Emergency Physician Liability for In-House Emergencies, Curbside Consultations,
August 1, 1998 22 minutes read
Emergency Physician Liability for In-House Emergencies, Curbside Consultations, and Unofficial Patients
By James R. Jacobs, MD, PhD, Third Year Resident, Emergency Medicine Residency Program, Carolinas Medical Center, Charlotte, North Carolina. Robert A. Bitterman, MD, JD, FACEP, Director of Risk Management and Managed Care, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina; Clinical Assistant Professor of Emergency Medicine, University of North Carolina Medical School, Chapel Hill, North Carolina
Introduction
When an emergency physician (EP) treats officially registered patients within the emergency department (ED), he meets the Physician Group's contractual obligation to the hospital, is functioning in a mode that is rather naturally responsive to the regulatory mandates of Emergency Medical Treatment and Active Labor Act (EMTALA), and is incurring liability that is explicitly acknowledged by his malpractice insurance carrier. The purpose of this article is to consider potential legal perils that await the well-intentioned EP who provides care within the hospital but to persons other than official ED patients. Such situations include so-called "in-house emergencies,"1 where the EP leaves the ED to offer emergency assistance elsewhere in the hospital, but also includes insidious in-house dangers that lurk even within the confines of the ED, in the guise of unofficial consults and unofficial patients. Central to each of these scenarios is the question of whether the EP has a duty to provide the service acutely requested of him, with the associated issues of liability and standard of care.
Emergency Physician Response to In-House Emergencies
In many small hospitals, the physician covering the ED will at times be the only physician in the hospital, especially at night. Even if there is an in-house staff physician (hereafter referred to as the house physician) ostensibly available to cover acute in-patient problems, situations may arise in which pressure is placed on the EP to leave the ED to address a crisis elsewhere in the hospital.
Duty to Respond
The foremost determinant for the EP in deciding whether to respond to an out-of-ED in-house request for medical intervention rests in the issue of duty. Whereas the EMTALA legislation establishes an unqualified duty to all patients presenting to the ED,2,3 any responsibility the EP might have to provide patient care outside of the ED is determined by contractual obligation and medical staff by-laws.
In general, EPs are well advised to avoid mandates to provide coverage outside the ED, but sometimes winning a contract to staff an ED may be contingent upon agreement to provide certain in-house services. Similarly, financial incentives being offered by the hospital may be so great that the EP Group feels that the monetary benefits outweigh the inconvenience and legal risks of venturing outside the ED. Whatever the business arrangement, EPs who find themselves with an obligation to cover in-house emergencies should be cognizant of the medicolegal issues involved, both to minimize legal jeopardy and to optimize patient care.
If the EP is not obligated by contract or by law to respond to requests for help elsewhere in the hospital, the decision-making process should be simple: In spite of perceived moral imperative, morbid curiosity, or intellectual challenge, don't leave the ED! By staying in the ED, the EP avoids any possible liability for bad outcome with the in-house situation. Leaving the ED renders the EP liable to charges of abandonment from existing ED patients or new arrivals with an emergent condition.
While this is an easy decision from a legal perspective, it isn't from a medical or ethical perspective. Most physicians' moral compass drives them to respond to others in crisis; however, the on-duty EP must carefully consider the risks that leaving the ED means to the ED patients before responding to in-house calls.
Abandonment
Contractual obligation or otherwise, the EP who leaves the ED to care for an in-house patient risks charges of patient abandonment, a type of negligence claim, if the ED is left without adequate physician coverage to provide needed emergency care.4 The EP's primary duty is always to the patients already in the ED. Furthermore, EMS and the public expect the EP to be immediately available to treat patients they bring in who have life-threatening emergencies. If a single-coverage EP is contractually required to respond to out-of-ED emergencies, it creates an untenable double-jeopardy situation for the physician: One should never contract to be in two places at the same time. Even if not contractually bound, if a hospital's lone EP is frequently voluntarily leaving a busy ED unattended to answer floor calls, the institution is not adequately addressing the needs of either its ED patients or its inpatients and its practices should be reexamined.
