Risk Management

Don’t Defer Emergency Cases When Covering Calls for a Colleague

By Richard A. Deutsche, MD

Argus, August, 1992

Weekend, night and vacation call scheduling presents potential risk management problems if the on-call ophthalmologist does not see emergency cases in a timely manner. A review of ophthalmic claims reveals instances in which the operating surgeon and the on-call ophthalmologist were sued for failing to treat postoperative complications in a timely manner.

One case involved an elderly man who had an uncomplicated extracapsular extraction with a posterior chamber intraocular lens performed on a Thursday. The eye was doing well when the operating surgeon saw the patient the following day. On Saturday, two days postop, the patient developed pain and decreased vision. After failing to reach the surgeon, who had signed out to another ophthalmologist for the weekend, the patient was eventually able to contact the covering ophthalmologist by phone. He relayed his symptoms and was told to take Tylenol.

The next day, still complaining of pain and decreased vision, the patient was referred to another on-call ophthalmologist. When the patient was seen that evening, a diagnosis of enophthalmitis was made. On Monday, the patient was seen by a retinal specialist who did a vitreous tap followed by the appropriate treatment for enophthalmitis. Despite these best efforts, the eye was lost. The patient sued the operating surgeon and both on-call ophthalmologists for abandonment and delay in diagnosis.

Another case involved a middle-aged woman who had an uncomplicated retinal detachment repair with intravitreal gas performed on Friday. That evening, she developed pain and blurred vision. She called the retinal specialist, who had gone out of town, and was referred to the on-call ophthalmologist who prescribed Empirin with codeine No. 4 for pain. The severe pain continued and her vision worsened.

When the on-call ophthalmologist saw the patient the next day, her intraocular pressure was 70. Although the ophthalmologist immediately began appropriate treatment for intravitreal gas and control of the glaucoma, permanent damage to the eye had occurred, presumably from the prolonged elevated intraocular pressure, and the eye was lost. The patient sued the retinal specialist and the on-call ophthalmologist for failure to respond to the emergency.

In both instances, the claims may have had stronger defenses or been avoided altogether if the ophthalmologist on call had seen the patient in a timely manner.

Ophthalmologists are strongly advised to adhere to these risk management principles when arranging or accepting weekend, night or vacation coverage:

• When signing out, be sure to inform the ophthalmologist who is taking your calls of any recent surgical cases or any problem patients.
• When on call, keep your home telephone line open as much as possible so the answering service can reach you.
• If you are taking calls for a colleague, be readily available and willing to see patients regardless of the time of day.
• Keep notes of telephone calls you take while on call, and place these notes in the proper charts when you return to the office.
• Inform your colleague of any patients who contacted you during his or her absence.
• Remember that certain general ophthalmic emergencies such as a chemical splash in the eye, perforating eye injury, recent bulging of the eye, rapid onset of vitreous floaters, curtains or veils across the vision, photopsia and foreign bodies in the eye must be evaluated immediately.
• Postoperative patients who complain of pain, acute complete or partial loss of vision, infectious discharge or increased redness of the eye must be seen by an ophthalmologist as soon as possible. Do not delegate this duty to a non-ophthalmologist.

By following these guidelines, you can provide your patients with optimal ophthalmic care and decrease your exposure to litigation.