EDITOI ALS Common Sense The scene opens. In the middle of a busy hospital, n u r s e s are s c u r r y i n g and a physician is d e m a n d i n g to have the p e r m i s s i o n slip signed on a child before he is willing to operate to save a life. C u t to t h e fax m a c h i n e . A n u r s e is faxing a p e r m i s s i o n f o r m somewhere in the world. Cut to the o p e r a t i n g r o o m . T h e p h y s i c i a n is scrubbing. C u t b a c k to the fax machine. A p i e c e of p a p e r is c o m i n g through w i t h a signature at the bott o m . C u t to t h e o p e r a t i n g r o o m , where the nurse bursts in as the surgeon is readying his gloves and says, "We've got the permission; n o w you can operate." T h i s r a t h e r t a w d r y m e l o d r a m a is currently playing on your television set as an a d v e r t i s e m e n t for a particular brand of fax machine. T h e manufacturers w o u l d l i k e y o u to b e l i e v e t h a t this c h i l d ' s life was saved because t h e p e r m i s s i o n c a m e t h r o u g h in t i m e for the surgeon to operate. I would propose another analysis, that a child's life was nearly lost because some misguided physician thought he n e e d e d a scribble on a piece of paper before doing what anyone's c o m m o n sense w o u l d tell h i m to do, ie, to act in defense of the patient. See related article, p 297.
J
In this issue of Annals, an article by Treloar et a] looks to the question of u n a c c o m p a n i e d m i n o r s i n t h e emergency service and the m a n n e r in w h i c h t h e y are t r e a t e d by m e d i c a l staff. T h r o u g h a survey i n s t r u m e n t , the authors d o c u m e n t delays in therapy on c h i l d r e n w i t h m e d i c a l probl e m s w h i l e w a i t i n g for p e r m i s s i o n . T h e y f o u n d an i n s t a n c e in w h i c h a child w i t h a s i g n i f i c a n t a s t h m a attack was not treated awaiting the eontact of a parent or parental substitute. T h e tragedy in this situation is more t h a n potential. I well r e m e m b e r early in m y medicolega] career being asked to evaluate the case of a 19-year-old who brought her g-year-old sister to a major Detroit hospital emergency d e p a r t m e n t 20:3 March 1991
a n d p r e s e n t e d to t h e r e g i s t r a t i o n clerk c l a i m i n g the child had a sore throat. Because t h e 19-year-old was n o t t h e child's m o t h e r , t h e y asked h e r t o h a v e a seat in t h e w a i t i n g r o o m w i t h the child u n t i l the m o t h e r got h o m e from w o r k some two hours later and a proper p e r m i s s i o n could be obtained. The child, unfort u n a t e l y , did n o t have to w a i t t w o hours to be seen because w i t h i n an hour she was rushed up to the registration clerk again, this t i m e in respir a t o r y a r r e s t f r o m e p i g l o t t i t i s . You can imagine h o w i m p o r t a n t t h a t jury thought it was that the hospital had waited for a signed p e r m i s s i o n to see a sick child. All of our senses do inform against us on this issue. The authors suggest that the current l i t i g i o u s c l i m a t e is t h e reason for this overly c a u t i o u s approach. I disagree. F r o m t h e t i m e of t h e fam o u s O'Brien v Cunard case, 1 "sil e n c e gives c o n s e n t " h a s b e e n t h e m e d i c a l m a x i m . If a child s o m e h o w appears or is brought to an ED, w h y do we t h i n k he is there? For the food? For the clean restrooms? ]?or the amb i a n c e ? H a r d l y . H e is p r e s e n t i n g himself or being presented by someone else because in someone's m i n d there is a need for i m m e d i a t e medical attention. N o t to act and provide an evaluation and m o v e to treat urg e n t or e m e r g e n c y m e d i c a l c o n d i tions is folly. There is no legal precedent for fear on the part of the e m e r g e n c y physician. AR Holder, in his now-famous article, " M i n o r s ' Rights to C o n s e n t to Medical Care, ''z reviewed 30 years of e m e r g e n c y m e d i c i n e cases to find a single case in w h i c h c o n s e n t was the issue. It should be reassuring that w i t h an average of 80 m i l l i o n emergency visits a year t i m e s 30 years, he was unable to find one case in all the US l a w s u i t s in w h i c h c o n s e n t was the basis of the judgment against an emergency physician. W h e n w e t h i n k a b o u t it, t h i s m a k e s perfect sense. N o m a t t e r h o w jaded and cynical our view of the current US legal s y s t e m , it m o v e s alm o s t beyond belief that a p h y s i c i a n Annals of Emergency Medicine
