NCBI home page Elsevier - PMC COVID-19 Collection logo editorial J ISAKOS. 2021 Nov 22;5(5):261–263. doi: 10.1136/jisakos-2020-000549 Good samaritan law: ‘Is there a doctor on board‘? C Niek Van Dijk 1,* Author information Article notes Copyright and License information PMCID: PMC9585655 As orthopaedic surgeons, we used to travel a lot. A glance at the conference and meetings calendar showed weekly opportunities for continuous medical education. The COVID-19 pandemic has changed all this from one moment to the other. It has a dramatic impact on all of us, involving all our daily activities and our practices, including our medical education. Conferences have been cancelled or postponed. Webinars, virtual learning and virtual conferencing have taken over the exchange of knowledge and learning, and yes, the field is changing so quickly that we need this lifelong learning. After 10 years of practice, a third of my procedures were new; a third were modifications of what I had learnt during my residency; and only the remainder were—more or less—unchanged. So it continued. We learn from our own experience, but we also gain from others.
Virtual training and webinars will probably remain also in the future but only to a certain extent. However, virtual learning and webinars miss the one-to-one (social) interaction. The personal interaction with teachers, presenters and fellow congress participants cannot be replaced by a webinar. Visiting a conference requires you to force yourself away from your local activities, set yourself to register to find yourself in a place away from your daily environment. An important part of any orthopaedic conference is the industry exhibition, where we may find new tools and which feeds us with new ideas.
Moreover, there are other socioeconomic factors which will drive the return to a full conference and meetings calendar once the COVID-19 pandemic is history. It probably needs a vaccine or effective treatment to achieve this. Billions of dollars are currently spent towards these developments, so it is safe to assume that, somewhere in 2021, we will resume (international) travelling. International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) members are especially prone to travelling abroad because of the international character of our society.
As orthopaedic surgeons and other healthcare providers in sports medicine care, we resume flying and, sooner or later, we will hear the announcement: ‘Is there a doctor on board? We have an emergency’. It seems that 5% of intercontinental flights have a ‘medical incident‘1: mostly cardiovascular, neurological or gastroenterological, although contusions, fractures or distortions may occur as a result of turbulence.2 Pulmonary embolisms may occur when leaving the aeroplane.
The call for a doctor happened to me, after an ISAKOS-approved conference in Buenos Aires. On my KLM (Royal Dutch Airlines) flight down from Amsterdam, I had a friendly talk with the purser and the captain about my journey. I explained that I was an orthopaedic surgeon, about to lecture at a Congress. Three days later, on the return flight, it was the same KLM crew. They welcomed me back, and we talked about the importance of continuous education for pilots and for doctors. However, next morning before breakfast, there was this announcement: ‘Is there a doctor on board? We have an emergency’.
I was caught! Even if I would have tried to hide behind my newspaper, the purser was already trying for eye contact. So I followed him all the way back to the rear-pantry to find a 65-year-old man. It was not easy to diagnose someone who could not speak and could not understand my directions (he was Spanish). But given his blood pressure and his asymmetric pupillary reflex, and my basic medical knowledge, I was able to diagnose a stroke, although I had not done this for over 40 years. I said that he would benefit from urgent treatment—I seemed to remember that a rapid thrombolysis gives a better prognosis—and the purser said we were close to Madrid. So I advised a landing, and our Boeing 747—with 406 passengers—made an emergency landing, with an ambulance on the runway, waiting to further transport my patient to one of the Madrid hospitals.
The patient was actually a retired surgeon, and accompanied by his wife. After he was dismissed from our aeroplane, of course I was curious to know if my diagnosis was correct. But on the ground the Rules of Privacy apply, so I will never know.
Anyway an emergency landing, disembarking my patient, handling the formalities and getting a new time-slot—all this delayed us by 4 hours. This almost triggered European Union Aviation Safety Agency rules about the maximum flight times for crew. Because of the delay, many passengers missed their connections and had their plans disrupted.
