OFFICE EMERGENCIES: MANAGEMENT AND LEGAL LAND MINES
From the American Academy of Family Physicians’ 2006 Scientific Assembly, Washington, DC
Participants: Brad L. Blake, JD, Private Law Practice, St. Louis, MO Lloyd A. Darlow, MD, Clinical Assistant
Professor of Family Medicine, University of Rochester School of Medicine, Rochester, NY, and Cornell-Weil College
of Medicine, New York, NY
| WHAT IS AN OFFICE EMERGENCY?
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| Definition: acute event that may or may not be life-threatening or of concern to patient when it happens, and may require
treatment by physician before emergency medical service (EMS) arrives; responsibility may not end when patient leaves
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| Case of man 20 yr of age: sudden onset of abdominal pain after meal on previous day; pain dull and constant around
umbilicus, with some nausea; no diarrhea or fever; able to eat; small amount of blood in stool; on physical examination,
abdomen tender in left lower quadrant, no guarding or rebound; bowel sounds normal; rectal examination, guiac, and
anoscopy negative; initial diagnosis diverticulitis; computed tomography (CT) indicated patient had intussusception requiring
surgery
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| Case of woman 42 yr of age: developed numbness and weakness of left arm after reaching to pick up something; taking
oral contraceptives; left forearm tender on physical examination; otherwise, evaluation normal; CT indicated stroke
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| STANDARD OF CARE AND GUIDELINE ISSUES
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| Standard of care: degree of skill and learning ordinarily used under same or similar circumstances by members of physician’s
profession; caveat—family physicians (FPs) who deliver babies subject to standards set by American College of
Obstetricians and Gynecologists (ACOG); negligence refers to failure to meet standard of care
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| How negligence claims prosecuted and defended: standards set by medical experts, not lawyers; in preparing
case, attorneys read literature, practice guidelines, and recommendations related to case, including those on American
Academy of Family Physicians (AAFP) web site; deposition then ensues
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| Depositions: best to have them in attorney’s office, away from defendant’s medical textbooks and literature; defendant
needs to “bone up” on related literature before deposition; attorneys often require physician to complete written questions
(interrogatory) before deposition
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| National vs local standards of care: physicians now held to national standards; in past, local standards usually set by
department chair or experts in area
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| “No harm, no foul” rule: legal term “proximate cause” or causation; if something done wrong but patient not hurt,
most malpractice lawyers reluctant to take case; reasonable degree of medical certainty—means “it is more likely than
not” that something done to cause injury
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| OFFICE PLANS AND EQUIPMENT
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| Automated external defibrillators (AEDs): most states do not obligate FP office to have AED; generally required
for health facilities, cruise ships, and other places where emergency heart problems might arise; if most of physician’s
peers have AEDs, or if patient coded in physician’s office in past, principle of forseeability requires that physician have
one; physicians with AEDs responsible for training office personnel on their use and for regular servicing of devices
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| Good Samaritan laws: cover physicians rendering emergency aid, as long as they do not ask for money or engage in
gross negligence
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| Office emergency plan: essential; should be in written document or handbook to which all office staff members have
access; remarks—in at least 37 states, physicians not legally obligated to render emergency care if they do not advertise
themselves as providers of emergency or urgent care; certification training in advanced cardiac life support (ACLS) advised
for physicians and office staff
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| Case of 35-yr-old man with large knee effusion: faints upon seeing syringe and needle; questions—crash cart or
defibrillator available to revive patient? who is in charge of medications? does office run mock disaster drill?
