Clinical Scenario
A 48-year-old homeless man presents to the emergency department (ED) of your local hospital by ambulance at 1:00 a.m., following an argument with and assault by another individual over the disputed ownership of a tent in an encampment. The attending emergency medicine physician, Dr. Sims, calls and requests your presence for an on-site consultation and treatment for this patient. Although you normally see only your own patients or those referred by long-standing physician colleagues in the ED, you are still “officially” on the list of otolaryngology consultants.
According to Dr. Sims, Mr. John Doe has no insurance, no established physician relationship, and a history of hepatitis, alcoholism, and malnutrition. Dr. Sims’ initial examination revealed facial trauma with periorbital ecchymosis and tenderness over the nasal dorsum and zygomatic arch, and significant swelling and bruising posterior to the right auricle. CT imaging demonstrates a displaced nasal fracture, a zygomatic arch fracture, and a temporal bone fracture involving the right mastoid and middle ear. There is bloody otorrhea in the right ear and a noticeable weakness of the right facial muscles. Dr. Sims indicates that the patient appears to be intoxicated.
Although you do have experience with facial trauma, including temporal bone trauma, these injuries are not a common part of your practice. You are also concerned about medical liability, no compensation for a likely difficult treatment and follow-up plan, and the impact on your schedule in the coming days. Dr. Sims indicates that his options for another consulting otolaryngologist are very limited, and he practically begs you to evaluate the patient.
You pause to consider this request. What is your duty and responsibility to this patient? Should you refuse to evaluate him? If so, on what grounds? Do you have a duty to the hospital system in which you regularly practice, as well as the medical profession?
Discussion
Cases such as this are rarely about the immediate clinical question alone. The imaging can be reviewed, the injuries categorized, and the management options outlined with relative clarity. The ethical question, however, is less precise and, in many ways, more consequential. What is the nature of our obligation as otolaryngologists when we are asked to see a patient who is not our own, who cannot pay, and whose care may depend entirely or in good part on our willingness to respond?
For many of us, the instinct is immediate—we go in. The patient is vulnerable, the need is real, and the expertise required is ours. The temporal bone fracture, in particular, raises concern for hearing, balance, and facial nerve function, and these are not issues easily deferred or reassigned. Yet, if we are candid, there is often a moment of hesitation—not reluctance, but recognition. Recognition that modern practice has changed. Sub-specialization has narrowed our routine clinical exposure. Time away from scheduled patients has consequences. Encounters with uninsured patients frequently represent uncompensated care, and repeated disruptions carry both financial and professional impact. There is also a persistent awareness of liability. Trauma care, often delivered with incomplete or unreliable historical information and uncertain follow-up, introduces risk that is not easily dismissed. These realities do not negate our professional commitments, but they do shape how we experience them.
It is tempting to frame this scenario as a simple question of duty—either we go in, or we do not. In practice, the situation is often—or usually—more nuanced. The patient before us is not simply a clinical problem but a person without resources, continuity of care, or a reliable path forward unless someone engages to manage his injuries. Justice, in its most practical sense, requires that access to appropriate care should not depend on circumstance. At the same time, the physician is not an unlimited medical resource. We work within systems that are often imperfect, relying on individual effort to compensate for structural gaps. When emergency care is repeatedly uncompensated or unsupported, the burden becomes uneven and, over time, unsustainable.
The question, therefore, is not whether responsibility exists, but how it is best fulfilled.
Increasingly, the answer lies in thoughtful engagement rather than reflexive action. The initial response does not always require immediate physical presence. Telehealth now allows real-time review of imaging, direct communication with emergency physicians, and guidance regarding urgency and disposition. This approach, accelerated during the COVID-19 pandemic, has demonstrated that meaningful clinical input can often be provided efficiently and safely. At the same time, telehealth has clear limits. A temporal bone fracture with potential facial nerve involvement will ultimately require in-person evaluation, and the hands-on examination by an otolaryngologist remains the most important step in providing expert and thoughtful management planning.
For physicians whose practices are less centered on trauma, collegial collaboration becomes essential. Reaching out to a partner, a colleague, or a regional specialist helps ensure that care remains both competent and timely. This is not a deflection of responsibility but an extension of it. While oral and maxillofacial surgeons play a vital role in facial trauma, the otologic implications of temporal bone injury in particular remain firmly within the domain of otolaryngology, and our involvement is essential.
