EMERGENCIES IN GENERAL PRACTICE Stephen Newell 10/01
What is an emergency? A highly volatile, dangerous situation requiring immediate remedial action. An unexpected situation or sudden occurrence of a serious and urgent nature that demands immediate action. “A physician can sometimes parry the scythe of death, but has no power over the sand in the hourglass”. Hester Piozzi, Mrs. Thrale (1741-1821). English writer.
Nature of GP emergencies • How does it differ from, say, A & E work? • time pressures • social / psychological / physical problems • the primary care physician may be able • to provide complete solution • Who decides it is an emergency? • patient / relatives / neighbours / health professionals • Surgery emergencies • emergencies at the surgery • what would make you go out during surgery? • Home visit emergencies - should all requests for visits - even daytime - be screened by a doctor? • Out-of-hours emergencies
Area A: Management of presenting problems Area B: Modification of help-seeking behaviour Area C: Management of continuing problems Area D: Opportunistic health promotion What about the Stott & Davis model? (Stott & Davies, The Exceptional Potential In Each Primary Care Consultation, JRCGP, 1979, 29, 201-205) - especially modification of help-seeking behaviour
Cardiovascular emergencies “Collapse“ - often vasovagal attack Chest pain LVF Stroke - how much is stroke an emergency? - role of admission e.g. CT scan prior to anticoagulation Haemorrhage Anaphylaxis Diagnosis - should you carry an ECG machine? Treatment Time of response Thrombolytic therapy (Should GPs give thrombolytic therapy? DTB, 32, 9, 5/9/94) CPR training now prerequisite for taking MRCGP Why not just dial 999? - referral without assessment can lead to breach of terms of service if there is subsequently a problem
Respiratory emergencies SOB Asthma - steroids - nebulisers - pros & cons - oxygen Airway obstruction - epiglottitis Surgical emergencies Abdominal pain - common - acute abdomen is rare Torsion Strangulation Bleeding - also haematemesis / malaena Injury
Orthopaedic emergencies What is the correct assessment of bony injuries in practice? Diabetic emergencies Hyperglycaemia - depends on clinical situation - do all patients with all grades of DKA need admission? Hypoglycaemia - what is the correct management? - who should provide it? Gynaecological emergencies Pelvic pain Abdominal pain Bleeding Ectopic pregnancy
Obstetric emergencies Unexpected delivery at home - ergometrine? - equipment for iv infusion? PPH What if you undertake GP deliveries? What is your responsibility if you do not? Contraception emergencies Requests for emergency contraception
Dermatological emergencies Rashes Injury / lacerations Burns, scalds, sunburn Insect bites & stings Neurological emergencies Fitting Faints Collapse Headache Vertigo Eyes / ENT Otalgia Visual loss Glaucoma
Social / psychiatric emergencies “Something must be done“ - often coping with (psycho)geriatric patients - may be provoked by visit / 'phone call from relatives - relatives 'phoning from their home - typically at a weekend Somatisers / neurotic symptoms - somatic symptoms creating demand - abdominal pain - those who cannot cope with viral illnesses Overdose / other self-harm True psychiatric emergencies - Mental Health Act - possible harm to themselves or others - social worker / nearest relative Death in the home - practicalities of what to do - helping the bereaved - what is the right management? - when should Coroner's Officer be involved?
Paediatric emergencies Earache - what about middle of the night call? Asthma Upper airways obstruction / epiglottitis Meningism Abdominal pain Ingestion of poisons Intussussception NAI Urinary tract emergencies UTI / pyelonephritis - do you carry antibiotics? analgesia? referral? Ureteric colic - analgesia? referral? what about starting investigations in the middle of the night?
Tongue depressors Examination torch Stethoscope Ophthalmoscope Auriscope Examination gloves & gel Blood sugar testing equipment Urine dipsticks (Multistix) Sphygmomanometer Patella hammer Cusco's speculum? Tape measure Thermometer : normal reading? low reading? Fluorets Specimen pots - blood / urine / stool Syringes, needles phlebotomy tourniquet?
Local anaesthetic Sutures / Steristrips / tissue glue Stitch cutter / scalpel blade Dressings / scissors Airway Working transport Bleep / mode of contact - what message should go on the answering machine? Answering facility - mobile 'phone / 'phonecard Pens - more than one which works Torch Map of locality Visit log / diary / something to keep record of what you do Something to keep clinical notes on List of 'phone nos. of nurses, hospital, social services, etc
Prescription pad Medical certificates Blood / urine test forms Headed notepaper / envelopes Mental Health Act forms “Doctor visited" notes Nebuliser? ECG machine? Green flashing Doctor light for the car? Urinary catheter? Does it make a difference where you practice? - rural vs. urban Good physical & mental health morale esp. over out-of-hours work isolation when you are on call - different from hospital work Up to date medical defence subscription Awareness of medicolegal responsibilities
What drugs should GPs have?TASK 2 1: oral analgesics what about paracetamol? should GPs carry Calpol? Co-proxamol or equivalent are they really any more effective than PCM? how medicalising is it to issue such drugs? does it matter? oral opiate? sublingual buprenorphine? controlled drug regulations aspirin - not for analgesia but for chest pain anti-emetic / anti-vertigo antibiotics What drugs should GPs have available? TASK 2
1: oral Analgesics: what about paracetamol? should GPs carry Calpol? Co-proxamol or equivalent? are they really any more effective than PCM? how medicalising is it to issue such drugs? does it matter? oral opiate? sublingual buprenorphine? controlled drug regulations aspirin - not for analgesia but for chest pain Anti-emetic / anti-vertigo Antibiotics: starter packs of ampicillin / amoxycillin? starter packs of erythromycin? adult & paediatric doses treatment for urinary infection? any others? Others: sedatives / hypnotic prednisolone oral diuretic? glucose tablets? oral rehydration sachets? anti-convulsants? digoxin?
