mazzillo 118 Advanced Wound Closure Techniques. . . . . . . . . . . . . 1025
95 Field Amputation of the Extremity . . . . . . . . . . . . . . . 808 Eric F. Reichman
Joshua T. Bucher and Michael S. Westrol 119 Management of Specific Soft Tissue Injuries . . . . . . . . . 1034
96 Extensor Tendon Repair . . . . . . . . . . . . . . . . . . . . . 813 Thomas M. Kennedy and Christopher J. Russo
JoAnna Leuck and Keegan Bradley 120 Subcutaneous Foreign Body Identification
97 Arthrocentesis . . . . . . . . . . . . . . . . . . . . . . . . . 819 and Removal . . . . . . . . . . . . . . . . . . . . . . . . . 1049
Eric F. Reichman, John Larkin, and Brian Euerle David Murray, Laura Chun, and Dhara Patel Amin
98 Methylene Blue Joint Injection . . . . . . . . . . . . . . . . . 842 121 Ultrasound-Guided Foreign Body Identification
Pholaphat Charles Inboriboon and Katherine Gloor Willet and Removal . . . . . . . . . . . . . . . . . . . . . . . . . 1060
99 Basic Principles of Fracture and Joint Reductions. . . . . . . . 848 Daniel S. Morrison and Chirag N. Shah
Scott C. Sherman and John Robert Hardwick 122 Hair Tourniquet Management . . . . . . . . . . . . . . . . 1066
100 Ultrasound for Fracture and Dislocation Identification Asim A. Abbasi
and Management . . . . . . . . . . . . . . . . . . . . . . . . 852 123 Tick Removal . . . . . . . . . . . . . . . . . . . . . . . . . 1069
Adrian H. Flores Laurie Krass and Dhara Patel Amin
101 Sternoclavicular Joint Dislocation Reduction . . . . . . . . . . 864 124 Fishhook Removal . . . . . . . . . . . . . . . . . . . . . . 1073
Michael D. Burg Eric F. Reichman
102 Shoulder Joint Dislocation Reduction. . . . . . . . . . . . . . 871 125 TASER Probe Removal . . . . . . . . . . . . . . . . . . . . . 1076
Damali N. Nakitende, Tina Sundaram, and Michael Gottlieb Myles C. McClelland, Alfred Coats III, and Thuy Tran T. Nguyen
103 Elbow Joint Dislocation Reduction . . . . . . . . . . . . . . . 895 126 Ring Removal . . . . . . . . . . . . . . . . . . . . . . . . . 1080
Angelique Campen Abraham Berhane, Abdoulie Njie, Robert Needleman, and
104 Radial Head Subluxation (Nursemaid’s Elbow) Steven H. Bowman
Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 900 127 Subungual Hematoma Evacuation . . . . . . . . . . . . . . 1088
Mark P. Kling Steven H. Bowman, Neera Khattar, and Natasha Thomas
105 Carpometacarpal Dislocation Reduction . . . . . . . . . . . . 904 128 Subungual Foreign Body Removal . . . . . . . . . . . . . . 1094
Rene Carizey and Priya D. Perumalsamy Ginger Clinton, Ameera Haamid, and Steven H. Bowman
106 Metacarpophalangeal Joint Dislocation Reduction . . . . . . . 908 129 Nail Bed Repair . . . . . . . . . . . . . . . . . . . . . . . . 1097
Michael Gottlieb Dayle Davenport
107 Interphalangeal Joint Dislocation Reduction . . . . . . . . . . 914 130 Ganglion Cyst Aspiration and Injection . . . . . . . . . . . . 1105
Michael Gottlieb Thomas P. Graham
108 Hip Joint Dislocation Reduction. . . . . . . . . . . . . . . . . 919 131 Subcutaneous Abscess Incision and Drainage . . . . . . . . 1108
Michael Gottlieb Priya D. Perumalsamy
109 Patellar Dislocation Reduction . . . . . . . . . . . . . . . . . 925 132 Paronychia or Eponychia Incision and Drainage . . . . . . . 1119
Mark P. Kling Lisa Palivos and Tim Richardson

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 x Contents

133 Felon Incision and Drainage . . . . . . . . . . . . . . . . . 1123 154 Topical and Noninvasive Anesthesia . . . . . . . . . . . . . 1257
Lisa Palivos and Sonali Gandhi Sonali Gandhi and Michael A. Schindlbeck
134 Pilonidal Abscess or Cyst Incision and Drainage . . . . . . . 1126 155 Hematoma Blocks. . . . . . . . . . . . . . . . . . . . . . . 1267
Carolyn Chooljian Thomas P. Graham
135 Perianal Abscess Incision and Drainage. . . . . . . . . . . . 1130 156 Regional Nerve Blocks (Regional Anesthesia) . . . . . . . . 1271
John Ramos and Deena Ibrahim Bengiamin Eric F. Reichman and Jehangir Meer
136 Sebaceous Cyst Incision and Drainage . . . . . . . . . . . . 1137 157 Intravenous Regional Anesthesia . . . . . . . . . . . . . . . 1312
Carlos J. Roldan Christopher Freeman and Emily Cooper
137 Hemorrhage Control . . . . . . . . . . . . . . . . . . . . . 1141 158 Nitrous Oxide Analgesia. . . . . . . . . . . . . . . . . . . . 1320
Christopher Freeman and Ariana Wilkinson René Ramirez and Leann Mainis
138 Trigger Point Injections . . . . . . . . . . . . . . . . . . . . 1154 159 Procedural Sedation and Analgesia
Danielle D. Campagne (Conscious Sedation) . . . . . . . . . . . . . . . . . . . . . 1328
139 Escharotomy . . . . . . . . . . . . . . . . . . . . . . . . . 1159 Hagop M. Afarian
Michael A. Schindlbeck and Carlos E. Brown, Jr.
140 Subcutaneous Hydration (Hypodermoclysis) . . . . . . . . . 1163 SECTION 10 Obstetrical and Gynecologic Procedures . . . . 1347
Mary J. O 160 Ultrasound in Early Pregnancy . . . . . . . . . . . . . . . . 1347
141 Subcutaneous Extravasation and Infiltration Srikar Adhikari, Wesley Zeger, and Lori Stolz
Management . . . . . . . . . . . . . . . . . . . . . . . . . 1168 161 Uterine Bleeding . . . . . . . . . . . . . . . . . . . . . . . 1363
Henry D. Swoboda Leah W. Antoniewicz, Beth R. Davis, Kara N. Purdy, Alexis R. Taylor,
Lindsay K. Grubish, and Sarah J. Christian-Kopp
SECTION 8 Neurologic and Neurosurgical 162 Normal Spontaneous Vaginal Delivery . . . . . . . . . . . . 1371
Procedures . . . . . . . . . . . . . . . . . . . . . . 1175 Stephen N. Dunay and Simeon W. Ashworth
142 Lumbar Puncture . . . . . . . . . . . . . . . . . . . . . . . 1175 163 Episiotomy . . . . . . . . . . . . . . . . . . . . . . . . . . 1384
Damali N. Nakitende, Michael Gottlieb, and Tina Sundaram Francisco Orejuela and Padraic Chisholm
143 Blood Patching for Postdural Puncture (Lumbar Puncture) 164 Shoulder Dystocia Management . . . . . . . . . . . . . . . 1393
Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . 1195 Christopher Freeman and Adi Abramovici
Gunnar Subieta-Benito, Maria L. Torres, and Ned F. Nasr 165 Breech Delivery . . . . . . . . . . . . . . . . . . . . . . . . 1401
144 Burr Holes . . . . . . . . . . . . . . . . . . . . . . . . . . . 1200 Sarah J. Christian-Kopp
Caleb P. Canders, Noah T. Sugerman, and Amir A. Rouhani 166 Postpartum Hemorrhage Management . . . . . . . . . . . 1409
145 Lateral Cervical Puncture . . . . . . . . . . . . . . . . . . . 1207 Leah W. Antoniewicz
Eric F. Reichman 167 Perimortem Cesarean Section
146 Intracranial Pressure Monitoring . . . . . . . . . . . . . . . 1210 (Perimortem Cesarean Delivery) . . . . . . . . . . . . . . . 1418
Hannah Kirsch, Shahed Toossi, and Debbie Yi Madhok Jeanne A. Noble
147 Ventriculostomy . . . . . . . . . . . . . . . . . . . . . . . 1217 168 Symphysiotomy . . . . . . . . . . . . . . . . . . . . . . . . 1424
John Burke, Shahed Toossi, and Debbie Yi Madhok Ikem Ajaelo
148 Ventricular Shunt Evaluation and Aspiration . . . . . . . . . 1223 169 Bartholin Gland Abscess or Cyst Incision and Drainage . . . . 1427
Daniel W. Weingrow and Jacob Lentz Alison Uyemura and Charlie C. Kilpatrick
149 Subdural Hematoma Aspiration in the Infant . . . . . . . . 1231 170 Sexual Assault Examination . . . . . . . . . . . . . . . . . 1433
Sarah J. Christian-Kopp Monique A. Mayo and Christopher J. Russo
150 Skeletal Traction (Gardner-Wells Tongs) for Cervical Spine 171 Culdocentesis . . . . . . . . . . . . . . . . . . . . . . . . . 1445
Dislocations and Fractures . . . . . . . . . . . . . . . . . . 1236 JoAnna Leuck and Jennalee Cizenski
Thomas W. Engel and Rebecca R. Roberts 172 Prolapsed Uterus Reduction . . . . . . . . . . . . . . . . . 1449
151 Reflex Eye Movements Andrea Dreyfuss and Eric R. Snoey
(Caloric Testing and Doll’s Eyes) . . . . . . . . . . . . . . . . 1241
Atilla Üner SECTION 11 Genitourinary Procedures . . . . . . . . . . . . . 1455
152 Myasthenia Gravis Testing . . . . . . . . . . . . . . . . . . 1245 173 Urethral Catheterization . . . . . . . . . . . . . . . . . . . 1455
Eric F. Reichman Richard Dean Robinson and Caleb Andrew Rees
174 Suprapubic Bladder Aspiration . . . . . . . . . . . . . . . . 1466
SECTION 9 Anesthesia and Analgesia . . . . . . . . . . . . . . 1249 Richard Dean Robinson, Teresa Proietti, and Andrew Shedd
153 Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . 1249 175 Suprapubic Bladder Catheterization
Mark Supino and Daniel Yousef (Percutaneous Cystotomy) . . . . . . . . . . . . . . . . . . 1473
Richard Dean Robinson, Aaron W. Bull, and Andrew Shedd

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 Contents xi

176 Retrograde Urethrography and Cystography . . . . . . . . . 1481 199 Tympanocentesis . . . . . . . . . . . . . . . . . . . . . . . 1622

Richard Dean Robinson and Sasha Michael Dib Paul J. Jones
177 Anesthesia of the Penis, Testicle, and Epididymis. . . . . . . 1487 200 Auricular Hematoma Evacuation . . . . . . . . . . . . . . . 1625
Eric F. Reichman Eric F. Reichman
178 Priapism Management . . . . . . . . . . . . . . . . . . . . 1493 201 Nasal Medication Administration . . . . . . . . . . . . . . . 1633
Steven Go Crystal Ives Tallman and Joel Tallman
179 Paraphimosis Reduction . . . . . . . . . . . . . . . . . . . 1500 202 Nasal Foreign Body Removal . . . . . . . . . . . . . . . . . 1637
Matthew D. Schwartz and Ann P. Nguyen G. Carolyn Clayton, Katarzyna M. Gore, and Melissa M. Rice
180 Phimosis Reduction . . . . . . . . . . . . . . . . . . . . . . 1506 203 Nasal Fracture Reduction . . . . . . . . . . . . . . . . . . . 1646
Kevin O’Rourke Eric F. Reichman
181 Dorsal Slit of the Foreskin . . . . . . . . . . . . . . . . . . . 1510 204 Nasal Septal Hematoma Evacuation . . . . . . . . . . . . . 1655
Carlos J. Roldan Michael Friedman and Jessica Tang
182 Manual Testicular Detorsion . . . . . . . . . . . . . . . . . 1514 205 Epistaxis Management . . . . . . . . . . . . . . . . . . . . 1660
Steven Go Steven Lai and Matthew Waxman
183 Zipper Injury Management . . . . . . . . . . . . . . . . . . 1519 206 Laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . 1676
Anthony W. Catalano and Ricky N. Amii Steven J. Charous
184 Genitourinary Foreign Body Removal. . . . . . . . . . . . . 1523 207 Airway Foreign Body Removal . . . . . . . . . . . . . . . . 1683
Dennis Hsieh, Claire H. Lyons, and Karen Lind Guy Shochat, Jacqueline Nemer, David L. Walner, and
Martin E. Anderson, Jr.
SECTION 12 Ophthalmologic Procedures. . . . . . . . . . . . 1535 208 Peritonsillar Abscess Incision and Drainage . . . . . . . . . 1690
185 Eye Examination . . . . . . . . . . . . . . . . . . . . . . . 1535 Daniel S. Morrison and Chirag N. Shah
Shari Schabowski and Carmen Alcala
186 Contact Lens Removal . . . . . . . . . . . . . . . . . . . . 1556 SECTION 14 Dental Procedures . . . . . . . . . . . . . . . . . . 1699
Scott A. Heinrich and Dino P. Rumoro 209 Dental Anesthesia and Analgesia . . . . . . . . . . . . . . . 1699
187 Ocular Burn Management and Eye Irrigation . . . . . . . . . 1560 Eric F. Reichman
Steven J. Socransky 210 Dental Abscess Incision and Drainage . . . . . . . . . . . . 1711
188 Intraocular Pressure Measurement (Tonometry) . . . . . . . 1567 Richard Dean Robinson and Peter S. Kim
Rosalia Njeri Mbugua and Adam Jennings 211 Post-Extraction Pain and Dry Socket (Alveolar Osteitis)
189 Digital Globe Massage . . . . . . . . . . . . . . . . . . . . 1576 Management . . . . . . . . . . . . . . . . . . . . . . . . . 1718
Carlos J. Roldan and Eric F. Reichman Eric F. Reichman
190 Anterior Chamber Paracentesis . . . . . . . . . . . . . . . . 1579 212 Post-Extraction Bleeding Management . . . . . . . . . . . 1720
Rene Carizey Eric F. Reichman
191 Corneal Foreign Body Removal . . . . . . . . . . . . . . . . 1582 213 Defective Dental Restoration Management . . . . . . . . . 1724
Scott A. Heinrich and Dino P. Rumoro Richard Dean Robinson and Daisha McLarty
192 Corneal Rust Ring Removal . . . . . . . . . . . . . . . . . . 1588 214 Subluxed and Avulsed Tooth Management . . . . . . . . . . 1728
Adam Jennings, Marcus Holmes, and Devin Sandlin Richard Dean Robinson, Adam Flink, and Ryan Nathaniel Krech
193 Eye Patching and Eye Shields . . . . . . . . . . . . . . . . . 1591 215 Fractured Tooth Management . . . . . . . . . . . . . . . . 1736
Teresa D. Le and Adam Jennings Richard Dean Robinson, Mahmuda Farha, and Bharti R. Chaudhari
194 Acute Orbital Compartment Syndrome 216 Temporomandibular Joint Dislocation Reduction . . . . . . 1740
(Retrobulbar Hemorrhage) Management . . . . . . . . . . 1595 Marilyn M. Hallock
Andrew F. Perin, Jamil D. Bayram, and Sami H. Uwaydat 217 Arch Bar Separation . . . . . . . . . . . . . . . . . . . . . . 1747
195 Globe Luxation Reduction . . . . . . . . . . . . . . . . . . 1600 Richard Dean Robinson, Amanda Pientka,
Briana D. Mazur, Adam Jennings, and Heidi Knowles and Phuc Ba Duong
196 Hordeolum (Stye) Incision and Drainage . . . . . . . . . . . 1603
Sami H. Uwaydat, Andrew F. Perin, and Jamil D. Bayram SECTION 15 Podiatric Procedures . . . . . . . . . . . . . . . . 1751
218 Ingrown Toenail Management . . . . . . . . . . . . . . . . 1751
SECTION 13 Otolaryngologic Procedures . . . . . . . . . . . 1607 Sean Dyer and Jeffrey Schaider
197 External Auditory Canal Foreign Body Removal . . . . . . . 1607 219 Plantar Puncture Wound Management . . . . . . . . . . . . 1755
G. Carolyn Clayton, Katarzyna M. Gore, and Melissa M. Rice Vishal Bhuva and Dhara Patel Amin
198 Cerumen Impaction Removal . . . . . . . . . . . . . . . . . 1616 220 Toe Fracture Management . . . . . . . . . . . . . . . . . . 1760
Dayle Davenport JoAnna Leuck and Tyler Hedman

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 xii Contents

221 Plantar Wart Management . . . . . . . . . . . . . . . . . . 1764 227 Hyperthermic Patient Management . . . . . . . . . . . . . 1821
Kevin O’Rourke Jessica Mann and J. Elizabeth Neuman
222 Neuroma Management . . . . . . . . . . . . . . . . . . . . 1769 228 Autotransfusion . . . . . . . . . . . . . . . . . . . . . . . . 1828
Justin C. Bosley and Eric R. Snoey Carlos J. Roldan and Amit Mehta
223 Management of Select Podiatric Conditions . . . . . . . . . 1775 229 Helmet Removal . . . . . . . . . . . . . . . . . . . . . . . 1833
JoAnna Leuck, Jacob Hurst, and Anant Patel Ashley N. Sanello and Atilla Üner
230 Pneumatic Antishock Garment (MAST Trousers) . . . . . . . 1841
SECTION 16 Miscellaneous Procedures . . . . . . . . . . . . . 1789 Evan J. Weiner
224 Relief of Choking and Acute Upper Airway 231 Hazmat Patient Management . . . . . . . . . . . . . . . . 1845
Foreign Body Removal . . . . . . . . . . . . . . . . . . . . 1789 Atilla Üner
Guy Shochat and Jacqueline Nemer 232 Physical Restraints . . . . . . . . . . . . . . . . . . . . . . 1859
225 Induction of Therapeutic Hypothermia Dean Sagun
(Targeted Temperature Management) . . . . . . . . . . . . 1797 233 Chemical Restraint . . . . . . . . . . . . . . . . . . . . . . 1867
Eleanor Dunham David K. Duong and Dara Mendelsohn
226 Hypothermic Patient Management . . . . . . . . . . . . . . 1806
Jessen D. Schiebout Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1879

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 Contributors

Asim A. Abbasi, MD, MPH [122] Steven E. Aks, DO, FACMT, FACEP [78]
Assistant Professor Director, the Toxikon Consortium
Department of Pediatric Emergency Medicine Division of Toxicology, Department of Emergency Medicine
University of Rochester Cook County Health and Hospitals System
Rochester, New York Professor of Emergency Medicine
Rush Medical College
Adi Abramovici, MD [164] Chicago, Illinois
Maternal-Fetal Medicine
Sinai Perinatal, LLC Carmen Alcalá, MD [185]
Plantation, Florida Resident Physician
Department of Emergency Medicine
Tiffany Abramson, MD [49] Cook County Health and Hospital Systems
Chicago, Illinois
Resident Physician
Department of Emergency Medicine
LAC+USC Medical Center Thomas Alcorn, MD [38]
Keck School of Medicine of USC Assistant Professor
Los Angeles, California Rush University Medical Center
Department of Emergency Medicine
Srikar Adhikari, MD, MS [64, 160] Chicago, Illinois
Chief, Section of Emergency Ultrasound
Associate Professor Piotr C. Al-Jindi, MD [15, 16]
Department of Emergency Medicine Associate Program Director
University of Arizona Attending Physician
Tucson, Arizona Department of Anesthesiology
John H. Stroger, Jr. Hospital
Hagop M. Afarian, MD, MS, FACEP [117, 159] Cook County Health and Hospitals System
Chicago, Illinois
Associate Clinical Professor of Emergency Medicine
UCSF School of Medicine
Attending Physician, Department of Emergency Medicine Paulino A. Alvarez, MD [47]
UCSF Fresno Cardiology Fellow
Associate Chief Medical Informatics Officer Houston Methodist Hospital
Community Medical Centers Houston, Texas
Fresno, California
Ricky N. Amii, MD [183]
Ikem Ajaelo, MD [168] Assistant Clinical Professor
Independent Attending Physician Department of Emergency Medicine
John Muir Urgent Care David Geffen School of Medicine at UCLA
John Muir Medical Group Los Angeles, California
Walnut Creek, California
Dhara Patel Amin, MD [120, 123, 219]
Abayomi E. Akintorin, MD [36] Assistant Program Director of Cook County Emergency Medicine
Chairman Department of Emergency Medicine
Division of Pediatric Anesthesia John H. Stroger, Jr. Hospital
Division of Critical Care Cook County Health and Hospital Systems
Attending Physician Assistant Professor of Emergency Medicine
Department of Anesthesiology Rush University Medical College
John H. Stroger, Jr. Hospital Chicago, Illinois
Cook County Health and Hospitals System
Clinical Assistant Professor Martin E. Anderson, Jr., MD, FACS [207]
University of Illinois at Chicago
Division of Pediatric Otolaryngology
Chicago, Illinois
Advocate Children’s Hospital
Park Ridge, Illinois

xiii

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 xiv Contributors

Leah W. Antoniewicz, MD [161, 166] Abraham Berhane, MD [126]

