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Legal harards of telephone triage
7. Pederson RS, Jorgenson KA, Olesen AS, et al: Charcoal hemoperfusion for antidepressant overdose. Lancet 1:719, 1978. 8. Diaz-Buxo JA, Farmer CD, Chander JT: Hemoperfusion in the treatment of amitriptyline intoxication. Trans Am Soc Artif Intern Organs 24:699-702, 1978.
Legal Hazards of Telephone Triage To the Editor: I read with interest the article by Shah et al (9:617, 1980) on the role of telephone services in the emergency department of a Canadian pediatric facility but am not particularly sanguine regarding the application of their approach to the over-litigated climate of the United States. Certainly one could anticipate a high demand for such a service by patients - - the process is quick, convenient, anonymous, and without cost. In the busy emergency d e p a r t m e n t there exists the ceaseless temptation over the phone to discourage the patient with an ostensibly mild condition from coming to the hospital. Yet for the physician, telephone triage and treatment is almost always a medicolegally hazardous undertaking, and for the emergency nurse, dispensing such advice may be considered tantamount to practicing medicine without a license. Such concessions only obscure the real dangers attendant to prescribing treatment over the telephone without benefit of even prior personal contact or a physical examination. Moreover, I should think these problems would only be compounded by dealing with children, where it is often so vital for the pediatrician to assess how the patient "looks." J. Douglas White, MD Emergency Ward Massachusetts General Hospital Boston
Author's Reply The letter by Dr. White points out the medicolegal hazards of an organized medical information service such as we described. These are certainly important considerations which we did consider in establishing such a service. We want to emphasize that the service nurses do not ~practice medicine" but stay within the limits of their own training and expertise. Well-trained nurses have much to offer worried parents in the way of reassurance, reinforcement of a physician's instructions, and the dispensing of good common sense advice - - none of which is the monopoly of the medical practitioner. Information Centre nurses are trained to be conservative, to follow advice protocols developed with physician assistance, and to refer patients to a physician immediately if there is any doubt about patient safety. The dull prose of a journal article does not convey the depth of feeling expressed by worried parents in the survey questionnaire. It became clear that factors such as being a single parent away from family support systems, being a first-time mother, not understanding personal physician instructions, and being afraid to ask for further clarification, were potential
10:4 (April) 1981
causes of unnecessary trips to an emergency department. Return calls by the nursing staff to support a worried parent elicited many expressions of gratitude for the interest shown in their problem. As is true in the case of a personal caring physician, such patients are unlikely to consider legal action against a benefactor. I would judge that an institution and its staff run a far greater risk when such calls for assistance are inflicted on personnel without specific training who are busy with other assignments which they may consider a priority. Thomas J. Egan, MD, FRCP (C) Director, Ambulatory Services The Hospital for Sick Children Toronto, Ontario, Canada
Angina Associated with Pseudoephedrine To the Editor: We wish to report a case of angina associated with the ingestion of a pseudoephedrine-containing compound (Actifed*). A 51-year-old Puerto Rican woman was admitted to the emergency department complaining of chest pain. Four days prior she had come to the emergency department complaining of chest pain radiating to the left arm and throat, without shortness of breath or diaphoresis. She denied any prior cardiovascular history, did not smoke, and her reported medications included only meclizine and diazepam. Physical examination showed a blood pressure of 140/80 mm Hg and pulse of 84, and was otherwise unremarkable. Her ECG showed ST depressions in the lateral and inferior leads and the patient was hospitalized with a diagnosis of coronary insufficiency. Admission laboratory work showed SGOT, 52; SGPT, 54; and CPK, 72 (normal 0-190). CBC was normal. Calcium was 10.7. The patient was treated with acetaminophen, flurazepam, meclizine, hydrochlorothiazide, pseudoephedrine-triprolidine combination (Actifed~), and nitroglycerin. She had a second episode of chest pain on the third hospital day, quickly relieved by nitroglycerin. Serial ECGs showed prompt resolution of ischemic changes without evidence of myocardial infarction, and cardiac enzymes remained normal. The patient was discharged with prescriptions for hydrochlorothiazide and nitroglycerin on the fifth hospital day. She returned to the emergency department later that day with recurrence of chest pain. An ECG again showed ischemic changes. E x a m i n a t i o n was unchanged. The patient had taken an Actifed ® tablet 30 to 40 minutes prior to onset of chest pain, and had come to the emergency department when the pain had not resolved after 90 minutes. She had not yet had her new prescriptions filled. Further probing revealed that the patient had also taken an Actifed ® tablet 30 to 40 minutes prior to the first episode of chest pain. In the emergency department nitroglycerin afforded prompt relief, and 20 minutes later her ECG abnormalities had largely resolved. Pseudoephedrine is a steroisomer of ephedrine and is used primarily for the treatment of nasal congestion. It produces vasoconstriction, and is said to have a preferential action on the vessels of the nasal