2: rectal Analgesics: NSAID - diclofenac suppository paracetamol Anticonvulsants: diazepam - Stesolid rectal tubes - what about the temperature in the bag? any others? Anti-emetic: prochlorperazine supp. Anything else?
3: aerosol GTN spray Beta-agonist inhaler 4: injectable Diuretic: frusemide Antiemetic:metoclopramide? prochlorperazine? Analgesia: opiate +/- antiemetic Glucose / glucagon: are both needed? Anticonvulconvulsant: diazepam / Diazemuls anything else?
4: injectable (contd.) Tranquilisers: diazepam / Diazemuls major tranquiliser NSAID: e.g. diclofenac Steroid: hydrocortisone Antibiotics: benzylpenicillin powder ( & water for injection) anything else? Adrenaline Atropine Ergometrine Naloxone?
Telephones / message taking Who does it? - receptionist? doctor's partner answering service? Primary Care Centre? What do messages need to convey? - patient's details problem urgency telephone number Records / notes What should be recorded? - time / day / place? history & examination - positive & negative features What notes are used? - use record cards or paper? computer? timesaver slips? collect from surgery? Referral to hospital & EBS
Patient's views What are the issues for patients? simple means of contacting doctor simple means of seeing doctor speed of response explanation accurate diagnosis accurate & effective treatment Other stakeholders? Government view?
Medico-legal issues Doctor now decides on need to visit - is telephone advice sufficient? Need to put yourself in position to make diagnosis Records - what to write and where? Responsibilities if drugs are given - dispensing liability A high proportion of complaints come after "emergencies" - have to be sure that "all necessary treatment of the type usually provided by GPs" has been provided Confidentiality when relatives are around – chaperones? Referral - what if people are sent home by hospital? Regulations GPs are obliged to arrange provision of 24 hour care at present themselves, partners or deputies? Primary Care Centres? NHS Direct Good idea? Bad idea? Who is this for? Protocols More work or less for GPs? Legal issues
Deputising Pros GP does not have to answer the 'phone GP's family is not disturbed by 'phone GP's staff do not have to answer 'phone GP does not have to undertake the visits GP can sleep before the work of the next day patients will obtain visits without "haggling" Consresponsibility for provision and quality remains with GP drugs prescribed spend GP's drug budget possible "inappropriate" prescribing and medicalisation GP has to pay for the deputising service Primary Care Centres / Co-ops Local GPs No shareholders to consider What protocols are being used? Cheaper?
References Emergencies in General Practice: Moulds et al. MTP Press. First Aid Manual. The NHS Direct Healthcare Guide. One of the Trainee Guides - A Guide To General Practice - Oxford publications. - A Guide For Trainees In General Practice: Fry et al. On-Call: Knox. Oxford Medical Press. Resuscitation guidelines (BMJ).
Some Scenarios TASK 3
1: You are in the middle of a busy morning surgery when an urgent telephone call is put through to you. A 65 year old woman whom you know well tells you that she has had crushing central chest pain for about an hour. She is a smoker and has hypertension. You still have 16 patients to see in the surgery and all doctors in the surgery have a similar number to see. You are the duty doctor. It is 09.50 hours. What are the management options (with benefits and disadvantages of each option identified)? 2: It is 2 a.m. You are on-call when a 'phone call comes through to you from your answering service. The patient is a well-known insulin-dependent diabetic, a man aged 55. His wife says he is unconscious in a "hypo". What are your management options?
3: It is 2 a.m. Tuesday morning. You are on-call. A call comes through from your answering service. The patient is a child aged 8. She has earache of 4 hours duration. Describe your management. What if it were 2 a.m. Sunday morning? 4: It is 2 p.m. on a weekday. A call comes from your receptionist that a woman is requesting a house-call for her 8-year old child who has earache. You have a surgery booked for 4 p.m. Describe your management.
5: It is 3 a.m. Your answering service call you about a child of 8 with croup. What is your management of this situation? 6: It is 2 p.m. on Saturday afternoon. The mother of a male patient aged 22 'phones with the story that he has been "depressed" for several days and today has violently smashed up his room at home. What reactions might you have to this situation? Describe your management. 7: It is 2 p.m. on Saturday. Your answering service reports that an airline company wants your advice because they have had to turn a plane back after one of your patients became unwell after take-off. What would your management be?