Assistant Professor Department of Emergency Medicine
Department of Obstetrics and Gynecology Cook County Health and Hospitals System
Baylor College of Medicine Chicago, Illinois
Houston, Texas
Vishal Bhuva, MD [219]
Simeon W. Ashworth, DO [162] Resident Physician
Clerkship Director Department of Emergency Medicine
Department of Emergency Medicine Cook County Hospital
Madigan Army Medical Center Chicago, Illinois
Tacoma, Washington
Clinical Instructor of Emergency Medicine Charles Boland, MD [15, 32]
University of Washington School of Medicine
Former Chief Resident
Seattle, Washington
Cook County Hospital
Chicago, Illinois
Bashar M. Attar, MD, PhD, MPH (Epid), MBA, FACP, FACG, Cardiothoracic Fellow
AGAF, FASGE, AGSF, FAASLD [80, 81] Virginia Commonwealth University
Systemwide Chair for Gastroenterology and Hepatology Richmond, Virginia
Cook County Health and Hospitals System
Director, GI Fellowship Program David W. Boldt, MD [12]
John H. Stroger, Jr. Hospital of Cook County Associate Clinical Professor
Professor of Medicine and Surgery Department of Anesthesiology
Rush University Medical Center Division of Critical Care Medicine
Chicago, Illinois University of California Los Angeles School of Medicine
Los Angeles, California
Michael Balkin, MD [86]
Chief Resident Justin C. Bosley, MD, CAQSM [222]
Department of Emergency Medicine Emergency Medicine Physician
John Peter Smith Hospital Sports Medicine Physician
Fort Worth, Texas The Permanente Medical Group
Oakland, California
Kenny Banh, MD [54]
Associate Professor of Clinical Emergency Medicine Steven H. Bowman, MD, FACEP [126-128]
Assistant Dean of Undergraduate Medical Education Program Director
University of California San Francisco Fresno Department of Emergency Medicine
Fresno, California Cook County Health and Hospitals System
Associate Professor of Emergency Medicine
John Bass, MD [44] Department of Emergency Medicine
Resident Physician Rush Medical College
Madigan Army Medical Center Chicago, Illinois
Tacoma, Washington
Keegan Bradley, MD [96]
Jamil D. Bayram, MD, MPH, EMDM, MEd, PhDc [87, 194, 196] Resident Physician
Associate Professor Department of Emergency Medicine
Department of Emergency Medicine John Peter Smith Hospital
Johns Hopkins University School of Medicine Fort Worth, Texas
Department of International Medicine
Bloomberg School of Public Health Carlos E. Brown, Jr., MD [139]
Medical Director, National Capital Region Resident Physician
Johns Hopkins Medicine International Department of Emergency Medicine
Baltimore, Maryland Cook County Health and Hospital System
Chicago, Illinois
Daniel Belmont, MD [59, 61]
Attending Physician Curtis Blake Buchanan, MD [20]
Department of Emergency Medicine Attending Physician
Elmhurst Hospital US Acute Care Solutions
Elmhurst, Illinois Department of Emergency Medicine
Florida Hospital Tampa
Deena Ibrahim Bengiamin, MD, RDMS [135] Temple, Florida
Clinical Assistant Professor
Department of Emergency Medicine
Loma Linda University Medical Center
Loma Linda, California

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 Contributors xv

Joshua T. Bucher, MD, FAAEM [95] Paul Casey, MD, FACEP [38]
Assistant Professor Associate Professor
EMS Medical Director, RWJ-MHS Vice Chairman, Operations
Department of Emergency Medicine Associate Chief Medical Informatics Officer
Rutgers–Robert Wood Johnson Medical School Department of Emergency Medicine
New Brunswick, New Jersey Rush University Medical Center
Chicago, Illinois
Aaron W. Bull, MD [175]
Department of Emergency Medicine Anthony W. Catalano, MD [183]
John Peter Smith Health Network Emergency Medicine Physician
Fort Worth, Texas Cottage Hospital
Santa Barbara, California
Michael D. Burg, MD [101]
Associate Clinical Professor of Emergency Medicine Divya Karjala Chakkaravarthy, MD [9]
Department of Emergency Medicine Anesthesiologist and Fellowship in Pain Management
UCSF/Fresno Medical Education Program Department of Anesthesiology and Pain Management
Fresno, California John H. Stroger, Jr. Hospital, Cook County
Chicago, Illinois
John Burke, MD, PhD [147]
Resident Physician Steven J. Charous, MD, FACS [206]
Department of Neurological Surgery Clinical Professor
University of California at San Francisco Director, Voice and Swallow Center
San Francisco, California Department of Otolaryngology–Head and Neck Surgery
Loyola University Medical Center
Beech S. Burns, MD, MCR [23, 70] Maywood, Illinois
Assistant Professor
Departments of Emergency Medicine and Pediatrics Bharti R. Chaudhari, DO [215]
Division of Emergency Medicine Attending Physician
Oregon Health & Science University Department of Emergency Medicine
Portland, Oregon John Peter Smith Health Network
Fort Worth, Texas
Danielle D. Campagne, MD, FACEP [93, 138]
Associate Professor of Clinical Emergency Medicine Alan T. Chiem, MD, MPH [68]
Department of Emergency Medicine Assistant Clinical Professor
UCSF School of Medicine Department of Emergency Medicine
Fresno, California Olive View–UCLA Medical Center
David Geffen School of Medicine
Angelique Campen, MD, FACEP [103] Los Angeles, California
Emergency Department
Providence Saint Joseph Medical Center Padraic Chisholm, MD [163]
Clinical Instructor of Emergency Medicine Former Resident
Ronald Reagan UCLA Medical Center Department of Obstetrics and Gynecology
Emergency Department Baylor College of Medicine
Providence Saint Joseph Medical Center Houston, Texas
Assistant Adjunct Professor of Medicine Obstetrician Gynecologist
UCLA Emergency Department Women’s Clinic of South Texas
Los Angeles, California Edinburg, Texas

Caleb P. Canders, MD [68, 144] Carolyn Chooljian, MD [134]

Clinical Associate Professor Clinical Professor, Emergency Medicine
Department of Emergency Medicine Department of Emergency Medicine
David Geffen School of Medicine at UCLA UCSF Fresno Emergency Medicine Residency Program
Los Angeles, California University of California, San Francisco
Fresno, California
Rene Carizey, DO [105, 190]
Associate Professor
Department of Emergency Medicine
Rush University
Chicago, Illinois

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 xvi Contributors

Sarah J. Christian-Kopp, MD, FAAP [149, 161, 165] Dayle Davenport, MD [129, 198]
Clinical Assistant Professor of Pediatric Emergency Medicine & Assistant Professor
Emergency Medicine Department of Emergency Medicine
Loma Linda University Medical Center and Children’s Hospital Rush University Medical Center
Clinical Assistant Professor of Emergency Medicine Chicago, Illinois
UCLA/Olive View Medical Center
Attending Physician Beth R. Davis, MD [161]
Department of Emergency Medicine
Assistant Professor
Providence Tarzana Medical Center
Baylor College of Medicine
Attending Physician
Houston, Texas
Department of Emergency Medicine
Kaiser Permanente Hospitals
Fontana and Ontario, California Shoma Desai, MD [13, 49]
Clinical Associate Professor of Emergency Medicine
Laura Chun, MD [120] Department of Emergency Medicine
Keck School of Medicine
Resident Physician
University of Southern California
Department of Emergency Medicine
Los Angeles, California
John H. Stroger, Jr. Hospital
Cook County Health and Hospital Systems
Chicago, Illinois Sasha Michael Dib, MD [176]
Emergency Medicine Resident
Jennalee Cizenski, MD [171] John Peter Smith Hospital
Fort Worth, Texas
Resident, Emergency Medicine
John Peter Smith Hospital
Fort Worth, Texas Kevin J. Donnelly, MD [17]
Resident Physician
G. Carolyn Clayton, MD [197, 202] Department of Anesthesiology and Pain Management
John H. Stroger, Jr. Hospital of Cook County
Clinical Assistant Professor
Chicago, Illinois
Department of Emergency Medicine
Rush Medical College
Rush University Medical Center Andrea Dreyfuss, MD, MPH [172]
Chicago, Illinois Ultrasound Fellow
Department of Emergency Medicine
Ginger Clinton, MD [128] Highland Hospital–Alameda Health System
Oakland, California
Emergency Medicine
Cook County Health and Hospital Systems
Chicago, Illinois Stephen N. Dunay, MD, MHS [162]
Resident Physician
Alfred Coats, III, FNP-C [43, 125] Department of Emergency Medicine
Madigan Army Medical Center
Nurse Practitioner
Tacoma, Washington
Department of Emergency Medicine
San Jacinto Methodist Hospital
University of Texas Health Science Center at Houston Eleanor Dunham, MD [225]
Houston, Texas Assistant Professor
Department of Emergency Medicine
Emily Cooper, MD [157] Penn State Health Milton S. Hershey Medical Center
Penn State University College of Medicine
Chief Resident
Hershey, Pennsylvania
Department of Emergency Medicine
Jackson Memorial Hospital
Miami, Florida David K. Duong, MD, MS, FACEP [233]
Alameda Health System, Highland Hospital
John Cruz, DO [66] Department of Emergency Medicine
Associate Professor
Resident Physician
University of California, San Francisco School of Medicine
Department of Emergency Medicine
Oakland, California
Madigan Army Medical Center
Tacoma, Washington
Phuc Ba Duong, DO [217]
Bryan Darger, MD [4] Resident Physician
Department of Emergency Medicine
Department of Emergency Medicine
John Peter Smith Health Network
University of San Francisco School of Medicine
Fort Worth, Texas
San Francisco, California

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 Contributors xvii

Sean Dyer, MD [218] Christopher Freeman, MD [137, 157, 164]

Department of Emergency Medicine Program Director Emergency Medicine
Cook County Health and Hospital System Jackson Memorial Hospital
Instructor, Department of Emergency Medicine Affiliated Assistant Professor
Rush Medical College Department of Surgery
Chicago, Illinois University of Miami Miller School of Medicine
Miami, Florida
Erick A. Eiting, MD, MPH, MMM, FACEP [82]
Vice Chair of Operations Michael Friedman, MD [204]
Mount Sinai Downtown Professor and Chairman
Assistant Professor of Emergency Medicine Section of Otolaryngology
Icahn School of Medicine at Mount Sinai Advocate Illinois Masonic Medical Center
New York, New York Medical Director
ChicagoENT
Tamer Elattary, MB, ChB [11, 31] Chicago, Illinois
Anesthesia Resident
Department of Anesthesiology and Pain Management Kimberly Lynn Fugok, DO [60]
Cook County Health and Hospitals System Emergency and Hospital Medicine
Chicago, Illinois Pediatric Emergency Medicine
Nemours/Alfred I. duPont Hospital for Children
Thomas W. Engel, II, MD [150] Wilmington, Delaware
Resident
Department of Emergency Medicine Sonali Gandhi, MD [133, 154]
Cook County Hospital Resident Physician
Chicago, Illinois Department of Emergency Medicine
Cook County Health and Hospitals System
Brian Euerle, MD [7, 97] Chicago, Illinois
Associate Professor
Department of Emergency Medicine Molly Garcia [39]
University of Maryland School of Medicine Emergency Medical Technician
Baltimore, Maryland Sacramento, California

Mahmuda Farha, DO [215] Christopher A. Gee, MD, MPH [112]

Emergency Medicine Resident Clinical Associate Professor
Department of Emergency Medicine Department of Orthopaedics
John Peter Smith Hospital University of Utah School of Medicine
Fort Worth, Texas Salt Lake City, Utah

Rosaura Fernandez, MD [77] Steven Go, MD, FACEP [178, 182]

Assistant Program Director of Cook County Emergency Medicine Professor of Emergency Medicine
Department of Emergency Medicine Department of Emergency Medicine
Cook County Health and Hospital Systems Truman Medical Center, Hospital Hill
Assistant Professor of Emergency Medicine University of Missouri—Kansas City School of Medicine
Rush Medical College Kansas City, Missouri
Chicago, Illinois
Chad Gorbatkin, MD [44, 66]
Brandon M. Fetterolf, DO [92] Assistant Professor
Special Operations Resuscitation Team “A” Medical Director Department of Military and Emergency Medicine
528th Sustainment Brigade (SO)(A) Uniformed Services University of the Health Sciences
1st Special Forces Command Staff Physician, Madigan Army Medical Center
Fort Bragg Tacoma, Washington
Fort Bragg, North Carolina
Katarzyna M. Gore, MD [197, 202]
Adam Flink, MD [214] Clinical Assistant Professor
Department of Emergency Medicine Department of Emergency Medicine
John Peter Smith Hospital Rush University Medical Center
Fort Worth, Texas Chicago, Illinois

Adrian H. Flores, MD, MPH [100]

Assistant Clinical Professor
Department of Emergency Medicine
UCSF School of Medicine
San Francisco, California

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 xviii Contributors

Michael Gottlieb, MD, RDMS [50, 102, 106, 107, 108, 110, 142] John Robert Hardwick, MD [99]
Director of Emergency Ultrasound Associate Emergency Physician
Assistant Professor Northern Nevada Emergency Physicians
Department of Emergency Medicine Reno, Nevada
Rush University Medical Center
Chicago, Illinois Tarlan Hedayati, MD, FACEP [19]
Assistant Professor
Thomas P. Graham, MD [130, 155] Associate Program Director
Professor of Emergency Medicine Department of Emergency Medicine
Department of Emergency Medicine Cook County Health and Hospitals System
UCLA School of Medicine Chicago, Illinois
Los Angeles, California
Tyler Hedman, MD [220]
Justin Grisham, DO [72] Emergency Medicine Resident
Resident Department of Emergency Medicine
Department of Emergency Medicine John Peter Smith Hospital
Madigan Army Medical Center Fort Worth, Texas
Tacoma, Washington
James A. Heilman, MD, MBA [23, 70]
Andrew Grock, MD [74] Assistant Professor
Faculty Physician Department of Emergency Medicine
Division of Emergency Medicine Oregon Health and Science University
Greater Los Angeles VA Healthcare System Portland, Oregon
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine Scott A. Heinrich, MD [186, 191]
University of California Los Angeles
Assistant Professor
Los Angeles, California
Department of Emergency Medicine
Rush Medical College
Lindsay K. Grubish, DO [161] Chicago, Illinois
Staff Physician
Madigan Army Medical Center H. Gene Hern, Jr., MD [34]
Tacoma, Washington
Associate Clinical Professor
University of California, San Francisco
Ashrith Guha, MD, MPH, FACC [47] Vice Chair of Education, Emergency Medicine
Assistant Professor Alameda Health System–Highland General Hospital
Department of Cardiology Oakland, California
Methodist DeBakey Heart and Vascular Center
JC Walter Transplant Canter Tyson Jay Higgins, MD [91]
Houston Methodist Hospital
Resident Physician
Houston, Texas
Department of Emergency Medicine
John Peter Smith Health Network
Ameera Haamid, MD [128] Fort Worth, Texas
Resident Physician
Department of Emergency Medicine Jean W. Hoffman, MD [73]
John H. Stroger, Jr. Hospital of Cook County
Assistant Professor
Chicago, Illinois
Departments of Emergency Medicine and Anesthesia
University of Colorado School of Medicine
Christopher J. Haines, DO [33, 79] Aurora, Colorado
Clinical Associate Professor
Department of Pediatrics Jordan R. H. Hoffman, MPH, MD [73]
Division of Pediatric Emergency Medicine
Fellow, Cardiothoracic Surgery
Rutgers Robert Wood Johnson Medical School
Department of Surgery
New Brunswick, New Jersey
Division of Thoracic Surgery
University of Colorado School of Medicine
Marilyn M. Hallock, MD, MS, FACEP [216] Aurora, Colorado
Clinical Assistant Professor
Department of Emergency Medicine Chad Holmes, DO [90]
Rush University Medical College
Associate Ultrasound Director
Chicago, Illinois
Department of Emergency Medicine
JPS Health Network
Fort Worth, Texas

Reichman_FM_pi-xxx.indd 18 13/08/18 6:28 PM

 Contributors xix

Katherine Holmes, DO [86] Adam Jennings, DO, FACEP [188, 192, 193, 195]
Medical Student Clerkship Director Assistant Professor
JPS EM Director of New Media Department of Emergency Medicine
Department of Emergency Medicine TCU & UNTHSC School of Medicine
John Peter Smith Hospital Fort Worth, Texas
Fort Worth, Texas
Megan Johnson, MD [13]
Marcus Holmes, DO [192] Department of Emergency Medicine
Chief Resident LAC+USC Medical Center
Department of Emergency Medicine Keck School of Medicine of USC
John Peter Smith Health Network Los Angeles, California
Fort Worth, Texas
Paul J. Jones, MD, FACS [199]
Louis G. Hondros, DO, FACEP [3] Associate Professor
Director Pediatric/General Otolaryngology
Emergency Medical Systems Department of Otolaryngology–Head and Neck Surgery
Assistant Professor Loyola University Medical Center
Department of Emergency Medicine Maywood, Illinois
Assistant Professor
Department of Anatomy and Cell Biology Kimberly T. Joseph, MD, FACS, FCCM [51]
Rush University Medical Center
ATLS Subcommittee Chair
Chicago, Illinois
Committee on Trauma of the American College of Surgeons
Assistant Professor
Dennis Hsieh, MD, JD [184] Department of General Surgery
Assistant Professor Rush University Medical College
Department of Emergency Medicine Voluntary Attending Surgeon
Harbor-UCLA Medical Center Department of Trauma & Burns
University of California, Los Angeles John H. Stroger, Jr. Hospital
Torrance, California Cook County Health and Hospitals System
Chicago, Illinois
Charles Huggins, MD, FACEP [88]
Core Faculty Emergency Medicine Residency Program Marianne Juarez, MD [48, 52]
Department of Emergency Medicine Assistant Clinical Professor
John Peter Smith Hospital Department of Emergency Medicine
Fort Worth, Texas University of California San Francisco
San Francisco, California
Jacob Hurst, MD [223]
Resident Physician Thomas M. Kennedy, MD [119]
Department of Emergency Medicine Fellow, Pediatric Emergency Medicine
John Peter Smith Health Network Sidney Kimmel Medical College at Thomas Jefferson University
Fort Worth, Texas Nemours/Alfred I. duPont Hospital for Children
Division of Pediatric Emergency Medicine
Pholaphat Charles Inboriboon, MD, MPH, FACEP [20, 98] Wilmington, Delaware
Clinical Associate Professor
Department of Emergency Medicine Neera Khattar, MD [127]
University of Missouri Kansas City School of Medicine Resident Physician
Kansas City, Missouri John H. Stroger, Jr. Hospital of Cook County
Chicago, Illinois
Konstantin Inozemtsev, MD [14]
Resident Physician Basem F. Khishfe, MD [6, 37]
Department of Anesthesiology and Pain Management Emergency Ultrasound Director
John H. Stroger, Jr. Hospital of Cook County Mercy Hospital and Medical Center
Chicago, Illinois Assistant Professor of Emergency Medicine
Chicago Medical School
Eric Isaacs, MD [1, 4] Chicago, Illinois
Clinical Professor
Department of Emergency Medicine Charlie C. Kilpatrick, MD, MEd [169]
University of California, San Francisco Residency Program Director, Vice Chair of Education
San Francisco, California Associate Professor | Female Pelvic Medicine, Reconstructive
Surgery
Department of Obstetrics and Gynecology
Baylor College of Medicine
Houston, Texas

Reichman_FM_pi-xxx.indd 19 13/08/18 6:28 PM

 xx Contributors

Claudia Kim [88] Ryan Nathaniel Krech, MD, JD, FACEP [214]
Resident Physician Medical Director
Department of Emergency Medicine Department of Emergency Medicine
John Peter Smith Health Network John Peter Smith Health Network
Fort Worth, Texas Fort Worth, Texas

Peter S. Kim, MD [210] John C. Kubasiak, MD [51]

Emergency Medicine Resident Assistant Instructor of Surgery
John Peter Smith Hospital Department of Surgery
Fort Worth, Texas Division of General and Acute Care Surgery
UT Southwestern School of Medicine
Jessica J. Kirby, DO, FACEP [2] Dallas, Texas
Associate Medical Director
Department of Emergency Medicine Elizabeth Kwan, MS, MD [45]
John Peter Smith Health Network Assistant Professor
Fort Worth, Texas Department of Emergency Medicine
University of California San Francisco
Ryan P. Kirby, MD, FACEP [2] San Francisco, California
Program Director
Department of Emergency Medicine Steven Lai, MD [205]
John Peter Smith Healthcare Network Assistant Residency Program Director
Fort Worth, Texas UCLA Emergency Medicine Residency
Olive View-UCLA Medical Center | Ronald Reagan-UCLA
Hannah Kirsch, MD [146] Medical Center
Assistant Clinical Professor
Resident in Neurology
Department of Emergency Medicine
Department of Neurology
David Geffen School of Medicine at UCLA
University of California, San Francisco School of Medicine
Los Angeles, California
San Francisco, California

Mark P. Kling, MD, FAAEM, CSCS [104, 109] John Larkin, MD [97]
Assistant Medical Director
Former Assistant Clinical Professor
Attending Physician
Cook County (Stroger) Emergency Medicine Residency
Emergency Department
Former Private Practice Emergency Healthcare Physicians and
CHI Baylor–St. Luke’s Medical Center
IEMS of Illinois Senior Attending Physician
Houston, Texas
TeamHealth NW–Franciscan Affiliates
Gig Harbor, Washington
Teresa D. Le, MD [193]
Heidi Knowles, MD, FACEP [195] Resident Physician
Department of Emergency Medicine
Core Faculty
John Peter Smith Hospital
Department of Emergency Medicine
Fort Worth, Texas
John Peter Smith Health Network
Fort Worth, Texas
Ahmad M. Abou Leila, MD [36]
Igor V. Kolesnikov, MD, PharmD [21] Assistant Professor of Anesthesiology
Cleveland Clinic
Senior Attending Physician
Anesthesiology Attending
Chief of Head and Neck Anesthesia Section
Department of Anesthesiology
Assistant Professor of Anesthesiology
Hillcrest Hospital
Rush University Medical Center
Mayfield Heights, Ohio
Attending Physician
Department of Anesthesiology and Pain Management
John H. Stroger, Jr. Hospital Jacob Lentz, MD [148]
Chicago, Illinois Resident
Department of Emergency Medicine
Alex Koo, MD [75, 83] University of California at Los Angeles
Los Angeles, California
Department of Emergency Medicine
Madigan Army Medical Center
Joint Base Lewis McChord, Washington JoAnna Leuck, MD, FACEP [96, 171, 220, 223]
Assistant Professor
Laurie Krass, MD [123] Academic Vice Chair
Program Director
Department of Emergency Medicine
Department of Emergency Medicine
John H. Stroger, Jr. Hospital of Cook County
John Peter Smith Health Network
Chicago, Illinois
Fort Worth, Texas

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 Contributors xxi

Eric S. Levy, DO [33, 79] Briana D. Mazur, DO [195]

Department of Emergency Medicine Department of Emergency Medicine
Rutgers Robert Wood Johnson Medical School John Peter Smith Health Network
New Brunswick, New Jersey Fort Worth, Texas

Karen Lind, MD, MACM, FACEP [184] Justin Mazzillo, MD [94]