should be handed social and financial retribution for acting in a c o m m o n sense manner. The law does not require a perfect outcome, only due dili g e n c e a n d s i m p l e h u m a n i t y for t h o s e seeking our care. If w e have c o m e to t h e p o i n t in t h i s c o u n t r y where we sit and watch a child s t r a i n i n g for b r e a t h a n d w i t h h o l d n e c e s s a r y t h e r a p y w a i t i n g for t h e scrawled s i g n a t u r e of a p a r e n t w h o would never understand why we w a i t e d a n y w a y , t h e n w e are all in serious trouble. But I do not t h i n k this is the case. In reviewing m y o w n series of legal cases on w h i c h I have advised, and in discussions w i t h people involved in emergency medicine legal cases throughout the U n i t e d States, I have found that there is no support for the idea t h a t delay of any k i n d in urgent or emergency cases m a k e s any sense. T h e federal g o v e r n m e n t has clearly m a n d a t e d t h r o u g h COBRA and t h e son of COBRA, OBRA, that all w h o present to emergency facilities shall be e x a m i n e d . After all, t h e r e is no w a y for a physician to k n o w w h e t h e r a true urgent or emergency condition exists unless a proper e x a m i n a t i o n is conducted. With younger children, t h e r e is v i r t u a l l y a l w a y s s o m e o n e w h o brought t h e m to t h e ED w h o acts in the s u b s t i t u t e or in loco parentis role. T h e i r r e q u e s t for t r e a t m e n t s h o u l d be e n o u g h . In older, teenaged children, the concept of the m a t u r e m i n o r should again eradicate any delay or h e s i t a t i o n for evaluation and treatment. Would I do everything w i t h o u t parental permission? No. There is proba b l y no r e a s o n for t h e e m e r g e n c y p h y s i c i a n to perform an elective tonsillectomy, breast augmentation, or a r o u t i n e cholera i n o c u l a t i o n w i t h o u t some reasonable discussion w i t h the p a r e n t s or the guardian. But again, c o m m o n sense should be the guide. A f t e r e v a l u a t i o n , r e a s o n a b l e decisions on w h a t is truly elective can be made, but this can only be done after a presenting patient's history and physical examination have been properly performed. 319/155
EDITORIALS
One of the real factors involved in physician burnout in emergency m e d i c i n e is that of c o n t i n u o u s conflict. W h e n the emergency physician has to agonize over such questions, it is f u r t h e r u n n e c e s s a r y s t r e s s t h a t adds to the i n c r e d i b l e h u m a n price paid by those who practice our prof e s s i o n . T h i s is an a r e a in w h i c h stress is t o t a l l y unnecessary. It w o u l d be an excellent project for each ACEP s t a t e c h a p t e r to m a k e c e r t a i n t h a t there are current statutes to resolve this simple consent issue. The great
e m e r g e n c y p h y s i c i a n deserves such legal backup; the mediocre emergency physician needs it. A b o v e all else, the m e s s a g e t h a t should be carried from the combinat i o n of T r e l o a r et al's a r t i c l e , case law, and the tenets of the Hippocratic O a t h is: Act! Act like the p a t i e n t is s o m e o n e you care about. Act like you have the courage and intelligence to tell the difference b e t w e e n n e c e s s a r y and u n n e c e s s a r y care and t e s t i n g and t h a t y o u have done for the patient what you would have
done for y o u r o w n f a m i l y m e m b e r . H a m l e t u n d e r s t o o d the p r o b l e m of t h i n k i n g too m u c h and acting too little: "Thus, the native hue of resolution is sicklied o'er w i t h the pale cast of thought . . . and lose the n a m e of action. ''3 - Caput deum!