EPs, in conjunction with the hospital administration and the medical staff, should resolve the issue of in-house emergency care by written policy and procedure, which is reasonable considering the volume and acuity of the ED patients, frequency of in-house need for the EP's services, and other facts and circumstances particular to that institution.
Good Samaritan Laws
There is some good news for the EP who voluntarily responds to an in-house emergency: Civil case decisions support application of Good Samaritan laws to protect physicians from certain liability claims for emergency care provided to in-house patients. Good Samaritan laws were initially promulgated to encourage physicians and other qualified professionals to render aid when they incidentally happen upon the scene of an automobile collision or other emergency in a public setting, not inside the hospital.5 Several courts, however, have extended this statutory protection to physicians who render appropriate emergency assistance, even within the hospital, so long as there is no preexisting duty to render assistance and no remuneration is requested or accepted.6,7,8 In the California case of McKenna v. Cedars of Lebanon Hospital, a nurse summoned a chief internal medicine resident, who happened to be available, to the ED to treat an actively seizing patient. The court granted the physician Good Samaritan immunity for voluntarily responding because he was not on-call, was not on the hospital's code team, and had no physician-patient relationship with the patient; thus, he had no duty to respond.9
Good Samaritan laws do vary among the states,10 but an EP who responds to an in-house emergency may be protected unless the state's legislation specifically denies coverage for emergencies that occur within the hospital setting. The elements required for Good Samaritan protection include 1) no contractual obligation to respond; 2) no federal law (such as EMTALA), state law, or medical staff by-law that requires a response, such as from physicians who accept on-call duty for the ED; 3) no doctor-patient relationship existed; and 4) there was no custom or practice of responding to similar emergencies.10 The first two of these caveats are self explanatory, with the second case possibly implying a more general duty for all available physicians within the hospital to respond to code situations until relieved by a designated member of the medical staff. The third caveat raises specific concerns for surgeons or primary care physicians who moonlight in the ED of a hospital where they also admit patients, but it could also apply to an EP who has written admission orders if the patient has not yet been seen by the attending physician (see below). The fourth caveat raises interesting and ill-defined issues. What constitutes a "custom or practice of responding?" During his internship year, one of the residents in our program developed a reputation for aggressively pursuing the opportunity to participate in codes outside the ED. While rotating on the medical and surgical services, he would run to codes announced overhead whenever he was available, often arriving before the designated Code Team. If, however, this unbridled enthusiasm were to continue in the private practice setting, the appearance of a "custom or practice of responding" might be established, which could jeopardize future protection under Good Samaritan statutes for the physician and, possibly, for other members of the EP Group.
Transfer Patient to the ED
Unless there are local regulations to the contrary, the EP faced with the decision of "abandoning" patients in the ED to respond to an in-house emergency should consider the option of directing that the in-house patient be transported emergently to the ED. Alternatively, the EP could report to the scene to initiate the resuscitation but then accompany the patient to the ED, possibly even with CPR in progress, for continuing resuscitation or stabilization. This recommendation is probably most viable when the emergency situation involves a visitor or employee rather than a regular inpatient.
Liability Insurance Coverage
If the EP is required to respond to in-house emergencies, great care should be taken to ensure that the medical malpractice policy explicitly include these activities within the scope of coverage. One approach is for the hospital to indemnify the EPs for required out-of-ED in-hospital care. The other approach is for the EP Group to purchase insurance that includes specific language extending coverage to the non-ED activities. It is vital that all physicians endeavor to understand the scope of their insurance coverage, an issue that will rise again later in this article. The EP should also ensure that he is appropriately credentialed by the hospital for any care he is expected to provide outside the ED.
