June 7, 2013
Human medical emergencies pose conundrum for veterinarians
By: Phyllis DeGioia
For The VIN News Service
A rural veterinarian happens upon a car collision. The first driver is uninjured but the passenger has severe lacerations and bleeding. The veterinarian uses his field kit to stop the bleeding. Then he notices the second driver has gone into cardiac arrest. He performs chest compressions on the second driver until emergency services arrive. The second driver dies; the injured passenger survives.
Photo by Alison Avocet
Dr. Laura McLain Madsen, pictured with her dog Pippin, acted decisively when a teenaged employee needed emergency medical attention. Madsen did not worry about her personal legal risk, a concern of many veterinarians pondering what to do when the patient in a medical crisis is human.
The veterinarian had no first-aid training for humans. Did he do anything wrong?
This hypothetical scenario is one of several posed by Dr. Charlotte Lacroix, a veterinarian and lawyer in Flemington, N.J., in a newsletter article she wrote for her veterinary clients.
Lacroix's conclusion is "likely not."
"When the Good Samaritan is a person who is medically trained, albeit not a physician,” Lacroix wrote, “the public is entitled to expect more in the way of emergency assistance than it expects of an ordinary citizen."
But fearful of losing their licenses and thus their livelihood, many veterinarians are unsure what to do when faced with medical emergencies involving people. They don't know if veterinarians, having medical backgrounds, are expected to do more than an untrained bystander — and if so, how far may they go?
When it comes to providing emergency medical care for one mammal veterinarians have not studied and are not licensed to treat, the law is as steady as quicksand. Each state has its own Good Samaritan law and its own veterinary practice act, but neither necessarily gives clear direction about veterinarians administering emergency medical aid to human patients.
"There is a gray zone between rendering first aid and treating, and it will be governed by circumstances," Lacroix said.
For example, it's illegal for veterinarians to give humans epinephrine, a synthetic adrenaline used to counter anaphylactic shock, or the sedative Valium. However, if the action saved the person’s life, authorities likely would look the other way, she said.
"Under the right circumstances you could be a hero, especially if there's not too much publicity, because they won't want to start a precedent,” she said. On the other hand, she added, “If you ... cause harm to the person, that would be a different story."
Administering drugs is high-risk and generally not advisable, in Lacroix’s view. Not only might veterinarians lose their licenses in such cases, but they may face other legal consequences, as well.
"Giving oxygen is first aid, but if you administer drugs, the best thing is (to) hope for the best and that nothing (bad) happens," Lacroix said. "There's a difference between violation and enforcement. When we speed, we don't always get caught, and therefore don’t suffer the consequences of a violation of law. It's basically government discretion; they sometimes decide to pick their battles and go after (only) egregious incidents."
In the United States, Good Samaritan laws are intended to protect untrained people from liability if their actions result in injury or death. The details vary. In some states, the law protects those with good intentions, but not those who expect or receive payment for their actions. Some laws address aid provided by health-care professionals, but only those trained in human medicine, not veterinary medicine.
Photo courtesy of Veterinary Business Advisors, Inc.
Dr. Charlotte Lacroix, a veterinarian and lawyer, believes that the public is “entitled to expect more in the way of emergency assistance” from someone with medical training, including veterinarians, than from ordinary citizens.
Veterinarians who have some training in human medicine, such as former paramedics or emergency medical technicians (EMT), may wonder if their limits differ from those that apply to other veterinarians.
In Lacroix’s view, the answer depends on the action being contemplated. For example, she believes ex-paramedics may perform a procedure for which they were trained, but administering drugs is more complicated. Giving drugs intended for use on human patients, such as would be found in a paramedic or EMT bag, may be permissible, but giving a veterinary drug crosses the line, Lacroix said.
Members of the Veterinary Information Network, an online community for the profession, from time to time have asked colleagues for feedback about experiences dealing with human medical emergencies. Illustrating the sensitivity of the topic, several declined to speak about it publicly for fear of legal consequences.
In one such case, a veterinarian in Florida, faced with a co-worker having a grand mal seizure, administered oxygen while waiting for paramedics to arrive. When a colleague later said that she should have given the patient intravenous Valium, the veterinarian was stunned.
"I can't think of a faster way to lose my license," she said.
How authorities in Florida would view a veterinarian administering Valium to a person in an emergency is unclear. Dr. Robert O’Neil, chair of the Board of Veterinary Medicine in Florida, declined to discuss a hypothetical scenario. The state attorney general's office also declined comment. Beth Frady, a spokeswoman for the Department of Business and Professional Regulation, stated by email, "I do know that under Florida’s veterinary practice act, veterinarians are not permitted to treat humans, and any cases brought before the Board are handled individually on a case-by-case basis."