Gregory L Henry, MD, FACEP Ann Arbor, Michigan 1. O'Brien v Cunard, SS Co. 154 Mass. 272, 28 N E 266. 2. H o l d e r AR: M i n o r s ' rights to c o n s e n t to m e d i c a l care. JAMA, 1987;257:3400. 3. W i l l i a m Shakespeare: Hamlet, III, i, 83.
The Future of Critical Care Medicine Within Emergency Medicine The ACEP Critical Care C o m m i t tee p o s i t i o n p a p e r " T h e F u t u r e of Critical Care Medicine W i t h i n Emergency M e d i c i n e " by A b r a m s o n and colleagues I is a comprehensive docum e n t t h a t addresses m a n y c o m p l e x issues regarding the relationship bet w e e n emergency m e d i c i n e and critical care m e d i c i n e . I n c l u d e d are discussions of practice issues as well as e d u c a t i o n a l and t r a i n i n g i s s u e s at both the residency and postresidency levels. I w i l l e m p h a s i z e w h a t I believe are the m o s t i m p o r t a n t positive aspects. Our value as emergency physicians to our c o m m u n i t i e s and our profession lies p r i m a r i l y in our a b i l i t y to r e s u s c i t a t e the c r i t i c a l l y ill and injured p a t i e n t s we e n c o u n t e r in the p r e h o s p i t a l and e m e r g e n c y d e p a r t m e n t settings. A l t h o u g h our efforts in providing p r i m a r y and urgent care are both useful and generally appreciated by our patients and colleagues, there should be no question in anyo n e ' s m i n d t h a t w e o w e o u r existence as a specialty to our ability to provide i m m e d i a t e , lifesaving care to our critically c o m p r o m i s e d patients. Therefore, it is i m p e r a t i v e t h a t our residency graduates be highly accomplished in the critical care skills required to assess and treat these patients. 156/320
The Committee's position paper points out that one third of our residency programs surveyed by the Society of Teachers of Emergency Medicine several years ago "were dissatisfied with their current ICU curriculum." Since that survey, many new residency programs in e m e r g e n c y m e d i c i n e have been established. Because I C U s t e n d to be c o m p l i c a t e d p o l i t i c a l e n v i r o n m e n t s , i t is safe to a s s u m e that critical care experience for emergency m e d i c i n e residents m a y be even less ideal in these newly developed programs. Therefore, it is i m p e r a t i v e t h a t w e act quickly to i m p l e m e n t the STEM reco m m e n d a t i o n s to i m p r o v e c r i t i c a l care training of our residents, w h i c h i n c l u d e d i n c r e a s i n g the t i m e s p e n t and the quality of the experience in b o t h a d u l t and p e d i a t r i c ICUs. T h e c o m m i t t e e ' s suggestions that we dev e l o p a core c u r r i c u l u m a n d b i b l i ography for critical care m e d i c i n e in emergency m e d i c i n e are excellent. Subspecialty postgraduate training in c r i t i c a l care m e d i c i n e for emergency physicians is urgently needed. T h e r a t i o n a l e for this t r a i n i n g is to develop a cadre of physicians w i t h i n the specialty of emergency m e d i c i n e w h o are c a p a b l e of p r o v i d i n g acad e m i c and clinical leadership in carAnnals of Emergency Medicine
ing for and studying the critically ill and i n j u r e d p a t i e n t s in the ED and prehospital phases of their illnesses. Fellowship-trained subspecialists could play a pivotal role w i t h i n their EDs in e s t a b l i s h i n g p r o t o c o l s for monitoring, resuscitating, and transporting these patients. It is u n l i k e l y that emergency physicians with critical care training w o u l d seek to b e c o m e i n - h o u s e int e n s i v i s t s p r o v i d i n g ongoing care in critical care units. Local hospital politics, rather than any n a t i o n a l policy, d e t e r m i n e w h o can obtain privileges for that role. However, the n u m b e r of individuals from emergency medicine w h o w o u l d s e e k such a career track w o u l d be