Faculty Physician Assistant Professor
Department of Emergency Medicine Assistant Medical Director
Alameda Health System/Highland Campus Department of Emergency Medicine
Oakland, California University of Rochester Medical Center
Rochester, New York
Jenny J. Lu, MD, MS [76, 77]
Assistant Professor Rosalia Njeri Mbugua, MD [188]
Rush University Medical College Staff Physician
Cook County Health and Hospitals System Department of Emergency Medicine
Department of Emergency Medicine Medical City Healthcare, Alliance
Division of Medical Toxicology Fort Worth, Texas
Chicago, Illinois
James J. McCarthy, MD, FACEP, FAEMS [65]
Claire H. Lyons, MS, MD [184] Professor
Resident Physician Department of Emergency Medicine
Department of Emergency Medicine McGovern Medical School, Part of UTHealth
Highland Hospital–Alameda Health System The University of Texas Health Science Center at Houston
University of California at San Francisco–Medical School Houston, Texas
San Francisco, California
Myles C. McClelland, MD, MPH, CMQ [43, 47, 125]
O. John Ma, MD [23, 70] Medical Director
Professor and Chair Department of Emergency Medicine
Department of Emergency Medicine Willowbrook Methodist Hospital
Oregon Health & Science University Houston, Texas
Portland, Oregon
Daisha McLarty, MD [213]
Debbie Yi Madhok, MD [146, 147] Emergency Medicine Resident
Assistant Clinical Professor John Peter Smith Hospital
Zuckerberg San Francisco General Hospital Fort Worth, Texas
Department of Emergency Medicine
University of California San Francisco Jehangir Meer, MD [7, 156]
San Francisco, California
Seattle Emergency Physicians
Department of Emergency Medicine
Leann Mainis, MD [84, 158] First Hill & Cherry Hill Campuses
Chief Resident Swedish Medical Center
Department of Emergency Medicine Seattle, Washington
UCSF Fresno
Fresno, California Amit Mehta, MD, CMQ [228]
Assistant Professor
Jessica Mann, MD, MS [67, 227] Department of Emergency Medicine
Assistant Professor of Emergency Medicine Director of Medical Informatics
Life Lion EMS Medical Director–Berks County and Community McGovern Medical School at UTHealth
Paramedicine Houston, Texas
EMS Fellowship Core Faculty
Department of Emergency Medicine Dara Mendelsohn, MD [233]
Penn State Health Milton S. Hershey Medical Center
Resident
Hershey, Pennsylvania
Department of Emergency Medicine
Highland Hospital
Monique A. Mayo, MD [170] Oakland, California
Attending Physician
Department of Emergency Medicine Marco Mikhael, MD [22]
Division of Pediatrics
Senior Pediatric Anesthesiologist
Nemours/Alfred I. duPont Hospital for Children
Cook County Health and Hospitals System
Sidney Kimmel Medical College at Thomas Jefferson University
Pediatric Anesthesia Attending
Wilmington, Delaware
St. Alexius Medical Center
AMITA Heath-Hoffman Estates
Chicago, Illinois

Reichman_FM_pi-xxx.indd 21 13/08/18 6:28 PM

 xxii Contributors

Ruth E. Moncayo, MD [28] Robert Needleman, MD [126]

Senior Faculty Attending Physician Resident Physician
Department of Anesthesiology and Pain Management Department of Emergency Medicine
Cook County Health and Hospital Systems John H. Stronger, Jr. Hospital
Chicago, Illinois Cook County Health and Hospital Systems
Chicago, Illinois
James Montoya, MD, FAAEM, FACEP [39]
CEP Physician, Partner Jacqueline Nemer, MD, FACEP [48, 52, 207, 224]
Vice-Chief, Department of Emergency Medicine Professor of Emergency Medicine
Sutter Medical Center-Sacramento Director of Advanced Clinical Skills
Sacramento, California Department of Emergency Medicine
Clinical Associate Professor University of California San Francisco School of Medicine
Department of Emergency Medicine San Francisco, California
California Northstate University College of Medicine
Elk Grove, California J. Elizabeth Neuman, DO, FACEP [67, 227]
Assistant Professor of Emergency Medicine
Daniel S. Morrison, MD, FACEP [40, 41, 42, 121, 208] Department of Emergency Medicine
Associate Professor Penn State Hershey Medical Center
Department of Emergency Medicine Hershey, Pennsylvania
Rutgers Robert Wood Johnson Medical School
New Brunswick, New Jersey Ann P. Nguyen, MD [179]
Attending Physician
Ivette Motola, MD, MPH [114] Emergency Trauma Center
Assistant Director, Gordon Center for Research in Medical Hackensack University Medical Center
Education Hackensack, New Jersey
Director, Division of Prehospital & Emergency Healthcare
Associate Professor of Emergency Medicine Thuy Tran T. Nguyen, FNP-C [43, 125]
University of Miami Miller School of Medicine
Nurse Practitioner
Miami, Florida
Department of Emergency Medicine
Methodist Hospital
David Murray, MD [120] University of Texas Medical Branch
Department of Emergency Medicine Galveston, Texas
John H. Stroger, Jr. Hospital of Cook County
Chicago, Illinois Abdoulie Njie, MD [126]
Department of Emergency Medicine
Arun Nagdev, MD [63] Cook County Hospital
Director, Emergency Ultrasound Chicago, Illinois
Alameda Health System
Highland General Hospital Flavia Nobay, MD [69]
Associate Clinical Professor
Associate Professor of Emergency Medicine
UCSF School of Medicine
Department of Emergency Medicine
San Francisco, California
Associate Dean for Admissions
University of Rochester School of Medicine and Dentistry
Damali N. Nakitende, MD, RDMS [102, 142] University of Rochester
Ultrasound Faculty at Advocate Christ Medical Center Rochester, New York
Department of Emergency Medicine
Chicago, Illinois Jeanne A. Noble, MD, MA [71, 167]
Assistant Professor of Emergency Medicine
Isam F. Nasr, MD [9, 12, 16, 29] UCSF-SFGH Emergency Medicine Residency Simulation Director
Clinical Assistant Professor Department of Emergency Medicine
Department of Emergency Medicine University of California, San Francisco
Rush Medical College San Francisco, California
Chicago, Illinois
Mary J. O, MD, FACEP [140]
Ned F. Nasr, MD [11, 12, 14-18, 21, 22, 24, 26, 28-32, 36, 143] Assistant Professor of Emergency Medicine
Vice Chairman for Academic Affairs and Program Director Frank H. Netter MD School of Medicine
Chairman, Division of Neuroanesthesiology Quinnipiac University
Department of Anesthesiology and Pain Management St. Vincent’s Medical Center
Cook County Health and Hospitals System Bridgeport, Connecticut
Chicago, Illinois

Reichman_FM_pi-xxx.indd 22 13/08/18 6:28 PM

 Contributors xxiii

Julie Kautz Oliva, MD [34] Priya D. Perumalsamy, MD [105, 131]

Resident Physician Associate Professor
Department of Emergency Medicine Department of Emergency Medicine
Highland Hospital Rush University Medical Center
Oakland, California Chicago, Illinois

Francisco Orejuela, MD [163] Amanda Pientka, MD [217]

Associate Professor Chief Resident
Department of Obstetrics and Gynecology Department of Emergency Medicine
Division of Female Pelvic Medicine and Reconstructive Surgery John Peter Smith Health Network
Baylor College of Medicine Fort Worth, Texas
Houston, Texas
Teresa Proietti, DO [174]
Kevin O’Rourke, MD [180, 221] Resident
Assistant Professor Department of Emergency Medicine
Department of Emergency Medicine John Peter Smith Hospital
Truman Medical Center Fort Worth, Texas
University of Missouri at Kansas City School of Medicine
Kansas City, Missouri Kara N. Purdy, MD, MS [161]
Doctor, Department of Emergency Medicine
Guillermo Ortega, MD [42] Madigan Army Medical Center
Emergency Medicine Resident Tacoma, Washington
Rutgers–Robert Wood Johnson Medical School
New Brunswick, New Jersey Yanina Purim-Shem-Tov, MD, MS, FACEP [3]
Associate Professor
Scott T. Owens, MD, MPH [93] Vice Chairperson
Acting Instructor, Senior Fellow Faculty Development and Research
Department of Emergency Medicine Department of Emergency Medicine
University of Washington Medical Director of Chest Pain Center
Seattle, Washington Rush University Medical Center
Chicago, Illinois
Hyang won Paek, MD, MBA [18]
Pediatric Anesthesiologist Abed Rahman, MD, MS [29]
Department of Anesthesiology and Pain Management Interventional Pain Service
John H. Stroger, Jr. Hospital of Cook County Oak Forest Health Center
Assistant Professor of Anesthesiology Anesthesiology and Pain Management
Rush Medical College John H. Stroger, Jr. Hospital
Chicago, Illinois Chicago, Illinois

Lisa Palivos, MD, FACEP [132, 133] René Ramirez, MD, FACEP [84, 158]
Assistant Professor Scribe Director
Rush Medical College Assistant Clinical Professor
Attending Physician Department of Emergency Medicine
Department of Emergency Medicine Community Regional Medical Center
Cook County Health and Hospital Systems University of California San Francisco-Fresno
Chicago, Illinois Fresno, California

Anant Patel, DO [223] John Ramos, MMS, PA-C [135]

Assistant Medical Director Assistant Professor
Core Faculty Dominican University of California
Department of Emergency Medicine: John Peter Smith Health Department of Emergency Medicine
Network Marin General Hospital
Integrative Emergency Services San Rafael, California
Fort Worth, Texas
Caleb Andrew Rees, MD [173]
Andrew F. Perin, MD [194, 196] Resident Physician
Little Rock Eye Clinic Department of Emergency Medicine
Little Rock, Arkansas John Peter Smith Health Network
Fort Worth, Texas

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 xxiv Contributors

Eric F. Reichman, PhD, MD, FAAEM, FACEP, NBPAS [53, 55-58, John S. Rose, MD, FACEP [5]
85, 87, 97, 113, 116, 118, 124, 145, 152, 156, 177, 189, 200, Professor
203, 209, 211, 212] Department of Emergency Medicine
Clinical Associate Professor of Emergency Medicine University of California, Davis Health System
Attending Physician, Department of Emergency Medicine Sacramento, California
UT-Health
McGovern Medical School Matthew Rosen, MD [74]
University of Texas Health Science Center at Houston-Medical Resident
School Department of Emergency Medicine
Voluntary Attending Physician, Emergency Department UCLA Emergency Medicine Residency Program
Memorial Hermann Hospital-Texas Medical Center Ronald Reagan UCLA Medical Center
Houston, Texas Olive View-UCLA Medical Center
Los Angeles, California
Nicole Remish, DO [89]
Department of Emergency Medicine Andrew Rotando, DO [94]
John Peter Smith Hospital Attending Physician
Fort Worth, Texas Department of Emergency Medicine
Rochester Regional Health
Melissa M. Rice, MD [197, 202] Rochester, New York
Assistant Professor
Department of Emergency Medicine Jason M. Rotoli, MD [69]
Rush University Medical College Assistant Professor
Chicago, Illinois Department of Emergency Medicine
University of Rochester
Tim Richardson, MD [132] Assistant Residency Director
Department of Emergency Medicine Department of Emergency Medicine
John H. Stroger, Jr. Cook County Hospital Deaf Health Pathways, Director
Chicago, Illinois University of Rochester Medical Center
Rochester, New York
Rebecca R. Roberts, MD [150]
Attending Physician
Amir A. Rouhani, MD [144]
Research Director Assistant Clinical Professor
Department of Emergency Medicine Director of Simulation Education
John H. Stroger, Jr. Hospital Olive View-UCLA Medical Center
Assistant Professor of Emergency Medicine Department of Emergency Medicine
Rush University Medical College David Geffen School of Medicine at UCLA
Chicago, Illinois Los Angeles, California

Richard Dean Robinson, MD [2, 91, 173-176, 210, Dino P. Rumoro, DO, MPH [186, 191]
213-215, 217] Associate Professor
Vice Chairman Department of Emergency Medicine
Department of Emergency Medicine Rush Medical College
John Peter Smith Health Network Chicago, Illinois
Associate Professor
Department of Emergency Medicine Christopher J. Russo, MD [10, 60, 115, 119, 170]
University of North Texas Health Science Center Clinical Assistant Professor of Pediatrics
Fort Worth, Texas Sidney Kimmel Medical College of Thomas Jefferson University
Philadelphia, Pennsylvania
Patrick J. Rogers, DO [40, 41] Attending Physician
Department of Emergency Medicine Division of Emergency Medicine
Jersey Shore University Medical Center Nemours/Alfred I. duPont Hospital for Children
Neptune, New Jersey Wilmington, Delaware

Carlos J. Roldan, MD, FACEP, FAAEM [46, 136, 181, 189, 228] Alia Safi, MD [28]
Associate Professor of Emergency Medicine Former Anesthesiology Resident
The University of Texas, Health Science Center at Houston Medical Department of Anesthesiology
School John H. Stroger, Jr. Hospital
Assistant Professor of Pain Medicine Cook County Health and Hospitals System
The University of Texas MD Anderson Cancer Center Chicago, Illinois
Houston, Texas

Reichman_FM_pi-xxx.indd 24 13/08/18 6:28 PM

 Contributors xxv

Dean Sagun, MD [232] Luis Sequera-Ramos, MD [26]

Attending Physician Anesthesia Resident
Department of Emergency Medicine Department of Anesthesiology and Pain Management
TeamHealth Cook County Health System
Memorial Hermann Hospital Northeast Chicago, Illinois
Humble, Texas
Fred A. Severyn, MD [25]
Joseph A. Salomone, III, MD [35] Associate Professor of Emergency Medicine
St. Croix, United States Virgin Islands University of Colorado School of Medicine
Aurora, Colorado
Stephen Sandelich, MD [115]
Emergency Medicine Physician Chirag N. Shah, MD, FACEP [40-42, 121, 208]
Division of Emergency Medicine Associate Professor
Summerville Medical Center Department of Emergency Medicine
Trident Health System Rutgers-Robert Wood Johnson Medical School
Charleston, South Carolina New Brunswick, New Jersey

Devin Sandlin, MD [192] Andrew Shedd, MD, FACEP [174, 175]

Clinical Faculty Associate Residency Director
Department of Emergency Medicine Ultrasound Director
John Peter Smith Hospital Department of Emergency Medicine
Fort Worth, Texas John Peter Smith Health Network
Fort Worth, Texas
Ashley N. Sanello, MD [229]
Emergency Medicine Physician Scott C. Sherman, MD [99]
Torrance Memorial Medical Center Associate Residency Director
Medical Director, City of Compton Fire Department Cook County Emergency Medicine Residency
Torrance, California Associate Professor of Emergency Medicine
Rush Medical College
Shari Schabowski, MD [185] Chicago, Illinois
Assistant Professor
Rush Medical College Guy Shochat, MD [207, 224]
Attending Physician Clinical Associate Professor
Department of Emergency Medicine Department of Emergency Medicine
Cook County Health and Hospital Systems University of California, San Francisco School of Medicine
Chicago, Illinois San Francisco, California

Jeffrey Schaider, MD [218] Craig Sisson, MD, RDMS, FACEP [63]

Chairman, Department of Emergency Medicine Clinical Associate Professor
Cook County Health and Hospital System Director, Division of Ultrasound
Professor, Department of Emergency Medicine Director, Emergency Ultrasound Fellowship
Rush Medical College Co-Director, Combined Ultrasound and Global Health Fellowship
Chicago, Illinois Co-Director, Longitudinal Medical Student Ultrasound
Curriculum
Jessen D. Schiebout, MD [226] Adjunct Associate Professor, Department Cell Systems and
Anatomy
Associate Professor
UTHSCSA Department of Emergency Medicine
Department of Emergency Medicine
Joe R. and Teresa Lozano Long School of Medicine
Rush University Medical Center
San Antonio, Texas
Chicago, Illinois

Michael A. Schindlbeck, MD, FACEP [139, 154] Elaine H. Situ-LaCasse, MD [92]

Clinical Assistant Professor
Associate Program Director
Department of Emergency Medicine
Cook County Emergency Medicine Training Program
University of Arizona College of Medicine
Assistant Professor of Emergency Medicine
Banner University Medical Center
Rush Medical College
Tucson, Arizona
Chicago, Illinois

Matthew D. Schwartz, DO [179] Eric R. Snoey, MD [172, 222]

Clinical Professor of Emergency Medicine
Attending Emergency Physician
UCSF School of Medicine
Department of Emergency Medicine
Designated Institutional Official and Vice Chair
Southside Hospital
Department of Emergency Medicine
Bay Shore, New York
Alameda Health System–Highland Hospital
Oakland, California

Reichman_FM_pi-xxx.indd 25 13/08/18 6:28 PM

 xxvi Contributors

Steven J. Socransky, MD, FRCPC [187] Crystal Ives Tallman, MD [111, 201]
Associate Professor Assistant Clinical Professor of Emergency Medicine
Northern Ontario School of Medicine Department of Emergency Medicine
Sudbury, Ontario, Canada UCSF Fresno
Fresno, California
Jennifer L’Hommedieu Stankus, MD, JD, FACEP [72]
Contract Emergency Physician Joel Tallman, PharmD [201]
Department of Emergency Medicine Clinical Pharmacist
Madigan Army Medical Center Department of Pharmacy
Tacoma, Washington Community Regional Medical Center
Fresno, California
Lori Stolz, MD, RDMS [64, 160]
Assistant Professor Jessica Tang, MD [204]
Banner University Medical Center Fellow in Otolaryngologic Research
Tucson, Arizona Chicago ENT
Advanced Center for Specialty Care
Gunnar Subieta-Benito, MD [143] Advocate Illinois Masonic Medical Center
Chicago, Illinois
Attending Physician
Department of Anesthesiology
John H. Stroger, Jr. Hospital Katie Tataris, MD, MPH, FAEMS, FACEP [27]
Cook County Health and Hospitals System Assistant Professor of Medicine
Assistant Professor Section of Emergency Medicine
Rush Medical College EMS Medical Director, Chicago South EMS System–Region XI
Chicago, Illinois The University of Chicago Medicine and Biological Sciences
Chicago, Illinois
Noah T. Sugerman, MD [144]
Health Sciences Assistant Clinical Professor Alexis R. Taylor, MD, MSc [161]
Department of Emergency Medicine Emergency Medicine Resident
Olive View-UCLA Medical Center Madigan Army Medical Center
Los Angeles, California Tacoma, Washington
Staff Physician
Department of Emergency Medicine Benjamin Thomas, MD [63]
Los Robles Hospital and Medical Center
Senior Resident
Thousand Oaks, California
Department of Emergency Medicine
Highland Hospital
John E. Sullivan, MD [114] Oakland, California
Attending Physician, Emergency Medicine
Boca Raton Regional Hospital Natasha Thomas, MD [127]
Voluntary Clinical Assistant Professor
Resident Physician
Florida Atlantic University
Department of Emergency Medicine
School of Medicine
John H. Stroger, Jr. Hospital
Boca Raton, Florida
Cook County Health and Hospital Systems
Chicago, Illinois
Tina Sundaram, MD, MS [102, 142]
Clinical Instructor Dedra R. Tolson, MD [92]
Department of Emergency Medicine
Staff Physician
Rush University Medical School
Department of Emergency Medicine
Chicago, Illinois
Madigan Army Medical Center
Tacoma, Washington
Mark Supino, MD, FACEP [153]
Associate Program Director Shahed Toossi, MD [146, 147]
Department of Emergency Medicine
Neurocritical Care Attending
Jackson Memorial Hospital
Departments of Neurology and Neurosurgery
Miami, Florida
Cedars-Sinai Medical Center
Los Angeles, California
Henry D. Swoboda, MD [78, 141]
Departments of Emergency Medicine and Psychiatry Maria L. Torres, MD [143]
Rush University Medical Center
Director Pain Management Center
Assistant Professor
Department of Anesthesiology and Pain Management
Rush Medical College
Cook County Health and Hospital System
Chicago, Illinois
Chicago, Illinois

Reichman_FM_pi-xxx.indd 26 13/08/18 6:28 PM

 Contributors xxvii

Serge G. Tyler, MD [9] David L. Walner, MD [207]

Chairman, Adult Anesthesia Pediatric Otolaryngology
Senior Attending, Section of Airway Anesthesia Anesthesiology Advocate Children’s Hospital
OR Manager, Department of Anesthesiology and Pain Park Ridge, Illinois
Management Clinical Professor
Cook County Health and Hospitals System Departments of Surgery and Pediatrics
Chicago, Illinois Rosalind Franklin University of Medicine and Science
North Chicago, Illinois
Jaroslav Tymouch, MD [24]
Department of Anesthesiology Ryan Walsh, MD [75, 83]
Division of Cardio-Thoracic Anesthesia Assistant Professor
John H. Stroger, Jr. Hospital of Cook County Department of Emergency Medicine
Clinical Associate Professor Vanderbilt University Medical Center
Anesthesiology Department Nashville, Tennessee
Rush University
Chicago, Illinois Hao Wang, MD, PhD [86, 88-91]
Director of Research
Anna Tzonkov, MD [30] Department of Emergency Medicine
Clinical Associate Professor Integrative Emergency Services
Department of Anesthesiology and Pain Management John Peter Smith Health Network
Cook County Hospital and Health Systems Fort Worth, Texas
Chicago, Illinois
Matthew Waxman, MD, DTM&H [205]
Atilla Üner, MD, MPH [151, 220, 231] Associate Clinical Professor of Emergency Medicine and
Health Science Clinical Professor of Emergency Medicine and Internal Medicine
Nursing Department of Emergency Medicine Olive View-UCLA
David Geffen School of Medicine at UCLA Medical Center
Los Angeles, California David Geffen School of Medicine at UCLA
Los Angeles, California
Erika Flores Uribe, MD, MPH [82]
Assistant Professor of Clinical Emergency Medicine Ariana Wilkinson Weber, MD [137]
Department of Emergency Medicine Emergency Medicine Resident
LAC + USC Medical Center Jackson Memorial Hospital
Keck School of Medicine Miami, Florida
Los Angeles, California
Joseph M. Weber, MD [27]
Sami H. Uwaydat, MD [194, 196] Associate Professor of Emergency Medicine
Associate Professor Rush Medical College
Director, Vitreoretinal Service Department of Emergency Medicine
Jones Eye Institute Cook County Hospital
University of Arkansas for Medical Sciences Chicago, Illinois
Little Rock, Arkansas
Grant Wei, MD [79]
Alison Uyemura, MD [169] Associate Professor
Obstetrics and Gynecology Department of Emergency Medicine
Baylor College of Medicine Rutgers Robert Wood Johnson Medical School
Houston, Texas New Brunswick, New Jersey

Gennadiy G. Voronov, MD [11, 14, 17, 18, 21, 22, 24, 26, 30-32] Evan J. Weiner, MD, FAAP, FACEP, FAAEM [230]
Assistant Professor of Anesthesiology Program Director, Pediatric Emergency Medicine Fellowship
Rush University Medical Center St. Christopher’s Hospital for Children
Chairman Assistant Professor of Pediatrics
Department of Anesthesiology and Pain Management Drexel University College of Medicine
Cook County Health & Hospitals System Philadelphia, Pennsylvania
Chicago, Illinois
Daniel W. Weingrow, DO [68, 148]
Clinical Assistant Professor
Department of Emergency Medicine
Ronald Reagan UCLA Medical Center
David Geffen School of Medicine at UCLA
Los Angeles, California

