Case Scenario

While driving home from work one evening, I saw the car ahead of me cross the median strip and crash into an oncoming car. Luckily, traffic was light, and I was able to stop safely. Using my cell phone, I immediately dialed 9-1-1 and approached the wreckage. The driver had been thrown into the back seat and was bleeding profusely from his mouth. I couldn't tell if he was breathing, and I could not find a pulse. I wasn't sure what else to do. CPR certainly didn't seem possible, given the bleeding and the man's inaccessible position. It seemed I should be better prepared for such an emergency, even though, in my office-based practice, I rarely encounter one.

There have been other occasions, less urgent, when I wasn't sure how to intervene or if I should intervene. For example, while some medical students and I were waiting for a train one afternoon, we found a man lying on the floor of the subway station. The students looked at me expectantly. I checked for a medical alert bracelet. The man appeared groggy but roused a little when I called to him. I thought he might be drunk or under the influence of another drug. Besides alerting the station manager, what should I have done? What legal responsibilities does a physician have in this situation? What skills should we keep current for such emergencies?

Commentary

Family physicians who encounter an unexpected medical emergency face a myriad of ethical, legal, and competency issues. Add to these issues a clinical scenario that would have a sage emergency physician shaking in his boots, and suddenly the overwhelming feeling of being in “the wrong place at the wrong time” can consume the physician.

Without detailing the exact response that a physician should take in such a situation, a number of medical organizations have implicitly addressed a physician's ethical obligations in a medical emergency. The International Code of Medical Ethics of the World Medical Association (1983) asserted, “A physician shall give emergency care as a humanitarian duty unless he is assured that others are willing and able to give such care.” The Code of Medical Ethics of the Canadian Medical Association (1990) declared, “An ethical physician shall, except in an emergency, have the right to refuse to accept a patient; will render all possible assistance to any patient, where an urgent need for medical care exists.” And the Principles of Ethics of the American Medical Association (1992) pro-claimed,“A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve.”¹

Despite the professional and humanitarian desire to assist in cases of emergencies, concern about legal reprisal might result in a physician's inclination to shy away from rendering assistance in such cases. In 1959, the first “good samaritan” law was created specifically to protect individuals from civil liability for any negligent acts or omissions committed while voluntarily providing emergency care. Since the passage of the first good samaritan statute in California, all 50 states have enacted some form of legislation designed to encourage doctors to respond to victims of an emergency by granting immunity from civil damages and removing the fear of liability.

Some states, Nevada, for example, have simple good samaritan laws that apply to all citizens, not just physicians. Other states have statutes written specifically for doctors. Three states—Vermont, Louisiana, and Minne-sota—actually have failure-to-act laws requiring all citizens, at the risk of penalty, to assist a victim in need. Because 50 different laws exist, family physicians are encouraged to become familiar with the laws in their states. Some good samaritan laws are quite detailed and extend beyond the street emergency to include acts within the hospital itself. In California, for example, “a staff physician of a hospital, who treats another physician's patient at the hospital in response to a medical emergency, is protected by the good samaritan laws.”¹

Does such legislation actually provide immunity to the physician who provides good samaritan care? To date, there have been no documented cases of a suit brought against a physician for providing emergency care outside a hospital setting in such a scenario.^1–3

What does this mean for the physician who is faced with an uncomfortable emergency situation? Would it be appropriate for a family physician whose entire career has been in an office-based practice to attempt a risky intubation or chest tube insertion in a multitrau-ma victim in the field? The Pennsylvania good samaritan statute reasonably answers this question. In this law, medical personnel who provide emergency care in good faith are protected from liability, except when performing “… any acts or omissions intentionally designed to harm, or any grossly negligent acts or omissions which result in harm to the person receiving emergency care.”⁴ This statute outlines a standard in which the physician is to act reasonably and not recklessly.

Essentially, a physician can and should render assistance within his or her scope of capability and comfort. For example, if the family physician works daily in an emergency department setting, he or she should have some level of comfort with airway and trauma management. However, for a physician who has not stepped inside an emergency department for some time, attempting a rapid-sequence intubation in the field is probably not a good idea. The same applies to the insertion of chest tubes and other invasive procedures. Could you imagine an ophthalmologist attempting such an intervention? Remember: Primum non nocere (first, do no harm).

Attempting to help an injured or ill person in the field can be challenging and intimidating. Often the victim, the victim's family, and bystanders are anxious, agitated, and perhaps even irrational. Furthermore, the necessary tools, technology, and ancillary personnel are not immediately available. Therefore, the physician should call for help immediately—this is not the time to be a hero and go it alone. Once help has been summoned, the physician should remember the ABCs of basic life support measures: Airway, Breathing, and Circulation. These measures are the most crucial interventions that onsite medical personnel can provide, and they should be part of most family physicians' armamentarium. Possible subsequent interventions such as intubation, C-spine stabilization, needle tho-racostomy, or defibrillation (in the absence of a portable defibrillator) are impossible to perform until emergency medical services (EMS) personnel arrive with the appropriate equipment. When EMS personnel arrive at the scene, these procedures should be performed by the person with the most experience. For example, if intubation is required and the EMS provider has done hundreds of them and the physician has not done an intubation since residency, the EMS provider should perform the procedure. This is not the time for the physician's ego to get in the way.

For family physicians who want to sharpen their skills to be prepared for an unexpected emergency, the American Heart Association's advanced cardiac life support (ACLS) course is a good starting point. Although there has been some controversy over a couple of particular recommendations in the 2000 guidelines, the course reinforces the ABCs of cardiopul-monary resuscitation. Advanced trauma life support (ATLS), pediatric advanced life support (PALS), neonatal resuscitation, and advanced life support in obstetrics (ALSO) courses are available to advance physicians' resuscitation skills in special circumstances. For the physician who wants to review all of these resuscitation scenarios in one CME program, a two-day, comprehensive advanced life support (CALS) course is available through the Minnesota Chapter of the American Academy of Family Physicians (AAFP).

If a more extensive review of emergency medicine beyond the basics of cardiopul-monary resuscitation is desired, the AAFP's “Emergency and Urgent Care for Family Physicians” course is recommended. The course is scheduled for September 18 through 21, 2003, in San Francisco and is specifically designed for family physicians who want to update their skills in emergency and urgent care. The course is taught by emergency and family physicians using lecture and small-group discussion modes so that the family physician can become more comfortable with the common and uncommon clinical scenarios we encounter in our day-to-day practices.