How should you respond to an urgent call for a physician outside of the medical environment? What are an otolaryngologist’s ethical and professional obligations to care for these people, even if their conditions fall outside of the scope of practice of otolaryngology-head and neck surgery?
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January 2016Here are three fictional cases depicting a potential scenario you may encounter, with an ethical discussion for each.
Clinical Scenario 1
Rodney Hallowell, MD, and his wife, Norma, are excited to finally embark on a two-week cruise on the Rhine River in Europe. Both feel that this is a well-deserved vacation after seeing their last child off to college and experiencing “empty nest syndrome.” Dr. Hallowell’s general otolaryngology practice will be well covered by his practice partners, and Norma is on a six-month sabbatical from the university to study, in part, the architecture of European churches built in the Middle Ages. Rodney’s plan is to catch up on a growing list of fiction books on his electronic reader and not be bothered by any medical responsibilities.
Tonight’s after-dinner entertainment on the boat features Austrian singers performing excerpts from several well-known operas. Midway through the performance, Dr. Hallowell is approached by an officer of the boat, who asks for a private word in the hallway. The officer nervously explains that there has been an altercation between two of the boat’s cooks and that one has been stabbed with a dining knife. The victim is not doing well at all, and since Dr. Hallowell is the only available physician on board, will he attend to the victim? Reluctantly, Dr. Hallowell agrees to evaluate the patient.
Immediately, Dr. Hallowell can see that the man is in trouble—pale, diaphoretic, and poorly responsive. The stab wound is in the upper right quadrant of the abdomen, with rather brisk bleeding noted. A female crewmember is applying mild pressure to the wound with a table napkin. The assailant is nowhere to be seen. All hands are expectantly waiting for Dr. Hallowell to take charge of the situation.
Clinical Scenario 2
Jane Billingsley, MD, is in flight, on her way from her home in Florida to a major otolaryngology meeting in Texas, where she is to present a research paper and serve on a panel discussion. The past two years have been very busy for Dr. Billingsley, as she has finally become board certified in neurotology. Both her academic practice and research are challenging and rewarding, and she will be presenting the results of a new clinical study on the treatment of Ménière’s disease.
Midway into the flight, she notices a flurry of activity in the first class section of the aircraft, with passengers forward of her seat craning to observe what is happening. Curious, but not too curious, she is reviewing her presentation on her laptop computer when she hears a flight attendant’s urgent request—“Is there a medical professional on the plane? Please ring the call button above you.” As she anticipates a ring from another professional pressing the attendant call button, she realizes that no one seems to be responding. Surely I am not the only physician or nurse on this plane, she thinks.
Rather reluctantly, she presses the call button and identifies herself as a physician, and the attendant rushes to her seat with a relieved look on his face. “Thank God you are on the plane,” he gasps. “We have an emergency situation. Please come with me quickly.” Following the attendant up the aisle to the cockpit door, Dr. Billingsley sees the other flight attendants clustered around a person on the deck—the pilot! He is clutching his chest and upper abdomen and is in obvious distress. Noting that his color is ashen, his peripheral pulses diminished, and his breathing rapid and shallow, Dr. Billingsley quickly understands the gravity of the situation. The crewmembers are looking to her to care for the stricken pilot.
Clinical Scenario 3
Charles Baker, MD, and his family are participating in a church retreat on a rather remote ranch in West Texas. This retreat, the culminating event of a summer of spiritual renewal for the congregation, has been planned as a time for family outdoor activities and appreciation of the wonder of natural creation. So far, all expectations are being met, and the families are enjoying their shared experiences. Dr. Baker feels that this time away from his head and neck oncologic practice is going to be well worth it, as this is a rare opportunity for his family to be together, without iPads and the Internet to distract them.
