How to prepare your office for medical emergencies

Issue: February 2000

ByStephen Winbery, MD PhD

ByKari Blaho, PhD

This is the first of a series of three articles focusing on the prevention and management of common urgencies and emergencies that may occur in an optometric setting. Office practices generally have a very low rate of true medical emergencies, and rarely does death occur from iatrogenic complications.

However, systemic medications, invasive procedures and chronic disease increase the potential for emergencies. Emergency preparedness will differ depending on practice setting, time and distance from emergency facilities, types of medications used, types of procedures performed and staff training.

Prevention, preparedness

The most effective strategy for managing emergencies outside of a hospital involves prevention and preparedness. Essential to both is the ability to anticipate and recognize potential and actual emergencies. Simultaneous with prevention, office practices should be prepared to treat the worst-case scenario.

In general, an emergency is any condition or clinical event that will result in loss of life or significant morbidity such as the loss of a limb, loss of an organ system function or loss of sight within 48 hours. Urgency is defined as a condition or clinical event that may result in significant morbidity at a later time (greater than 48 hours) or may progress to an emergency.

Certainly, there is some ambiguity between urgency and emergency, but most situations can be resolved with common sense and consultation depending on available options. Each office practice should have a management plan for medical emergencies, especially those resulting from iatrogenic complications of medications and procedures.

In general, emergencies should be referred immediately by whatever means possible to a qualified acute care facility, usually a hospital emergency department. While emergency medical services (EMS) is not for all patient transport and referral, an office practice should have its own set of guidelines for when and how to activate EMS.

Urgencies should be referred by direct communication between the referring and accepting practitioners with involvement and agreement from the patient and relevant family members. The obligation for training in an office setting is to recognize and promptly stabilize consequences resulting from therapy or diagnostic procedures.

Levels of training

The highest level of training recommended is certification as an advanced cardiac life support (ACLS) provider by the American Heart Association (AHA). This training is available through a combination of self-study and 8 to 16 hours of on-site training and testing.

Basic life support (BLS) is a prerequisite to ACLS and includes basic cardiopulmonary resuscitation (CPR). The AHA recommends that all able adults, not just medical professionals, be trained in BLS.

The BLS course is benign and provides the student with necessary skills to intervene in the majority of situations where a life can be saved by quick action. The essential elements to this type of training are assessment of the patient, airway management and support of circulation until more advanced help arrives.

Emergency transportation

Most populated areas in the United States are located several minutes (5 to 15) from an acute care center capable of resuscitation for cardiopulmonary arrest. However, there are still many remote locations with transport times greater than 30 minutes.

Most ambulance services are able to render ACLS on the scene. When an emergency situation occurs, it is important that the EMS is activated early and that the caller be very clear concerning the type of emergency and the need for a unit capable of resuscitation. For remote areas, the practitioner should be prepared to continue resuscitation for at least as long as it takes for help to arrive.

Emergency preparedness demands a detailed emergency plan and introduction to transport services and receiving providers (usually hospitals) before they are needed. Even when the EMS is activated, it is a common courtesy and is essential to continuity of care that the receiving practitioner be notified as soon as possible. An emergency department can initiate several actions long before the patient arrives if it has advance notice concerning the nature of the emergency.

Urgent referrals should be achieved through direct communication with the doctor or designated staff. Whenever possible, the patient or his or her representative should fully understand and agree to the plan for emergent and urgent referral. Any helpful information should be sent or faxed to the receiving care provider. However, copying records should never delay transportation and emergent referral. Future follow-up is appropriate and generally appreciated.

Medical-legal considerations

A health care provider is expected to manage iatrogenic complications, including immediate resuscitative efforts, stabilization and prompt referral. Most emergencies are predictable and preventable. History, brief exam and vital signs should appropriately screen patients before medications are given or procedures are performed. Rare reactions to medication and some exacerbation of chronic disease are not predictable.

The obligation of the practitioner is to document the indications for medication given or procedures performed. Once an indicated procedure is undertaken, the provider should have appropriate training, skill and knowledge. Indications, risks and benefits should be discussed with the patient or his or her designee.

On the occasion that an accidental emergency occurs in front of a medical practitioner, the “Good Samaritan” statutes apply. Under these statutes, a provider has no liability for rendering the best care that he or she is able. The conditions are that there is an accident (not iatrogenic or because of negligence) and that the care provider does not charge for services rendered.

General Recommendations for Emergency Training
Office Practice	Examples of Emergencies	Level of Training	Suggested Equipment
Topical medications only	Local allergic reactions, elevated blood pressure	BLS/CPR	Barrier bag mask
Oral medications only	Systemic, but rarely morbid allergic knowledge of reactions, nausea and vomiting, orthostasis, choking	BLS/CPR, drug’s untoward effects	Barrier bag mask, IV needles, fluid
Parenteral medications	Anaphylactic shock, respiratory failure, cardiovascular collapse	ACLS, maintain equipment^*	Monitors, airway kit, IV needles and fluid, ACLS drugs^**
Invasive procedures (IV contrast local and general anesthesia)	Anaphylactic shock, respiratory failure, cardiovascular collapse	ACLS, maintain equipment^*	Monitors, airway kit, IV needles and l fluid, ACLS drugs^**
^*Maintaining equipment is optional if it can be brought from another area within 5 minutes.
^**Contact your local fire department about purchasing an ACLS kit with medications. These kits require routine testing, battery and drug replacement.

For Your Information:

Stephen Winbery, MD, PhD, and Kari Blaho, PhD, may be reached at the Emergency Medicine Department at the University of Tennessee at Memphis, 842 Jefferson Ave., A645, Memphis, TN 38103; (901) 545-8699; fax: (901) 545-8996. Neither Dr. Blaho nor Dr. Winbery has a direct financial interest in the products mentioned in this article, nor is either a paid consultant for any companies mentioned.

The American Heart Association can be contacted at National Center, 7272 Greenville, Ave., Dallas, TX 75231; Web site: www.americanheart.org.

Reference:

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