Ann Emerg Med
93
Legal Hazards of Telephone Triage To the Editor: I read with interest the article by Shah et al (9:617, 1980) on the role of telephone services in the emergency department of a Canadian pediatric facility but am not particularly sanguine regarding the application of their approach to the over-litigated climate of the United States. Certainly one could anticipate a high demand for such a service by patients - - the process is quick, convenient, anonymous, and without cost. In the busy emergency d e p a r t m e n t there exists the ceaseless temptation over the phone to discourage the patient with an ostensibly mild condition from coming to the hospital. Yet for the physician, telephone triage and treatment is almost always a medicolegally hazardous undertaking, and for the emergency nurse, dispensing such advice may be considered tantamount to practicing medicine without a license. Such concessions only obscure the real dangers attendant to prescribing treatment over the telephone without benefit of even prior personal contact or a physical examination. Moreover, I should think these problems would only be compounded by dealing with children, where it is often so vital for the pediatrician to assess how the patient "looks." J. Douglas White, MD Emergency Ward Massachusetts General Hospital Boston
Author's Reply The letter by Dr. White points out the medicolegal hazards of an organized medical information service such as we described. These are certainly important considerations which we did consider in establishing such a service. We want to emphasize that the service nurses do not ~practice medicine" but stay within the limits of their own training and expertise. Well-trained nurses have much to offer worried parents in the way of reassurance, reinforcement of a physician's instructions, and the dispensing of good common sense advice - - none of which is the monopoly of the medical practitioner. Information Centre nurses are trained to be conservative, to follow advice protocols developed with physician assistance, and to refer patients to a physician immediately if there is any doubt about patient safety. The dull prose of a journal article does not convey the depth of feeling expressed by worried parents in the survey questionnaire. It became clear that factors such as being a single parent away from family support systems, being a first-time mother, not understanding personal physician instructions, and being afraid to ask for further clarification, were potential
10:4 (April) 1981
causes of unnecessary trips to an emergency department. Return calls by the nursing staff to support a worried parent elicited many expressions of gratitude for the interest shown in their problem. As is true in the case of a personal caring physician, such patients are unlikely to consider legal action against a benefactor. I would judge that an institution and its staff run a far greater risk when such calls for assistance are inflicted on personnel without specific training who are busy with other assignments which they may consider a priority. Thomas J. Egan, MD, FRCP (C) Director, Ambulatory Services The Hospital for Sick Children Toronto, Ontario, Canada
Angina Associated with Pseudoephedrine To the Editor: We wish to report a case of angina associated with the ingestion of a pseudoephedrine-containing compound (Actifed*). A 51-year-old Puerto Rican woman was admitted to the emergency department complaining of chest pain. Four days prior she had come to the emergency department complaining of chest pain radiating to the left arm and throat, without shortness of breath or diaphoresis. She denied any prior cardiovascular history, did not smoke, and her reported medications included only meclizine and diazepam. Physical examination showed a blood pressure of 140/80 mm Hg and pulse of 84, and was otherwise unremarkable. Her ECG showed ST depressions in the lateral and inferior leads and the patient was hospitalized with a diagnosis of coronary insufficiency. Admission laboratory work showed SGOT, 52; SGPT, 54; and CPK, 72 (normal 0-190). CBC was normal. Calcium was 10.7. The patient was treated with acetaminophen, flurazepam, meclizine, hydrochlorothiazide, pseudoephedrine-triprolidine combination (Actifed~), and nitroglycerin. She had a second episode of chest pain on the third hospital day, quickly relieved by nitroglycerin. Serial ECGs showed prompt resolution of ischemic changes without evidence of myocardial infarction, and cardiac enzymes remained normal. The patient was discharged with prescriptions for hydrochlorothiazide and nitroglycerin on the fifth hospital day. She returned to the emergency department later that day with recurrence of chest pain. An ECG again showed ischemic changes. E x a m i n a t i o n was unchanged. The patient had taken an Actifed ® tablet 30 to 40 minutes prior to onset of chest pain, and had come to the emergency department when the pain had not resolved after 90 minutes. She had not yet had her new prescriptions filled. Further probing revealed that the patient had also taken an Actifed ® tablet 30 to 40 minutes prior to the first episode of chest pain. In the emergency department nitroglycerin afforded prompt relief, and 20 minutes later her ECG abnormalities had largely resolved. Pseudoephedrine is a steroisomer of ephedrine and is used primarily for the treatment of nasal congestion. It produces vasoconstriction, and is said to have a preferential action on the vessels of the nasal
Ann Emerg Med
93