Admissions Orders Written by the EP
When admission orders have been written by the EP on behalf of the attending physician, the EP has assumed de facto responsibility for the patient until the patient has been seen by the primary physician. In a worst case scenario, the EP could find him or herself in the untenable position of receiving a critically ill patient in the ED at the same time he was being paged to go to the ward to address an acute problem with a patient for whom he had written the admission orders one hour previously (i.e., as the physician of record to that point), even if there is no contractual obligation per se to cover in-house emergencies.
For these reasons, the ACEP Policy Statement11 on writing admission orders exhorts that the EP "should not be compelled to write any orders that extend, or appear to extend, control and responsibility for the patient beyond treatment in the emergency department to the inpatient setting." If, however, political or economic pressures are such that the EP is contractually obligated to write admission orders at the behest of the consultant, the orders should be written in a way that provides for the best possible patient care but that also indemnifies the EP to the fullest extent possible.12
EP admitting orders should be limited in time, to cover only the brief period of transition of responsibility from the EP to the attending physician; limited in scope to cover only the acute problem managed by the EP; and identify the admitting physician who should be called, rather than the EP, if any problems arise on the floor.
Medical staff credentials and hospital by-laws must distinguish between admitting privileges and the writing of initial, temporary admitting orders by emergency physicians. Furthermore, the by-laws should require the attending physician to come into the hospital to personally assume care of the patient within a mutually agreeable, reasonable period of time.
Critical Contract Clauses
When the EP Group does agree to cover in-house emergencies, it is critical that the contract with the hospital be negotiated to provide maximum protection for the EPs and to optimize delivery of patient care. Foremost, the term "emergency" must be defined explicitly. Cardiac arrest and respiratory arrest will nominally be included in any definition of in-house emergency, but many other potentially serious conditions (such as chest pain, shortness of breath, abdominal pain, back pain, wound dehiscence) might not be. The scope of coverage for in-house emergencies should specifically exclude obstetrical care. One objective in promulgating these definitions is to ensure that the EP cannot be exploited as a ready resource to intervene in a non-life-threatening situation simply because the patient's attending physician cannot be reached or is not accommodating the nursing request.
There must be a clear policy defining the role, if any, of the house physician with regard to in-house emergencies. The EP might, for example, be assigned to airway management, whereas the house physician has overall responsibility for running the code and formulating a disposition for the patient. This would allow the EP to return to the ED immediately after intubating the patient and securing the airway.
Protocols should be in place to automatically notify the patient's attending physician when the emergency occurs and to allow the EP to turn over care to the attending physician or other staff physician if he or she arrives while intervention by the EP is in progress.
The hospital must ensure that the nursing staff maintain advance life support training (including pediatric training if applicable) and understand their role on the Code Team. A hospital committee must assume responsibility for the content and maintenance of code carts, and the EP Group should be well represented on this committee. The EP Group should ensure that each of its members periodically tours the hospital to learn routes to the various patient care areas. The EP Group should participate in quality assurance and quality improvement activities related to its role in in-house emergencies.
Documentation
The EP must meticulously document any care provided outside the ED. Since management of in-house emergencies is likely to be scrutinized by colleagues and potential plaintiffs, the EP should document a record that provides appropriate protection.1 Special attention should be paid to documenting the timing and content of telephone conversations with the attending physician or other consultants who were asked to see the patient in response to the acute events. It is advisable to err on the side of excess, documenting, for example, times that other physicians were paged, the time the page was returned, and the EP's specific request that the physician come to the hospital immediately.
Moonlighting
When an EP elects to provide locum tenens or moonlighting services to an ED, he should inquire specifically about whether there are any out-of-ED responsibilities. Given the potential for abandonment liability, inadequate life-support training of floor personnel, inadequate or malfunctioning resuscitation equipment, and vagaries of insurance coverage, any requirement to respond to in-house emergencies should give the EP cause to look askance at such an ED assignment.
Scenario 1. A residency-trained EP is moonlighting at a mid-size rural hospital. The tranquility of the 3 a.m. lull in patients presenting to the ED is interrupted by a loud announcement over the paging intercom, "CODE BLUE 3 WEST, CODE BLUE 3 WEST."