So there were consequences to my intervention. What if my diagnosis had been incorrect? What if new guidelines—unknown to me— no longer required treatment within 6 hours? What if passengers had sued the airline for disruption? Worse than that, what if they would sue me for medical incompetence? It all began to weigh on my shoulders.
As I left, the captain thanked me for my help and told me he would get the whole crew together for a debriefing. However, back at home, and talking it over with my wife, I felt the unanswered questions, and my sleep was a troubled sleep.
The following were some of the questions.
Problem of competence Are we obliged as doctors to make ourselves known on ‘is there a doctor on board, we have an emergency‘? It is most likely that the patient has a disorder outside the field of your own expertise. What then is the best approach? Because of our training, we are still competent to make a better decision than the untrained bystander, but what if we just had a few glasses of wine and a sleeping pill?
Problem of litigation Could the patient sue us for a wrong diagnosis? Could other passengers sue us for their missed-connections and disruption? Could the airline sue us for incompetence?
Are there differences aboard an American airline, a Chinese domestic airline or my KLM flight?
Problem of confidentiality When we make a diagnosis, we establish a doctor–patient relationship and cannot share information with civilians, like an aeroplane's purser or captain.
However, if we diagnose in an airplane incident, does that create a doctor–patient relation, with similar confidentiality?
Problem of continuity Imagine a heart-attack patient who needs continuous resuscitation. This must continue until ground professionals can take over, but what to do if the fasten-seatbelt sign comes on, and the captain asks the cabin crew (and all other passengers) to resume their seats for landing?
I searched the literature for answers, but with little success. So I contacted the Airport Medical services (AMS) of KLM and made an appointment for an interview with Dr Brinio Veldhuijzen van Zanten (BVvZ), who is managing director of KLM Health Services and Peter Nijhof (PN), responsible physician of AMS, at Amsterdam's Schiphol Airport.
CNvD: As doctors, are we legally obliged to respond, when we hear “Is there a doctor aboard? We have an emergency”, even if we have drunk a few glasses of wine, and taken a sleeping-pill? The surgeons on 17th century warships may have worked better, after they had drunk the rum they used for anaesthesia, but those were the good old days.
PN: For Dutch doctors it is simple. If you are a registered as a doctor, you come under the BIG Act (the Dutch Individual Healthcare Professions Act which covers all health-care professionals). And the BIG Act obliges you to help. If you refuse, there are legal consequences. The BIG Act states that you should only do what you are competent to, and what you are authorized to do. If you are a general-practitioner, for example, you should not operate, because although you are “qualified”, you are not “competent”. But in an emergency you should act to the best of your ability. If you have been drinking or taking sedatives—and feel less able to help—then you should inform the crew of that.
CNvD: What about other countries' doctors?
PN: There are similar laws across Europe and some other countries. But Common-Law countries—such as England, Canada and America—they follow different rules. You only need to help a patient if it happens to be one of your own patients. So if there is a prior doctor-patient relationship. In all other cases you are not (legally) obliged to help.
CNvD: So that's essentially different from Europe
PN: Yes, but of course there is a moral requirement. If you are the only doctor on board, and you are called to help with a medical-incident, but refuse (by keeping silent), then you have failed your moral-duty. And there may be a civil redress against you.
CNvD: Oh yes? And even for an American doctor?
PN: Yes, I believe so. If you are qualified and competent, you must respond to an emergency situation, especially if you have been asked. If you fail to do so In Europe, you can be called to account, and disciplined.
But because there is no legal obligation under US Law, they passed the “Good Samaritan Law”. This states that, when a doctor offers assistance aboard an American aircraft, he cannot be held responsible (liable) for his medical treatment, provided that he acted in accordance with professional standards (and provided he was not drunk or drugged). If you are qualified and competent, then you are authorized to act, and you will not be held liable for the consequences of your medical-action.
CNvD: Does this Good Samaritan Law only apply to aviation?
BVvZ: Yes, There is a special “Aviation Medical Assistance ACT”, (https://www.govinfo.gov/content/pkg/CRPT-105hrpt456/pdf/CRPT-105hrpt456.pdf) for US airplanes, with reference to the Good Samaritan Law.
CNvD: And does it only apply to American flights?