Reichman_FM_pi-xxx.indd 27 13/08/18 6:28 PM

 xxviii Contributors

Elizabeth Barrall Werley, MD [62] Peter C. Wroe, MD [63]

Assistant Professor Resident Physician
Department of Emergency Medicine Department of Emergency Medicine
Penn State Health Milton S. Hershey Medical Center Highland Hospital–Alameda Health System
Penn State University College of Medicine Oakland, California
Hershey, Pennsylvania
Daniel Yousef, PharmD [153]
Michael S. Westrol, MD [95] Clinical Pharmacy Specialist
Assistant EMS Medical Director Department of Pharmacy
Department of Emergency Medicine Jackson Memorial Hospital
AtlantiCare Regional Medical Center Miami, Florida
Atlantic City, New Jersey
Wesley Zeger, DO, FACEP [8, 160]
Katherine Gloor Willet, MD [98] Director of Clinical Operations
Attending Physician Department of Emergency Medicine
Department of Emergency Medicine University of Nebraska Medical Center
Hickson-Lied Medical Center Omaha, Nebraska
Omaha, Nebraska
Nestor Zenarosa, MD, FACEP [89]
Jon Wolfshohl, MD [90] Attending Physician
Chief Resident Department of Emergency Medicine
Department of Emergency Medicine John Peter Smith Health Network
John Peter Smith Hospital Fort Worth, Texas
Fort Worth, Texas

Reichman_FM_pi-xxx.indd 28 13/08/18 6:28 PM

 Preface

Emergency Medicine is extremely broad and the advances have to perform a procedure. While alternative techniques are described
been amazing in recent years. The field covers the neonate through in many chapters, we have not exhaustively included all alternative
the geriatric, surgical and medical, and encompasses all organ sys- techniques. Key information, cautions, and important facts are
tems. Emergency Medicine is rapidly evolving. Procedural skills highlighted throughout the text in bold type.
must supplement our cognitive skills. Achieving proficiency in Each chapter, with a few exceptions, has a standard format. The
procedural skills is essential for the daily practice of Emergency relevant anatomy and pathophysiology is discussed followed by
Medicine. We have produced a clear, complete, and easy to under- the indications and contraindications for the procedure. A list is
stand textbook of Emergency Medicine procedures. This new edi- provided of the necessary equipment. The patient preparation
tion addresses the diverse topic of Emergency Medicine. This text including consent, anesthesia, and analgesia is addressed. The
will provide medical students, residents, advanced practice practi- procedure is then described in a step-by-step format. Cautions are
tioners, and the seasoned Emergentologist with a single procedural placed where problems commonly occur. Alternative techniques
reference on which to base clinical practices and technical skills. and helpful hints for each procedure are presented. The aftercare
The primary purpose of this text is to provide a detailed and and follow-up are discussed. Any potential complications are
step-by-step approach to procedures performed in the Emergency described including the methods to reduce and care for the com-
Department. It is expressly about procedures. It is not meant to be plications. Finally, a summary contains a review of any critical or
a comprehensive reference but an easy to use and clinically useful important information.
procedure book that should be in every Emergency Department. This book covers a wide variety of procedures that may be per-
The contents and information are complete. It is organized and formed in a rural or urban Emergency Department. This includes
written for ease of access and usability. The detail is sufficient to procedures performed routinely or rarely; procedures that are often
allow the reader to gain a thorough understanding of each proce- performed in the acute care, clinic, and office settings; procedures
dure. When available, alternative techniques or hints are presented. that are performed frequently in the daily practice of Emergency
Each chapter provides the reader with clear and specific guidelines Medicine; and procedures that are seldom to rarely performed but
for performing the procedure. Although some may use this text as critical to the practice of Emergency Medicine. Some procedures
a library reference, its real place is in the Emergency Department are uncommon, may not be known to the reader, and provide an
where the procedures are performed. Despite its size, I hope that opportunity to acquire new information that may be converted
this book will find its way to the bedside to be used by medical with proper practice and training into a useful skill. A few of the
students, residents, advanced practice providers, and practicing procedures are performed only by Surgeons and are included to
clinicians. promote understanding when the patient presents to the Emergency
This book will satisfy the needs of a variety of backgrounds and Department with a complication. This new edition has added
training. While this text is primarily written for Emergentologists, chapters, algorithms, clinical pictures, cutting-edge technological
many other practitioners will find this a valuable reference. This advancements, radiographs, and tables based upon readers’ com-
book is written for those who care for people with acute illness or ments, input, and suggestions.
injury. Medical students and residents will find this an authorita- We have drawn on a wide variety of authors. The majority
tive work on procedural skills. Medical students, residents, nurse of authors are residency-trained, board-certified, and practicing
practitioners, physician’s assistants, and practitioners with lim- Emergentologists. We have the honor of having some contributors
ited experiences will find all the information in each chapter from outside the field of Emergency Medicine and who are experts
to learn the complete procedure. Family Physicians, Internists, in their own specialty. All authors do have biases because of dif-
and Pediatricians will find this text useful to review procedures ferences in education, experience, and training. We have tried to
infrequently performed in the clinic, office, or urgent care center. base all recommendations on sound clinical and scientific data.
Intensivists and Surgeons involved in the care of acutely ill patients However, we have not excluded personal experience or preferences
will also find this book a wonderful resource. The experienced cli- when appropriate. In these cases, the authors also present alterna-
nician can get a quick refresher on the procedure while enhancing tive techniques.
their knowledge and skills. Physicians actively involved in educa- This book has grown and changed with this third edition. I
tion will find this text an easy to understand and well-illustrated am happy and privileged to edit this third edition of the text.
source of didactic material. Continued input and suggestions from you, the reader, would be
The book is organized into sections with each representing an most appreciated. Let me know what additional procedures should
organ system, an area of the body, or a surgical specialty. Each chap- be included or excluded in the future. Any errors, in the end, are
ter, with a few exceptions, is devoted to a procedure. This should mine. Please let me know of any mistakes or omissions, big or small,
allow quick access to complete information. The chapters have a at [email protected].
similar format to allow information to be retrieved as quickly and
Eric F. Reichman, PhD, MD
as efficiently as possible. There are often several acceptable methods

xxix

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 Acknowledgments

I must thank my wife Kristi for all of her patience during this I want to thank all the authors. Many of you are good friends that
endeavor that took many hours. Phoebe, Joey, Kobi, and Freya I cherish, and all of you gave of yourselves and your time.
always kept me entertained, day and night. Thanks to Ken and Russ Susan Gilbert is a wonderful medical illustrator and friend. Her
for all the support and help. input and assistance only added to the illustrations of the editions of
I would like to acknowledge the support of friends, colleagues, this book. Working with her was easy, fun, and simple.
current residents, and former residents in the Departments of Thanks to all those at McGraw-Hill Education, especially
Emergency Medicine at The University of Texas at Houston Medical Kim Davis and Amanda Fielding. The tracking of the chapters,
School and Cook County Hospital. They provided friendship and communication, and assistance when needed made this edition
encouragement and were always there when needed. A special easier to complete than previous editions.
thanks always goes to Bob Simon, MD and Jeff Schaider, MD who
Eric F. Reichman, PhD, MD
got me started and set me on this academic path.
The support from Janet Sherry, Yolanda Torres, and Jamie
McCarthy, MD was invaluable.

xxx

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 SECTION

Introductory Chapters 1
for efficiency and protocol compliance independent of the patient’s
Informed Consent preferences and needs. Examples include a trauma activation or a
1 Eric Isaacs
public health emergency. Increasing space constraints and crowd-
ing found in most EDs create a lack of privacy that can impede the
free exchange of sensitive information. Procedural interventions in
the ED are often concurrently diagnostic and therapeutic, further
This chapter is designed as a practical reference for the Emergency complicating informed decisions.
Physician (EP). It focuses on the unique challenges of informed con- The torrent of complex medical information physicians provide
sent in the Emergency Department (ED). It presents a practical guide patients is overwhelming in the most controlled settings. It is only
for the informed consent process, reviews the exceptions, and offers made worse in the high-emotion and high-stress environment of the
suggestions on difficult scenarios of informed consent in the ED. ED. EPs often make rapid decisions with limited information. Many
of our colleagues in other specialties may not share this skill. The
INFORMED CONSENT EP’s expectations of patients must be equally, if not more, tolerant.
The absence of an ongoing physician–patient relationship offers no
The right of a patient to make decisions about their body, includ-
basis upon which to build trust, elicit values, and draw preference
ing the refusal of recommended procedures and treatment, is an
knowledge. Lack of a prior relationship tests the ability to establish
important concept in medical practice with foundations in law
an immediate rapport with patients and renders patients’ ability to
and medical ethics. Informed consent is the process of commu-
express their values most important.
nication that demonstrates respect for a patient’s right to make
There may not be time to ponder the intricacies of medical ethics
autonomous decisions about their health care. Informed consent
in the ED or to satisfy all the requirements of searching for the best
is an ethical practice and a legal requirement for all procedures
surrogate decision maker when there is uncertainty about a patient’s
and treatments.1
preferences or a potential refusal. Many EPs will default to doing as
much as possible in these difficult situations.5 There is often enough
UNIQUE CHALLENGES OF INFORMED time to make a considered decision before acting in the most aggres-
CONSENT IN THE ED sive fashion. While some say that it is easier to withdraw care once
Each practice environment presents its own challenges to the pro- the clinical picture becomes clearer, this aggressive course of action
cess of obtaining informed consent. Physicians frequently fail to must be balanced with the knowledge that EP may be performing
fulfill all the requirements of obtaining informed consent.2-4 a painful or unwanted procedure on a patient who has previously
The ED presents significant challenges, which despite assumptions made their wishes clear. Informed consent was often bypassed in
to the contrary, results in a greater need to spend time delivering the past under the presumption that a patient would want aggressive
information and engaging patients in their care decisions to the treatment. The scope of ED care and societal norms have shifted in
extent possible (Table 1-1). Time pressure and acuity are the most recent years. Informed consent for procedures in the ED needs to
critical factors that influence the care paradigm in the ED. Care reflect the current standards of practice.
provided in the ED spans the full continuum of care as nonacute
care is increasingly sought in the ED. Care in the ED addresses the
full spectrum of society with patients from diverse health literacy,
LEGAL FOUNDATION FOR INFORMED CONSENT
language origins, socioeconomic backgrounds, and recognized Consent originates in the legal doctrine of battery (i.e., touching of
vulnerable populations (e.g., children, elderly, and prisoners). EPs the body without permission). The notion of protecting a patient
need to be prepared to address the broad clinical needs of diverse from the bodily trespass of a procedural invasion was framed by
patients under pressure without the traditional physician–patient Justice Cardozo in 1914: “[e]very human being of adult years and
relationship. Systemic constraints exacerbate this challenged pro- sound mind has a right to determine what shall be done with his
fessional context as patients have no choice in the treating physi- own body; and a surgeon who performs an operation without
cian or the treating facility. The location to transport the patient is his patient’s consent commits an assault, for which he is liable in
often dictated by prehospital protocols. Tension may arise when a damages….”6 By 1957, the notion of consent shifted from mere per-
patient’s wishes conflict with greater societal or institutional needs mission to an authorization following “the full disclosure of facts
necessary to an informed consent.”7 Emerging at the same time as the
bioethics movement’s shift away from paternalistic medicine toward
TABLE 1-1 Challenges for the EP to Spend Time Engaged in Conversation with a patient’s rights focus in medicine was Cantebury v. Spence.8 This
a Patient case resulted in an appeals court establishing a physician’s duty to
Lack of facility choice disclose the risks and benefits of a procedure and its alternatives
Little privacy and introduced the reasonable patient standard. The reasonable
No prior relationship patient standard is what a reasonable patient would need to know
Pace of care challenges lay person decisions to make an informed choice, shifting away from the professional
Public health or system-imposed constraints standard, what most physicians deemed necessary. The standard
Time pressure for disclosure today varies by state.9 As a result of the informed
1

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 2 SECTION 1: Introductory Chapters

consent “duty,” the legal and risk management function of informed TABLE 1-2 The Goals of EPs in the Informed Consent Process
consent (i.e., consent process that meets institutional and/or legal
Allow autonomous authorization (patient may consent or refuse)
parameters for formal recognition, referred to as “effective consent”)
Give information (more than we think we need to give)
overshadows the ethically driven process of informed consent (i.e., Make information accessible
consent as a communication process that demonstrates respect for Offer guidance in weighing information
a patient’s autonomy, referred to as “autonomous authorization”). Support patients to make their own decision
These two aspects serve distinct functions that are often conflated
under “informed consent.” Both are necessary for valid informed
consent and are addressed separately throughout this chapter.10
The exception presuming permission to treat in an emergency EPs must pay attention to the informed consent process to
has equally deep roots. Justice Cardozo’s opinion continues, “[t] accomplish the goal of respect for autonomy (Table 1-2). EPs
his is true except in cases of emergency where the patient is uncon- need to provide more information to the patient than they think
scious and where it is necessary to operate before consent can be is needed. Research indicates that patients need more information
obtained.”6 In Canterbury v. Spence, “the emergency exception” is than physicians think they need to feel “informed” in the decision-
included as a privilege from the duty to disclose when “the patient is making process.13 The need for a procedure seems obvious to the EP,
unconscious or otherwise incapable of consenting, and harm from and the balance of the considerations clearly tips in the favor of “do
a failure to treat is imminent and outweighs any harm threatened it.” EPs must slow down to fully explain the rationale for their rec-
by the proposed treatments.” It also states that a “physician should, ommendation with patients and to offer patients information that
as current law dictates, attempt to secure a relative’s consent if pos- allows their meaningful consideration of the recommendation so
sible.” In the emergency context, one may presume permission: that they can reach their own decisions. A good guideline is to offer
(1) to do what is necessary when (a) there is imminent harm from more time and information for procedures carrying greater risk.14
nontreatment and (b) when harm from nontreatment outweighs EPs must make the effort to work against the features of the ED
the harm from the proposed intervention; (2) where the patient (Table 1-1 and presumption of consent). Allow patients capable
is unconscious or unable to participate in care decisions; and (3) of engaging in their care decisions to express autonomous autho-
when the patient’s preferences are not known and no surrogate is rization. This is achieved by giving patients sufficient information,
immediately available to provide authorization.11 in an understandable way, and by honoring their decisions.

ETHICAL FOUNDATION FOR INFORMED COMPONENTS OF THE INFORMED CONSENT

CONSENT AND INFORMED REFUSAL PROCESS
In an era of patients’ rights and shared decision-making, robust Informed consent is the communication process that demonstrates
informed consent reflects a process of communication that secures and protects a patient’s self-determination by providing a patient
that a patient “gives an informed consent to an intervention if (and with decision-making capacity with sufficient, understandable infor-
perhaps only if) one is competent to act, receives a thorough disclo- mation and allows the patient to make a voluntary, knowledgeable
sure, comprehends the disclosure, acts voluntarily, and consents to decision. There are five requirements that must be satisfied.9 These
the intervention.”9 include the patient having decision-making capacity, the EP pro-
It is not uncommon to encounter the challenge of a patient refus- viding sufficient information, the patient understanding the infor-
ing a recommended procedure or intervention in a health care mation, the patient giving consent in a voluntary fashion without
environment where there is an expectation for more active patient coercion, and the patient communicating their decision (Table 1-3).
participation in health care decisions. Central to a strong patient–
physician relationship is the desire to promote patient well-being DECISION-MAKING CAPACITY
and simultaneously respect patient autonomy. Conflict between
The terms “competence” and “decision-making capacity” are fre-
EPs and patients may arise when views of what is in a patient’s best
quently used interchangeably, but their strict meanings are differ-
interest differ between them. EPs with the greatest integrity come
ent. Competence is a legal term with broader applications related
to work with the intention to act in the best interests of patients,
to financial matters and the determination of personal choices.
and do so with a focus on the prevention and eradication of disease
Decision-making capacity is a clinical term that speaks to the
to preserve life and improve disability. The patient may consent
specific capacity to make a clinical decision. Many people who are
or refuse the recommendation after an EP has fully informed a
legally “incompetent” retain health care decision-making capacity.
capable patient about an intervention in an understandable way.
If the patient does not have decision-making capacity, informed
An initial refusal of recommended treatment should begin a crit-
consent cannot be obtained and it must be obtained from a sur-
ical conversation that confirms all the elements of an informed
rogate decision maker, or the patient may fall into an exception
refusal. The informed refusal process will respect patient auton-
from informed consent.
omy by accepting a patient’s view of well-being and may require
honoring a refusal of the recommendation.12

TABLE 1-3 Requirements of the Informed Consent Process9

EP’S ROLE AND GOALS IN INFORMED CONSENT 1. Does the patient have the decision-making capacity to make this decision?
The EP’s role in the informed consent process is to provide 2. Has there been disclosure of relevant procedural information (including risks/benefits for
patients the information needed to make their own decisions. intervention, alternatives, and nonintervention)?
Provide written sheets that cover all aspects of the procedure if 3. Has the information been presented in a way that is understandable to the patient?
available. It is important not to overwhelm a patient with too much 4. Has the information been presented in a way that allows the patient to make their own
information or complex clinical decisions. Including patients in decision voluntarily while still being informed of the physician’s recommendation?
appropriate care decisions (e.g., the informed consent process for 5. Has the patient communicated a decision?
a procedural intervention) is an ethically important goal. 6. Does an exception apply?

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 CHAPTER 1: Informed Consent 3

DETERMINING DECISION-MAKING CAPACITY to inform these patients of the procedure and to engage their assent.
Unlike consent, assent is not determinative. It does offer the pos-
The determination that a patient has decision-making capacity sibility of the individual participating in their care.15
is at the core of informed consent. By default, EPs assume that a
patient has capacity and confirm this through routine dialogue with
the individual. Confirm six elements when there is a question about PATIENTS LACKING DECISION-MAKING
a patient’s capacity to make an informed decision about procedures CAPACITY
or treatment.15 The patient must be able to: understand and process
It is not possible to obtain informed consent when a patient lacks
the options, weight the benefits and risks, apply a set of values and
decision-making capacity. Necessary treatment may be provided
goals to the decision, arrive at a decision, communicate a choice,
to patients who lack decision-making capacity without obtain-
and demonstrate capacity to make the decision (Table 1-4).
ing the patient’s informed consent. Make every effort to learn the
Determination of capacity is a clinical decision based on the
patient’s previously stated preferences for treatment (e.g., written
judgment of the EP regarding the patient’s actual level of func-
advance directives or communication with a primary care provider).
tioning and appreciation of the ramifications of the clinical
Make efforts to obtain consent from a surrogate decision maker
situation.16 The degree of capacity needed to understand risks and
if prior preferences are not available. A surrogate decision maker
benefits of suturing a finger laceration differs from a cardiac cath-
is a person entrusted with making health care decisions because
eterization. A patient may be able to understand one choice but not
they know the patient best and can bring the patient’s values and
another. An Alzheimer patient who is pleasant, oriented to place,
goals into the clinical decision process. This role can be challenging
and oriented to year may be unable to appreciate the consequences
for even the most capable decision makers. It is not uncommon for
of a decision. This patient may have capacity for some tasks but may
surrogates to have a role conflict between applying their own values
lack the capacity to consent for a specific procedure (e.g., lumbar
and/or wishes and those of the patient.
puncture).
EPs must pay attention to the language used when asking a
The EP needs to assess the ability for the individual to weigh the
surrogate decision maker for consent. Frame the discussion with
risks considering their (i.e., the patient’s) own values. An example
phrases asking what the patient would want in the situation, such as
would be the ramifications of a fracture reduction on the dominant
“How would your father view this situation?” or “What would your
hand. A construction worker or musician may decide different than
father’s preference be based on his values?” Avoid general phrases
an individual whose livelihood does not depend on perfect hand
such as “What should we do?”, “What do you want us to do?”, or
function.
“What do you think he would want?” An EP can ask the surrogate
A recognized element of decision-making capacity is whether
“Why do you think he would choose that?” if the decision seems to
the patient’s decision is consistent over time. This is not necessar-
stem from a role conflict. No prior conversation covers every clini-
ily applicable specifically to the ED. A possible heuristic is whether
cal scenario perfectly, and the gravity of the decision can frequently
the decision is consistent with the person’s narrative and values
be overwhelming for the surrogate.12
as expressed consistently over time in life choices. The decision-
The choice of a surrogate decision maker may be obvious in some
specific nature of capacity acknowledges that the level of capacity
cases (e.g., the parent or legal guardian of a child). The choice can
needed depends upon the complexity of the decision, with greater
be more complex in other cases. Who may serve as a surrogate and
capacity needed for decisions with graver consequences. The degree
their scope of authority varies by state. What if the appropriate sur-
of capacity needed to consent does not necessary equal the degree
rogate is in question and there is no statutory guidance? A useful
of capacity needed to refuse a recommended intervention.12
guide is that the surrogate’s authority arises from a close relationship
Informed refusal will be discussed later in this chapter.
to the patient that affords accurate and informed communication of
Decision-making capacity is a dynamic process and changes
the patient’s values. Refer challenges in resolving conflict between
depending upon the patient’s evolving condition and task in
potential surrogates (e.g., siblings with different opinions regarding
question. The ED patient may be able to participate to a greater
parental care) to an ethics committee or other institutional mech-
or lesser extent depending on fluctuations in their condition and
anisms to offer guidance unless emergent conditions make that
alterations of their sensorium from the administration of medica-
impractical.
tions. Make efforts whenever possible to enhance the patient’s deci-
sion-making capacity (e.g., reduce pain medication temporarily or
visit patients at optimal times) to engage them to the fullest extent INFORMATION TRANSMITTAL
possible in their care.
Emancipated minor and adolescent laws vary from state to state.9 The EP must relate sufficient information about the procedure to
Emancipated minors are legally recognized as adults and respon- the patient. This raises the questions of what information to pres-
sible for their own finances and care. They can provide fully ent and how much to present. Relevant information includes the
informed consent. Know the local laws where minors who are not risks and benefits of the procedure, any alternatives to the pro-
emancipated may give consent for sensitive conditions or proce- posed course of action, and the consequences of nonaction. The
dures (e.g., those of a reproductive nature or substance abuse). question remains how much information needs to be disclosed to
Informed consent may not be possible with some populations patients, particularly considering the potential that legal action may
(e.g., young children and elderly with dementia). It is still possible be taken if an EP does not obtain informed consent properly.17
There are two standards that are commonly used, and these vary
by state. The traditional “professional standard” requires the EP to
TABLE 1-4 Elements to Determine if a Patient Has Decision-Making Capacity provide information based on what the profession’s standard of prac-
1. The patient is able to understand and process the options presented. tice would deem necessary to disclose for a patient to be informed.
2. The patient is able to weight the relative benefits, burdens, and risks of the options. The more common “reasonable person standard” requires the EP to
3. The patient is able to apply a set of values and goals to the decision. include all the information that a reasonable patient would want to
4. The patient is able to arrive at a decision that is consistent over time. know to make a knowledgeable decision. Information that should
5. The patient is able to communicate a choice. be communicated includes: the patient’s current medical condi-
6. The patient demonstrates capacity appropriate and sufficient to make this decision. tion and how will it progress if no treatment is given, the treatment

