- September 2004 -- FP Report

•Resident & Student News•

Common office emergencies may demand creativity

In a role-playing exercise, workshop facilitator Brenda O'Hara, M.D., waves an ammonia ampule under the nose of a "patient" who has lost consciousness in the waiting room.

BY CINDY BORGMEYER

All images of the popular TV show ER aside, the concept of triaging patients originated on the battlefields of the Civil War. It grew out of a need to conserve resources by assessing which wounded soldiers could benefit from treatment and which would likely perish despite the most valiant medical efforts.

In a primary care setting, triage determines who can be safely treated in the office and who should be transported to an emergency care facility. That's what Brenda O'Hara, M.D., told participants during a July 29 National Conference workshop.

O'Hara directs the Fort Wayne (Indiana) Medical Education Program, which offers family medicine precepting opportunities for medical students at Indiana University, Fort Wayne. She laid out the basics of making in-office triage decisions:

What is the emergency? When did it start?
Who is the patient? What is his or her medical history?
What do the patient's vital signs tell you about his or her status?
What treatments have already been administered?
Who is with the patient? How did the patient get to your office?

"A lot of things people get very excited about aren't true emergencies," O'Hara cautioned. "A person with a laceration -- particularly a head wound -- may be the bloodiest, most ghastly thing on earth. Yet nine times out of 10, if you put a little pressure on it, it's not an emergency, and you can sew it up right in your office.

"On the other hand, there are some things that may not look at first blush like a true emergency, but if you keep those people in your office, they could begin to deteriorate very quickly."

O'Hara cited a cardinal rule when dealing with others' emergencies: First, check your own pulse.

"It's hard not to get excited," she said, "but one of the best things you learn as a physician is that despite how scared you are and how bad it looks, you're the one in charge, and you have to keep calm."

Other emergency dos and don'ts O'Hara recounted:

Assess the patient's condition yourself; don't rely on others' reports.
Look at the overall setting -- an unconscious man in the waiting area may be far different from an unconscious man in the blood-drawing lab.
It may be best to transfer one patient to avoid problems for others.

"Someone who's vomiting, for instance," O'Hara said. "If I can't get it under control quickly, it's best to get them out of the office -- otherwise, you'll have two or three more people who'll start vomiting, too."

If an ambulance is called, notify family members about the situation and give the emergency room a heads-up.

As for what to do in the meantime, there's no substitute for having the right equipment on hand, O'Hara advised. Here's a partial list of what the well-dressed FP's office is wearing this season:

supplemental oxygen;
intubation and bag/mask/valve set-ups, both adult- and child-sized;
basic resuscitation medications, such as epinephrine and adrenaline;
a defibrillator; and
IV supplies (worry about starting an IV only after all other emergent needs have been met, she advised).

Finally, think creatively, O'Hara said. She recalled one instance involving an elderly woman who walked into the office in obvious distress. "I knew she was having an allergic reaction," O'Hara said. "She was real hypotonic; she had a lot of rigid spasms." The woman also had absolutely no veins, O'Hara added.

"They (nursing staff) drew up some epi, and I pulled up her tongue, stuck the needle under there and injected it," she said. "I thought, 'Sublingual -- it works for nitro..' Well, it worked for her, I'm happy to say."

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