PN: It applies to American territory, but if you are inside an American aircraft, you are presumed to be on American territory.
As far as I know— and as far as literature shows—there has never been a lawsuit against a medical professional, who was asked for assistance by the airline. But you must be asked by the airline, that's to say by the Captain. If you are sitting next to a passenger who stops breathing, and you start resuscitation immediately—before you have been asked by the aircrew, then that is your own responsibility.
CNvD: So it's important, that the airline asks you to help?
PN: Absolutely, the Captain (or his representative) should ask you to help. The Cabin Crew is fully trained in resuscitation, and they have a first-aid kit. They must first see the problem, report to their Captain, who -if there is enough time- will contact the airline's medical services on the ground. When Cabin Crew asks: “is there a doctor on board?”, the airline requests the help from a passenger-doctor, because obviously they don't have their own doctor on board. The airline however retains control.
CNvD: So if there is a request, there has already been contact between captain and ground medical staff?
PN: Certainly on intercontinental flights. Inside Europe, there may be no direct communication, but only control-tower talking to control-tower. There is no satellite-link. Sometimes we are alerted by our control tower: “an airplane is landing, and somebody has breathing problems, so get an ambulance to the gate”. In these cases there is no direct contact.
With intercontinental flights, there is satellite-linkage, and we will have direct contact with the Captain. And sometimes he will ask a passenger-doctor to enter his cabin, to speak directly with the ground medical staff
CNvD: What about my case? A passenger with possible brain haemorrhage, and my recommendation about emergency landing? I didn't have contact with medical staff on the ground. I didn't even know it was possible.
PN: Probably the Captain had contact: “We have a passenger with a suspected brain-haemorrhage. A doctor-on-board has diagnosed him, and advises landing in Madrid. Do you agree?” Then we would ask about the symptoms: “Our doctor says Hemi-paralysis, a high blood pressure, asymmetric pupillary reflex, the patient is hardly approachable etc., etc” . Then we would approve an emergency landing. But the captains makes the final decision if it safe to make an emergency landing.
CNvD: When I made my diagnosis, I shouldn't really have spoken with the purser. I should have said: “I have medical confidentiality, and cannot share information with a layman”.
PN: Yes, strictly speaking, but this was an emergency.
CNvD: So, do the same again next time?
PN: Absolutely. How would you do it differently?
CNvD: Maybe I could say: “I would like to discuss my diagnosis with a doctor on the ground”.
Yes, In principle that is possible, but it rarely happens. Of course you don't have to give details to the purser. You only need to say that it's really an emergency, and you advise landing as quickly as possible. Whether that violates your professional secrecy is for lawyers to decide. But you are acting in the patient's best interests and, as I have already mentioned, there hasn't been a problem so far.
Just remember, the Captain is fully responsible for his flight, for everything that happens on his flight. As a doctor, you are giving medical advice to the Captain, who relays it to his ground medical staff.
CNvD: So the overall decision is the Captain's, and not the doctor's?
PN: Yes. The Captain issues his orders, after consulting you.
CNvD: And I cannot be called to account for my advice?
PN: No, the Captain asks for your advice, but he makes the decision. When the passenger-doctor agrees with the ground-doctor, it's easy for him. It's more difficult—and annoying—when there is a difference of opinion. But in that case he would normally follow the ground-doctor, simply because we deal with these problems on a daily basis.
Returning to your case, where you diagnosed a brain haemorrhage, and urged treatment within 6 hours. Yes, it would have been more convenient—at least for the airline— to continue to Amsterdam, rather than stopping in Madrid, gaining those 90 minutes, but with 400 people in the wrong place.
But that is why the Good Samaritan Law was passed: to overcome the fear of providing medical assistance and to provide treatment advice or advice to make an emergency landing. You provide professional advice, only when the airline asks for it. And they take the responsibility.
CNvD: If you diagnose a patient in an airplane, do you have a doctor-patient relation? Should I have made a report on my findings?
If you diagnose a patient in an emergency situation you do indeed create a doctor-patient relationship. This normally requires written notes, which can be sealed, and accompany the patient to his treating physician.
