"Is There a Doctor in the House?” Addressing Bystander Physician Involvement on Scene

The dispatcher comes across the radio: “Medic 8, motor vehicle crash, thruway northbound, reported serious. Be advised that PD and FD are also responding.” You confirm the transmission and make it to the scene to find one patient, entrapped and critically injured, following a single-vehicle accident. As you begin to assess and treat the patient and the fire department sets up for extrication, a car pulls up and a man jumps out. “I’m a doctor,” he says to no one in particular. You and your partner exchange glances that seem to say, “Oh, no—not again.”

Most EMS providers will face a scenario like this at some point in their careers. There are many well-intentioned physicians who are more than willing to lend their hands and training at emergency scenes. Unfortunately, even if they have a working knowledge of emergency medicine, these doctors may not always be cognizant of the formal hierarchy of medical oversight controlling EMS operations in the field. This ignorance can often lead to confusion in regard to responsibility for out-of-hospital patient care, overall adherence to EMS system protocols and online medical authority. Sometimes the difference between appropriately utilizing these physicians and alienating them lies in your approach to handling these interactions, as well as their understanding of your system policies.

This article will deal with commonly identified issues surrounding the presence of a bystander physician on an EMS scene, discuss the inherent legal issues and illustrate examples of strategies EMS systems have employed to mitigate this common and potentially contentious situation.

Perspectives

Medical organizations such as the National Association of EMS Physicians (NAEMSP), the American College of Emergency Physicians (ACEP) and the American Medical Association (AMA) have all addressed this subject in publications and position statements. The consensus is that the direction of prehospital care at the scene of a medical emergency should be the responsibility of the individual in attendance who is most appropriately trained in providing prehospital emergency care and transport.1 ACEP offers that an “intervener physician is a physician who provides evidence of medical licensure, has not established a prior physician/patient relationship, wishes to take charge of a medical emergency and is willing to accompany the patient to the hospital when so requested.”1 The AMA outlines guidelines to be applied in instances where a physician happens upon an emergency scene and desires to take medical and legal responsibility for the patient. It recognizes that prehospital EMS systems operate under the authority and direction of a licensed physician who has both medical and legal responsibility for the system.2

But even with these official assertions, the realities of these situations still place EMS providers squarely in the middle, forcing them to handle the question of whom to listen to while still addressing their primary responsibility of providing patient care.

Legal Issues

In general, the matter of the bystander physician is full of legal landmines of which EMS providers should be aware. Concerns include questions of medical authority, possible deviations from accepted local, regional or statewide protocols, and overall liability.

There are some essential steps that should be taken as soon as someone presents himself as a physician to EMS providers at an emergency scene. First, an attempt should be made to ascertain what sort of medical discipline the purported doctor practices and the extent of his knowledge of emergency procedures. Do not be afraid to ask for identification. Some states’ medical boards and regional medical advisory committees offer identification cards to doctors for just such situations.

Second, impress upon the physician that online medical control must be willing to transfer responsibility for directing patient care. Many areas require the intervening doctor to accompany the patient to the hospital. There is no point in going through the time and trouble of this process if the doctor does not understand this necessity.

Third, notify online medical control of the presence of the on-scene physician and express his desire to actively participate in the direction of patient care. Medical control must be convinced of this physician’s qualifications and be comfortable authorizing the EMS providers to act under his direction.

Finally, have the physician sign a statement accepting control of patient care.3 This affirmation can be captured on either the standard patient care report or on a form specially created for this purpose. Only after these conditions have been met should the EMS provider feel secure in sharing patient-care responsibilities with the bystander physician.

Online medical control may revoke the authority it has given to the on-scene physician at any time. And at no time are you, the EMS provider, relieved of your duties to act in this situation; the bystander physician cannot direct you to practice outside of your scope of practice or your system’s protocols. EMS providers must promptly report orders from these doctors that deviate from accepted prehospital care procedures and give medical control the ability to reestablish its oversight if needed.

As always, documentation is crucial, and your run report needs to contain all pertinent details of this encounter. At a minimum, this includes the doctor’s name, medical license number and signature. If policy dictates, you may want to complete a supplemental incident report to fully capture what occurred on scene. These types of events could be deemed as unusual occurrences and may be subject to further clinical or administrative review. You need to accurately document the facts relating to such incidents while they’re fresh in your mind.

Strategies

Systems around the country have developed various strategies to help EMS providers successfully handle intervening physicians. A common tool used is a business-size card outlining the alternatives open to the doctor seeking to assist in prehospital patient care. One such card has been created by the California EMS Authority and the California Medical Association (Figure 1). This card is easily carried by EMS providers and can assist in quickly educating a bystander physician that the EMS providers are acting under the guidance of medical control, thanking him for his offer to assist and listing multiple possibilities for his involvement. This is most helpful where there is an online physician to whom the intervening doctor can speak.

Often used in lieu of or in conjunction with a card notification is a form for a bystander physician to read and complete after he approaches an EMS crew on a scene. This form makes it clear that should the physician wish to deliver medical care, and online medical control agrees to relinquish authority, he will need to sign for acceptance of the patient. This method is not as easy to implement as the card method, but presents roughly the same sort of information and gives the crew the ability to gain a legally binding signature. Also, making the doctor responsible via a sworn, signed statement tends to impress upon him the enormity of the liability being assumed, especially if online communications with medical control are unavailable.