This is the classic example of an in-house emergency. If the contract requires the EP to respond, he must leave the ED, find his way to 3 West, and evaluate and treat the patient. All the issues in the preceding paragraphs apply. If the EP's contract obliges him to the ED only, he should ignore any temptation to become involved in management of the Code, unless no one else is available and he has no immediate care to provide in the ED.
Scenario 2. The charge nurse in the Intensive Care Unit (ICU) calls the ED asking to speak with the EP. The nurse states that a patient admitted to the ICU one hour previously has developed more chest pain, though the patient's vital signs are stable and the EKG unchanged. The patient's attending physician has been paged and is en route from home, but the nurse requests that the EP come to the ICU immediately to evaluate the patient.
Even if the EP has contractual obligation to cover in-house emergencies, chest pain may not fall within the scope of conditions constituting an emergency, and the EP would not have a duty to this patient at this time. The EP might advise the nurse to initiate the ICU's chest pain protocol if the attending physician did not give specific orders, but the EP should otherwise avoid involvement unless it is to invite the nurse to transport the patient to the ED for evaluation and management pending arrival of the patient's physician. If, however, this patient had been initially evaluated in the ED and the EP wrote admission orders at the behest of the attending physician, who has not yet seen the patient, then it could be construed that the EP has an ongoing doctor-patient relationship with this patient, which would obligate an active role in caring for the patient until the attending physician arrives.
Scenario 3. A patient who underwent hip arthroplasty one day previously is complaining of severe leg pain not relieved by the oral analgesics ordered for him and is demanding to speak with a physician. The on-call orthopedic surgeon has been paged twice but has not yet replied. The nurse caring for the patient calls the ED and requests that the EP come upstairs briefly to talk with the patient.
This patient's leg pain could portend a serious situation, such as deep vein thrombosis or compartment syndrome, but the situation as described does not represent an emergency, the patient does have an attending physician, and there is clearly no role for intervention by the EP. If the EP does consent to talk with the nurse, no advice should be given regarding patient care per se, but, rather, the EP might suggest that the nurse try to contact one of the surgeon's partners or chief of the orthopedic service.
"Curbsiding" and the Emergency Physician
The EP is an ubiquitous and well known commodity within the hospital. Further, the EP will generally be presumed to command a wide breadth of experience and expertise. No matter what the hour, the outside world-fellow physicians in particular-knows that there is a physician stationed in the ED . . . ripe for the consulting.
"Curbsiding," or informal consultations between physicians, is a common and important element in daily clinical practice for virtually all physicians.13,14 Absent the formality of a doctor-patient relationship, most physicians consider opinions expressed and advice given in curbside conversations to be devoid of obligation or liability, which is generally true.14,15,16 It is assumed that the informal consultation is provided at no charge to the patient or to the other physician. Similarly, it is assumed that the consultant will not generate any sort of written report of his opinion.
Scenario 4. It is 2 a.m. The staff physician or house officer covering the Medical ICU comes to the ED and asks the EP (the only attending-level physician awake in the hospital at the time) to "take a look at this x-ray or ECG and tell me what you think."
This scenario is representative of the most common manner in which EPs are curbsided. Because he does not have a doctor-patient relationship with the patient, the EP can offer advice to the fullest extent of his discretion or level of comfort, or he can defer altogether. Of course, all parties must appreciate that the EP's interpretation or opinion is based on limited data and is not supported by independent review of the medical record or examination of the patient.17,18
Scenario 5. The EP and the trauma surgeon are talking together informally in the hallway of the ED awaiting the impending arrival of a trauma patient. The surgeon states that she thinks her teenage son has strep pharyngitis but that "I can't get him in to see the pediatrician until Monday, and it's been a long time since I've treated a sore throat." She asks the EP for advice on what to prescribe for her son.