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 4 SECTION 1: Introductory Chapters

alternatives, the risks and benefits of each potential treatment and Some hospitals have patients sign “blanket” consent forms agree-
their probabilities, and the financial costs of each if those estimates ing to all emergency tests and treatments upon their registration
exist. Finally, the EP should provide a personal recommendation as in the ED. Such consent forms provide no information regarding
to the best alternative.9 specific individual procedures.23 These forms are not acceptable
because they fail to respect patient autonomy. Blanket consent
forms cannot substitute for the usual informed consent process
UNDERSTANDABLE PRESENTATION OF for procedures in the ED, where a dialogue with the patient is
INFORMATION required.24
Information must be given in a way that is understandable. The
patient must be able to adequately weigh the benefits, burdens, EXCEPTIONS TO THE INFORMED
and risks of the treatment in the context of their own beliefs, CONSENT PROCESS
goals, life, and values. The obvious differential in knowledge and
understanding between patients and EPs may be exacerbated by lan- EMERGENCY EXEMPTION
guage barriers, literacy, low educational levels, and numeracy.18 Such
barriers may be overcome by speaking at a level easy for the patient Society’s overriding assumption is that a person would want lifesav-
to comprehend, being sensitive to patients who may be unable to ing treatment in an emergency. Consent to treatment is generally
read, and being sensitive of patients who may not be highly edu- presumed under specific emergency circumstances where inter-
cated. Understanding is bidirectional and necessitates that the EP vention is necessary to save life or limb, the harm of nontreatment
confirms that the patient understands what they are told.19 Commu- is greater than the harm of the intervention, a patient is unable to
nicating numbers (e.g., risk and probabilities) is the most complex participate in care decisions, and patient preferences are not known
task asked of the EP.20 Frame numbers in multiple ways and present with no surrogate available. This emergency exception is not abso-
outcomes in positive and negative contexts to enhance informed lute. This is particularly true when there is clear evidence that the
consent.20 For example, “three out of four children have no side patient’s wishes are contrary to the intervention being considered
effects, but one in four will have nightmares from this medication.” (e.g., prehospital advance directive or a wallet card stating no blood
Language barriers are frequent in the ED and pose significant transfusions).
concern in obtaining and documenting informed consent.21 Under- Some EPs believe that any patient in the ED qualifies for an
standing languages is situational. It is imperative to know when emergency exception by being in the ED. This is not true. Loca-
to call an interpreter even though some EPs may have additional tion by itself cannot be used to justify the emergency exception
non-English language proficiency. Limited language skills allow the or to infer an “implied consent” for broad ED care. The emer-
EP to extract some critical clinical information. Patients may need gency exception may be invoked only when the patient will be
more information than the EP’s skills allow. Calling an interpreter harmed by the delay necessary to obtain informed consent.25 The
may be essential for meeting a minimum standard of care.22 EP should ask themselves a few brief questions to determine if a
patient meets the criteria for an emergency exception to informed
consent (Table 1-5).
VOLUNTARY NATURE OF THE DECISION
Forced treatment where any real choice is removed from the THERAPEUTIC PRIVILEGE
patient being involved in the decision-making process violates
the doctrine of informed consent. Any form of coercion based on The therapeutic privilege is a disfavored concept but recognized
threats or intolerable consequences (e.g., the withholding of pain exception. It excuses the EP from the duty to disclose in the limited
medication) would fall into this category. EPs cannot manipulate circumstances where disclosure might create harm to the patient
patient decisions by withholding or distorting information that and interrupt the treatment process. This privilege is rarely invoked
the EP believes may sway the patient toward a preferred course. as it could almost negate the entire informed consent process. Ther-
Persuasion is permissible. It is an obligation as trained professionals apeutic privilege may be applied when direct disclosure to a patient
to synthesize the information and recommend a course of action. would create harm, generally recognized as occurring in some psy-
An appropriate recommendation includes laying out the risks, ben- chiatric conditions and for some cultural groups.9
efits, and reasoning behind the recommendation as well as explain-
ing the reasoning for not selecting an alternate approach. EPs can WAIVER OF INFORMED CONSENT
utilize the resources of the patient’s family or significant others to The EP has a duty to disclose information. Patients may differ in
provide arguments in favor of a course of treatment. The EP must how they approach their participation in care decisions. Some patients
be careful to avoid overwhelming the patient, as the goal should be a may prefer that another person (e.g., a close family member) receive
shared solution by consensus and not forcing the patient to surren- health care information and make treatment decisions on their
der to the wants of others.9 Strategies to approach a patient’s refusal behalf (i.e., delegated autonomy). This may be due to personal pref-
are discussed in depth later in this chapter. erence or cultural variation. The delegation of the decision-making

EFFECTIVE INFORMED CONSENT AND REFUSAL TABLE 1-5 Questions to Justify an Emergency Exception
There is a difference between the autonomous authorization 1. Will failure to treat quickly result in serious harm to the patient?
informed consent (i.e., information and dialogue) and the effec- 2. If their condition worsens, will the patient die or suffer serious harm before definitive care
tive informed consent (i.e., to meet legal and institutional require- can be delivered?
ments). Document the discussion of the benefits, burdens, risks, 3. Would most capable and reasonable people want treatment for this type of injury?
and alternatives addressed in the discussion with the patient for 4. Is the patient unable to participate in care decisions?
the autonomous authorization to be recognized as effective and 5. Are the patient’s preferences known or knowable in a timely way from a surrogate?
the entire informed consent to be valid. Reference local institu- 6. Is there any evidence that the patient would refuse this specific treatment?
tional policies to confirm an effective informed consent or refusal.10 7. Would failure to treat result in greater harm than the proposed intervention?

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 CHAPTER 1: Informed Consent 5

must be confirmed with the patient and not assumed based on Help the patient not feel cornered into following the recommenda-
cultural norms. The delegation reflects a patient’s right to waive tion while confirming their informed refusal. A refusal is an oppor-
informed consent. Honor the patient’s choice to delegate that right tunity to learn how to practice persuasive reasoning. A patient might
to another person as it demonstrates an autonomous choice.15 have misheard numbers, or the proposed procedure may resemble a
Some patients may interrupt the informed consent process after prior negative experience during the barrage of information disclo-
only partial information is disclosed and elect to follow the recom- sure. Take time to listen to the patient’s concerns and reasons for
mendation. If the EP confirms the patient’s acceptance of the conse- refusal. This can help navigate the informed refusal process.
quences of consent with only partial information, the EP may accept
this as consent via waiver of the informed consent process.25 The EP CONFIRM THE ADEQUACY OF INFORMATION
may accept a waiver of consent if the patient has capacity, under- WITH AN EMPHASIS ON UNDERSTANDABILITY
stands that they are giving up an important right, and has made the
request voluntarily. The EP who is uncomfortable with this respon- Reflect the patient’s refusal reasons back to the patient so that they
sibility may ask the patient to designate another person to assume feel they have been heard. It is important for the EP to acknowledge
this role. the patient’s perspective, even if they disagree with the reasons.
This allows the patient to engage in listening as the EP provides
additional information to support the recommendation. Normaliz-
IMPLIED CONSENT ing an “irrational concern” allows the patient to feel “okay” and still
Implied consent is a disfavored concept. It may be considered to follow the recommendation. For example, “I can understand that
“apply” in the very limited circumstances when an EP is undertak- your sister’s complication from procedural sedation several years
ing a clinical activity with a well-known risk-benefit profile.26 The ago would give you some concerns about this recommendation. I
most favored implied consent example is when a patient extends his want to reassure you that today we take these additional steps….”
arm for a blood draw. The volitional act of extending the arm is Tailor the revised recommendation to address the concerns of the
deemed as implied consent to the blood draw and its risks (e.g., pain patient and focus on making sure that the information provided is
and possible bruising). The assumption of “implied consent” poses simple, direct, and understandable.
a dangerous trap for the EP. What an EP considers routine and
well-known risks may differ greatly from what the patient knows. ADDRESS BARRIERS TO UNDERSTANDING
This is particularly true in the ED where there is little trust and no
Make significant efforts to enhance the patient’s ability to under-
knowledge of the patient’s health literacy.
stand the information when a refusal occurs. A professional inter-
Emergency Medicine research shows at least 50% of patients
preter must be utilized to compensate for any communication
wanted time spent on “detailed” information, including a review
barriers to the patient’s understanding in an informed refusal
of the risks of only 1% chance of occurrence. For example, lumbar
process. Revisit all the information from the initial discussion of
punctures are clinically safe and pose little risk. The patient per-
information that occurred with an informal interpreter (e.g., fam-
ceives lumbar puncture as an invasive procedure that requires more
ily member or health care provider). Residual misinformation can
information for informed consent.13 Implied consent is not suffi-
prolong a patient’s refusal. Start from the beginning of the clinical
cient when informed consent is required or possible.12
communication, even if it takes more time. This can often remedy
the situation. Use language or pictures tailored to a patient’s lower
UNREPRESENTED PATIENTS OR educational or functional level when necessary.19 Address any anxi-
THE PATIENT ALONE ety and pain as quickly and as safely possible as they may contribute
A patient who is unable to participate in care decisions and has no as a barrier to understanding.
surrogate decision makers is known as the “unrepresented patient”
or the “patient alone.” These highly vulnerable patients have no CONFIRM CAPACITY TO REFUSE
social networks to assist the care team in navigating consent and care RECOMMENDATIONS
decisions.27 Attention to clinical decision-making for this patient
population is growing.27 Statutory guidance on decision-making Is decision-making capacity a potential issue? The EP must take
for this patient population varies by region. Review institutional steps to mitigate any factors leading to impaired decision-making
policies to determine whether a policy exists for decision-making so that the patient may participate in their care to the fullest
for the “unrepresented patient.” Consultation with the ethics ser- extent possible.
vice is recommended in the absence of a policy, and make efforts to It was thought in the past that patients with certain diagnoses by
develop a consistent and transparent approach to care decisions for default lacked decision-making capacity. Many clinicians now rec-
this vulnerable population.15 ognize that patients with severe mental illness, early dementia, and
some organic brain syndromes are at risk for impaired decision-
making but may possess decision-making capacity for selected
INFORMED REFUSAL procedures and treatments.15 There are certain red-flag scenarios
The EP often begins with the presumption that patients possess when an EP should scrutinize a patient’s decision-making capacity
decision-making capacity to consent and refuse procedures. The EP with greater depth (Table 1-6). Actions or decisions with greater
may question a patient’s capacity in clinical practice more readily consequences require a more intense evaluation of the patient’s
when the patient disagrees with recommendations. capacity. A more careful evaluation of capacity is indicated when
the patient’s choice seems unreasonable or if the patient is unwill-
ing to discuss their thought process. Chronic psychiatric and neu-
UNDERSTAND THE REASONS FOR THE REFUSAL rologic conditions remain a risk for, but should not be equated with,
A refusal for a recommended intervention should be the begin- impaired decision-making. Cultural, educational, and language
ning of an important conversation with the patient. A refusal of a barriers impact the decision-making process. High levels of anxiety
recommendation when first proposed may seem a rebuff or poten- (e.g., untreated pain or the inevitable stress of the ED) are known to
tial time challenge. Approach a refusal with openness and curiosity. impair decision-making.28

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 6 SECTION 1: Introductory Chapters

TABLE 1-6 Red Flag Scenarios That Require Additional Assessments of the that must be documented in these cases. Document the patient’s
Patient’s Decision-Making Capacity medical condition and the procedure or treatment that is suggested,
including the urgency and necessity. Document the patient’s current
Abrupt change in mental status
Anxiety or untreated pain decision-making abilities with a description of the impediments
Chronic psychiatric or neurologic conditions to capacity and the actions taken by the EP to maximize capacity.
Cultural and language barriers Include the availability of family or other surrogate decision makers
Extremes of age and any relevant discussions.
Limited education Documentation will vary by institution and local laws. Being
Patients readily consenting to invasive or risky treatment familiar with the appropriate measures to make an informed con-
Refusal of recommended treatment sent or refusal is effective is a critical part of the informed consent
or informed refusal process in the ED.29

Many providers outside the ED setting will utilize psychiatric

consultations to assist with the evaluation of a patient’s decision- SHARED DECISION-MAKING
making capacity. The utility of such a consultation is frequently
limited by time and consultant availability. Consultations in the ED There has been much discussion about the concept of shared
may prove useful when evaluating a thought or delusional disorder decision-making (SDM).30-36 The concept was brought to the fore
that may impede understanding. in the Institute of Medicine (IOM) report “Crossing the Quality
Chasm.”30 It was in the context of improving quality and safety
through patient-centered care, “care that is respectful of and
EFFECTIVE DOCUMENTATION TO DOCUMENT responsive to individual patient preferences, needs, and values.”30
THE INFORMED REFUSAL The report went on to specify “that patient values guide all clinical
Honoring a refusal of emergency treatment that would be benefi- decisions.”30 There is a good deal of rhetoric surrounding patient-
cial or may result in decompensation or death is never easy. Use of centered care in the literature, attempting to move clinicians away
the standard hospital “Against Medical Advice” form can create an from the traditional role as the sole authoritarian and into the
adversarial relationship that an EP may find damaging to future role of a partner in care. SDM is a way of actualizing these words,
patient interactions and the subsequent treatment plan. Anecdotal engaging patients in the essential role as a participant in their care,
reports include cases where patients reconsidered their decision and breaking down communication barriers between providers
when presented with such a document. Document refusal of care and patients.
for medicolegal protection and to confirm that clear communica- Expert consensus argues that SDM is different than informed
tion with the patient had occurred. consent.31 Informed consent is used when there is one distinctly
The documented recommendations when a patient refuses treat- superior treatment choice. The informed consent process ensures
ment should include: the patient has refused the recommended the patient understands the risks and benefits from a particular pro-
procedure, test, or treatment; the patient’s reasons for the refusal; cedure and consents to the treatment freely and without persuasion.
and the consequences of the refusal were explained to the patient SDM is a process entered when there is more than one reasonable
including the alternatives, if any, being offered or performed in course of treatment indicated for a particular clinical situation, each
lieu of the recommended procedure. Include statements that show with its own set of outcomes and potential complications. The EP
the patient understood and continued to refuse the specific proce- and the patient exchange information involving their expertise in
dure or treatment and has the capacity to do so. Document that the the process of SDM. The EP shares the potential treatment options
patient’s wishes are being honored against medical advice. It would and describes the risks and benefits of each. The patient communi-
be preferable if the EP could have the patient read this documen- cates their values and preferences regarding each treatment. This is
tation followed by the patient signing the medical record below not to say that all responsibility for decisions is placed on the patient.
this documentation in acknowledgement. Each person contributes to the other’s understanding of important
Additional documentation is required when an EP recognizes aspects of the shared decision about how to move forward with
a “red-flag” scenario for impaired decision-making (Table 1-6) or treatment. “SDM is best described as a conversation between the
has other reasons for concern (Table 1-7). These are essential items clinician and the patient in which they figure out together what
to do to address this patient’s situation.”31
The mechanical approach to implementing SDM seems to disturb
TABLE 1-7 Mnemonics for Documentation of Decision-Making Capacity the spirit of a personalized strategy for a particular patient. There
Assessments are some fundamental components to include in a conversation.
U and I GLAD Clarify the patient’s understanding of their condition. Identify the
U–understanding of the procedure/discussion issue requiring treatment. Offer and describe options for treatment,
I–impairing conditions emphasizing the advantages and disadvantages of each. Develop an
G–goals and values understanding for the patient’s values and how they may affect pref-
L–logic used to decide erences for treatment. What matters most to the patient? Review
A–actual functioning the understanding of the patient’s preferences and move toward a
D–danger or risks of decision decision based on a combination of available treatment data and the
CURVES* patient’s preferences.
C–choose or communicate (Can the patient make and communicate their choice?) The ED may not lend itself well to the original approach to SDM
U–understand (Can the patient understand the risks, benefits, and alternatives?) using interventions crafted by specialists, hospitalists, and primary
R–reason (Can the patient make a logical and rational choice?) care providers. These tools include risk calculators, decision aids,
V–value (Is the choice consistent with patient values?) and conversation aids. Many of these were used outside the clinical
E–emergency (Is there impending risk?) encounter. Patient deliberation regarding options is a key task sup-
S–surrogate (Is a surrogate available or is there any documentation guiding treatment?) ported by SDM. Implementing SDM may not always be feasible in
*The first four refer to the decision-making capacity. The last two refer to treatment without consent. the ED with the pressures of acuity, flow, time, and variable volume.

Reichman_Section1_p001-p054.indd 6 20/03/18 5:55 pm

 CHAPTER 1: Informed Consent 7

8. Canterbury v. Spence, 464 F.2d 772 (D.C. 1972), cert. denied, 409 U.S. 1064
TABLE 1-8 The Order for Surrogates for the Delegation of Decisions (1973).
Spouse 9. Beauchamp TL, Childress JF: Principles of Biomedical Ethics, 7th ed. Oxford,
Adult child who has the consent of other children United Kingdom: Oxford University Press, 2012.
Majority of adult children 10. Faden RR, Beauchamp TL: The concept of informed consent, in: Faden RR,
Parent Beauchamp TL (eds): A History and Theory of Informed Consent. Oxford,
A person authorized by the patient United Kingdom: Oxford University Press, 1986.
Nearest living relative 11. Menikoff J: Law and Bioethics. An Introduction. Washington, D.C.:
Georgetown University Press, 2001.
Clergy member 12. Derse A: What part of “No” don’t you understand? Mount Sinai J Med 2005;
72:221-227.
13. Easton RB, Graber MA, Monnahan J, et al: Defining the scope of implied
consent in the emergency department. Am J Bioethics 2008; 7(12):35-38.
SDM is already occurring in the ED as we work with patients on 14. McCullough L, Whitney S: Consent: informed, simple, implied and pre-
timing of cardiac disease risk stratification, choice of imaging sumed first. Am J Bioethics 2007; 7:49-50.
modalities, wound care methods, and many other procedures and 15. Post LF, Blustein J: Handbook for Health Care Ethics Committees, 2nd ed.
pathways. Baltimore, MD: Johns Hopkins University Press, 2015.
16. Bradford-Saffles A, Arambasick JJ: Consent and capacity issues in the emer-
gency department. Crit Decisions Emerg Med 2013; 27(6):2-10.
SPECIAL CIRCUMSTANCES 17. Moskop J: Informed consent in the emergency department. Emerg Med Clin
N Am 1999; 17(2):327-340.
Consent may be obtained over the telephone if the patient is unable 18. Gaeta T, Torres R, Kotamraju R, et al: The need for emergency medicine
to consent, the surrogate is not on premises, and the surrogate is resident training in informed consent for procedures. Acad Emerg Med 2007;
only reachable by telephone. Have two persons on the phone with 14(9):785-789.
the surrogate during the consent process. Note the person’s name 19. Schillinger D, Piette J, Grumbach K, et al: Closing the loop: physician com-
and relationship on the consent. Have both persons on the phone munication with diabetic patients who have low health literacy. Arch Intern
Med 2003; 163:83-90.
sign the consent as witnesses. The general order of surrogacy is 20. Apter AJ, Paasche-Orlow MK, Remillard JT, et al: Numeracy and com-
noted in Table 1-8. munication with patients: they are counting on us. J Gen Intern Med 2008;
Other issues with consent arise in the ED. A person in custody 23:2117-2124.
retains their right to consent except in emergencies and under court 21. Schenker Y, Wang F, Selic FJ, et al: The impact of language barriers on docu-
orders. Contact a minor’s parent or guardian for consent if they mentation of informed consent at a hospital with on-site interpreter services.
are in custody except in an emergency, under a court order, or in J Gen Intern Med 2007; 22(Suppl 2):294-299.
22. Schenker Y, Lo B, Ettinger KM, et al: Navigating language barriers under
a situation described previously. A minor placed in adoption or in difficult circumstances. Ann Intern Med 2008; 149:264-269.
the custody of the county or state requires contact with the welfare 23. Patel PB, Anderson HE, Keenly LD, et al: Informed consent documentation
department for consent unless in emergency. A minor serving in the for lumbar puncture in the emergency department. West J Emerg Med 2014;
U.S. Armed Forces may give consent. Pregnant minors may consent 15(3):318-324.
to all care related to the pregnancy and newborn. 24. Boisaubin E, Dresser R: Informed consent in emergency care: illusion and
reform. Ann Emerg Med 1987; 16(1):62-67.
25. Moskop J: Information disclosure and consent: patient preferences and pro-
vider responsibilities. Am J Bioethics 2007; 7(12):47-49.
SUMMARY 26. Iserson K: The three faces of “Yes”: consent for emergency department pro-
The informed consent should be performed by the EP performing cedures. Am J Bioethics 2007; 7(12):42-45.
the procedure. Do not have the nurse obtain the consent. A written 27. White DB, Curtis JR, Lo B, et al: Decisions to limit life-sustaining treatment
for critically ill patients who lack both decision-making capacity and sur-
informed consent is preferred over a verbal consent. The written con- rogate decision makers. Crit Care Med 2006; 34(8):2053-2059.
sent is a record of the verbal consent. Obtain verbal consent when 28. Grisso T, Appelbaum PS: Assessing Competence to Consent to Treatment: A
the patient is unable to write. Have the verbal consent signed by two Guide for Physicians and Other Health Professionals. Oxford, United Kingdom:
witnesses to the consent. The signed consent for treatment when the Oxford University Press, 1998.
patient registers is not a substitute for a consent form for the proce- 29. Iserson K: Is informed consent required for the administration of intra-
dure. Know the institution and state requirements for consent. Involve venous contrast and similar clinical procedures? Ann Emerg Med 2006;
49(2):231-233.
the ethics committee if time allows. 30. National Research Council: Crossing the quality chasm: a new health system
for the 21st century. Accessed May 17, 2017 from www.nationalacademies.
REFERENCES org, 2001.
31. Kunneman M, Montori VM, Castaneda-Guarderas A, et al: What is
1. Brach C: Even in an emergency, doctors must make informed consent an shared decision making? (and what it is not). Acad Emerg Med 2016;
informed choice. Health Aff 2016; 35(4):739-743. 23(12):1320-1324.
2. Koyfman SA, Reddy CA, Hizlan S, et al: Informed consent conversations 32. Barry MJ, Edgman-Levitan S: Shared decision making: the pinnacle of
and documents: a quantitative comparison. Cancer 2016; 122:464-469. patient-centered care. N Engl J Med 2012; 366(9):780-781.
3. Moore GP, Moffett PM, Fider C, et al: What emergency physicians should 33. Elwyn G, Frosch D, Thomson R, et al: A model for shared decision making.
know about informed consent: legal scenarios, cases, and caveats. Acad J Gen Intern Med 2012; 27(10):1361-1377.
Emerg Med 2014; 21(8):922-927. 34. Lindor RA, Kunneman M, Hanzel M, et al: Liability and informed con-
4. Derse A: Is patients’ time too valuable for informed consent? Am J Bioethics sent in the context of shared decision making. Acad Emerg Med 2016;
2007; 7(12):45-46. 23:1428-1433.
5. Moskop J: Informed consent and refusal of treatment: challenges for emer- 35. Krauss CK, Marco CA: Shared decision making in the ED: ethical consider-
gency physicians. Emerg Med Clin N Am 2006; 24:605-618. ations. Am J Emerg Med 2016; 34:1668-1672.
6. Schloendorff v. Society of New York Hospital (1914), 211 N.Y. 125(1914). 36. Spatz ES, Krumholz HM, Moulton BW: The new era of informed consent:
7. Salgo v. Leland Stanford Jr. University Board of Trustees, 154 Cal.App.2d 560, getting to a reasonable-patient standard through shared decision making. J
1957, at 579. Am Med Assoc 2016; 315(19):2063-2064.

