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 emergenciesemergencies at the surgerywhat 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 B:  Modification of help-seeking behaviour 

Area A:  Management of presenting problems  Area C:  Management of continuing problems  

Area D:  Opportunistic health promotion

 

(Stott & Davies, The Exceptional Potential In Each Primary Care Consultation, JRCGP, 1979, 29, 201-205) - especially modification of help-seeking behaviour

What about the Stott & Davis model?

Cardiovascular emergencies

“Collapse“ - often vasovagal attackChest painLVFStroke - how much is stroke an emergency?

- role of admission e.g. CT scan prior to anticoagulationHaemorrhageAnaphylaxis

  Diagnosis - should you carry an ECG machine?

Treatment Time of responseThrombolytic therapy

(Should GPs give thrombolytic therapy? DTB, 32, 9, 5/9/94)CPR training now prerequisite for taking MRCGPWhy not just dial 999?

- referral without assessment can lead to breach of terms of service if there is subsequently a problem

Respiratory emergencies

SOBAsthma - steroids

- nebulisers - pros & cons- oxygen

Airway obstruction- epiglottitis

 

Surgical emergencies

Abdominal pain - common- acute abdomen is rare

TorsionStrangulationBleeding - also haematemesis / malaenaInjury

 

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 painAbdominal painBleedingEctopic 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 emergenciesRashesInjury / lacerationsBurns, scalds, sunburnInsect bites & stings

  Neurological emergenciesFittingFaintsCollapseHeadacheVertigo

 

Eyes / ENTOtalgia

Visual lossGlaucoma

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?AsthmaUpper airways obstruction / epiglottitisMeningismAbdominal painIngestion of poisonsIntussussceptionNAI

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?

 

What equipment should GPs have available?

TASK 1

Tongue depressorsExamination torchStethoscopeOphthalmoscopeAuriscopeExamination gloves & gel

Blood sugar testing equipment Urine dipsticks (Multistix)SphygmomanometerPatella hammerCusco's speculum?

Tape measureThermometer : normal reading?

low reading?

FluoretsSpecimen pots - blood / urine / stoolSyringes, needles

phlebotomy tourniquet?

Local anaestheticSutures / Steristrips / tissue glueStitch cutter / scalpel bladeDressings / scissors

Airway

Working transportBleep / mode of contact - what message should go on the answering

machine?Answering facility - mobile 'phone / 'phonecard Pens - more than one which worksTorchMap of locality

 Visit log / diary / something to keep record of what you doSomething to keep clinical notes onList of 'phone nos. of nurses, hospital, social services, etc

 

 

Prescription padMedical certificatesBlood / urine test formsHeaded notepaper / envelopesMental 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 healthmorale esp. over out-of-hours workisolation when you are on call - different from hospital work

 

Up to date medical defence subscriptionAwareness of medicolegal responsibilities

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 regulationsaspirin - not for analgesia but for chest pain

 

Anti-emetic / anti-vertigo 

Antibiotics: starter packs of ampicillin / amoxycillin?starter packs of erythromycin? adult & paediatric dosestreatment for urinary infection?any others?

 

Others: sedatives / hypnoticprednisoloneoral diuretic?glucose tablets?oral rehydration sachets?anti-convulsants?digoxin?

2: rectal

Analgesics: NSAID - diclofenac suppositoryparacetamol

Anticonvulsants: diazepam - Stesolid rectal tubes - what about the temperature in the bag?any others?

 Anti-emetic: prochlorperazine supp. Anything else?

3: aerosol

GTN sprayBeta-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 / Diazemulsmajor 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 partneranswering service?Primary Care Centre?

 What do messages need to convey? - patient's detailsproblemurgencytelephone 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 doctorsimple means of seeing doctorspeed of responseexplanationaccurate diagnosisaccurate & 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 diagnosisRecords - what to write and where?Responsibilities if drugs are given - dispensing liabilityA high proportion of complaints come after "emergencies" - have to be sure that "all necessary treatment of the type usually provided by GPs" has been providedConfidentiality 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 presentthemselves, partners or deputies?Primary Care Centres?

 

NHS Direct

Good idea? Bad idea? Who is this for?ProtocolsMore work or less for GPs?Legal issues

Deputising

Pros GP does not have to answer the 'phoneGP's family is not disturbed by 'phoneGP's staff do not have to answer 'phoneGP does not have to undertake the visitsGP can sleep before the work of the next day patients will obtain visits without "haggling"

 

Cons responsibility for provision and quality remains with GPdrugs prescribed spend GP's drug budgetpossible "inappropriate" prescribing and medicalisationGP has to pay for the deputising service

 

Primary Care Centres / Co-ops

Local GPsNo 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?