The congregation’s early morning hike along the edge of a plateau to experience the rising sun is just outstanding. Suddenly, a scream is heard, followed by loud voices calling for Dr. Baker to come forward. Rushing to the area of the commotion, Dr. Baker sees what has happened: A boy has slipped off the edge of the trail and has fallen about 15 feet to a ledge below. His leg appears to be twisted, and he is screaming with pain. Urged by the boy’s parents, Dr. Baker climbs down to the ledge and examines the boy. He appears to be neurologically intact, with no obvious spinal injury, but he has a hematoma of the right thigh and a malrotation of the right leg. The boy responds to questions but is in obvious extreme pain. His mother beseeches Dr. Baker to “please take care of my boy.”
Discussion
Image Credit: Aliwak/shutterstock.com
Otolaryngologist-head and neck surgeons are well qualified by training and experience to evaluate and manage certain emergencies—notably, airway obstruction, facial trauma (including fractures and lacerations), disorders of the balance mechanisms, and acute infectious diseases of the soft tissues of the head and neck and aerodigestive tract. Most practitioners in our specialty have little or no reservation when it comes to responding to requests for urgent care in a public setting in the face of these disorders. The question of stepping forward becomes more difficult when the emergencies involve injuries, disorders, or illnesses that fall outside of the general scope of clinical practice for most otolaryngologist-head and neck surgeons. Therein lies the ethical challenge: “Is it better for me to help, with my limited capabilities, or to let others step forward who might actually have more or less capability than I have? Do I have a moral responsibility to volunteer, no matter what the circumstance?”
Hesitation about responding to a call for a physician can certainly be based on capability and scope of practice, but it could also be based on other issues, including fear of possible litigation, potential personal and/or professional embarrassment, concerns about how responding might impact travel plans, and lack of information regarding availability of therapeutic or resuscitation equipment. Most calls for physician assistance are unexpected and urgent, reducing the time for consideration before the need to respond is required.
Another debate that may be involved in a physician’s consideration of whether or not to respond is whether there is another healthcare provider in the immediate area who may be better qualified to assist the victim than the otolaryngologist. Additionally, is there enough time before things get critical for nearby first responders to arrive and resolve the critical issue? In some circumstances, it may be immediately obvious that you are the only provider capable of assisting. Conversely, given the wide range of healthcare providers available these days, it may be impossible to know who is best qualified to respond until the capabilities of those responding begin to sort themselves out. In fact, perhaps the best possible scenario in an urgent call for a “doctor” would be for multiple providers to respond and, after a brief assessment of the victim’s condition and needs, identify the most appropriate and capable individual to direct the medical care. Such a decision need not be based on academic degree, but rather on who has the appropriate knowledge and experience in dealing with the situation at hand—for instance, an EMT or critical care nurse might be better suited to care for a patient with a suspected MI than the responding otolaryngologist. An alternative, and certainly salutary, approach would be to quickly work out a team effort, in which each professional handles an aspect of care that is most appropriate to his/her training, giving the victim the benefit of professionals working together for the best outcome.
Additional issues facing an otolaryngologist who is deciding whether or not to respond to a call for a physician include liability risk and ethical and moral obligations. There will likely not be a lot of time for the otolaryngologist to determine a course of action in an urgent or emergent situation, so it is wise to give thoughtful consideration to what one’s response would be in a range of possible circumstances.
Legislation in Place
Medical liability should usually not be a major concern for a physician who responds to an emergency call because of the “Good Samaritan Laws” in effect in all 50 states. While the details of these laws vary somewhat from state to state, their commonality is that a physician who is responding to an urgent or emergent situation and acting in good faith and reasonable prudence on behalf of the victim will be protected from any liability arising from his or her actions. These laws were passed to encourage healthcare providers to come to the assistance of victims of accidents and other emergencies.
A review of the Good Samaritan statutes in the U.S. states by Stewart and colleagues revealed a number of common elements or requirements: 1) a physician acting in good faith to render first aid or emergency care; 2) no expectation of compensation; and,
3) a victim who is not presently the physician’s patient.1 Under these conditions, a physician would not be liable for civil damages resulting from simple or ordinary negligence. All but the state of Kentucky provide immunity to physicians who hold licenses from another state. Three states—Louisiana, Minnesota, and Vermont—require a physician to provide basic emergency care, with the risk of violation of the law if the physician “walks away” from the emergency. It must be emphasized that acts of gross negligence or misconduct are not immune from liability.