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 8 SECTION 1: Introductory Chapters

TABLE 2-2 The Misconceptions Involved with Leaving AMA 4,5,22,25,26

Against Medical Advice
2 Ryan P. Kirby, Jessica J. Kirby, and Richard D. Robinson
AMA means the patient leaves with nothing
Blood alcohol predicts decision-making capacity
Decision-making capacity is all-or-nothing
Decision-making capacity is consistent over time
Determining decision-making capacity compromises patient safety
INTRODUCTION Forms signed by the patient offers legal protection
Patients electing to leave against medical advice (AMA) represent a Insurance will not pay if leaving AMA
Leaving AMA means you can’t be sued
growing population in the United States and provide unique chal-
Legal competence equates to decision-making capacity
lenges to the Emergency Physician.1 Discharge AMA is defined as
Minors cannot give consent
the patient leaving before the Emergency Physician finishes the Only Psychiatrists can make an accurate assessment of decision-making capacity
evaluation and establishes the disposition.2 It is estimated that 1% Psychiatric diagnoses negate a patient’s decision-making capacity
of Emergency Department visits result in a discharge AMA.3,4 The The AMA form must be signed
prevalence rate of leaving AMA varies between Emergency Depart-
ments.5 Discharge AMA patients often present again within a few
days, resulting in increased costs associated with repeat testing and essential to treat the patient against their wishes (e.g., altered mental
higher acuity therapeutic interventions due to worsening of their status, homicidal patients, life-threatening situations, public health
condition.3 The AMA patient has an increased risk of repeated risk with meningitis or tuberculosis, or suicidal patients). Docu-
admission, increased admission length of stay, increased morbidity, ment these exceptions clearly in the medical record.
and increased mortality.2,6-17 This chapter provides an overview of Many Emergency Physicians struggle internally with the AMA
the legal obligations to treat and elements associated with the refusal patient. They want to allow the patient autonomy in the decision-
of care and discusses special populations that may be encountered. making process while maintaining what they believe is in the patient’s
Start with the assumption that the patient can make their own best interest (i.e., beneficence). A patient going against the Emer-
decisions, unless there is suspicion otherwise.18-21 This practice is gency Physician’s recommendations may set up a poor physician–
consistent with general principles of patient autonomy. Any deci- patient relationship for the encounter.
sions made must be in the best interest of the patient. Lack of
decision-making capacity requires an assessment and documen- MISCONCEPTIONS OF LEAVING AMA
tation of how this was determined (Table 2-1). Lack of capacity
requires an impairment of the patient’s brain or mind significant There are many misconceptions involving the patient who is leaving
enough to interfere with decision-making. The determination of AMA (Table 2-2).4,5,22,25,26 The main one is that a patient leaving AMA
decision-making capacity is specific to a relative point in time and needs no further care. Offer pain medications for the patient’s condi-
does not apply to later decisions. The CURVES mnemonic was tion when appropriate. Do not withhold pain medications. The use
developed to be used in an acute setting such as the Emergency of these drugs may make the patient more agreeable to completing
Department (Table 2-1). the work-up and recommendations. This can be a new starting point
The patient has their own reasons, good or not, for leaving AMA. and prevent the patient from leaving AMA. Offer several options for
Not every decision by a patient is considered reasonable by the Emer- treatment if the patient refuses the primary and most ideal option.
gency Physician.15,21 Patients often present voluntarily to the Emer- Many Emergency Physicians need to be educated regarding the mis-
gency Department for evaluation and management. Leaving AMA conceptions surrounding the patient leaving AMA.
can be considered a withdrawal of the patient’s consent signed
when they initially presented for evaluation.22-24 The patient has RISK FACTORS FOR LEAVING AMA
the right to participate in the medical decision-making process Specific groups and complaints are associated with leaving AMA
and may refuse any care offered.18-20 It may be impossible to change (Table 2-3).10,16,17,27-34 Many complaints are associated with extensive
a patient’s mind once they decide to leave AMA. Sometimes it is and prolonged work-ups. Administrators and Emergency Physicians
should anticipate the needs of this group and proactively intervene to
TABLE 2-1 The U and I GLAD and CURVES Mnemonics for Determining a improve upon completion of the planned work-up. Early identification
Patient’s Decision-Making Capacity of these patients may prevent discharges AMA and negative outcomes.
Develop strategies to prevent patients leaving AMA. Be proactive
U and I GLAD
to address anger, anxiety, and emotional distress among patients.
U–understanding of the procedure/discussion
I–impairing conditions
G–goals and values
L–logic used to decide TABLE 2-3 The Risk Factors for Leaving AMA10,16,17,27-34
A–actual functioning Abdominal pain Lack of primary physician
D–danger or risks of decision Adolescents who register themselves Lack of social support
CURVES* Age 19–40 years Lower socioeconomic status
Communicate: Is the patient able to choose and communicate this choice? Alcohol-related disorders Lower triage categories
Understand: Does the patient understand the alternatives to treatment, benefits of treatment, Black Male
and risks of leaving? Chronic disease Nonspecific chest pain
Reason: Can the patient make a rational choice? Headache Prior AMA discharge
Values: Is the patient’s choice consistent with their values? Hepatitis Psychiatric disorders
Emergency: Is there impending risk to the patient? Homelessness Sickle cell anemia
Surrogate: Are there patient surrogates available? Is there any documentation guiding Human immunodeficiency virus Seen within last 72 hours in an Emergency
treatment (e.g., advance directives)? Lack of commercial insurance Department
*The first four are for decision-making capacity. The last two are for treatment without consent. Lack of insurance Substance abuse

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 CHAPTER 2: Against Medical Advice 9

TABLE 2-4 The Reasons Given for Adults and Children Leaving been debated in the courts where allegations argue that EMTALA
AMA5,6,9,14,16,17,25,31,34-41 may even continue into the inpatient environment, as seen in the
2009 court case of Moses v. Providence Hospital.43 One possible way
Anxiety about other children at home Job issues for other family members
Change their mind Job issues for themselves the duty to treat may be terminated is via a patient’s informed refusal
Chronic disease Lack of confidence in health care system of care.44-46 Great care must be taken in completing the process of
Concern for pets Lack of confidence in physician discharging a patient AMA in terms of fulfillment of EMTALA
Conflict with child caregivers at home Living away from home obligations. The patient often has a high risk of readmission and
Delays in treatment Long waits increased morbidity and mortality.2,6-17,47,48
Disagreements with physicians Outside obligations
Dissatisfaction with care Poor communication with physician ELEMENTS ASSOCIATED WITH
Elderly parents at home Prolonged hospital stay REFUSAL OF CARE
Faith in local healers Refusal of referral
Faith in religious beliefs Refusal of surgery Consent must be obtained prior to the treatment of a patient to
Faith in social customs Second opinion avoid committing battery or the unwanted touching of a person
False perception of improvement Spontaneous resolution of illness (Chapter 1). Similarly, inform the patient completely before they
Finances Spontaneous resolution of pain make a final decision to refuse care.26 The informed refusal of
Frequent blood sampling Transportation issues care is a process and requires more than having the patient sim-
Hunger Travel issues ply sign the AMA form.
Improvement with treatment Unknown (not noted) The patient may elect to refuse any or all treatment offered them
during the hospital or Emergency Department encounter. It is the
responsibility of the Emergency Physician to evaluate the patient
Improve physician–patient communication. Nurses are often first to and ensure that all the elements listed below are met and then
know the patient wishes to leave AMA. Train the nurses to proac- to clearly document the patient’s informed decision-making pro-
tively address concerns that may prevent a patient from leaving AMA. cess leading to refusal of care or discharge AMA.
Consider involving case managers or social workers to ensure patient
needs are met and improve communication. DECISION-MAKING CAPACITY
Decision-making capacity is sometimes simply referred to as
REASONS FOR LEAVING AMA capacity. It is determined by a physician and represents the
patient’s ability to make rational decisions.21,49 Any physician,
Patients give many reasons for leaving AMA (Table 2-4).5,6,9,14,16,17,25,31,34- including Emergency Physicians, who cares for a patient can
41
The main reasons include communication issues, drug addiction, clinically determine if the patient has decision-making capacity.25
long wait times, inadequate pain control, outside obligations, physi- Consulting a Psychiatrist or their delegated representative (e.g.,
cian personality, second opinions, and teaching hospital environ- Psychiatric Nurse Practitioner, Psychiatric Physician Assistant, or
ments. Knowledge of the reasons for leaving AMA can improve the Psychiatric Social Worker) is not necessary in most cases. It may
approach and management of these patients. Understanding the be necessary to contact a Psychiatrist or their representative on a
reasons for leaving AMA may allow Emergency Physicians and hos- case-by-case basis.22 This is true when decision-making capacity
pital administrators to address these issues and minimize adverse cannot be determined or the patient is to be involuntarily commit-
outcomes among this group. These patients are at risk for excessive ted (e.g., danger to others, danger to self, or incapable of self-care)
morbidity, mortality, and increased associated costs. to a facility. Decision-making capacity changes, is task-specific, is
Question the reason(s) the patient desires to leave AMA. Some- not all-or-nothing, and can be affected by many things (e.g., fatigue,
times the resident or nurse can obtain this information as they typi- medications, psychiatric disorders, and stress).
cally have a closer relationship with the patient.25 Consider involving The term “decision-making capacity” is used by physicians. This is
family members and friends of the patient as allies to assist in con- opposed to the legal term of competence as used by the courts.25,50,51
vincing the patient to follow the recommendations. They may help These terms are often incorrectly used interchangeably by physi-
the patient better understand the treatment and the consequences cians. Only a court of law can decide competency and appoint a
of the lack of treatment and reveal additional patient questions to guardian to make important decisions for the patient.
be addressed. Apologize for any waits. Do not become angry or The Emergency Physician must question the patient to deter-
frustrated when the patient wants to leave AMA. This only upsets mine if the patient has decision-making capacity (Table 2-1). The
the patient and encourages them to leave even more. Ensure the patient must have the ability to understand information related
patient knows that you are on their side and have their best inter- to their condition and treatment decisions. It is not possible to
est in mind. Do not refuse to provide treatment if the patient wants assess decision-making capacity unless the patient is fully informed.
to leave AMA. Offer any treatment acceptable and appropriate for The patient must have the ability to appreciate the significance of
the patient’s condition that they will accept. Some care is better the information presented to them. The patient must explain the
than no care. information presented rather than simply repeating it back. The
patient must have the ability to weigh the treatment options and
DEFINING THE DUTY TO TREAT demonstrate reasoning. The patient must express their choice for
treatment or refusal of treatment. Failure of one part can result in
Emergency Departments across the United States are bound by the lack of decision-making capacity. All this must occur in the patient
Emergency Medical Treatment and Active Labor Act (EMTALA) not under the influence of alcohol or drugs or not with an altered
requiring them to provide medical screening examinations and sta- mental status. The patient must not have a reason for involuntary
bilization for all patients who present to the facility.42 This obligation commitment to a facility.
extends to Emergency Physicians who work at facilities that par- The Emergency Physician must first ensure the individual patient
ticipate in one or more Centers for Medicare and Medicaid Services has the capacity to participate in their own decision-making process
(CMS) programs. The timeline to which the obligation extends has prior to engaging in a refusal of care discussion.25 Always ensure that

Reichman_Section1_p001-p054.indd 9 20/03/18 5:55 pm

 10 SECTION 1: Introductory Chapters

capacity exists because the decision to refuse treatment may be Physicians need to be formally educated on what to say, document,
viewed as unreasonable. The additional use of resources from psy- and do when the patient wants to leave AMA.
chiatry, if available, may be of benefit. Consider other conditions that
affect a patient’s ability to fully participate in their care (Table 1-6).
Correct any reversible causes affecting the patient’s decision-making SPECIAL POPULATIONS
capacity. A discussion must ensue regarding the disclosure of risk Obtaining a refusal of care or discharging AMA can be an anxiety-
following a careful review of the patient’s decision-making capacity. producing encounter while trying to provide care. This situation can
Formal and structured assessment tools are often used to deter- become further complicated when a patient has consumed alcohol,
mine decision-making capacity.52,53 These tools include the Aid to is currently incarcerated, is a minor, or has an active psychiatric
Capacity Evaluation (ACE), MacArthur Competence Assessment diagnosis. There are unique features to consider when dealing with
Tool (MacCAT), Montreal Cognitive Assessment (MoCA), and these populations.
University of California San Diego Brief Assessment of Capacity
to Consent (UBACC). These tools use standardized questions and
scoring systems to objectively determine decision-making capacity. INTOXICATED PATIENTS
No specific test of decision-making capacity is better than another Patients who have consumed alcohol represent the most difficult of
test. The tests take time to assess the patient and generate a score. the special populations from whom to obtain informed consent or
Most of these tests are unfamiliar to the Emergency Physician who refusal.29 The blood alcohol concentration can affect patients dif-
is untrained with their use. ferently. The Emergency Physician often assumes that the acutely
Lack of decision-making capacity or refusal of treatment may intoxicated patient lacks decision-making capacity. The patient’s
allow the Emergency Physician to share information with friends decision-making capacity must first be established by the same
and relatives. A person close to the patient can often convince the standard as an individual who has not consumed alcohol before
patient when the Emergency Physician is unsuccessful.21 This option discharging an intoxicated patient AMA.57
can be explored to assess the patient’s best interest. The involvement Each individual state may have specific laws regarding the abil-
of others shows that the Emergency Physician is advocating for the ity to give consent while intoxicated. An intoxicated patient was
patient in solicitation of additional input to make the right decision. considered unable to provide consent and a diagnostic procedure
Another physician may intervene to provide care if a patient and was completed against his request in Miller v. Rhode Island.58 A
Emergency Physician disagree. Consider another Emergency Physi- New York court found the hospital and Emergency Physician could
cian taking over the care of the patient. Consider calling the Pri- not detain an intoxicated person against their will in Kowalski v.
mary Physician if the patient has one. Offer to transfer the patient to St. Francis Hospital.59
another facility. Clearly document all offers and refusals. Determining the degree of intoxication presents a challenge.
Emergency Physicians have been previously shown to have poor
DISCLOSURE OF RISK ability in determining clinical sobriety. The patient often does not
remember things that occurred while intoxicated when they become
The Emergency Physician must follow the principles established sober.57 Serum and/or breath testing of alcohol does not directly
in the Canterbury v. Spence decision when disclosing risk.54 This correlate to a patient’s degree of intoxication and is likely not help-
requires disclosure of the condition being treated, proposed treat- ful in determining capacity.60,61 Documenting the patient’s activities
ment being offered, alternative treatment options, and risks asso- and ability to eat, walk, engage in conversation, and to rationally
ciated with both treatment and refusal. Take care to ensure the understand questions and discussions can be helpful as this suggests
patient understands all available options. Engaging family mem- their ability to understand care options and treatment plans. Acutely
bers, friends, or on-duty Emergency Department personnel in this intoxicated patients may have decision-making capacity regardless
discussion may prove beneficial. of their blood alcohol concentration.15,57,62

INSURANCE PAYMENTS INCARCERATED PATIENTS

A fallacy sometimes conveyed to patients is the idea that their insur- Patients who present in the custody of police or a correctional
ance will not pay for the visit should they elect to leave AMA.4,25,55 Many institution (e.g., jail or prison) represent another special popula-
Residents and Attending Physicians believe insurance payments will tion when considering the ability to refuse medical care. Prisoners
be denied if the patient leaves AMA.4 They often inform the patient have the same rights to refuse or submit to medical care as the
of this to coerce the patient in remaining.2,4 There are no documented general population. The standards described regarding capac-
instances of insurance companies denying the bill of a patient leav- ity remain the same.63 Unique to the incarcerated patient is their
ing AMA.4 There are no policies of payment denial for leaving AMA. inability to determine where they are incarcerated. The correc-
Insurance companies determine payment based on medical neces- tional institution responsible for the patient may choose to super-
sity. The Arkansas Supreme Court in Loretta Long v. Arkansas Blue vise them in a jail ward or within a medical setting while respecting
Cross and Blue Shield ruled that services prior to discharge are payable their right to refuse treatment if a patient who has capacity elects
because of benefits due to the patient before the AMA.56 to refuse care.63
Statements addressing the lack of insurance payment must be
avoided verbally and on the AMA form.2,15 This appears to be an
“urban legend” passed down during residency training and often per-
MINORS
sists throughout a physician’s career. There is often a breakdown in Minors (e.g., those < 18 years old) represent a special population
the physician–patient relationship when the patient is falsely warned of patients who present to the Emergency Department and may
of negative financial consequences if leaving AMA. The insurance elect to refuse care. State laws vary regarding types of treatment,
payment should not be a concern when caring for the patient con- age of consent, and conditions that apply to a minor who presents
sidering leaving AMA. The Emergency Physician must respect the for emergent care. A minor making one decision may not have
patient’s autonomy when they do not agree. Resident and Attending the capacity to make other decisions. Some states allow minors to

Reichman_Section1_p001-p054.indd 10 20/03/18 5:55 pm

 CHAPTER 2: Against Medical Advice 11

obtain contraception, treatment for sexually transmitted infections, TABLE 2-5 The Patient-Centered Approach for Leaving AMA65
and treatment for substance abuse without parental permission.
Determine if the patient has decision-making capability
Minors must be emancipated and can be determined to have
Is the patient alert and oriented?
decision-making capacity if they meet the following qualifica- Does the patient have mental impairment?
tions. The qualifications for emancipation vary between states. Does the patient have active mental illness?
They must have the ability to understand the diagnosis, treatment Is the patient under the influence of alcohol or drugs?
or lack of treatment, and that the choices have consequences. They Determine the patient’s preferences and values
must have the ability to understand the information presented to Don’t stigmatize the patient
them. They must have the ability to make a decision based on the Don’t berate the patient
information they receive from the Emergency Physician. Minors Don’t coerce the patient
must have the ability to understand the intervention, its benefits, Don’t express frustration
and its risks. They must have the ability to understand any alterna- Don’t express anger
tives, along with the associated risks and benefits. The minor must Don’t mention insurance will not pay if they leave
make a choice between treatment and lack of treatment, or choose Assure the patient the decision-making has nothing to do with their ability to pay
another person to make the decision on their behalf (e.g., usually Assure the patient the decision-making is in their interest of well-being
a parent or spouse). The minor cannot be coerced or forced into a Involve family members personally or by phone
decision, and pressure should never be applied. What is the treatment plan if staying?
What about the minor who lacks decision-making capacity for Discuss the benefits and risks if staying
any reason? Decisions are often made by parents or legal guardians.5 Discuss how treatment will differ as an outpatient
Make an effort to involve the minor in order to gain their coopera- Discuss the benefits and risks if leaving
tion. Provide them with information in terms that they will under- Make and provide an outpatient treatment plan if patient leaves AMA
stand based on their age.35 Minors are vulnerable because they may Provide follow-up
Provide prescriptions
not adequately understand the ramifications of a decision to leave
Provide discharge instructions
AMA. Leaving AMA may not be in their best interest.
Document everything in the medical record
States work under the principle of parens patriae, or parent of the
state. The state has an interest in the welfare of its citizens. This includes
minors. The specifics regarding parens patriae vary among the states.
Parens patriae is a mechanism for the state to override the rights of a based on the Emergency Physician’s recommendations with the
parent and provide their substituted consent. Parens patriae is not patient’s right to accept or refuse the recommendation. Consensus
an option left to the Emergency Physician or hospital as a mecha- and agreement are made between the Emergency Physician and the
nism by which to override parental control. Providing care in vio- patient when determining the goals of care that affect the patient.
lation of parental consent may make an Emergency Physician and A more agreeable plan is made when the Emergency Physician
hospital liable for violating consent. Do not proceed with care over has clear information regarding the patient’s motivation and val-
parental objections without authorization from state authori- ues. This involves the exchange of information, deliberation, and
ties unless it is necessary to preserve life or limb. Treatment in a decision-making. Good communication with the patient is essential
true life-threatening situation can be considered prevention of child to avoid dissatisfaction and frustration of the Emergency Physician
abuse, and the Emergency Physician may take emergent custody of and the patient.
the child. Get a second physician, if available, to agree and attest The choice to designate the patient leaving AMA is made by
via signed documentation in a life-threatening situation to override the Emergency Physician when they do not agree with the patient
the parents until the courts can render a decision. This may require decision. A patient-centered approach is used to support informed
separation of the minor from the parents with assistance from police patient choices even if they conflict with physician recommenda-
or security. tions. Be empathetic and nonjudgmental toward the patient. Engage
the patient politely to determine their motivations behind their
desire to leave AMA. Explore this motivation through discussion
PSYCHIATRIC PATIENTS and avoid conflict that undermines the physician–patient relation-
An active psychiatric diagnosis does not automatically mean the ship. Embrace and respect the informed decision made by a patient
patient lacks decision-making capacity. An active psychiatric diag- who has decision-making capacity.
nosis may result in the lack of decision-making capacity. A psy-
chiatric patient managed with appropriate medications can easily
make decisions. Psychiatric patients may be in denial, dissatisfied DOCUMENTATION
with their treatment, fearful, mistrustful of the medical system, and/ Emergency Physicians and hospitals are not unequivocally protected
or paranoid. It may be necessary to contact a Psychiatrist or their from lawsuits and successful litigation resulting from bad outcomes
delegated representative when managing psychiatric patients who simply because the patient signs the AMA form.5,22,34,36,66,67 This is con-
refuse care.22,52 This is true when decision-making capacity cannot trary to the belief of many physicians that the AMA form offers legal
be determined or in the setting where the patient is to be involun- protection if the patient rejects their recommendations. Courts have
tary committed (e.g., danger to others, danger to self, or incapable found the AMA discharge terminates the physician–patient rela-
of self-care) to a facility. tionship and the physician’s duty to treat.45,46 Family members often
believe more could have been done for an ill patient despite the irra-
PATIENT-CENTERED APPROACH tionality of their thinking.22 The attending Emergency Physician,
and not a resident or nurse, must interact with the patient con-
The patient-centered approach uses shared decision-making in a templating leaving AMA and document the discussion.
collaborative effort between the Emergency Physician and patient The Emergency Physician must document the situation and dis-
(Table 2-5).2,64,65 It takes into account scientific evidence along with cussions to memorialize the encounter.66 Clearly document the efforts
patient goals, preferences, and values. Shared decision-making is offered to the patient to get them to stay. Emergency Physicians