For the scenario as described, the EP has no obligation or liability and can offer advice with impunity, for the surgeon to accept or reject in accordance with her own medical judgment. If, however, the son happens to be a volunteer in the hospital and located his mother in the ED to complain of the sore throat and is still in the ED when the surgeon-mother curbsides the EP, the EP might have an obligation under EMTALA to examine the patient.
Scenario 6. It is 2 a.m. again. The physician covering the hospital's Rehabilitation Unit calls the ED and asks to speak with the EP. The physician tells the EP that he is caring for a patient who appears to have developed atrial fibrillation. The physician states that he wants to start the patient on digoxin but that it has been a long time since he has initiated digoxin therapy and asks for the EP's advice about the dosing of this drug. The physician also states that he plans to obtain a cardiology consult in the morning but that he does not want to bother the cardiologist so late at night.
Again, the EP has no duty to this patient and therefore, has no duty to provide advice. If the EP chooses to offer digoxin dosing guidelines, it is up to the other physician to decide whether to accept the recommendations, and liability remains with the other physician. Of greater concern, however, is that the other physician does not appear to have the knowledge or resources to answer this rather simple issue on his own, raising the question of whether digoxin is actually appropriate for the patient. In the interest of patient care, the EP might want to find a pleasant or subtle way to suggest to this physician that he go ahead and consult the cardiologist now rather than wait until morning.
Scenario 7. The EP covering a small rural hospital calls the ED at the tertiary care hospital asking permission to transfer a patient with acute spinal cord trauma. The transfer is arranged. Before ending the conversation, the transferring EP asks the receiving EP whether he should initiate a methylprednisolone protocol while waiting for the helicopter.
In accepting the patient in transfer, the receiving physician establishes a doctor-patient relationship with the patient. Once this relationship is established, telephone advice given by the receiving physician is no longer just a collegial opinion, but it carries both a legal duty and liability.
Unofficial Patients and the Emergency Physician
For our purposes, an "unofficial" patient will be defined as a person physically present within the ED requesting services of the EP-or a person for whom services are being requested-without benefit of the official triage and registration processes. By implication, these are persons for whom a contemporaneous ED chart has not been generated and from whom payment will not be sought. The phenomenon of the unofficial patient (e.g., family members, friends, colleagues) is a common experience for physicians in all disciplines, but attendant obligations and liabilities may be especially high when such encounters occur within the walls of the ED.
Duty
EMTALA states, "If any individual comes to the emergency department and a request is made on the individual's behalf for examination and treatment, the hospital must provide an appropriate medical screening exam . . . including ancillary services routinely available to the emergency department."3,19 Therefore, if a person is in the ED requesting medical attention or it is being requested on their behalf, federal law mandates that the EP has a duty to the would-be patient.
Standard of Care
"Informal" patients are likely to receive "informal" care, whether out of deference, precedent, or convenience. In trying to provide the would-be patient with a courtesy, the EP may perform acts of omission or commission resulting in practices that fall below the standard of care. For example, if the patient is a friend or colleague who pulls the EP aside in the ED to ask a "favor," there will often be reluctance to ask the patient to disrobe adequately for an appropriate examination, or the exam might be omitted altogether. Similarly, important questions, such as regard substance abuse, violent behavior, or sexual propriety might go unasked in the hope of avoiding embarrassment for either party.
In North Carolina, the Medical Board holds that "no prescriptions . . . should be issued for a patient in the absence of a documented physician-patient relationship."20 The implication is clear. The EP providing undocumented informal care might not only be practicing beneath the standard of care but might also be risking disciplinary action against his or her medical license.
Informal care can also lead to a real or perceived double standard. Provision of ED care to one class of patients that is faster, less intrusive, cheaper, or otherwise better than that provided to other classes of patients may again constitute violation of EMTALA. One solution is for the EP Group and hospital to establish a policy that no care can be provided in the ED unless the patient has gone through the usual triage and registration process and a chart created to document the interaction. Then, if the EP is asked to provide informal care he can blame "the rules" for his insistence that the patient first be triaged and registered into the department. If the EP does ultimately decide to provide care to an unofficial patient, it is critical that, at a minimum, an appropriate examination be performed and that the encounter be documented, possibly in the form of a note dictated to the EP's personal file.