Emergency care rendered by physicians and other healthcare providers during domestic air flights is protected by the Aviation Medical Assistance Act of 1998. This act, which “declares that an individual shall not be liable for damages in any such action arising from out of acts of omissions in providing, or attempting to provide, such assistance, except for gross negligence or willful misconduct,” is especially important because of the isolated and inaccessible conditions inherent to an in-flight emergency, as well as limited access to diagnostic and therapeutic equipment.2
Scope of Training
Limited scope of practice, training, and experience may be a concern for some otolaryngologists. While management of an airway emergency would fit nicely into an otolaryngologist’s capabilities, managing other medical or surgical emergencies—such as an acute hypertensive crisis/stroke, MI, diabetic crisis, or precipitating delivery—could be disconcerting or daunting. Outside of special experiences, such as military duty as a general medical officer or previous training in general or emergency medicine, some calls for a physician may stretch the scope of practice for an otolaryngologist. While all hospitals likely require basic CPR certification for staff privileges, not many otolaryngologists routinely recertify in advanced cardiac life support or advanced trauma life support, although it might be helpful for them to do so. There also may be some trepidation in an adult otolaryngologist treating a pediatric victim, and vice versa. Yet, the most common issues that prompt a call for a physician involve such “emergencies” as syncope/dehydration, nausea and vomiting, hypoglycemia, and shortness of breath, all of which are within the general scope of knowledge of an otolaryngologist.
An otolaryngologist is, first and foremost, a physician, and there is a societal expectation that physicians will respond to a need for medical rescue. To put it a different way, wouldn’t we like to think that a physician would come to our rescue, or that of a family member, in an emergent or urgent situation?
Medical kits on domestic air carriers likely will provide the necessary equipment for starting intravenous fluids; for administering intravenous glucose, sublingual nitroglycerine, and anti-nausea medications; for checking blood pressure; for listening to the heart, lungs, and abdomen; and similar interventions. Most aircraft are also equipped with an automatic external defibrillator, the proper use of which is an important part of basic CPR training for physicians. When faced with a serious or life-threatening emergency, otolaryngologists may have to rely upon their common sense and general medical training to do the best they can under the circumstances. It is also generally held that the most experienced and appropriately trained healthcare professional on the scene should take charge of the victim’s care, and that may be an emergency medical technician, combat medic, intensive care unit nurse, or other physician or surgeon. The best interests of the patient should always be the priority.
Moral and Ethical Considerations
Perhaps the most compelling arguments for a physician to respond to an urgent or emergency call are their moral and ethical duties to society—i.e., their fellow human beings. Under professional oaths and codes of ethics, a physician has a specific duty for “medical rescue,” which requires a prompt response to a call for assistance. In such emergency situations, the physician may not have the luxury of waiting until no one else responds, particularly if CPR, airway obstruction clearing, hemorrhage treatment, or defibrillation is required. Fortunately, most emergency calls are not immediately life threatening, but that determination is not certain until the physician evaluates the victim. At minimum, we should be able to stabilize the victim until more experienced and capable assistance arrives.
The AMA Principles of Medical Ethics addresses this issue with the following language: “A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.”3 Of course, the emphasis here is on “except in emergencies,” which carries the implication that it is a physician’s duty/responsibility to respond.
An otolaryngologist is, first and foremost, a physician, and there is a societal expectation that physicians will respond to a need for medical rescue. To put it a different way, wouldn’t we like to think that a physician would come to our rescue, or that of a family member, in an emergent or urgent situation? Finally, altruism and a basic respect for human life and well-being compel us to respond, even if we are limited in skills or capabilities for a given emergency. If we do not respond, and the outcome is to the detriment of the victim, then we live with that knowledge.
Now, let’s address the specific scenarios.