A less-often-utilized yet highly effective strategy is education, both of EMTs and physicians. The topic of bystander physicians is only briefly dealt with in most EMT and paramedic course curricula. ALS providers receive additional exposure to procedures for handling doctors presenting on scene in area protocols, but this material may not be revisited after initial credentialing, and BLS providers are usually not as informed. Also, despite the documents promulgated by ACEP, NAEMSP and AMA, the vast majority of physicians are unfamiliar with these requirements. The capabilities of modern EMS systems and the various levels of providers found practicing in them (CFR, EMT-B, EMT-I, EMT-P) are a mystery to most general practitioners, and even some emergency medicine specialists. There are few fully integrated prehospital/hospital systems where medical students are allowed to do ride-alongs with their local EMS agencies. Even more rare are physician-education programs that have incorporated the completion of this prehospital time into their clinical requirements.

Certain systems have incorporated policies and procedures for addressing bystander physicians, as well as techniques for dealing with them, into training programs for prehospital providers and the doctors who provide online medical control. These types of programs are making strides toward bridging any gaps in understanding that may exist, and would certainly better familiarize the emergency physician with EMS as a whole, to say nothing of changing the way the physician will think the next time he is a bystander who stops to help. Creating methods for introducing such basic understanding among doctors from other disciplines remains a challenge. Education regarding roles and responsibilities—those of both responding EMS providers and bystander physicians—is sorely needed.

Special Circumstances

As with any other EMS issue, there are always unique circumstances that require special actions, and the bystander physician scenario is no different. EMS providers may respond to a call where a doctor already on scene identifies himself as the patient’s primary care provider. A common enough occurrence at medical offices, it becomes more challenging when it happens in a nonprofessional setting. This becomes especially delicate in the case of the active management of a cardiac/respiratory arrest or applying a “Do Not Resuscitate” (DNR) order. Although ACEP states that a prehospital provider should defer to the orders of the private physician,1 AMA makes it clear that a physician should avoid involvement in resuscitative measures that exceed his or her prior training or experience.2 As stated before, you should immediately try to confirm the identity of the bystander, his relationship to the patient and what courses of action he wishes to be taken. It is always good form to contact medical control early on during these interactions, as certain systems have complex policies in regard to revoking or establishing DNR orders, medical authority, etc.

A more recently highlighted problem is when bystander physicians show up to help during mass casualty incidents (MCIs). Although healthcare providers who show up on these scenes have the best of intentions, the reality is that there are well-thought-out and practiced MCI plans in place. For the most part, the bystander physician is usually not part of these plans and can get in the way of a smooth operation. There is also the distinct possibility that these professionals do not fully understand the austere nature of the prehospital environment and will hamper rescue efforts or even injure themselves in the process. Physicians should not respond to a disaster scene unless officially requested under the jurisdiction’s established incident command system. All personnel must understand the authority and resources of local EMS and healthcare systems, the importance of staffing their facilities as their primary responsibility, and the dangerous conditions associated with on-site operations.4

Considering the confusion that can permeate a large-scale emergency or disaster, having the ability to quickly identify and credential bystander physicians without committing needed EMS and medical control resources can be invaluable. As physician organizations have outlined a process for conferring emergency disaster privileges,5 so too should regional or county EMS systems look to address this problem proactively. Collaboration should be sought with local emergency management and public health officials to establish a physician registry prior to, or a single point of contact during, an event, in order to verify licensure and provide short-term credentials. In addition, it should be stressed to all prehospital providers that the bystander physician policy should still be adhered to in these situations, and while EMTs may be cleared to assist the physician in patient treatment, they should not independently operate outside the scope of their practice or training.

Conflict

As much as all parties involved would like to do the best they can for the sick and injured, these situations are rife with possibilities for conflict. Every effort should be made to resolve disagreements between the crew and the bystander physician in a professional and courteous manner. Allowing the bystander physician to speak directly to online medical control may help avert misunderstandings regarding EMS operating procedures. However, always keep in mind that good patient care is paramount. If no resolution can be reached, medical control should be recontacted, and it has the final authority. Be clear and civil, but if necessary, you may have to resort to police intervention to remove physicians who have been disallowed authority by medical control yet still insist on interfering with EMS operations. This action should be viewed as a last resort and, if needed, must be extremely well documented. Keep in mind that if the patient’s condition worsens and litigation ensues, a plaintiff’s attorney could have a field day with an EMS crew sending away a physician or having him forcibly removed.

Conclusion

EMS agencies must work to develop the tools and training needed to help their providers successfully interact with bystander physicians on emergency scenes. In order to properly and effectively manage such situations, while simultaneously minimizing conflict and maintaining our primary charge as care providers, significant proactive effort is needed.

Consider seeking partnerships with your local/regional/state medical societies, emergency medical oversight bodies and emergency management organizations to help deal with this issue. Having the support and assistance of a major medical fraternity in addressing its brethren on the subject is another possible opportunity for collaboration. But ultimately the greatest control you have is with your own staff and coworkers. Knowledge of your system’s policies, as well as utilization of the appropriate interpersonal skills to make the bystander physician aware of your position, are essential if you are to keep the scene controllable and, more important, deliver high-quality patient care.

References

1. American College of Emergency Physicians. Position statement: Direction of prehospital care at the scene of medical emergencies, October 2001.
2. American Medical Association. Protocol for emergency medical services personnel.
3. Cohn B, Azzara A. Chapter 12: Other issues for consideration. Legal Aspects of Emergency Medical Services, Philadelphia, PA: W.B. Saunders Company, 1998.
4. American College of Emergency Physicians. Position statement: Unsolicited medical personnel volunteering at disaster scenes, June 2002.
5. American College of Emergency Physicians. Position statement: Hospital disaster privileging, February 2003.