so small as to m a k e it a nonissue. N o w t h a t the field of e m e r g e n c y m e d i c i n e has achieved p r i m a r y board status, it can d e v e l o p s u b s p e c i a l t y c e r t i f i c a t i o n . T h i s p r o c e s s w i l l enhance d e v e l o p m e n t as a specialty in areas such as emergency medical services, pediatric e m e r g e n c y medicine, toxicology, and transport medicine. I b e l i e v e critical care m e d i c i n e m u s t also be c o n s i d e r e d one of our m o s t i m p o r t a n t areas for subspecialty development. D u r i n g the p o l i t i c a l process leading to t h e d e c i s i o n to g r a n t e m e r gency m e d i c i n e p r i m a r y board status, 20:3 March 1991
J
In this issue of Annals, an article by Treloar et a] looks to the question of u n a c c o m p a n i e d m i n o r s i n t h e emergency service and the m a n n e r in w h i c h t h e y are t r e a t e d by m e d i c a l staff. T h r o u g h a survey i n s t r u m e n t , the authors d o c u m e n t delays in therapy on c h i l d r e n w i t h m e d i c a l probl e m s w h i l e w a i t i n g for p e r m i s s i o n . T h e y f o u n d an i n s t a n c e in w h i c h a child w i t h a s i g n i f i c a n t a s t h m a attack was not treated awaiting the eontact of a parent or parental substitute. T h e tragedy in this situation is more t h a n potential. I well r e m e m b e r early in m y medicolega] career being asked to evaluate the case of a 19-year-old who brought her g-year-old sister to a major Detroit hospital emergency d e p a r t m e n t 20:3 March 1991
a n d p r e s e n t e d to t h e r e g i s t r a t i o n clerk c l a i m i n g the child had a sore throat. Because t h e 19-year-old was n o t t h e child's m o t h e r , t h e y asked h e r t o h a v e a seat in t h e w a i t i n g r o o m w i t h the child u n t i l the m o t h e r got h o m e from w o r k some two hours later and a proper p e r m i s s i o n could be obtained. The child, unfort u n a t e l y , did n o t have to w a i t t w o hours to be seen because w i t h i n an hour she was rushed up to the registration clerk again, this t i m e in respir a t o r y a r r e s t f r o m e p i g l o t t i t i s . You can imagine h o w i m p o r t a n t t h a t jury thought it was that the hospital had waited for a signed p e r m i s s i o n to see a sick child. All of our senses do inform against us on this issue. The authors suggest that the current l i t i g i o u s c l i m a t e is t h e reason for this overly c a u t i o u s approach. I disagree. F r o m t h e t i m e of t h e fam o u s O'Brien v Cunard case, 1 "sil e n c e gives c o n s e n t " h a s b e e n t h e m e d i c a l m a x i m . If a child s o m e h o w appears or is brought to an ED, w h y do we t h i n k he is there? For the food? For the clean restrooms? ]?or the amb i a n c e ? H a r d l y . H e is p r e s e n t i n g himself or being presented by someone else because in someone's m i n d there is a need for i m m e d i a t e medical attention. N o t to act and provide an evaluation and m o v e to treat urg e n t or e m e r g e n c y m e d i c a l c o n d i tions is folly. There is no legal precedent for fear on the part of the e m e r g e n c y physician. AR Holder, in his now-famous article, " M i n o r s ' Rights to C o n s e n t to Medical Care, ''z reviewed 30 years of e m e r g e n c y m e d i c i n e cases to find a single case in w h i c h c o n s e n t was the issue. It should be reassuring that w i t h an average of 80 m i l l i o n emergency visits a year t i m e s 30 years, he was unable to find one case in all the US l a w s u i t s in w h i c h c o n s e n t was the basis of the judgment against an emergency physician. W h e n w e t h i n k a b o u t it, t h i s m a k e s perfect sense. N o m a t t e r h o w jaded and cynical our view of the current US legal s y s t e m , it m o v e s alm o s t beyond belief that a p h y s i c i a n Annals of Emergency Medicine
