Some clinicians thrive on the unpredictability and chaos of emergency medicine while others prefer the steadier rhythm of general practice; however, emergency cases still occur in general practice and can be disruptive and stressful for team members. Although general practitioners may not have access to the same resources as emergency clinicians, critical patients can still be stabilized in the clinic.
Following are the author’s top 5 tips for managing emergencies in general practice.
1. Develop a Systematic Approach to Emergency Cases
A systematic approach to emergency situations can help ensure nothing is missed.
The first step when examining a critical patient is to evaluate the ABCs1:
Airway: Is there a patent airway?
Breathing: What is the respiratory rate and effort? Are abnormal respiratory noises or an abnormal breathing pattern present?
Circulation: What is the heart rate and rhythm, pulse quality, and blood pressure?
If any of these findings are abnormal, stabilization that focuses on improving oxygen delivery and circulation should be started (see Getting Comfortable With Basic Stabilization). Cardiopulmonary resuscitation (CPR) should be initiated if the patient is in cardiopulmonary arrest, unless a do not resuscitate (DNR) order has been provided. For guidance on performing CPR, the updated RECOVER guidelines are available (see Suggested Reading).
Once the patient is stabilized, or if initial triage reveals normal respiratory and cardiovascular systems, the remainder of the physical examination can be performed, and a plan for further treatment can be developed.
2. Get Comfortable With Basic Stabilization
Patients in respiratory distress should be administered oxygen and a sedative (eg, butorphanol), which can be given IM or IV depending on the patient’s stress level.
Handling should be minimized until the patient is breathing comfortably, which may mean delaying radiography and placement of IV catheters until the patient is stable. Empirical treatment can be performed based on initial examination, including thoracocentesis for patients with suspected pleural space disease or administration of a furosemide injection for patients with suspected congestive heart failure.
For patients with cardiovascular compromise, venous access should be obtained and fluid support provided. Balanced crystalloids are preferred for resuscitation. Rather than administering a large shock bolus, a small bolus can be given followed by reassessment.2 Target parameters (eg, heart rate, blood pressure) should be determined for each patient and boluses repeated until these targets are achieved. For patients with a history of trauma, hypotensive resuscitation is recommended to avoid disruption of clots internally. Up to date information on management of fluid therapy is available (see Suggested Reading).
3. Consult a Local Emergency Clinic
If a patient is not responding to typical stabilization efforts or has an unusual presentation, a nearby emergency clinic may be able to help. Many emergency clinicians discuss cases over the phone and can provide discussion on potential referral, which medications to administer, and which diagnostics to perform prior to transfer, as well as a cost estimate for the client.
Having an existing relationship with a local emergency clinic can help set expectations for how emergency clinicians prefer to communicate and receive records for transfers and how to set client expectations. Taking time to reach out to local emergency clinics and establish relationships can be beneficial.
4. Prioritize Proactive Client Communication
Patients with an emergent presentation often require transfer to a 24-hour facility after stabilization. It is important to set client expectations early and ensure referral for further care and hospitalization is feasible. Clients should be kept informed throughout the visit about the patient’s stability, prognosis, and potential outcomes with each treatment option. If referral is required, clients should be prepared for what to expect regarding wait times (if the patient is stable), cost, next steps, and possible outcomes.
5. Set Expectations for Clients With Routine Appointments
Team members should inform clients waiting for routine appointments that the team is managing an emergency. If the emergency causes significant scheduling delays, appointments may need to be rescheduled or clients advised prior to the appointment there is an extended wait time and given an option to reschedule. Proactive communication can help mitigate complaints, as most clients are understanding when they are kept informed and not left to wait.
Conclusion
Stabilization in general practice can be the difference between life or death—especially in rural settings where emergency clinics are scarce. Although these cases can be stressful, they can also be extremely rewarding. Online continuing education on emergency medicine is available.