Emergencies occur in every type of medical practice. The dermatologist may
not treat anaphylaxis as often as the emergency physician, but there is always
the chance that a patient will react to a drug. All physicians must consider the
types of emergencies that may arise in their practices and be prepared to deal
with them. Some minimum standards for all physicians are set by professional
organizations and hospital staff rules. Proficiency in basic life support at the
level necessary to maintain certification with the American Heart Association or
the American Red Cross has become such a common requirement for
employment or staff privileges that it is arguably a standard of care for all
The same general standards of care apply for emergencies as for routine care
in the office or the hospital. Specialists are expected to work to the standards
of their specialty and to have general competence in other areas of medicine.
This can be a problem for subspecialists who were not trained as general
practitioners before they did their specialty training. The law assumes that
there is a core body of medical knowledge shared by all physicians. This
includes the management of basic emergency conditions such as heart attacks
and the management of iatrogenic complications of specialty practice, such as
anaphylactic shock from a drug administered in the physician’s office.
Physicians should have appropriate emergency equipment available where they
practice, with the specific equipment needed tailored to the practice and the
patient panel. For example, physicians who give injectable drugs should have
all the equipment necessary to treat anaphylaxis. If the physician does not
treat anyone under the age of 16, pediatric-sized airways are not necessary. If
the physician does not treat anyone over the age of 10, a kit full of 18-gauge
needles and liter bottles of fluid would not be appropriate. Physicians whose
practices include older individuals should have the equipment and training to
deal with a myocardial infarction. Although the physician may not cause the
patient’s heart attack, heart attacks are an expected occurrence in the patient
The manufacturers of emergency kits are working to raise the standard of care
for office emergency equipment. A bite block made from a tongue depressor
and a syringe full of epinephrine taped to the wall is no longer acceptable
emergency preparation. Oxygen, intravenous fluids, and steroids may be
lifesaving. They are readily available in a suitcase kit that contains protocols
for the use of all the equipment. Appropriate drugs and equipment should be
readily available in usable form to treat a patient in a foreseeable emergency.
Losing a patient to anaphylaxis because there is no oxygen available or the
epinephrine is out of date is inexcusable.
Physicians should accompany their patients to the hospital in the emergency
transport vehicle if there is no proper paramedic service. Many helicopter
transport systems will not allow the attending physician to ride in the
helicopter, but these systems usually have appropriate personnel on board.
The attending physician should call ahead while the helicopter is en route and
talk to the staff physician at the receiving hospital.
Physicians rendering emergency medical care in the office should recognize the
limitations of the situation and of their skills. Physicians should not hesitate to
call an ambulance to transport a patient to an emergency room. If the
physician cannot manage the emergency, it is negligent not to transport the
patient to a proper emergency facility. The physician should never send a
patient with a serious condition to an emergency room in private
transportation. If the condition requires emergency care, the patient should be
transported in an ambulance. (This may not hold true in rural areas without
available ambulance service. In this case, the physician may need to
accompany the patient.) The ambulance personnel may not be able to keep
the asthmatic patient from dying, but a jury would never believe that the
ambulance would not have helped.