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| Case of patient who had severe reaction to allergy shot: throat tightens, and she becomes diaphoretic; nurse
saved patient’s life by using own epinephrine device (EpiPen)
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| Ambulance service: physician needs to know 1) how long it takes to get ambulance to office, and 2) how long it takes
to get patient to hospital or tertiary care center
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| Emergency equipment: defibrillator—new American Heart Association guidelines on AEDs call for giving patient 1
shock, then doing cardiopulmonary resuscitation (CPR), rather than 3 shocks in row; caveat—physician probably at
greater risk for liability for having equipment but not knowing how to use it correctly than for not having equipment;
other equipment—Ambu-bags and masks; oxygen (O2 ); pulse oximeter; intravenous (IV) catheters, tubing and solutions;
intubation set; sedating drugs; suction devices; crash cart—should include aspirin; may include nitroglycerin tablets
or spray, corticosteroids, and ACLS drugs; tailor crash carts to specific needs; data on preassembled kits available at
www.statkit.com; other helpful equipment—head lamp; tonometers; epistaxis sponges; nebulizers; peak flow meters
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| MANAGING ALLERGIC BEE STINGS
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| Case of elderly woman: walks into office with bee sting “the size of a walnut” on neck; nauseous, short of breath, and
cannot swallow
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| Treatment guidelines for anaphylactic reactions: begin with high-flow O2 via face mask (if available; cannula if
no mask); give epinephrine 0.3 to 0.5 mg of 1:1000 solution subcutaneously or down endotracheal tube (if necessary);
place patient in Trendelenburg’s position and give diphenhydramine; other measures—prednisone (for delayed reaction);
histamine-2 (H2 ) blockers; anticholinergics; glucagon (for patients on β-blockers); follow-up measures—if anaphylactic
reaction significant, hospitalize patient; if reaction mild, send patient home on both H1 and H2 blockers;
reassess serum tryptase in questionable cases; educate patient about diet and avoidance; consider allergy referral
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| Issue of walk-in patients: physicians not legally responsible for providing care to individuals not their patients (no
“duty” involved); however, physicians liable if office sign states “walk-ins welcome”; if catastrophic outcome occurs,
courts will probably find that someone had duty to help person (eg, office staffer who observes walk-in crash on entering
office should call “911”)
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| SUBARACHNOID HEMORRHAGE AND PNEUMONIA
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| Case of 36-yr-old man: patient calls office at 7:30 AM and tells receptionist he has worst headache of life; appointment
made for 9:30 AM ; problem—lack of communication between physician and office staff regarding possible implication
of words used by patient
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| Subarachnoid hemorrhage: 1 in 4 patients with this problem seen first by primary care physician; 15% of cases misdiagnosed;
delay in obtaining CT most common error; if CT not readily available, do lumbar puncture; if emergency care
not immediately available, give nimodipine to reduce morbidity, then get neurosurgical consultation
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| Telephone medicine: one of biggest areas for legal land mines because 1) immediate clinical assessment not possible,
and 2) person answering phone (eg, receptionist) often lacks knowledge of triage and importance of signs and symptoms
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| Litigation involving man in late 20s: wife calls office to report he has had variety of symptoms (eg, chest pain, nasal
drainage, sore throat, headache, cough, sputum) for several days; based on information conveyed by staff member who
took call, physician prescribes medication for upper respiratory infection; in second call 2 days later, wife reported her
husband had not improved; patient had fulminant bacterial pneumonia; questions asked in deposition—type of chest
pain; severity of headache; type of cough; color of sputum; physician could not answer these questions because he or she
had not taken call
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| Remarks: chest pain persisting for ≈2 wk places myocardial infarction (MI) low on differential; receptionist’s failure to
document third call by patient’s wife unfavorable for physician
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| Advice: train receptionist to document all calls, watch for such buzz words as “chest pain” and “headaches,” and to pass
call on to physician immediately if caller uses these words; document that training done
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| Case involving child 2 yr of age: falls and bangs head against table, may have lost consciousness, “clingy” since
then; nurse tells mother to bring child right to office; child vomits on way; CT shows 5-mm bleed; referred to neurosurgeon
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| Head injuries: cervical spine can be injured; patient may have lucid intervals; CT may not be required if patient fully
alert and oriented, has minimal signs of injury, normal neurologic examination, and only mild headache; if reliability in
doubt, admit patient for observation; order CT if patient gets worse; specific indications for CT include focal neurologic
signs, decreased level of consciousness, uncertain mental state, extremes of age, and intoxication; comments—physician
