Consultation skills - Dealing with medical emergencies

Preparation is essential if you are to tackle any eventuality in the surgery, says Dr Lizzie Croton.

One of the skills of general practice is to know when the person coming through the door is well or ill. Sometimes this is obvious, as when you see the sweaty, grey gentleman with chest pain.

We all get caught out by less obvious emergency presentations. I remember the young adult with a hoarse throat who happened to have epiglottitis. These cases don't happen often but can be frightening when they do. But there are ways to make things easier for yourself.

First things first
First, look carefully at the patient - do they look well or ill? I used to assume that everyone with chest pain would call 999. Not true: many people still wait to see their GP.

If the person looks unwell, is in severe pain or is breathing with difficulty, move them to the area in the surgery where emergencies are dealt with. Don't try to assess them in your room.

An emergency is difficult to manage on your own. Once you realise something isn't right call for help from other staff.

Give all acutely unwell patients high-flow oxygen while you are moving and assessing them. Should the patient become unconscious commence basic life support or advanced life support, if you have the equipment and skills, and call for paramedic assistance.

History and examination
In patients where it is less obvious what the problem is, minimise the risk of missing an emergency by taking a thorough history and performing a good examination. If you are still not sure what the problem is, err on the side of caution and think of the worst-case scenario. Could this be a leaking aneurysm in an elderly gentleman with abdominal pain? Refer to the hospital if you are not sure.

In patients who are obviously unwell, speed is of the essence. If the patient is unconscious, commence basic life support. In conscious patients, take a brief history and find out what the problem is. Follow this with an appropriate examination and monitoring.

What should you do next?
Once you have a fair idea of what might be going on, you need to decide what you are going to do next. In most cases, transport to hospital is the best option once the patient is stable.

In some cases, for example anaphylaxis, you will need to administer drugs. With a seizure that has resolved you may just want to insert a cannula. Pain relief is important if the patient is in severe pain.

Always ring the hospital and refer the patient formally before sending anyone to it, so that staff can be prepared. Also keep any relatives with the patient informed as to what is happening.

Once the paramedic crew arrive, give them a brief resume of the patient's history and what you have done for them. In particular, make sure that they know what drugs, if any, have been given and the times of administration. Let them know if the patient has any allergies. Always respect their opinions because their knowledge of emergency treatment is generally excellent.

If you have time, write a referral letter to the relevant department, letting them know the patient's history, and give this to the paramedics. If not, write the letter as soon as possible and fax it to the hospital.

Once the patient has departed for the hospital, write up their notes.

Debrief with colleagues following any emergency and discuss what went well and what could be improved to enable lessons to be learnt for the future.

Be prepared
Don't wait for an emergency to find out where the oxygen is. Take time now to become better prepared for any eventuality.

Familiarise yourself with the emergency equipment in the surgery. If it is locked, who has the key? If you have a defibrillator, don't assume that someone else will know how to work it. As a registrar, other GPs may look to you for advice, because you did hospital jobs more recently. If you are unsure, approach your ambulance service for training.

CPR algorithms have changed recently, so make sure you are familiar with them.

Although not a requirement for a GP, it is useful to keep your advanced life support course up to date. Many hospitals run one-day refresher courses.

Keep doses of adrenaline/anaphylaxis drugs handy for adults and children.

Make yourself available to practice staff when on-call and attend requests for a doctor promptly, bearing in mind that you may have to leave surgery and patients waiting.

Be aware that the methods for emergency referrals differ between hospitals. Find out where different conditions should be referred. For example, does a patient with chest pain go to casualty or to the medical assessment unit? This will save time.

Take chest pain seriously and always make time to assess the patient and the ECG. Recognise the limits of your competence and call for help from the ambulance service early once you realise that you need them.

If you are called out of the surgery, always keep yourself safe if attending patients' homes and tell someone where you are.

Dr Croton is a salaried GP in Birmingham

Learning points
How best to deal with emergencies:

1. Be prepared so that when an emergency happens you know how to handle it. Make sure you know where the emergency equipment is kept and that you know how to use it.

2. Give all acutely unwell patients high-flow oxygen while moving and assessing them. If a patient becomes unconscious commence life support and call for paramedic assistance.

3. In most cases, transport to hospital is the best option when the patient is stable. Ring the hospital to refer the patient. Keep any relatives with the patient informed as to what is happening.

4. Give the ambulance crew a brief patient history and what you have done. Tell them if any drugs have been given and if the patient has any allergies.

5. Debrief with colleagues after an emergency and discuss what went well and what could be improved to enable lessons to be learnt for the future.

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