should be handed social and financial retribution for acting in a c o m m o n sense manner. The law does not require a perfect outcome, only due dili g e n c e a n d s i m p l e h u m a n i t y for t h o s e seeking our care. If w e have c o m e to t h e p o i n t in t h i s c o u n t r y where we sit and watch a child s t r a i n i n g for b r e a t h a n d w i t h h o l d n e c e s s a r y t h e r a p y w a i t i n g for t h e scrawled s i g n a t u r e of a p a r e n t w h o would never understand why we w a i t e d a n y w a y , t h e n w e are all in serious trouble. But I do not t h i n k this is the case. In reviewing m y o w n series of legal cases on w h i c h I have advised, and in discussions w i t h people involved in emergency medicine legal cases throughout the U n i t e d States, I have found that there is no support for the idea t h a t delay of any k i n d in urgent or emergency cases m a k e s any sense. T h e federal g o v e r n m e n t has clearly m a n d a t e d t h r o u g h COBRA and t h e son of COBRA, OBRA, that all w h o present to emergency facilities shall be e x a m i n e d . After all, t h e r e is no w a y for a physician to k n o w w h e t h e r a true urgent or emergency condition exists unless a proper e x a m i n a t i o n is conducted. With younger children, t h e r e is v i r t u a l l y a l w a y s s o m e o n e w h o brought t h e m to t h e ED w h o acts in the s u b s t i t u t e or in loco parentis role. T h e i r r e q u e s t for t r e a t m e n t s h o u l d be e n o u g h . In older, teenaged children, the concept of the m a t u r e m i n o r should again eradicate any delay or h e s i t a t i o n for evaluation and treatment. Would I do everything w i t h o u t parental permission? No. There is proba b l y no r e a s o n for t h e e m e r g e n c y p h y s i c i a n to perform an elective tonsillectomy, breast augmentation, or a r o u t i n e cholera i n o c u l a t i o n w i t h o u t some reasonable discussion w i t h the p a r e n t s or the guardian. But again, c o m m o n sense should be the guide. A f t e r e v a l u a t i o n , r e a s o n a b l e decisions on w h a t is truly elective can be made, but this can only be done after a presenting patient's history and physical examination have been properly performed. 319/155
EDITORIALS
One of the real factors involved in physician burnout in emergency m e d i c i n e is that of c o n t i n u o u s conflict. W h e n the emergency physician has to agonize over such questions, it is f u r t h e r u n n e c e s s a r y s t r e s s t h a t adds to the i n c r e d i b l e h u m a n price paid by those who practice our prof e s s i o n . T h i s is an a r e a in w h i c h stress is t o t a l l y unnecessary. It w o u l d be an excellent project for each ACEP s t a t e c h a p t e r to m a k e c e r t a i n t h a t there are current statutes to resolve this simple consent issue. The great
e m e r g e n c y p h y s i c i a n deserves such legal backup; the mediocre emergency physician needs it. A b o v e all else, the m e s s a g e t h a t should be carried from the combinat i o n of T r e l o a r et al's a r t i c l e , case law, and the tenets of the Hippocratic O a t h is: Act! Act like the p a t i e n t is s o m e o n e you care about. Act like you have the courage and intelligence to tell the difference b e t w e e n n e c e s s a r y and u n n e c e s s a r y care and t e s t i n g and t h a t y o u have done for the patient what you would have
done for y o u r o w n f a m i l y m e m b e r . H a m l e t u n d e r s t o o d the p r o b l e m of t h i n k i n g too m u c h and acting too little: "Thus, the native hue of resolution is sicklied o'er w i t h the pale cast of thought . . . and lose the n a m e of action. ''3 - Caput deum!
Gregory L Henry, MD, FACEP Ann Arbor, Michigan 1. O'Brien v Cunard, SS Co. 154 Mass. 272, 28 N E 266. 2. H o l d e r AR: M i n o r s ' rights to c o n s e n t to m e d i c a l care. JAMA, 1987;257:3400. 3. W i l l i a m Shakespeare: Hamlet, III, i, 83.
