Ocular Urgencies and Emergencies

1. Ocular Urgencies and Emergencies

2. To determine an optometrist’s legal obligations for urgencies and emergencies, 4 questions must be addressed:1—what are ocular urgencies and emergencies?2—what is an optometrist’s legal responsibility to examine a patient seeking urgent or emergency care?3—what is the standard of care that will be applied to an optometrist who renders urgent or emergency care?4—what is an optometrist’s legal responsibility for the timely scheduling of patients who require urgent or emergency care?

3. There are 2 true ocular emergencies (conditions that require treatment within minutes to preserve vision):1—chemical burns of the cornea2—central retinal artery occlusionOther conditions must be considered ocular urgencies (requiring treatment within one to several hours to preserve vision).

4. The treatment for chemical burns is immediate and copious lavage.Acid burns cause damage within the first few hours, whilealkali burns may continue for hours if the substance (lye,lime, ammonia) remains in contact with the eye.

5. Treatment requires: • Irrigation of the eye with water—copiously • Removal of all particulate matter in contact with the eye (anesthetic needed) • Use of pH paper to ascertain if eye pH is back to normal • Antibiotic, steroid, cycloplegic treatment based on the severity of injury • Referral of severe cases to a specialist

6. The treatment of central retinal artery occlusion is intermittent massage of the eye (moderate pressure applied to the eye for 5 seconds, released,then repeated),until IOP is lowered, the central retinalartery dilates, and the embolus moves further along arterial circulation.

7. Paracentesis of the anterior chamber (inserting a needle and withdrawing aqueous) may also be attempted tolower IOP and movethe embolus.

8. Urgencies that have created liability issues for optometrists include: Penetrating injury of the globe

9. Situation ConditionTrue EmergenciesTherapy should be instituted Chemical burns of the corneawithin minutesCentral retinal artery occlusion

10. Semi-urgent SituationsOptic neuritisTherapy should be instituted within daysOcular tumorswhenever possible, or sometimes within weeksExophthalmos, acute Previously undiagnosed chronic open-angle glaucoma Old retinal detachment Strabismic or other remediable amblyopias in young children Blow-out fracture of the orbit

11. Corneal foreign body

12. Acute angle closure glaucoma and pupillary block glaucoma

13. Corneal ulcer

14. Corneal abrasion

15. Acute retinal tear

16. Endophthalmitis

17. An optometrist in private practice may refuse to examine a patient, even a patient requiring emergency care.However, the legal right to refuse treatment is at conflict with the ethical obligation of an optometrist to render emergency care.

18. The AOA’s Standards of Conduct says:“A request for optometric care in an emergency should receive immediate response. Once having undertaken an emergency case, an optometrist shall neither abandon nor neglect the patient.”But an optometrist who provides emergency care is acting legally as a “volunteer”.

19. A volunteer is defined legally as:“one who assists a person who is unable to aid, protect, or care for himself”.Such a person must exercise reasonable care while providing aid and will be held liable for any negligence that causes injury.

20. Fear of negligence lawsuits when helping accident or disaster victims led to passage of state “Good Samaritan” statutes.The purpose of these laws was to provide immunity from suit for physicians (and others named in the statute), even if they were negligent.The Alabama law is typical.

21. When any doctor of medicine or dentistry, nurse, member of any organized rescue squad, member of any police or fire department, member of any organized volunteer fire department, Alabama-licensed emergency medical technician, intern or resident practicing in an Alabama hospital with training programs approved by the American Medical Association, Alabama state trooper, medical aidman functioning as a part of the military assistance to safety and traffic program, chiropractor, or public education employee gratuitously and in good faith, renders first aid or emergency care at the scene of an accident, casualty, or disaster to a person injured therein, he or she shall not be liable for any civil damages as a result of his or her acts or omissions in rendering first aid or emergency care, nor shall he or she be liable for any civil damages as a result of any act or failure to act to provide or arrange for further medical treatment or care for the injured person.

22. A person or entity, who in good faith and without compensation renders emergency care or treatment to a person suffering or appearing to suffer from cardiac arrest, which may include the use of an automated external defibrillator, shall be immune from civil liability for any personal injury as a result of care or treatment or as a result of any act or failure to act in providing or arranging further medical treatment where the person acts as an ordinary prudent person would have acted under the same or similar circumstances, except damages that may result for the gross negligence of the person rendering emergency care. This immunity shall extend to the licensed physician or medical authority who is involved in automated external defibrillator site placement, the person who provides training in CPR and the use of the automated external defibrillator, and the person or entity responsible for the site where the automated external defibrillator is located.

23. It should be noted that “Good Samaritan” laws do not provide protection for optometrists in many states, only apply to aid rendered at scenes of an accident or disaster, andthus do not apply to efforts by optometrists to provide first aid or treatment in an office setting.

24. As a “volunteer” an optometrist who examines a patient with an urgency or emergency must act reasonably and conform to thestandard of care expected under the circumstances, which is medical.A medical standard of care applies to the examination and treatment of patients with ocular urgencies or emergencies.Thus optometrists must act as ophthalmologists do in rendering care.

25. In Alabama, there is also a legal obligation to assist in emergencies: 630-X-12-.04 Failure to Render Emergency Care. It shall be deemed unprofessional conduct for a licensee to refuse to render emergency care, within the scope of this act, to one of said licensee's patients. This section shall require a said licensee to render professional services to a patient of said licensee in an emergency regardless of the patient's ability to pay for said services. An emergency shall consist of a potentially sight-threatening situation for the patient and shall not consist of routine visual care.

26. Under “vicarious liability” law optometrists areliable for the acts or omission of employees that occur in the line and scope of the employee’s duties and cause injury.Thus an optometrist is legally responsible for the failure of a receptionist to schedule a patient for a timely appointment.

27. Employees who schedule patient appointments must be able to “triage” complaints and identify patients with emergencies or urgencies for examination on a same-day basis (or make a timely referral).Documentation of calls for care is also an important responsibility.

28. Assistants scheduling urgent or emergency patients must either make a same day appointment or promptly refer the caller to another provider or clinic for care. Documentation of calls (in writing) should be retained even if the call is the only contact with the patient. Assistants must understand how to determine if a complaint requires a same day examination.

29. Assistants need to ask 3 questions:1—are symptoms acute or chronic?2—are symptoms severe or mild?3—are symptoms progressive or stable?Based on the caller’s responses, “triage” can be determined and the caller can be scheduled appropriately or referred. The caller can be allowed to speak directly to the doctor in questionable cases.