Press release

Violence in the ER

p. 1245  Violence in the emergency department: a survey of health care workers ­ C.M.B Fernandes, MD; et al [full article]

p. 1262  Abuse of emergency department workers ­ L.J. Morrison, MD [full article]

Verbal and physical violence is common in emergency departments at urban hospitals and can severely affect staff working conditions, but several studies indicate that it remains an under-reported problem.

In their survey of emergency department personnel working at a hospital in downtown Vancouver, Christopher Fernandes and colleagues found that 90% of the 106 respondents experienced verbal abuse at least once a week and 57% reported being physically assaulted at work during 1996. Nurses and security personnel experienced the highest proportion of physical assault. As a result of this exposure to violent incidents at work, 73% reported some fear of patients and 38% had considered a job outside of health care.

In a related editorial, Laurie Morrison states that the emergency department is the interface between the office, the hospital and the community, and as such it is the barometer that indicates how well the health care system is working. When patients' expectations or their perceived needs or wants are not met, she cautions, violent outbursts and verbal abuse can occur.

p. 1251  Response of paramedics to terminally ill patients with cardiac arrest: an ethical dilemma ­ V. Guru, BSc; et al [full article]

p. 1264  Dignified death or legislated resuscitation? ­ G. Innes, MD; K. Wanger, MD [full article]

Ontario paramedics are bound by legislation to initiate aggressive life-support measures when responding to 9-1-1 cardiac-arrest calls, even though this duty may conflict with the expressed wishes of patients with terminal illnesses.

Veena Guru and colleagues reviewed the ambulance call reports of 144 terminally ill patients who were experiencing cardiac arrest and found that in 90 of these cases there was a request — in many cases written out in advance — that resuscitation not be done. Because of the law, however, paramedics ignored these requests in over 75% of the patients. Cardiopulmonary resuscitation was attempted and the patients were transported to emergency rooms against the wishes of the patient and relatives. None of the 144 patients survived.

In their commentary on the issue, Grant Innes and Karen Wanger state that it is up to physicians to educate patients and their families about these issues and discuss the policy of the local ambulance service. They also recommend that other jurisdictions follow the example of the British Columbia Ambulance Service that created a standard DNR form that is signed by both the patient (or advocate) and the physician to ensure that the patient's final wishes are followed.

p. 1281  Drug interactions and the statins — Robert J. Herman, MD [full article]

p. 1266  Drug­drug interactions: How scared should we be? — Lori E. Shapiro, MD; Neal H. Shear, MD [full article]

Drug interactions are common in patients taking multiple medications but most of them remain unrecognized because drugs, in general, have a wide margin of safety or the extent of change in drug levels is small when compared with the variation normally seen in clinical therapy. However, the incidence of muscle disorders can increase 10 times when statins are combined with certain other drugs.

Robert Herman reviewed the literature and pharmacology of statins and recommends caution when lovastatin and simvastatin are used in multidrug regimens because of their marked elevations in concentration if taken with drugs that inhibit the body's ability to metabolize drugs.

In a related editorial, Lori Shapiro and Neal Shear discuss the role of the prescribing physician in detecting and reporting drug interactions and toxicities.

p. 1257  Temporal changes in the outcomes of acute myocardial infarction in Ontario, 1992­96 — Jack V. Tu, MD, PhD; C. David Naylor, MD, DPhil; Peter Austin, PhD [full article]

A study of over 80 000 Ontario patients who had a myocardial infarction in Ontario, shows things are getting better, at least for younger male patients.

Jack Tu, David Naylor and Peter Austin studied patient data from 89 456 patients discharged from Ontario hospitals between 1992 and 1996 and found that mortality rates declined slightly from a one year mortality rate of 23.7% in 1992 to 22.3% in 1996.

The authors note however, the gains were limited to young men. Those 65 and over and women of all ages showed no statistically significant gains in survival. The gains and non-gains occurred in parallel with substantial increases in the use of angiography, percutaneous transluminal coronary angioplasty and CABG surgery.