Reichman_Section1_p001-p054.indd 11 20/03/18 5:55 pm

 12 SECTION 1: Introductory Chapters

do a poor job of documenting the encounters for patients leaving Many institutions elect to use standardized forms to complete the
AMA.32,36,68,69 The documentation involves extra time and disrupts discharge AMA process (Figure 2-1). Many Emergency Physicians
the workflow of the Emergency Physician. The Emergency Physi- use the hospital AMA form without a clear reason. It is used to doc-
cian may be sued years after the encounter. They may only have the ument patient symptoms, to facilitate discussions with the patient,
encounter documentation to rely upon to refresh their memory. to improve documentation, and for the ease of completion.70 The

73 Prototype
EMERGENCY PHYSICIAN RECORD
Competency for AMA Discharge
or Treatment without Consent

Patient Declined Not Feasible

All clinical information and issues reviewed / discussed with
family, patient, other Offered transfer /
Relevant issues reviewed / discussed with patient / family other physician evaluation
No criteria for involuntary commitment
Patient Declined Not Available
Cognition-
Offered to call
Oriented to person, place, time
patient’s physician
Gives appropriate answers
Speaks coherently
Offered to speak with
No slurred speech
family / relative
No signs of psychosis
No tangential thinking CLINICAL IMPRESSION
No auditory hallucinations
Competent to make decisions regarding the medical care being offered?
No visual hallucinations
__YES __NO
No delusional thinking
Abstract thought process intact Discharge Instructions / Arrangements
No suicidal ideations Discharge instructions were given to the patient / responsible party.
No homicidal ideations Discharge instructions were NOT given to the patient / responsible
Gives rational explanation for refusal of care party because:
Patient / responsible party eloped
Patient / responsible party refused
Informed patient that they could return at any time if problems
Comprehension- develop or if they change their decision regarding care.
Aware of suspected diagnosis suggested by initiated screening
exam: Treating PA
Acknowledges understanding of reasons for recommendations Treating Physician
regarding: STATEMENT OF REFUSAL OF CARE:
Medical treatment / intervention (Obtain signature by patient / responsible person if possible)
Medical tests / procedure I have read this paragraph. I understand that a doctor at this hospital
Transfer to other medical facility wants to give me certain medical care. The doctor explained that
Admission to facility care to me, and I understand what that care is. The doctor also
Further observation / testing explained to me what could happen to me if I leave here without
The following risks of refusal of recommended care were dis- having that care, and I understand what was said. I want to leave this
closed to patient, and patient acknowledged risks: hospital without receiving the recommended care.
RISKS DISCLOSED ACKNOWLEDGED I know that I am welcome to return to this hospital at any time to
receive the recommended care or any other care that I may need at
Death any time, regardless of my ability to pay for such care.

© 2014-2017 T-system, Inc.

Neurologic
Dysfunction
Permanent mental
impairment Patient / Person Signing on Patient’s Behalf
Loss of limb
Loss of sexual function
Witness
Loss of current lifestyle
Worsened / chronic cond Patient / responsible person refused to sign this statement when
Other requested to do so but indicated refusal of care in the following
manner:
Suspected diagnosis(es) based upon initiated medical
screening exam:
Other Comments:

Outpatient treatment:

Follow-up plan:

AMA Discharge - 73 Page 1 of 1

Circle positives, backslash negatives, check normals

FIGURE 2-1. A commercially available sample documentation for leaving AMA. (Courtesy of T-System Inc., Dallas, TX.)

Reichman_Section1_p001-p054.indd 12 20/03/18 5:56 pm

 CHAPTER 2: Against Medical Advice 13

form is often used to avoid further conversations with the patient. DISCHARGE
This “one size fits all” form is often just signed by the upset patient
and witnessed by the staff. Signing the AMA form can appear to the Provide the patient with a clear understanding of the discharge
patient as coercive or defensive and further exacerbate the poor phy- plan and alternative outpatient therapies.15,68,72-74 Provide any pre-
sician–patient relationship.70 The use of standardized forms has been scriptions to the patient that may be required for an alternative treat-
shown to improve documentation of required elements. Complete ment when leaving AMA. Provide prescriptions for pain control if
documentation and the patient’s signature on the AMA form are appropriate for the patient’s condition. Explain what to look for at
not a substitute for the informed refusal discussion.34,71 The use of home, medical reasons to return, and encourage the patient to return
a hospital AMA form does not substitute for clear and specific docu- if they change their mind. Provide follow-up plans to the patient.
mentation of the informed refusal documentation. Laws regarding Consider calling the follow-up physician to discuss the case, what was
liability are defined at the state level and vary based on jurisdiction.34 done, and why the patient left AMA to ensure appropriate care. Notify
Consider the AMA form as a document to make the patient aware police and/or a social worker in cases of suspected child and elder
of the benefits and risks associated with leaving AMA.36 The Emer- abuse.
gency Physician may elect to individualize and dictate the discus- Patients electing to leave AMA can stimulate negative feelings
sion with the patient (Figure 2-2). Document the exact words used among Emergency Physicians and staff. Ensure that the patient
when speaking to the patient. feels welcome to return and resume care at any time.66,74,75 This
Address the following elements when using a template form or includes persistence of symptoms, worsening of symptoms, or if
directly documenting in the electronic medical record according to the patient changes their mind. Continue to be cordial and do
EMTALA guidelines: explain the clinical scenario, explain admission not give the impression that it will be held against the patient if
or treatment is medically advised, document that admission or treat- they choose to leave AMA. Consider calling the AMA patient in
ment is refused by the patient, explain the potential consequences 24 hours to ensure they are better, to inquire into their safety and
of self-discharge, and document that the patient takes responsibility well-being, and to see if they have any questions. Document this
for any adverse outcomes.34,42 Include the date of the discussion, the discussion.
time of the discussion, and those persons (e.g., family, friends, and/ Avoid a punitive encounter to increase the likelihood that patients
or hospital personnel) present. The patient should have decision- will obtain the care needed.15,74,75 The ability of the patient or their
making capacity and not be under the influence of alcohol or drugs. insurance carrier to pay is not an issue for the Emergency Physician
The Emergency Physician and the patient should sign if electing to to discuss with the patient. The discharge and disclosure process
use a form. An alternative is to print out the medical record and must be free of coercion. End the encounter on good terms with
have the patient sign it. Document the lack of the patient’s signature the patient. Report all patients that leave AMA to risk manage-
if they refuse to sign, and have a witness to the refusal sign as well. ment for review.

The patient has decided to leave against medical advice because __________________
_________________________________________________________. The patient has a normal
mental status, is not under the influence of alcohol or drugs, and has adequate decision-making
capacity regarding medical decisions. The patient appears to have insight, judgment, and
reason. The patient refuses observation or admission and wishes to be discharged. The patient
presents with __________________________________________________________________
and I am concerned for __________________________________________________________.
Staying for observation or admission we may be able to better treat you. The benefits and risks of
leaving have been discussed and include ____________________________________________
_____________________________________________________________________________,
worsening illness, chronic pain, disability, and death. The benefits of observation or admission
have been explained including the availability of nurses and physicians, diagnostic testing,
monitoring, and treatment. The patient understands and can state the risks of leaving and benefits
of observation or admission. This was witnessed by me and _____________________________.
The patient was given the opportunity to ask questions about their medical condition, the risks of
leaving, and the benefits of staying. The patient was treated with _________________________
_____________________________________________________________________________.
I offered to treat the patient with __________ if they stayed but the patient refused. I have spoken
with Dr. ________________ and the patient is to be followed up on _________________ with Dr.
___________________. The patient was given prescriptions for __________________________
___________________________________________________. The patient was given discharge
instructions that included they may return at any time for care.
FIGURE 2-2. A hospital-made sample documentation for leaving AMA.

Reichman_Section1_p001-p054.indd 13 20/03/18 5:56 pm

 14 SECTION 1: Introductory Chapters

SUMMARY 18. Cruzan v. Director, Missouri Department of Health, 497 US 261, 279 (1990).
19. St. Mary’s Hospital v. Ramsey, 465 S02d 666 (1985).
Emergency Physicians face ethical, legal, and medical consider- 20. Harnish v. Children’s Hospital, 439 NE2d 240 (1982); in re Brooks estate, 205
ations as they encounter patients presenting for care who may ulti- NE2d 435 (1965).
21. Appelbaum PS, Grisso T: Assessing patients’ capacities to consent to treat-
mately elect to terminate their care plans in whole or in part. An
ment. N Engl J Med 1988; 319(25):1635-1638.
effort should be made to recognize patients at risk for leaving AMA 22. Devitt PJ, Devitt AC, Dewan M: Does identifying a discharge as “against
and attempts made to educate them as to the benefits and risks of medical advice” confer legal protection? J Fam Pract 2000; 49(3):224-227.
leaving AMA. Maintain good communication with the patient. 23. 42 CFR 489.24; 42 CFR 489.20. EMTALA regulations.
Ensure that the patient has no reason to be involuntarily hospital- 24. 64 Federal Register 61353 (1999). OIG/CMS Special advisory bulletin on
ized. Ensure the decision-making capacity for informed decision- EMTALA.
making and clearly document these encounters. Fully inform the 25. Bartley MK: Against medical advice. J Trauma Nurs 2014; 21(6):314-318.
26. Marco CA, Derse AR: Leaving against medical advice: should you take no
patient by reviewing the risks associated with failure to complete the
for an answer? Emerg Depart Legal Letter 2004. https://corescholar.libraries.
work-up in terms of worsening morbidity and mortality. Encour- wright.edu/emergency_medicine/176
aging the patient to return at any time for further evaluation and 27. Nelp T, Tichter AM: Don’t go yet: an analysis of patients who leave against
treatment is the best practice model for navigating potential pitfalls. medical advice across emergency departments in the United States. Acad
The Emergency Physician should always fully explain the discharge Emerg Med 2016; 23(S1):S139.
process and follow-up plan and prescribe any appropriate medica- 28. Muthusamy AK, Cappell MS, Manickam P, et al: Risk factors for discharge
tions despite the patient’s choice to leave AMA. against medical advice in patients with UGI bleeding or abdominal pain:
a study of 170 discharges against medical advice among 11,996 emergency
The attending Emergency Physician is responsible for the dis- department visits. Minerva Gastroenterol Dietol 2015; 61(4):185-190.
charge AMA. Residents and nurses can help with the process. Nurses 29. Jeong J, Song KJ, Kim YJ, et al: The association between acute alcohol con-
can discharge the patient in the usual manner once the attend- sumption and discharge against medical advice of injured patients in the ED.
ing Emergency Physician fills out the documentation. Nurses can Am J Emerg Med 2016; 34:464-468.
ensure the patient has all requirements (e.g., follow-up, instructions 30. Lelieveld C, Leipzig R, Gaber-Baylis LK, et al: Discharge against medical advice
to return, prescriptions, questions answered, etc.) upon discharge. of elderly inpatients in the United States. J Am Geriatr Soc 2017;65(9):2094-2099.
31. Mohseni M, Alikhani M, Tourani S, et al: Rate and causes of discharge
against medical advice in Iranian hospitals: a systematic review and meta-
analysis. Iran J Public Health 2015; 44(7):902-912.
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West London Med J 2010; 2(3):17-27. 40. Onukwugha E, Saunders E, Mullins CD, et al: Reasons for discharges against
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16. Alfandre DJ: “I’m going home”: discharge against medical advice. Mayo Clin 48. Glasgow JM, Vaughn-Sarrazin MV, Kaboli PJ: Leaving against medical
Proc 2009; 84(3):255-260. advice (AMA): risk of 30-day mortality and hospital readmission. J Gen
17. Alfandre D, Yang J, Harwood K, et al: “Against medical advice” discharges Intern Med 2010; 25(9):926-929.
among HIV-infected patients: health and health services outcomes. J Assoc 49. Leo RJ: Competency and the capacity to make treatment decisions: a primer
Nurses AIDS Care 2017; 28(1):95-104. for primary care physicians. J Clin Psychiatry 1999; 1(5):131-141.

Reichman_Section1_p001-p054.indd 14 20/03/18 5:56 pm

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Title: Whom God Hath Joined: A Question of Marriage

Author: Fergus Hume

Release date: September 17, 2017 [eBook #55571]

Most recently updated: October 23, 2024

Language: English

Credits: Produced by Charles Bowen from page scans provided by

Google Books (University of Illinois Library)

*** START OF THE PROJECT GUTENBERG EBOOK WHOM GOD

HATH JOINED: A QUESTION OF MARRIAGE ***
Transcriber's Notes:
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https://books.google.com/books/
about/whom_god_hath_joined.html?id=qaJBAQAAMAAJ.
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2. Lower left corner of page 144 (start of Chapter XVIII.) is

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by [* * *].

WHOM GOD HATH JOINED.

A Question of Marriage.
 BY

FERGUS HUME,

AUTHOR OF

"THE MYSTERY OF A HANSOM CAB," "THE MAN WITH A SECRET,"

"MONSIEUR JUDAS," etc., etc.

The saying that no one can serve two masters has its exception in
the case of a wife and mother, who is bound by her marriage vows
and maternal instincts to love in equal measure her husband and
children; but alas for the happiness of the family should she love one
to the exclusion of the other, for from such exclusion arise many
domestic heart burnings.

THIRD EDITION.

LONDON:
F. V. WHITE & CO.,
 14, BEDFORD STREET, STRAND, W.C.
1894.

PRINTED BY
KELLY AND CO. LIMITED, 182, 183 AND 184, HIGH HOLBORN. W.C.,
AND KINGSTON-ON-THAMES.

CONTENTS

I. Two Friends
II. An Incomplete Madonna
III. The Waning of the Honeymoon
IV. The Art of Conversation
V. An Australian Girl
VI. A Day's Shopping
VII. Lady Errington's Little Dinner
VIII. Eustace Examines His Mind
"Oh, Wilt Thou be my Bride,
IX.
Kathleen?"
X. Auf Wiedersehn
XI. A Maiden Lady
XII. Aunt Jelly's Opinion
XIII. Bringing Home The Bride
XIV. An Undesirable Acquaintance
XV. A Woman Scorned
XVI. The Events of Eighteen Months
XVII. Gossip
XVIII. From Foreign Parts
XIX. Aunt Jelly Discusses Family Affairs
XX. The Old House by the Sea
XXI. From The Husband's Point of View
XXII. From the Wife's Point of View
XXIII. Mrs. Veilsturm's "At Home"
"On Revient Tojours à ses
XXIV.
Premières Amours"
XXV. Fascination
XXVI. Aunt Jelly Interferes
XXVII. The Deity Called Fate
XXVIII. Husband and Wife
XXIX. The Question of Marriage
XXX. Cleopatra Victrix
XXXI. In the Coils of the Serpent
XXXII. What Made the Ball sae Fine?
XXXIII. Pallida Mors
XXXIV. The Assaults of the Evil One
XXXV. For my Child's Sake
XXXVI. The Death of the First-born
XXXVII. The Truth about Mrs. Veilsturm
XXXVIII. The Last Temptation
XXXIX. "And Kissed again with Tears"
XL. A Letter from Home

TO

MY CRITICS,
IN APPRECIATION
OF THE KIND MANNER
IN WHICH THEY HAVE REVIEWED
MY FORMER BOOKS,
I DEDICATE
THIS WORK.
 If marriages are made above,
They're oft unmade by man below,
There should be trust, and joy, and love,
If marriages are made above;
But should Heav'n mate a hawk and dove,
Such match unequal breeds but woe,
If marriages are made above,
They're oft unmade by man below.

WHOM GOD HATH JOINED.

CHAPTER I.

TWO FRIENDS.

"Like doth not always draw to like--in truth Old age is ever worshipful of youth,
Seeing in boyish dreams with daring rife, A reflex of the spring time of its life,
When sword in hand with Hope's brave flag unfurled, It sallied forth to fight the
blust'ring world."
It was about mid-day, and the train having emerged from the
darkness of the St. Gothard tunnel, was now steaming rapidly on its
winding line through the precipitous ravines of the Alps, under the
hot glare of an August sun. On either side towered the mountains,
their rugged sides of grey chaotic stone showing bare and bleak at
intervals amid the dense masses of dark green foliage.

Sometimes a red-roofed châlet would appear clinging swallow-like to

the steep hill-side--then the sudden flash of a waterfall tumbling in
sheets of shattered foam from craggy heights: high above, fantastic
peaks swathed in wreaths of pale mist, and now and then the
glimpse of a white Alpine summit, milky against the clear blue of the
sky.

On sped the engine with its long train of carriages, as though

anxious to leave the inhospitable mountain land for the fertile plains
of Italy--now crawling fly-like round the giant flank of a hill--anon
plunging into the cool gloom of a tunnel--once more panting into the
feverish heat--sweeping across slender viaducts hanging perilously
over foaming torrents--gliding like a snake under towering masses of
rock--and running dangerously along the verge of dizzy precipices,
while white-walled, red-roofed, green-shuttered villages, shapeless
rocks, delicately green forests, snow-clad peaks, and thread-like
waterfalls flashed past the tired eyes of the passengers in the train
with the rapidity of a kaleidoscope.

And it was hot--the insufferable radiance of the southern sun,

blazing down from a cloudless sky, beat pitilessly on the roofs of the
railway carriages, until the occupants were quite worn out with the
heat and glare from which they could not escape.

In one of the first-class carriages two men were endeavouring to

alleviate the discomfort in some measure, and had succeeded in
obtaining a partial twilight by drawing down the dark blue curtains,
but the attempt was hardly successful, as through every chink and
cranny left uncovered, shot the blinding white arrows of the sun-
god, telling of the intolerable brilliance without.

One of the individuals in question was lying full length on the

cushions, his head resting on a dressing-bag, and his eyes half
closed, while the other was curled up in a corner on the opposite
side, with his hands in his pockets, his head thrown back, and a
discontented look on his boyish face, as he stared upward. Both
gentlemen had their coats off, their waistcoats unbuttoned and their
collars loose, trying to make themselves as comfortable as possible
in the sweltering heat.

On the seats and floor of the carriage a litter of books and papers
showed how they had been striving to beguile the time, but human
nature had given in at last, and they were now reduced to a state of
exhaustion, to get through the next few hours as best they could
until their arrival at Chiasso, where they intended to leave the train
and drive over to their destination at Cernobbio, on Lake Como.

"Oh Jove!" groaned the lad in the corner, settling himself into a more
comfortable position, "what a devil of a day."

"The first oath," murmured the recumbent man lazily, with his eyes
still closed, "is apt, and smacks of classic culture suitable to the land
of Italy, but the latter is English and barbaric."

"Oh, bother," retorted his friend impatiently, "I can't do the subject
justice in the way of swearing."

"Then don't try; the tortures of Hades are bad enough without the
language thereof."

"You seem comfortable at all events, Gartney," said the boy crossly.

"St. Lawrence," observed Mr. Gartney, opening his eyes, "had a bed
of roses on his gridiron compared with this eider-down cushion on
which I lie--the saint roasted, I simmer--I'll be quite done by the
time we reach Chiasso."

"I'm done now," groaned his companion. "Do shut up, Gartney, and
I'll try and get some sleep."

Gartney laughed softly at the resigned manner in which the other

spoke, and once more closed his eyes while his friend, following his
example, fell into an uneasy slumber interrupted by frequent sighs
and groans.

He was a pleasant enough looking boy, but not what would be called
handsome, with his merry grey eyes, his rather wide mouth, his
well-cut nose with sensitive nostrils, and his wavy auburn hair
suiting his fair freckled skin; all these taken individually were by no
means faultless, yet altogether they made up a countenance which
most people liked. Then he had a tall, well-knit figure, and as he
dressed well, rode well, was an adept in all kinds of athletic sports,
with exuberant animal spirits and a title, Angus Macjean, Master of
Otterburn, was a general favourite with his own sex, and a particular
favourite with the other.

What wit and humour the lad possessed came from his Irish mother,
who died, poor soul, shortly after he was born, and was not sorry to
leave the world either, seeing it was rendered so unpleasant by her
stern Presbyterian husband. Why she married Lord Dunkeld when,
as a Dublin belle, she could have done so much better, was a
mystery to everyone, but at all events marry him she did with the
aforesaid results, death for herself after a year of unhappy married
life, and an heir to the Macjean title.

Lord Dunkeld was sincerely sorry in his own cold way when she died,
never dreaming, narrow-minded bigot as he was, that life in the
gloomy Border castle was unsuited to the brilliant, impulsive
Irishwoman, and after placing her remains in the family vault, he
proceeded to apply to his son's life the same rules that finished Lady
Dunkeld's existence. The boy, however, had Scotch grit in him as
well as Celtic brilliance, and as he grew up under his father's eye,
gave promise both intellectually and physically of future excellence,
so that when he reached the age of nineteen, he was the pride of
the old lord, and of the endless Macjean clan, who were very proud,
very poor, and very numerous.