Dr. Laura McLain Madsen of Salt Lake City was at work a few years ago when she found a teenage employee unconscious near the dog kennels. The girl had overdosed on street drugs, Madsen recalled.
How her actions in the next few moments might affect her license never crossed the veterinarian’s mind.
"Another doctor and I started CPR," Madsen said. "I am not certified for CPR but I would do it anyway. We had three techs, one who called 911 and stayed on the phone, another (who) got the anesthesia machine for oxygen. I didn't even think about repercussions. Same for the other vet. We both just jumped in. I tried to intubate, but it's harder to intubate a person than a dog. We were doing mouth-to-mouth, and giving chest compressions. The paramedics got there quickly because the firehouse was three blocks away, but it seemed like an hour."
Despite everyone's efforts, the girl died at the scene.
Utah's Good Samaritan law states: "A person who renders emergency care at or near the scene of, or during an emergency, gratuitously and in good faith, is not liable for any civil damages or penalties as a result of any act or omission by the person rendering the emergency care, unless the person is grossly negligent or caused the emergency."
Madsen and her colleague did not face legal repercussions for trying to intubate the unconscious teenager, even though the procedure is invasive, going far beyond basic first aid.
"The paramedics and cops gave us a funny look, but that's all," Madsen said. "I don't think trying to intubate someone would be called 'grossly negligent,' so I think I would have been OK even if the girl's parents or the cops questioned my actions."
Dr. Ben Leavens of Joplin, Mo., lives on a curvy rural road where car accidents occur regularly. Frequently the first person on the scene, Leavens doesn't hesitate to act. He sometimes moves victims to safety, stops bleeding, checks vitals and neurological status, and provides blankets or tarps.
Photo courtesy of of Main Street Pet Care
Living on a curving country road, Dr. Ben Leavens frequently is the first person on the scene of car accidents. The veterinarian does not hesitate to provide medical aid to victims.
Leavens said he leaves as soon as possible after paramedics arrive, but he will speak up and even take charge if he believes the responders are missing something important, such as in tending someone with flesh wounds while overlooking a victim with more critical injuries.
A former respiratory therapist who considered medical school before he chose veterinary school, Leavens was in Joplin when an EF5 tornado struck two years ago. In the midst of the destruction, Leavens helped take care of injured people and animals alike. He moved people to transport vehicles, set up a triage station, put on bandages and helped keep victims warm.
Leavens believes that veterinarians always should help people in emergency situations. But, he cautions, they should not perform non-emergent invasive procedures, such as suturing, removing embedded objects that are not causing an immediate problem, or intubating a patient who has a competent airway and is able to breathe. Yet in matters of life and death, Leavens maintains that a veterinarian should not hesitate to intubate or perform a cricoidectomy or a tracheotomy to establish an airway.
"Assuming a normal accident-injury situation, a first responder's goal, as I see it, is to address life-support and comfort issues: shock, shock-prevention, breathing, bleeding, circulation, stabilizing a fracture if needed (splint), and get to safety if it's not safe where they're at,” Leavens said by email.
He recommends that those on the scene of a fatal event also seek some kind of counseling afterwards, especially if they feel they did less than their best, or made a mistake, whether in acting or not acting. He suggests talking with a first responder who is a friend, if available.
"Persons who do not help in an on-the-street situation often may think about what they did (or didn’t do) over and over, and dissect it to death using a retrospective scope," Leavens said. "This is counterproductive mentally and spiritually, and experienced first responders can help you understand those feelings and how to deal with them."
Lacroix, the veterinarian-turned-lawyer, understands how difficult the choice to help or not to help may be. And although her expertise is the law, Lacroix recognizes that the law sometimes comes up short.
"As professionals, we make difficult decisions," Lacroix said. "Sometimes doing the right thing is a violation of the law. ... Some people want the world to be black and white, and don't want to (have to) defend their actions. Doing the right thing sometimes requires confronting the government to get the right results. That's standing on your principles, and we shouldn't discourage that."
Would Lacroix intubate or give epinephrine to a person in anaphylactic shock — despite those actions going beyond first aid?
"I'd do it," Lacroix said. "I'd take the heat later. It's pretty pathetic if we're so afraid of doing the right thing like saving a life because we are afraid of what the government will say. Can you imagine if the press gets ahold of that? Sometimes the press is a moral regulator."
Leavens never worries about helping people, but he has a good idea of where his personal limits lie.
"While you could face litigation, I can say from experience that it is better to act and save a life than to do nothing out of fear of litigation or error, even if your lifesaving attempts are not successful," Leavens said. "Either way, you will question your actions in retrospect, but it seems to be better if you did your best with the knowledge and skills God gives you. That being said, I do not think anything protects you from gross negligence."
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