"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.
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.