Liability Insurance Coverage
It should not be assumed that care provided free of charge is free of liability exposure. Friends and informal patients can file malpractice claims stemming from free care just as easily as official patients can file claims stemming from expensive care. In treating persons who are present in the ED when they request intervention, protection under Good Samaritan legislation would not apply because of the preexisting duty established by EMTALA. Further, if the EP felt that the patient could be treated outside the usual triage and documentation protocols, he or she is de facto acknowledging that the situation was not an emergency, thereby falling further outside the scope of Good Samaritan statutes.
Consequently, EPs must appreciate that the malpractice insurance provided by his or her group or hospital might not cover provision of unofficial care. Indeed, breadth of coverage varies widely from policy to policy. "With some policies, coverage is extended to the physician solely when acting within the scope of any existing contract with such a group or while under the control of or for the direct benefit of the group."21 An EP providing informal (and free-of-charge) care in the ED or who writes prescriptions for friends or family, is not acting for the direct benefit of the group (i.e., no reimbursement) and might lack applicable insurance coverage. It is critical for EPs (and all physicians) to understand the scope and limitations of the malpractice insurance policy under which they practice.
Again, some of the issues regarding treatment of unofficial patients in the ED are best illustrated by example:
Scenario 8. A female ED patient presents for dysuria and is diagnosed with trichomoniasis. She is given a prescription for metronidazole and instructions regarding follow-up of the cultures that were obtained. She is instructed in safer sexual practices and is admonished that her male sexual partner needs to be treated to prevent reinfection. She states that there is "no way that he will go to see a doctor about this" and requests that the EP also provide her with whatever prescriptions are needed to treat the partner.
Of the three examples to be presented in this section, this is the only scenario where the EP clearly has no duty to honor the request. Although there might be public health benefit in providing prescriptions for the sexual partners of patients being treated for sexually transmitted diseases, there is no medicolegal allowance for doing so. If the male partner were to present to the ED two days later holding a pill bottle with the EP's name on it while experiencing a severe disulfiram-like reaction after heavily imbibing in alcohol, the EP would have no defense in trying to explain why he wrote a prescription for a patient he had never seen.
Scenario 9. A mother brings her 5-year-old son to the ED to be evaluated for a scalp rash. The patient's 4-year-old brother is also along for the ride. The EP diagnoses tinea capitis in the 5-year-old and prescribes griseofulvin. The mother states that "the last time this happened they both got it" and requests a second prescription for the 4-year-old, who is not registered as a patient. Rather than summarily refusing the mother's request or insisting that the second child be triaged, the EP examines the younger sibling briefly and spots a small lesion possibly consistent with tinea, writes a second prescription, and documents the encounter as an addendum to the older sibling's chart.
Under EMTALA, the EP would be obliged to perform at least a medical screening exam for the younger child. Given the presentation, the EP's actions were not unreasonable, and she is to be applauded for actually examining the younger child and providing some form of documentation. Whether this patient encounter would be covered under the EP's malpractice insurance, however, depends on the terms of her policy.
Scenario 10. A 55-year-old male helicopter pilot from the hospital's Emergency Medical Flight Team ventures down to the ED and asks the EP for treatment with an antibiotic to "help get rid of this cough." The EP half-jokingly chastises his longtime pilot friend while he stands at the nurses station and blithely writes prescriptions for clarithromycin and benzonatate. The EP is then called into a room to evaluate a patient with abdominal pain. The next morning, the pilot is brought to the ED by ambulance, intubated, in florid pulmonary edema. The pilot's attorney later claims that the EP's failure to examine the patient at the first encounter represented not only poor medical care but was also a violation of federal EMTALA law.