CNvD: Lastly, what about resuscitation?
PN: The cabin crew is trained to start and continue resuscitation. Of course physicians on board can assist with this, especially when they are also trained. However, when the fasten seatbelt sign goes on, and cabin crew are asked to resume their seats, then, yes, you need to stop the resuscitation and return to your own seat. Cabin crew will continue the resuscitation.
In conclusion Conscience urges we treat all patients, no matter what. We will help, when we are asked. This also applies in the air. The big act—and similar acts across Europe and other continents—state that we should only do what we are competent to. In an emergency, we will act to the best of our ability. In the USA, there is no legal obligation to help; however, the ‘Good Samaritan Law’ regulates the liability for the medical treatment, provided that it is in accordance with professional standards and provided that medical assistance has been asked for by the airline.
Next time when you are on a flight and you hear 'we have an emergency: is there a doctor on Board?', I hope this editorial made you comfortable that 'Primum non nocere' (First do no harm) 3 does not translate to remain seated.
Footnotes Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.
References 1.Graf J, Stüben U, Pump S. In-flight medical emergencies. Dtch Arztebl Int. 2012;109:591–602. doi: 10.3238/arztebl.2012.0591. [DOI] [PMC free article] [PubMed] [Google Scholar] 2.Kleijne I. Dokteren OP dertigduizend voet (doctors at thirty thousand feet) Medisch contact. 2019;22 [Google Scholar] 3.Hippocrates. Asklepion, 400 bc. Articles from Journal of Isakos are provided here courtesy of Elsevier
What You Need to Know When Called Upon to Be a Good Samaritan picture_as_pdf PDF
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Understanding your legal protections and ethical obligations can make it easier to respond when duty calls.
ROBERT J. DACHS, MD, FAAFP, AND JAY M. ELIAS, JD
info Fam Pract Manag. 2008;15(4):37-40
assignment Dr. Dachs is assistant director of the Department of Emergency Medicine at St. Clare's and Ellis Hospitals in Schenectady, N.Y., and clinical assistant professor in the Department of Family Medicine at Albany Medical College in Albany, N.Y. Jay Elias is a malpractice defense attorney and partner at Ratcliffe Burke Harten & Elias in Providence, R.I. Author disclosure: nothing to disclose.
When the news broke in February that a 44-year-old woman died of complications from heart disease and diabetes on an American Airlines flight after receiving emergency treatment by airline staff and a pediatrician, it reminded physicians everywhere that their services may be needed when they least expect it and that these situations don't always have happy endings.1 Although there has never been a successful case against a physician who claimed Good Samaritan protection after providing emergency care outside a hospital, many physicians feel concerned about the legal consequences that might befall them in these situations.
The fact is that all 50 states have some type of law that seeks to encourage medical professionals to act as Good Samaritans by offering certain protections. The purpose of this article is to explain the basics of these laws, as well as physicians' ethical duties, so that when you encounter opportunities to act as a Good Samaritan, you will have a better understanding of what you're getting into.
How do Good Samaritan laws work? Most Good Samaritan statutes rely on the concepts of ordinary negligence and gross negligence. “Ordinary” negligence means that the individual providing aid did not act as a reasonable health care provider would under similar circumstances. Contrast that with “gross” negligence, which generally means not only that the individual did not conform to the accepted standard of care, but also that his or her actions rose to the level of being willful, wanton or even malicious. Typically, Good Samaritan laws provide immunity from civil damages for personal injuries, even including death, that result from ordinary negligence. They do not, for the most part, protect against allegations of gross negligence.
For example, say you witness an individual in cardiac arrest in a restaurant. You perform CPR to the best of your ability, alternating compressions and rescue breathing at a ratio of 15:2, but the patient does not survive. Emergency medical services (EMS) personnel arrive and note that the new recommendations are to perform this resuscitation at a ratio of 30:2. However, you have not had any reason to take the new basic life support course. Because you acted to the best of your professional abilities, you could expect to be protected by the Good Samaritan law in your state. On the other hand, if you were performing CPR but suddenly stopped because you recognized the individual as a known drug dealer in your town, that would be considered willful and wanton negligence and you would not be protected by a Good Samaritan law.