In the end, what we owe this patient is less about a single action and more about a professional posture. We owe him our attention, our judgment, and our willingness to engage. We may not owe it to him to personally manage every aspect of his care, but we do owe him the assurance that his condition will be appropriately evaluated and that he will not be left without a path forward.
In the October 2024 issue of ENTtoday, Jennifer Fink compared the refusal by some otolaryngologists to take ED call 20 years ago to the more current environment of institutional expansion and the demands of the Emergency Medical Treatment and Active Labor Act (EMTALA), which require hospitals that offer emergency services to provide on-call physicians with specialty-level competence to care for high level disorders, regardless of a patient’s ability to pay (ENTtoday. https://tinyurl.com/y3ewdj8j). However, otolaryngologists are increasingly bargaining with hospital systems for compensation for uninsured emergency patient care. For otolaryngologists who agree pre-emptively to remain on ED on-call rosters, financial compensation may be acceptable, but that does not mitigate the medical liability issue, which is a major concern for many surgical specialists. Yet there are no proven methodologies to determine whether any given individual patient may be a high risk for filing lawsuits, and the development of a positive patient–physician relationship is the best deterrent.
During the COVID-19 pandemic, otolaryngologists were thrust into the forefront of managing serious and life-threatening upper aerodigestive tract complications, as well as caring for other patients who required close, in-person attention for the more traditional otolaryngologic conditions. Our specialty has taught us a lot about facing changes in practice protocols, mitigating risks, and providing care in a mixed-specialty team effort. As part of the care teams, we coordinated care with our colleagues, shared best practices, and educated each other. We learned to use telehealth to both the patient’s and our advantage, and technology has blossomed in the remote care of patients; however, surgical judgment and communication with our colleagues (i.e., emergency medicine physicians) can allow for our expertise to be applied and patients to be helped.
In this scenario, which is not uncommon, the otolaryngologist is faced with a challenge that can be addressed in a number of ways. First, they could demur from seeing the patient by claiming inadequate expertise and experience in the injuries sustained by the patient. With this decision comes the need for veracity in describing the otolaryngologist’s actual capacity to evaluate and treat, with refusal to respond being potentially seen by other healthcare professionals as non-acceptance of a duty. If this choice is selected, the otolaryngologist would, at a minimum, be obligated to proffer other colleagues as potential caregivers or volunteer to find a replacement for the patient.
Second, the otolaryngologist could offer to review the history and physical, the imaging studies, and even a photograph of the patient’s injuries to provide options for next steps, with or without a follow-up later in the day in the ED or hospital. If the patient is indeed evaluated by the otolaryngologist at any point in person, then that will constitute a patient–physician relationship, with all of the attendant responsibilities thereof.
Third, the otolaryngologist could evaluate the patient in the ED as soon as possible, make determinations about further diagnostic and first-line treatment, and hand the patient off to a colleague who would be better able to care for the patient.
Finally, the otolaryngologist could see the patient in the ED and totally care for his injuries, with or without the assistance of an otologist or a maxillofacial or facial plastic surgeon, through the course of the treatment plan.
The duty to take call in otolaryngology has not disappeared, but it has evolved. It is no longer defined solely by physical presence or personal sacrifice, but by a broader commitment to ensuring that patients—particularly those who are vulnerable—have access to the expertise they require. Financial pressures and liability risks are real and should not be minimized, yet they do not relieve us of our professional obligations; rather, they challenge us to meet them more thoughtfully.
In the end, the question is not simply whether we go in, but whether we remain engaged in a way that is consistent with our values, responsive to patient needs, and sustainable for the profession we are entrusted to uphold. In the end, we must do what is best for the patient.
Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.
It used to be that hospital systems relied on physicians working things out when I started on call in 1995.
An ER doctor called the physician directly, asked for an opinion, comment or help with patient care. A common decision was made and the decision would be to see the patient when he was sober sometime in the morning. At the end of my career in 2023, when I last took call, the NP or PA in the ER would send a message via “Diagnotes” to the phone expecting a call back. Often, a decision would have been made to admit the patient to the hospitalist service runs by residents or internists who would baby sit the patient until the ENT consultant could see the patient the next day or two. We would often see the patient and defer any ear work to the otologists and peri-orbital work to the oculoplastics team.