comfort and index of suspicion should also be indications for CT; be aware of AAFP guidelines for closed head injuries
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| ADVICE ON CHARTING AND DOCUMENTATION
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| Legal trap in medical charting: avoid “told to return if condition gets worse”; better to give specific guidelines (eg,
temperature >100.6° F; presence of signs and symptoms)
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| What to chart and document: patient told [he or she]“faces the risk of death, etc” without further treatment; use
phrase, “including, but limited to,” then cite 1 or 2 specifics, eg, increased fever, increased cough
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| Observations: document everything; “if it’s not documented, it wasn’t done” not true; in court, physician can maintain
he or she acted “according to my habit and custom,” and “if [patient] had said something was abnormal I would have
charted that”; advice—detailed charting more important for higher-risk problems (eg, head injuries, heart, breast, and
colon problems); cite differential diagnosis in high-risk areas; jurors want to know thinking process physician used in
reaching diagnosis; jurors may excuse mistakes, but not sloppiness or carelessness; document advice and be specific on
directions given to patients; never alter, add to, or erase anything on chart; do not discard notes
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| TREATING ACUTE ASTHMA ATTACKS
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| Case of 6-yr-old girl: has history of asthma and allergic rhinitis; brought to office by mother after developing cough;
respiratory rate 26 breaths/min; has diffuse wheezing and loud breath sounds; no cyanosis
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| Acute asthma: patients at risk include those who have been previously intubated and those who delay seeking treatment
or are steroid dependent; patients usually underestimate problem; diagnostic aids include pulse oximeters and peak flow
meters; chest x-rays have poor yield for diagnosing asthma, but often done to exclude other conditions; arterial blood gasses
(ABGs) best for monitoring patients; comments—peak flow should be ≈370 L/min in 5-ft person and should increase
13 L/min for each additional inch; anything within 90% of that level considered normal, <80% abnormal
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| Management of acute attacks: includes use of terbutaline (loses β-specificity at higher doses), aerosolized β2 agents
(eg, levalbuterol), and corticosteroids
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 | Corticosteroids: methylprednisolone 160 mg/day for adults and 2 mg/kg per day for children; use in patients who are steroid
dependent, those with severe exacerbations, and those nonresponsive to ≥3 doses of β-agonist; use in adults—
oral and IV steroids have similar effect on lung function, but IV steroids have better effect on admission rate; inhaled
steroids act more quickly (≈3 hr) than IV steroids (≈6 hr); use in children—oral and IV steroids equally effective in
reducing need for hospitalization; oral agents recommended for moderate to severe exacerbations, unless patient cannot
take oral drugs; study involving oral vs inhaled steroids—involved fluticasone 2 mg vs oral prednisone 2 mg/kg
(patients already on albuterol and ipratropium); outcomes better at 4 hr in those on prednisone
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| Other drugs: anticholinergics—good additive drugs for patients on β-agonists; quaternary compounds tolerated better
amd last longer; aminophylline—use does not result in greater bronchodilation, compared to β-agonists, and associated
with more side effects; cromolyn—no role in acute asthma; antihistamines—no role for acute asthma; magnesium
sulfate—useful when forced expiratory volume in 1 sec (FEV1 ) <25% of predicted value
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| Comment on 6-yr-old girl: treated with IV steroids and fluids, had 3 nebulizer treatments, sent home and told to see allergist
in 1 wk; mother called 1 mo later, said child never saw allergist and still coughing; on return visit to ED, marble
found in respiratory tract
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| Referrals: when patient referred to specialist, FP may or may not be held liable; problem comes with breakdown in communication
about who is taking responsibility for patient’s condition
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| Ways FP can be held liable: 1) failure to read reports sent by specialist; 2) failure to follow up on reports; 3) failure to address
laboratory results; recommendation—develop system for outside referrals; “comparative fault”—legal term
for shared responsibility (often proportionally) by primary care physician and specialist; recommendation—read and
initial report, then place in chart
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| Approach if patient fails to keep appointment to review laboratory results: send note asking patient to reschedule at earliest
convenience; failure to do so has legal ramifications
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| Patients who have gone to hospital ED: obtain ED records; best to have ED records automatically sent to FP’s office; FP
should have staff call patient to make ED follow-up visit to FP; if patient declines, document that in chart
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Educational Objectives
| The goal of this program is to educate the listener about potential legal problems related to rendering emergency care
in the office. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Explain what legally constitutes “the standard of care” for practicing physicians.