The concept of “duty” is also central to Good Samaritan laws. To be afforded the protections of a Good Samaritan law, in most states a physician must not have a pre-existing duty to provide care to the patient. A physician does have a pre-existing duty if the victim is a current patient, the physician is contractually obligated to provide care to the victim, or there is an on-call agreement that requires the physician to provide services. The following examples are intended to be instructive:
If you happen upon an accident scene, you likely will be afforded Good Samaritan protection. If you use your black bag to provide aid to the victim, the fact that you had your black bag with you does not, in and of itself, mean you had a duty to respond and therefore should not compromise your immunity.
If a car accident occurs at the intersection in front of your clinic and your help is sought, you would likely have Good Samaritan immunity unless the victim was a patient of yours, in which case you may be held to a higher legal standard of care.
If you coach your child's Little League team and a player gets hit in the head with a ball, you may well have Good Samaritan protection because your role with the team is as the coach.
If you volunteer to staff a first-aid station at a marathon being run in your community and a participant has a severe asthma attack, you may not have Good Samaritan immunity because of the duty implicit in your agreement to serve in this role. If, however, the runner signed a waiver of liability as a condition of participating in the race, you may have some additional protection.
If you agree to be present at your local high school's football games, without pay, at the request of the athletic department and a player is nonresponsive following a tackle, you may not have Good Samaritan immunity – again, because of the duty implicit in your agreement with the athletic department.
If a member of your office staff collapses on the job, you would likely not have Good Samaritan immunity because of your duty to provide emergency services to individuals in need within that facility.
A physician without a pre-existing duty can expect to be provided immunity from liability in the event that he or she does respond in good faith and gets sued because of a bad outcome. Note, however, that three states do have “failure-to-act” laws: Louisiana, Minnesota and Vermont. In these states, if a physician is known to have walked away from a scene at which an individual required emergency medical treatment, then he or she can be in violation of the law.
State laws also differ as to the location where the Good Samaritan renders the emergency care. Although most Good Samaritan laws apply only to care provided outside the hospital, Good Samaritan laws in California and Colorado explicitly protect physicians who provide Good Samaritan care in a hospital. For example, if a physician in either of these states is rounding on hospitalized patients and responds to an urgent request by hospital staff to attend to another physician's patient who is in acute respiratory distress, he or she may be afforded Good Samaritan protection.
We are sometimes asked whether it is permissible to accept a gift for your efforts as a Good Samaritan. The answer is generally “yes” – and some laws even specify that physicians are entitled to payment for providing Good Samaritan care. In most states, however, the act of your sending a bill can complicate the issue of whether you had a pre-existing duty to provide care to the individual and, therefore, whether you have Good Samaritan immunity. You must be able to show that you provided the care without expecting remuneration, even if you decide after the fact to bill for your services, which can be difficult.
Your professional liability insurance carrier may be able to instruct you about other unique aspects of the Good Samaritan law in your state.
KEY POINTS ABOUT GOOD SAMARITAN LAWS
In most states, there is no legal obligation to provide Good Samaritan care.
If aid is given, it need be stabilization only.
The recipient of aid must not object to aid being rendered; implied consent exists if the victim lacks capacity to consent.
Physicians acting as Good Samaritans generally have legal immunity to claims of ordinary negligence, but not to gross, willful or wanton negligence.
Do you have an ethical duty to respond? When the opportunity to be a Good Samaritan presents itself, ethical considerations weigh as heavily on many physicians as legal ones. The primary question is whether physicians have an ethical duty to respond. The AMA's Code of Medical Ethics has this to say: “A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care [emphasis added].”2 And the AMA's Council of Ethical and Judicial Affairs has specified that physicians should “respond to the best of their ability in cases of emergency where first aid treatment is essential.”3 Ultimately, the decision of whether to act is a personal one based on many factors.