But whatever pride Dunkeld felt in the perfections of his heir he took
care never to show it to the lad on the principle that it would make
him vain, and vanity, according to Mr. Mactab, the minister who
looked after the spiritual welfare of the family, "was a snare o' the
auld enemy wha gaes roaring up an' doon the warld." So Angus was
never pandered to in that way, but led a studious, joyless existence,
his only pleasures being shooting and fishing, while occasionally
Dunkeld entertained a few of his friends who were of the same way
of thinking as himself, and made merry in a decorous, dreary
fashion.

At the age of nineteen, however, the lad rebelled against the dismal
life to which his father condemned him, for as the princess in the
brazen castle, despite all precautions, found out about the prince
coming to release her, so Angus Macjean, from various sources,
learned facts about a pleasant life in the outside world, which made
him long to leave the cheerless castle and rainy northern skies for a
place more congenial to the Irish side of his character. With such
ideas, it is scarcely to be wondered at that he became more
unmanageable every day, until Lord Dunkeld with many misgivings
sent him to Oxford to finish his education, but as a safeguard placed
by his side as servant one Johnnie Armstrong, a middle-aged
Scotchman of severe tendencies, who was supposed to be "strong in
the spirit."

So to this seat of learning, Otterburn went, as his progenitors had

gone before him, and falling in by some trick of Fate with a
somewhat fast set, indulged his Irish love for pleasure to the utmost.
Not that he did anything wrong, or behaved worse than the general
run of young men, but his 'Varsity life was hardly one which would
have been approved of by his severe parent or the upright minister
who had nurtured his young intellect on the psalms of David.

Still Johnnie Armstrong!

Alas, for the frailty of human nature, Johnnie Armstrong, the strong
in spirit, the guardian of morality, the prop of a wavering faith,
yielded to the temptations of the world, and held only too readily
that tongue which should have warned Otterburn against the snares
of Belial, for, truth to tell, Johnnie made as complaisant a guardian
as the most dissipated rake could have desired. The world, the flesh,
and the devil was too strong a trinity for Johnnie to stand against, so
he surrendered himself to the temptations of this life in the most
pusillanimous manner, aiding and abetting his young master with
misdirected zeal. Behold then, Angus Macjean and his leal henchman
both fallen away from grace and having a good time of it at Oxford,
so much so, indeed, that Otterburn was quite sorry when his father,
after two years' absence, summoned him to Dunkeld Castle to grace
the ceremony of his coming of age.

That coming of age was a severe trial to Angus, as the guests were
mostly Free Kirk ministers and their spouses, the ministers in lengthy
speeches, exhorting him to follow in the footsteps of his father, i.e.,
support the Free Kirk, make large donations to the funds thereof,
and entertain ministers of that following on all possible occasions.
Otterburn having learnt considerable craft at Oxford, made suitable
replies, promising all kinds of things which he had not the slightest
idea of fulfilling, and altogether produced a favourable impression
both by such guile and by a display of those educational graces with
which Alma Mater had endowed him. It is needless to say that,
aided by the faithful Johnnie Angus did not tell either his father or
Mactab of his gay life at the University, and the result of this
reticence was that the old lord, bestowing on him a small income out
of the somewhat straitened finances of the Macjeans, bade him
enjoy himself in London for a year, and then return to marry.
To marry! Poor Angus was horror-struck at such a prospect, the
more so when his father introduced him to the lady selected to be
his bride, a certain Miss Cranstoun who had a good income, but
nothing else to recommend her to his fastidious taste.

However, being a somewhat philosophical youth, he accepted the

inevitable, for he knew it would be easier to move Ben Nevis than
his father, and trusting to the intervention of a kind Providence to
avert his matrimonial fate, he went up to London with Johnnie to
enjoy himself, which he did, but hardly in the way anticipated by
Lord Dunkeld.

Thinking his marriage with the plain-looking Miss Cranstoun was

unavoidable, he made up his mind to see as much of life as he could
during his days of freedom, and proceeded to do so to his own
detriment, morally, physically and pecuniarily, when he chanced to
meet with Eustace Gartney.

Eustace Gartney, whimsical in his fancies, took a liking to the lonely

lad, left to his own devices in such a dangerous place as London,
and persuaded him to come to Italy hoping to acquire an influence
over the young man and keep him on the right path until his return
to Dunkeld Castle.

There was certainly a spice of selfishness in this arrangement, as

Eustace was attracted by the exuberant animal spirits and Irish wit
of the lad, which formed a contrast to the general run of young men
of to-day, and to his own pessimistic views of life, so, much as he
disliked putting himself out in any way, he determined to stand by
the inexperienced youth, and save him from his impulsive good
nature and love of pleasure.

Lord Dunkeld, deeming it wise that Angus should see something of

Continental life, and having full confidence in the
straightforwardness of Johnnie Armstrong, agreed to the journey,
much to his son's surprise, and this was how The Hon. Angus
Macjean, in company with Eustace Gartney, was in a railway train
midway between St. Gothard and Chiasso.

And Eustace Gartney, poet, visionary, philosopher, pessimist--what of

him? Well, it is rather difficult to say. His friends called him mad, but
then one's friends always say that of anyone whose character they
find it difficult to understand. He was eminently a child of the latter
half of this curious century, the outcome of an over-refined
civilization, the last expression of an artificial existence, and a riddle
hard and unguessable to himself and everyone around him.

For one thing, he always spoke the truth, and that in itself was
sufficient to stamp him as an eccentric individual, who had no
motive for existence in a society where the friendship of its members
depends in a great measure on their dexterity in evading it. Again
Gartney was iconoclastic in his tendencies, and loved to knock down,
break up, and otherwise maltreat the idols which Society has set up
in high places for the purposes of daily worship. The Goddess of
Fashion, the Idol of Sport, the Deity of Conventionalism, all these
and their kind were abominations to this disrespectful young man,
who displayed a lack of reverence for such things which was truly
appalling.

It was not as though he had emerged from that unseen world of the
lower classes, of which the upper ten know nothing, to denounce
the follies and fashions of the hour; no, indeed, Eustace Gartney had
been born in the purple, inherited plenty of money, been brought up
in a conventional manner, and the astonishing ideas he possessed,
so destructive to the well-being of Society, were certainly not derived
from his parents. Both his father and mother had been of the most
orthodox type, and would doubtless have looked upon their son's
eccentricities with dismay had they lived, but as they both finished
with the things of this life shortly after he was born, they were
mercifully spared the misery of reflecting that they had produced
such a firebrand. Indeed they might have checked his radical-
iconoclastic-pessimistic follies at their birth had they lived, but Fate
willed it otherwise, and in addition to robbing Eustace of his parents
had given him careless guardians, who rarely troubled their heads
about him, so that he grew up without discipline or guidance, and
even at the age of thirty-eight years was still under the control of an
extremely ill-regulated mind.

Tall, heavily-built, loose-limbed, with a massive head, leonine masses

of dark hair, roughly-cut features, and keen grey eyes, he gave the
casual observer an idea that he possessed a fund of latent strength,
both intellectual and physical, but he rarely indulged the former, and
never by any chance displayed the latter. Clean-shaven, with a
peculiarly sensitive mouth, his smile--when he did smile, which was
seldom--was wonderfully fascinating, and completely changed the
somewhat sombre character of his face. He usually dressed in a
careless, shabby fashion, though particular about the spotlessness of
his linen, rolled in his gait as if he had been all his life at sea, looked
generally half asleep, and, despite the little trouble he took with his
outward appearance, was a very noticeable figure. When he chose,
he could talk admirably, played the piano in the most brilliant
fashion, wrote charming verses and fantastic essays, and altogether
was very much liked in London Society, when he chose to put in an
appearance at the few houses whose inmates did not bore him.

Without doubt a singularly loveable man; children adored him,

animals fawned on him, and friends, ah--that was the rub, seeing
that he denied the existence of such things, classing them in the
category of rocs, sea-serpents, hippogriffs, and such-like strange
beasts. Therefore dismissing the word friends, which only applies to
uncreated beings, and substituting the word acquaintances, which is
good enough to ticket one's fellow creatures with, the acquaintances
of Mr. Gartney liked him--or said they liked him--very much.

Absence in this case doubtless made their hearts grow fonder, as

Eustace was rarely in England, preferring to travel in the most
outlandish regions, his usual address being either Timbuctoo, the
Mountains of the Moon, or the dominions of Prester John. He had
explored most of this small planet of ours, and had written books in
the Arabian Nights vein about things which people said never
existed, and talked vaguely of yachting in the Polar seas, exploring
the buried cities of Central America, or doing something equally
original. At present, however, he had dismissed these whimsical
projects for an indefinite period, as the marriage of his cousin Guy
Errington and the friendship of Angus Macjean now occupied his
attention.

Then again his last book of paradoxical essays had been a great
success, as everybody of his acquaintance, both friends and foes,
abused it--and read it. The critics, who know everything, had
denounced the book as blasphemous, horrible, coarse, drivelling,
with the pleasing result that it had an exceptionally large sale; and
although most people, guided by the big dailies, said they were
shocked at the publication of such a book, yet they secretly liked the
brilliant incisive writing, and wanted to lionise the author, but
Eustace getting wind of the idea promptly betook himself to the
Continent in order to escape such an infliction.

It was impossible that such a peculiar personage could be happy,

and Eustace certainly was not, as his fame, his money and his
prosperity were all so much Dead Sea fruit to his discontented mind.
And why? Simply because he was one of those exacting men who
demand from the world more than the world, which is selfish in the
extreme, is prepared to give, and because he could not obtain the
moon sulked like a naughty child at his failure to attain the
impossible.

If he made a friend, he then and there demanded more than the

most complaisant friend could give, so his friendship always ended in
quarrels, and he would then inveigh against the heartlessness of
human nature simply because he could not make his friend a slave
to his whims and fancies.
He had been in love, or thought so, many times, but without any
definite result, as he had a disagreeable habit of analysing
womankind too closely; and as they never by any chance came up to
the impossible standard of perfection he desired, the result was
invariably the same, irritation on his side, pique on the woman's, and
ultimate partings in mutual disgust. Then he would retire from the
world for a time, nurse his disappointment in solitude, and emerge
at length with a series of bitter poems or a volume of cynical essays,
in which he summarised his opinions regarding his last failure in love
or friendship. A bitter man, a discontented man, absurdly exacting,
intolerant of all things that were not to his liking, yet withal--strange
contrast--a loveable character.

Angus Macjean therefore was his latest friend, but it was not
altogether a selfish feeling, as he was genuinely anxious to save the
friendless lad from the dangerous tendencies of an impulsive nature;
nevertheless, his liking was not entirely disinterested, seeing that he
enjoyed the bright boyish nature of Otterburn, with his impossible
longings, and his enthusiastic hero-worship of himself. So this spoilt
child, pleased with his new toy, saw the world and his fellow men in
a more kindly light than usual, and, provided the mood lasted, there
was a chance that the happy disposition of Macjean might
ameliorate to some extent the gloom of his own temperament.

On his part, Angus was flattered by the friendship of such a clever

man, and moreover secretly admired the cynicism of his companion,
though, truth to tell, he did not always understand the vague
utterances of his oracle, for Gartney was somewhat enigmatic at
times. Still on the whole Angus liked him, and his enthusiastic nature
led him to enuow his idol with many perfections which it certainly
did not possess.

Thus these two incongruous natures had come together, but how
long such an amicable state of things would last was questionable.
There was always the fatal rock of boredom ahead, upon which their
friendship might be wrecked, and if Gartney grew weary of
Otterburn or Otterburn of Gartney, the result would be--well the
result was still to come.

CHAPTER II.

AN INCOMPLETE MADONNA.

"She is a maid
Who hath a look prophetic in her eyes,
A longing for--she knows not what herself; Yet if by chance when kneeling
rapt in prayer, She raised her eyes to Mother Mary's face, Within her breast
a thought--till then unguessed, Amazing all her dreamings virginal, Would
show her, by that vision motherly, The something needed to complete her
life."

"Then what is she?"

"She is an Incomplete Madonna."

They were near the end of their journey when Gartney made this
reply, and having reduced the chaos of books and papers into
something like order, they were both sitting up with their garments
in a more presentable condition, smoking cigarettes, and talking
about the Erringtons.

This family, consisting of two people, male and female, bride and
bridegroom, were staying at the Villa Tagni on Lake Como, and Sir
Guy Errington, being a cousin of Gartney's, had asked his eccentric
relative to pay them a visit while in the vicinity, which he had
consented to do. This being the case, Otterburn, who, unacquainted
with the happy pair, except as to their name and relationship to his
friend, was cross-examining Eustace with a view to finding out as
much as he could about them before being introduced.

Sir Guy, according to his cynical cousin, was a handsome young

fellow, with three ideas of primitive simplicity in his head, namely,
shooting, hunting, and dining. Quite of the orthodox English type,
according to the Gallic "it's-a-fine-day-let-us-go-and-kill-something"
idea, so Otterburn, having met many such heroes of sporting
instincts, asked no more questions regarding the gentleman, but
being moved by the inevitable curiosity of man concerning woman,
put the three orthodox questions which form a social trinity of
perfection in masculine eyes.

"Is she pretty?"

Silence on the part of Mr. Eustace Gartney.

"Is she young?"

Still silence, but the ghost of a smile on the thin lips.

"Is she rich?"

Oracle again mute, whereupon the exasperated worshipper queries

more comprehensively:

"Then what is she?"

Vague, enigmatic answer of the oracle:

"She is an Incomplete Madonna."

Otterburn stared in puzzled surprise at this epigrammatic response

to his boyish cross-examination, and after a bewildered pause burst
out laughing.

"You're too deep for me, Gartney," he said at length, blowing a cloud
of thin blue smoke. "I don't understand that intellectual extract of
beef wherein the qualities of one's friends are boiled down into a
single witty phrase."

This reply pleased Eustace, especially as he was conscious of having

said rather a neat thing, so glancing out into the brilliant world of
sunshine to see how far they were from their destination, he lighted
another cigarette and explained himself gravely:

"I am very fond of ticketing my friends in that way, as it saves such

a lot of trouble in answering questions; if you asked me what I
should like in my tea, I should not answer 'the sweet juice of cane
crystallized into white grains.' No! I should simply say 'sugar,' which
includes all the foregoing; therefore when you ask me to describe
Lady Errington, I say she is an incomplete Madonna, which is an
admirable description of her in two words."

"This," remarked Otterburn, somewhat annoyed, "is a lecture on the

use and abuse of epigrams. I don't want to know about epigrams,
but I do want to know about Lady Errington. Your two-word
description is no doubt witty, but it doesn't answer any of my
questions."

"Pardon me, it answers the whole three."

"I don't see it."

"Listen then, oh groper in Cimmerian gloom. You ask if Lady

Errington is young--of course, the Madonna is always painted young.
Is she pretty? The Madonna, as you will see in Italian pictures, is
absolutely lovely. Is she rich? My dear lad, we well know Mary was
the wife of a carpenter, and therefore poor in worldly wealth. Ergo, I
have answered all your questions by the use of the phrase
incomplete Madonna."

"A very whimsical explanation at best, besides, you have answered

more than I asked by the use of the word incomplete--why is Lady
Errington incomplete?"
"Because she is not yet a mother."

"Oh, confound your mystic utterances," cried the Master, comically,

"do descend from your cloudy heights and tell me what you mean. I
gather from your extremely hazy explanation that Lady Errington is
young, pretty, and poor, also that she is not a mother. So far so
good. Proceed, but for heaven's sake no more epigrams."

"I'm afraid the beauty of an epigram is lost on you Macjean?"

"Entirely! I am neither a poet nor a student, so don't waste your

eloquence on me."

"Well, I won't," answered Gartney, smiling. "I'll have pity on your

limited understanding and tell you all about Alizon Errington's
marriage in plain English."

"Do, it will pass the time delightfully until we leave this infernal
train.'

"Lady Errington, my young friend," said Eustace leisurely, "is what

you, with your sinful misuse of the Queen's English, would call 'a
jolly pretty woman,' of the age of twenty-five, but I may as well say
that she looks much older than that--this is no doubt the peculiar
effect of the life she led before her marriage."

"On the racket," interposed Otterburn, scenting a scandal.

"Nothing of the sort," retorted Gartney, severely. "Lady Errington has

led the life of a Saint Elizabeth."

"Never heard of her. The worthy Mactab didn't approve of saints, as

they savoured too much of the Scarlet Woman."

"At present I will not enlighten your ignorance," said Eustace drily,
"it would take too long and I might subvert the training of the
excellent Mactab which has been such a signal success with you."
Otterburn grinned at this fine piece of irony, but offered no further
interruption, so Eustace went on with his story.

"I knew Lady Errington first--by the way, in saying I know her, I
don't mean personally. I have seen her, heard her speak and met her
at the houses of friends, but I have never been introduced to her."

"Why not?"

"I don't know if I can give any particular explanation; she didn't
attract me much as Alizon Mostyn, so I did not seek to know her, nor
did she ever show any desire to make my acquaintance, so beyond
knowing each other by sight we remained strangers, a trick of Fate,
I suppose--that deity is fond of irony."

"You're becoming epigrammatic again," said Otterburn, warningly,

"proceed with the narrative."

Eustace laughed, and took up the thread of his discourse without

further preamble.

"Lady Errington is the daughter of the late Gabriel Mostyn, who was
without doubt one of the biggest scoundrels who ever infested the
earth, that is saying a great deal considering what I know of my
friends, but I don't think it is exaggerated. He was a man of good
family, and being a younger son, was, in conformity with that
ridiculous law of English primogeniture, sent out into the world with
a younger son's portion to make his way, which he did, and a very
black way it was. Why a man with a handsome exterior, a clever
brain, and a consummate knowledge of human nature, should have
devoted all those advantages to leading a bad life I don't know, but
the wicked fairy who came to Gabriel Mostyn's cradle, had
neutralised all the gifts of her sisters by the bestowal of an evil soul,
for his career, from the time he left the family roof until the time he
died under it, was one long infamy.
"He was a diplomatist first, and was getting on capitally, being
attaché at the Embassy at Constantinople, when he was caught
selling State secrets to the Russian Government somewhere about
the time of the Crimean War, and as the affair was too glaring to be
hushed up, he was kicked out in disgrace. After this disagreeable
episode he led a desultory sort of existence, wandering about the
Continent. He was well known at the gambling hells, and his
compatriots generally gave him a pretty wide berth when they
chanced to meet him. In Germany he married a charming woman, a
daughter of a Baron Von Something, and settled down for a time.
However, to keep his hand in, he worried his poor wife into her
grave, and she died three years after the marriage, leaving him two
children--a son and the present Lady Errington.

"Mrs. Mostyn had some property of her own, which she left to her
son, and in the event of the son's death the husband was to inherit.
It was a foolish will to make, knowing as she must have done her
husband's disposition, and it was rather a heartless thing for the
mother to leave her daughter out in the cold. No doubt, however,
the astute Gabriel had something to do with it. At all events he did
not trouble much about his children, but leaving them to the care of
their German relatives, went off to Spain, where he was mixed up in
the Carlist war, much to the delight of everyone, for they thought he
might be killed.

"The devil looks after his own, however, and Mostyn turned up at the
conclusion of the war minus an arm, but as bad as ever. Then he
went off to South America, taking his son with him."

"There was nothing very bad in that, at all events," said Otterburn,
who was listening with keen interest.

"Shortly after he arrived at Lima the son disappeared."

"The devil!" interrupted Angus, sitting up quickly; "he surely didn't

kill the boy?"
"That is the question," said Eustace grimly, "nobody knows what he
did with him, but at all events the boy disappeared and was never
heard of again. There was some of that eternal fighting going on
between the South American Republics, and Mostyn said the lad had
been shot, but if he was," pursued Gartney slowly, "I believe his
father did it."

"Surely not--he had no reason."

"You forget," observed Eustace sardonically, "I told you the boy
inherited his mother's money, that was, no doubt, the reason, for
Mostyn came back to Europe alone, claimed the money, and after
obtaining it with some difficulty, soon squandered it on his own
vicious pleasures. Then, as a reward for such conduct, his elder
brother died without issue, and Mr. Gabriel Mostyn, blackguard,
Bohemian and suspected murderer, came in for the family estates."

"The wicked flourish like a green bay tree," observed Angus,

remembering the worthy Mactab's biblical readings in a hazy kind of
way, and misquoting Scripture.

"The wicked man didn't flourish in this case," retorted Eustace,

promptly. "Nemesis was on his track although he little knew it. He
took his daughter back with him to England, duly came into
possession of the estate, and tried to white-wash his character with
society. His reputation, however, was too unsavoury for anyone to
have anything to do with him, so in a rage he returned to his old
ways and outdid in infamy all his previous life. No one was cruel
enough to enlighten his daughter, whom he had left in seclusion at
the family seat, and she remained quite ignorant of her father's
conduct, which was a good thing for her peace of mind.

"For some years Mostyn, defying God and man, pursued his evil
career, but at length Nature, generous in lending but cruel in
exacting, demanded back all she had lent, and he was struck down
in the full tide of his evil prosperity by a stroke of paralysis."
"Served him jolly well right," observed Otterburn heartily.

"So everybody thought. Well, he was taken down to his country

house, and there for four terrible years Alizon Mostyn devoted
herself to nursing him. What that poor girl suffered during those four
years no one knows nor ever will know, for despite the blow which
had fallen on him, Gabriel Mostyn was as wicked as ever, and I
believe his curses and blasphemy against his punishment were
something awful. No one ever came to see him but the doctors,
although I was told a clergyman did attempt to make some enquiries
after his soul, but retreated in dismay before the foul language used
by the old reprobate. His daughter put up with all this, and in spite
of the persuasions of her friends, who tried to take her away from
that terrible bed-side, she attended him to the end with devoted
affection. She saw him die, and from all accounts his death-bed was
enough to have given her the horrors for the rest of her life, for only
his lower extremities being paralysed, they said he tore the
bedclothes to ribbons in his last paroxysm, cursing like a fiend the
whole time."

"And did she stay through it all?"

"Yes! till the breath was out of his wicked old body. I believe his last
breath was a curse, and just before he died it took two men to hold
him down by main force in the bed."

"Great heavens! how awful," ejaculated Otterburn in a shocked tone;

"what a terrible scene for that poor girl to witness--and afterwards?"

"Oh, afterwards she came up to London," replied Gartney, after a

pause; "the old man had got rid of all the property, and even the
Hall was so heavily mortgaged that it had to be sold. She stayed
with some relatives, and there was some talk of her becoming a
Sister of Mercy. I dare say she would have done so, her vocation
evidently being in the Florence Nightingale line, had she not met
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