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| 2. Prepare guidelines for dealing with office emergencies.
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| 3. Equip his or her office for emergencies.
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| 4. Manage patients who have sustained bee stings, subarachnoid hemorrhage, acute bacterial pneumonia, head
injuries, or acute asthma attacks.
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| 5. Avoid legal pitfalls in managing patients in the office or when referring them to specialists or the hospital
emergency department.
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Suggested Reading
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external defibrillators in dental practice. N Y State Dent J 72:20, 2006; Chamberlain D: Anaphylaxis management
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Semin Speech Lang 24:313, 2003; Eppich WJ et al: Emergency and critical care pediatrics: use of medical simulation
for training in acute pediatric emergencies. Curr Opin Pediatr 18:266, 2006; Fishbain DA: Medico-legal
rounds: Medical-legal issues and breaches of “standards of care” in opioid tapering for alleged opioid addiction. Pain
Med 3:135, 2002; Freeman TM: Insect and fire ant hypersensitivity: what the primary care physician needs to
know. Compr Ther 23:38, 1997; Genius SJ: The proliferation of clinical practice guidelines: professional development
or medicine-by-numbers? J Am Board Fam Pract 18:419, 2005; Grant CC et al: Oral prednisone as a risk
factor for infections in children with asthma. Arch Pediatr Adolesc Med 150:58, 1996; Hall MA et al: Liability implications
of physician-directed care coordination. Ann Fam Med 3:115, 2005; Hunt LW: How to manage difficult
asthma cases: an action plan for physicians and patients. Postgrad Med 109(5):61, 2001; Kempe A et al: How safe
is triage by after-hours telephone call center? Pediatrics 118:457, 2006; Krugman SD et al: Diagnosis and management
of food-induced anaphylaxis: a national survey of pediatricians. Pediatrics 118:554, 2006; Linn FH,
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appropriately follow patients with an implantable cardioverter-defibrillator? J Intern Med 260:88, 2006; Sempowski
IP, Brison RJ: Dealing with office emergencies: stepwise approach for family physicians. Can Fam Physician
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1990; Toback SL et al: Impact of a pediatric primary care office-based mock code program on physician and staff
confidence to perform life-saving skills. Pediatr Emerg Care 22:415, 2006; Wolfsthal SD et al: Emergencies in diabetic
patients in the primary care setting. Prim Care 33:711, 2006; Yadav H, Lin WY: Patient confidentiality,
ethics, and licensing in telemedicine. Asia Pac J Public Health 13(Suppl):S36, 2001; Zorc JJ et al: Predictors of
primary care follow-up after a pediatric emergency visit for asthma. J Asthma 42:571, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
Dr. Darlow reports he is on the Speakers’ Bureaus of Eli Lilly, GlaxoSmithKline, and Pfizer Pharmaceuticals.
Mr. Blake and Dr. Darlow were recorded on September 30, 2006, at the Annual Scientific Assembly of the American
Academy of Family Physicians, held in Washington, DC. The Audio-Digest Foundation thanks the speakers and the
Academy for their help in the production and distribution of this program.
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