When responding to the need for Good Samaritan care, physicians may wonder at what point they should hand off the patient to other caregivers. Generally speaking, you should not leave the scene until someone of at least comparable capability can take over. Some EMS personnel might ask you to ride along to the hospital until you can hand off the patient's care to another physician. Others may insist that you step away immediately upon their arrival. The key to determining how best to respond is in quickly assessing the abilities of the responders. In some areas, the EMS personnel may be volunteers with basic life support skills. In other areas, you may encounter paramedics with extensive training and experience. Physicians and EMS providers have to put egos aside and assess who can do the best job under the circumstances. You may determine that you have an ethical duty to continue providing care until you can get the patient to the hospital, or you may be comfortable leaving the scene once the EMS providers have arrived.
When you're in the air The incidence of in-flight medical events on commercial airlines is unclear, given that there are no regulatory reporting requirements. One recent analysis by MedAire, an Arizona-based company that provides emergency medical advice to airlines that carry nearly half of the 768 million passengers on U.S. flights each year, found that the rate of medical emergencies aboard commercial flights nearly doubled from 2000 to 2006, from 19 to 35 medical emergencies per 1 million passengers.4 The majority of physicians in attendance at a recent AAFP Annual Scientific Assembly course reported having been confronted with an in-flight emergency at some point in their careers.
In the United States, physicians are under no legal obligation to provide assistance in these situations, but a federal law passed 10 years ago includes Good Samaritan immunity for those who do. The Aviation Medical Assistance Act of 1998 ensures that if you're flying in the United States, even if the airline is not owned by a U.S. company, you have Good Samaritan protection. Canada and the United Kingdom have similar laws. The laws on intercontinental flights are more complicated; the simplest explanation is that the laws of the country in which the airline is based are in effect. For example, on a flight from Los Angeles to Sydney, Australia, on Qantas Airlines, Australian law (which says you have a duty to act) would be in effect.
Like state statutes, the Aviation Medical Assistance Act provides Good Samaritans with protection from lawsuits alleging negligence “ … unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.” The act protects airline companies from liability as well “if the carrier in good faith believes that the passenger is a medically qualified individual.” Airline employees meet the “in good faith” requirement by asking whether the person who volunteers to help is a health care provider.
When responding to most in-flight medical emergencies, physicians have a variety of tools at their disposal. Most airplanes are equipped with automated external defibrillators (AEDs); the Federal Aviation Administration (FAA) requires that any plane weighing 7,500 pounds or more and carrying at least one flight attendant must have an AED on board. In addition, most U.S. airlines have 24/7 access to emergency physicians who can be consulted if needed. The FAA also requires that an emergency medical kit be available and that it be stocked with certain items, including medications, IV supplies and syringes. On many airlines, basic first-aid supplies are stored separately. In an emergency, it is a good idea to ask for both the emergency medical kit and the first-aid supplies to ensure that you'll have everything you need.
It is not unusual for physicians who respond to serious in-flight medical emergencies to be asked to advise the pilot on whether the plane should be diverted so that the passenger can be treated at a hospital sooner rather than later. Do not assume the burden of deciding whether the plane gets rerouted; that is a decision best left to the pilot. Instead, offer your medical opinion about the patient's condition and a prognosis expressed in terms of time, for example, “The patient has extremely high blood pressure, and there are indications she is having a stroke. The sooner she can be treated at a hospital, the better her prognosis will be.”
Just do your best As noted earlier, the odds of being successfully sued for malpractice as a result of providing Good Samaritan care are stacked well in your favor, so much so that the fear of litigation should not be a factor in your decision about whether to help when the situation presents itself. An attorney would much rather defend a physician for providing care and making a good-faith error than for not providing care in an emergency situation. Next time you happen upon an accident scene or hear a plea for emergency medical assistance, do unto others as you would have them do unto you, and be confident that your best effort will be good enough
https://www.aafp.org/pubs/afp/issues/2021/0501/p547.pdf
https://www.cdc.gov/yellow-book/hcp/travel-air-sea/perspectives-responding-to-medical-emergencies-when-flying.html
https://www.emra.org/about-emra/publications/emra-cast/in-flight-emergencies#shownotes