The Future of Critical Care Medicine Within Emergency Medicine The ACEP Critical Care C o m m i t tee p o s i t i o n p a p e r " T h e F u t u r e of Critical Care Medicine W i t h i n Emergency M e d i c i n e " by A b r a m s o n and colleagues I is a comprehensive docum e n t t h a t addresses m a n y c o m p l e x issues regarding the relationship bet w e e n emergency m e d i c i n e and critical care m e d i c i n e . I n c l u d e d are discussions of practice issues as well as e d u c a t i o n a l and t r a i n i n g i s s u e s at both the residency and postresidency levels. I w i l l e m p h a s i z e w h a t I believe are the m o s t i m p o r t a n t positive aspects. Our value as emergency physicians to our c o m m u n i t i e s and our profession lies p r i m a r i l y in our a b i l i t y to r e s u s c i t a t e the c r i t i c a l l y ill and injured p a t i e n t s we e n c o u n t e r in the p r e h o s p i t a l and e m e r g e n c y d e p a r t m e n t settings. A l t h o u g h our efforts in providing p r i m a r y and urgent care are both useful and generally appreciated by our patients and colleagues, there should be no question in anyo n e ' s m i n d t h a t w e o w e o u r existence as a specialty to our ability to provide i m m e d i a t e , lifesaving care to our critically c o m p r o m i s e d patients. Therefore, it is i m p e r a t i v e t h a t our residency graduates be highly accomplished in the critical care skills required to assess and treat these patients. 156/320
The Committee's position paper points out that one third of our residency programs surveyed by the Society of Teachers of Emergency Medicine several years ago "were dissatisfied with their current ICU curriculum." Since that survey, many new residency programs in e m e r g e n c y m e d i c i n e have been established. Because I C U s t e n d to be c o m p l i c a t e d p o l i t i c a l e n v i r o n m e n t s , i t is safe to a s s u m e that critical care experience for emergency m e d i c i n e residents m a y be even less ideal in these newly developed programs. Therefore, it is i m p e r a t i v e t h a t w e act quickly to i m p l e m e n t the STEM reco m m e n d a t i o n s to i m p r o v e c r i t i c a l care training of our residents, w h i c h i n c l u d e d i n c r e a s i n g the t i m e s p e n t and the quality of the experience in b o t h a d u l t and p e d i a t r i c ICUs. T h e c o m m i t t e e ' s suggestions that we dev e l o p a core c u r r i c u l u m a n d b i b l i ography for critical care m e d i c i n e in emergency m e d i c i n e are excellent. Subspecialty postgraduate training in c r i t i c a l care m e d i c i n e for emergency physicians is urgently needed. T h e r a t i o n a l e for this t r a i n i n g is to develop a cadre of physicians w i t h i n the specialty of emergency m e d i c i n e w h o are c a p a b l e of p r o v i d i n g acad e m i c and clinical leadership in carAnnals of Emergency Medicine
ing for and studying the critically ill and i n j u r e d p a t i e n t s in the ED and prehospital phases of their illnesses. Fellowship-trained subspecialists could play a pivotal role w i t h i n their EDs in e s t a b l i s h i n g p r o t o c o l s for monitoring, resuscitating, and transporting these patients. It is u n l i k e l y that emergency physicians with critical care training w o u l d seek to b e c o m e i n - h o u s e int e n s i v i s t s p r o v i d i n g ongoing care in critical care units. Local hospital politics, rather than any n a t i o n a l policy, d e t e r m i n e w h o can obtain privileges for that role. However, the n u m b e r of individuals from emergency medicine w h o w o u l d s e e k such a career track w o u l d be so small as to m a k e it a nonissue. N o w t h a t the field of e m e r g e n c y m e d i c i n e has achieved p r i m a r y board status, it can d e v e l o p s u b s p e c i a l t y c e r t i f i c a t i o n . T h i s p r o c e s s w i l l enhance d e v e l o p m e n t as a specialty in areas such as emergency medical services, pediatric e m e r g e n c y medicine, toxicology, and transport medicine. I b e l i e v e critical care m e d i c i n e m u s t also be c o n s i d e r e d one of our m o s t i m p o r t a n t areas for subspecialty development. D u r i n g the p o l i t i c a l process leading to t h e d e c i s i o n to g r a n t e m e r gency m e d i c i n e p r i m a r y board status, 20:3 March 1991
