Risk Management

Emergency Room Protocol for On-Call Ophthalmologists

By Kenneth C. Chern, MD

Argus, August, 1996

Many emergency room physicians receive little or no formal training in ophthalmology, yet they commonly see and treat acute ophthalmic injuries. As a consulting ophthalmologist, you may find yourself relying on an ER physician’s description of a patient’s condition and recommending treatment by phone without ever seeing the patient. Follow-up may not occur until days later, by which time the patient’s condition may have advanced beyond the window for optimal treatment. These factors increase the risk of ER-related claims.

The following is a typical scenario:

It is 10:00 on a Saturday night. A 35-year-old man comes to the ER with a red, painful right eye. The ER physician calls you at home:

“Hello, this is Dr. Jones, ophthalmology, on call.”

“This is Dr. Smith in the ER. I have a young man here for whom I want a sideline opinion. You don’t have to come in.”

“OK, what happened?”

“Mark wears extended wear contact lenses. He hasn’t worn them for the past 48 hours or so because of discomfort, although he regularly wears them continuously for up to two weeks. I think he may have scratched his cornea putting his lenses in since a small area of the cornea lights up with fluorescein. He says he has scratched his cornea several times before. What do you do for these corneal abrasions?

“Usually they heal with an antibiotic ointment and an overnight patch.”

“I’ll patch him up and have him see you on Monday morning.”

“That will be fine. Good night.”

On Monday morning, when the patient comes in, you find a dense stromal infiltrate and purulent material under the patch. The “scratched cornea” was the start of an infective corneal ulcer. With appropriate antibiotics, the cornea heals, leaving a residual scar and decreased vision.

With emergency rooms and urgent care centers fast becoming the first gateways for acute ophthalmic emergencies, a methodical and regimented routine is essential to ensure that the patient receives prompt and appropriate initial treatment.

It is not always necessary for the ophthalmologist to see the patient in the ER. Phone consultation may be sufficient and expedite care and treatment. However, when providing telephone consultation, a thorough history, vision test, and full physical exam are necessary to elicit other causes of the symptoms that the ER physician may not have considered. If you have any doubt about what has been described, there is no substitute for examining the patient yourself. Mentally run through a differential and treat the patient as if you were treating the most serious possibility. A corneal abrasion will heal even if it is treated as a bona fide infection with topical antibiotics.

Follow all emergencies closely until they are resolved. Referral follow-ups from the ER especially need to be re-evaluated in a timely fashion by an experienced ophthalmologist even if this means seeing the patient on a weekend or a holiday. This is part of appropriate patient management for an on-call physician.

Education is the best prevention against scenarios like the one described. Educate the ER physician and staff to recognize signs of serious ophthalmic problems, to express uncertainty, and to contact the on-call ophthalmologist immediately in complex cases. Encourage them to ask more probing questions when history and examination findings do not fit the diagnosis. When you are on call, report back to the ER physician about patient outcomes. This may be the only feedback and instruction they receive on ophthalmic emergencies. Their education is your best defense if a claim arises from care in the ER.