Since Florence Nightingale, nurses have agreed that care should be individualized for each patient. Emergency care is no different and texts on this subject instruct the nurse to involve the client in his own care and to recognize that being an emergency victim is physically and psychologically difficult for the client. But just what is client-centered emergency care and are clients getting it?

A client is brought to the emergency room, unconscious, with severe head trauma resulting from a motorcycle accident. In this instance client-centered care consists of the nurse reacting swiftly and probably unemotionally. It is not in the client's best interest at this time for the nurse to try to ascertain that person's values and life views. Here client-centered care is compatible with the values and views of both the nurse and the institution.

She is an attractive woman around 30 with two sons, the same husband she started out with, their mortgage (not the same one they started out with), and a license to practice nursing in Massachusetts.

And her story, anonymous but otherwise undisguised, will tell you more about the nursing shortage, the women's movement, the Medicaid crisis, the conservative revival and social change in America than any compilation of research, analysis, punditry and feminist literature. She is angry and the only reason she is going to take it any more is that she has not discovered a decent alternative.

She works odd, inflexible hours, some nights and Sundays, in the emergency room of a community hospital outside Boston. It is the kind of place to which your kindly old family doctor, interrupting a weekend frolic with the new cookie, refers his less affluent patients.

The lesson of this column is: In an emergency, treat first and ask legal questions later. This is both good medicine and good law.

There is no universally recognized definition of an emergency, and the law will generally accept the determination of health care professionals, if consistent with accepted practice, in defining an emergency condition or situation. The most common definition is that an emergency is any injury or acute medical condition liable to cause death, disability, or serious illness if not immediately attended to.

Obvious examples of emergency conditions that require the immediate attention of a physician or properly trained health professional to prevent loss of life include:

• Massive hemorrhage from major vessels

• Cardiac arrest

• Cessation or acute embarrassment of respiration

• Profound shock from any cause

• Rapidly acting poison

• Anaphylactic reactions

• Acute epidural hemorrhage

• Acute overwhelming bacteremia and

• toxemia

• Severe head injuries

• Penetrating wound of the pleura or pericardium

• Rupture of an abdominal viscus

• Acute psychotic states.

Should nurses carry their own malpractice insurance? This is a commonly asked question, to which no simple response can be given. The answer will be different for each individual nurse, and will depend upon a variety of factors; individual personal values will determine which factors are most important. Thus, while it is impossible to offer a definitive answer which is correct for all nurses, it is possible to provide a framework to aid in the development of individual answers. For purpose of discussion this column will examine the nursing malpractice insurance question from three perspectives — legal, ethical, and professional — though in reality, of course, the three overlap.

The legal issues raised by the malpractice insurance question are the most straightforward and therefore the easiest to deal with. The first question is: do nurses need malpractice insurance at all? Nurses are now viewed (legally and otherwise) as professionals accountable for their own actions.