The attorney is correct. If this 55-year-old male with a cough had presented from the street, the EP would have insisted that he go through the formal triage procedures. Following registration and triage, the patient would have been asked to disrobe to the waist, and the EP would have asked about prior history of cough, orthopnea, chest pain, cardiac risk factors, smoking history, and so forth. The medical screening examination would have included at least temperature, blood pressure, ENT exam, auscultation of the chest and heart, and a glance at the ankles to check for edema.3,19 Depending on findings, evaluation might have included a chest x-ray. To simply write an antibiotic prescription would clearly fall below the standard of care for a 55-year-old male with cough. No doubt, the pilot's attorney would be able to argue successfully that proper examination would have revealed the onset of heart failure and that significant morbidity could have been avoided. The EP's problems would be exacerbated by lack of documentation. And since the patient never registered through triage, the EP might be trying to defend himself without benefit of insurance coverage.
Summary
There are many legal perils for the EP in participating in the treatment of in-house patients and curbside consultations or unofficial patients in the ED. In each situation, legal liability is attached to the EP's assumption of a duty to the patient. In some cases, this duty is legislatively imposed, as under the federal EMTALA law, which requires all patients who present to the ED to be triaged, registered, generated a medical record, and evaluated to determine if an emergency exists. In other cases, physician's voluntarily assume a duty through accepting medical staff privileges or through contracting to provide services such as responding to in-house emergencies or writing admitting orders. EP's must understand their risks and liabilities when they agree to perform these functions, and should carefully draft contracts or policies and procedures to distinctly define their duties and minimize their liabilities.
References
1. O'Riordan WD. In-house emergencies. In: Henry GL, Sullivan DJ, eds. Emergency Medicine Risk Management, 2nd ed. Dallas; ACEP; 1997; 313-319.
2. 42 USC 1395dd
3. Bitterman RA. EMTALA. In: Henry GL, Sullivan DJ, eds. Emergency Medicine Risk Management, 2nd ed. Dallas; ACEP; 1997; 353-379.
4. Hernandez v. Smith, 552 F2d 142 (5th Cir. 1977)
5. See, e.g., Cal. Health & Safety Code Section 1799.102
6. Gordin v. William Beaumont Hosp., 447 NW2d 793 (Mich.App. 1989)
7. Hirpa v. IHC Hospitals, Inc., No. 94-4263, March 30, 1998 US App. Lexis 6487
8. `Good Samaritan' Law Covers In-Hospital Emergency. Emerg Depart Law 1998;10:1-2.
9. McKenna v. Cedars of Lebanon Hospital, 93 Cal.App.3d 282 (1979).
10. Trompler VA. Good Samaritan statute: Should emergency physicians be Levites or Samaritans? ED Legal Letter 1997;8:97-106.
11. Writing Admission Orders. ACEP Policy Statement, approved October 1993, reaffirmed October 1997.
12. Goldman PL. Admitting orders. In: Henry GL, Sullivan DJ, eds. Emergency Medicine Risk Management, 2nd ed. Dallas; ACEP; 1997; 343-346.
13. Manian FA, Janssen DA. Curbside consultations: A closer look at a common practice. JAMA 1996;275:145-147.
14. Fox BC, Siegel ML, Weinstein RA. "Curbside" consultation and informal communication in medical practice: A medicolegal perspective. Clin Infect Dis 1996;23:616-622.
15. Jones DF. Medical malpractice liability for responding to a colleague's questions. IDC Q 1996;6:22-27.
16. Hill v. Kokosk, 186 Mich.App. 300 (1990).
17. Minster v. Pohl, 426 SE2d 204 (Ga. Ct. App. 1992).
18. Flynn v. Bausch, 469 NW2d 125 (Neb. 1991).
19. Bitterman RA. What is an "appropriate" medical screening examination under COBRA? ED Legal Letter 1997;8:35-44.
20. North Carolina Medical Board, Forum, II(4), 1997, p 9-13.
21. Harris SM, Silverstein E. Insurance coverage. In: Henry GL, Sullivan DJ, eds. Emergency Medicine Risk Management 2nd ed. Dallas; ACEP; 1997; 131-138.
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