Clinical Scenario 1
This is a difficult situation, because European laws covering “Good Samaritan” acts may vary from country to country or, depending on the country, may not even exist. Because the emergency occurred on a river cruise boat that traverses a number of countries, it would not be possible for the otolaryngologist to know the applicable laws for that location. Additionally, under the circumstances, the otolaryngologist has not only limited resources but also limited training in any definitive therapy for a stab wound to the abdomen. Still, he needs to do something, as he is bound by professional standards to do the best he can for the victim. He will likely need to apply pressure to the wound, perhaps even a makeshift compressive abdominal garment, and reduce shock, as well as administer CPR should the victim become apneic or experience cardiac arrest or severe arrhythmia. Short of basic first aid—unless IV fluids are available—the otolaryngologist must call for the boat to dock at the soonest possibility and ask for emergency medical services to meet the boat and take charge of the victim’s care. Finally, he should ascertain whether other healthcare providers are on board to conduct a team effort in first aid. As long as the otolaryngologist acts in good faith and makes his best effort, there should be little risk of liability.
Clinical Scenario 2
Many physicians, including otolaryngologists, may be called to assist on an in-flight medical emergency during their careers. Fortunately, most flights will likely have more than one healthcare provider on board, and consulting and working with other providers can benefit the victim and the otolaryngologist who responds. The implications of this scenario are potentially quite serious, with the pilot at risk of succumbing to what might be a serious medical event, such as a myocardial infarct, ruptured aortic aneurysm, or another dire condition. At this point, immediate rerouting to the nearest airport with the appropriate hospital facilities is warranted, and basic emergency care should be instituted. The primary responsibility of the otolaryngologist is to assist in life-saving care, to provide information to the co-pilot, who is now in charge of the aircraft, and to help promote calm among the passengers. She should present an air of confidence and control. The Aviation Assistance Act is designed to protect the Good Samaritan physician who acts out of altruism and in good faith, and although this act applies to U.S.-registered aircraft only and the same provisions may not be provided by other countries, this uncertainty should not be a reason in itself to not respond to an emergency if called.
Clinical Scenario 3
A head and neck surgeon is likely well qualified to perform the primary assessment of an injured patient in this scenario and will likely have a practical knowledge of the injury and its immediate care. Reassurance of the victim and his parents, prevention of shock, protection of the injured leg, provision of comfort, and the call for an immediate evacuation of the victim are priorities. This will, in all probability, be an air evacuation situation. Few physician hikers and campers pack intravenous fluids and venipuncture equipment, but a comprehensive medical kit packed for a group campout might have been included—if so, other medical equipment might be available to the otolaryngologist. There is no way for the otolaryngologist, if he is the only physician in the group, to avoid tending to the victim. It is part and parcel of his professional duty.
Conclusion
The decision an otolaryngologist must make regarding whether or not to respond to an urgent call for a physician outside of the medical environment is, admittedly, a personal one. Neither this author nor the profession in toto, except in three U.S. states, can mandate that he or she respond. But, because of the altruism, oaths, expectations, and medical ethics of the profession of medicine, most physicians will step forward and do what they can under the circumstances. Good Samaritan Laws and the Aviation Assistance Act are designed to protect the responding physician from liability, and this premise has been proven time and again. Otolaryngologists who are faced with medical emergencies that are generally outside their scope of practice must draw upon their basic medical knowledge and training to provide assistance in a prudent and reasonable manner, even if it is only first aid or basic CPR. The important thing is just to be willing to help in an emergency medical situation to the best of one’s abilities.
Dr. Holt is professor emeritus in the department of otolaryngology-head and neck surgery at the University of Texas Health Science Center in San Antonio.
References
- Stewart PH, Agin WS, Douglas SP. What does the law say to Good Samaritans? A review of Good Samaritan statutes in 50 states and on US airlines. Chest. 2013;143:1774-1783.
- U.S. Government Publishing Office. Public Law 105-170 – Aviation Medical Assistance Act of 1998. 105th Congress. Passed April 24, 1998. Accessed December 21, 2015.
- AMA. Principles of Medical Ethics. Principle VI. Revised June 2001. Accessed December 21, 2015.