How Common Are Office-based Emergencies?

Robert Dachs, MD, FAAFP, gave a very lively and entertaining discussion on office-based emergencies for the family physician. With standing room only, he reviewed some of the most common emergencies that a physician might encounter during a regular patient office visit.

Dachs started off saying, “How common are office emergencies? We really don’t know.” The problem is that studies have been conducted, but are really retrospective. One physician might define an emergency differently from another, so how can you accurately quantify the number of office emergencies? There was an article in the December 2000 issue of Pediatrics, which evaluated the number of emergencies in three pediatrician offices. Heath et al. went into one office and learned that each of the seven people who they spoke with said a different number when asked about office emergencies. To test the accuracy of the numbers, 38 pediatric practices in Vermont participated in the study and were given a crash cart and if it was used, it would be called an emergency. After one year, the crash carts were only used a total of 28 times out of the 38 practices. These results demonstrate that Dachs’ statement is pretty accurate when asked to cite a specific number of office emergencies.

Because he was frustrated not having any data about office emergencies, Dachs worked with an organization to obtain some good data. In the January 2007 issue of the Journal of Urgent Care Medicine, Dachs published a study where he defined an emergency as a 911 call from a family physician’s office and evaluated the number of 911 calls that were made at 16 FP offices and six urgent care centers in 2002-2003. There were 706 calls where chest pain and respiratory problems were the most common aliments. If you treat more children, the number one problem is respiratory; if you treat more adults, the number one problem is chest pain, and sometimes shortness of breath (especially for the elderly). It is important to note that an overwhelming majority of office emergencies in pediatrics is respiratory—three-quarters. Dachs cautions physicians who treat a lot of children to be prepared for such instances.

Cardiac arrest/Chest pain

The worst case scenario is cardiac arrest which occurs approximately 1% of the time. Dachs did present some interesting data that showed family physician and urgent care offices have the same rate of cardiac arrests as internal medicine and cardiology offices. When he asked the audience how many people experienced cardiac arrest in their practice, Dachs said, “Doesn’t it really ruin the day?” It was strange to hear him say that he loves hearing the stories because they’re chaotic because cardiac arrest is uncommon. When a patient has cardiac arrest, it’s important that physicians remember their ABCDs (airway/breathing/circulation/defibrillator).

1. Open Airway
2. Make sure you have enough oxygen in your office and to have big and small bag-valve masks for pediatric patients. Do you need intubating materials? The Advanced Cardiac Life Support recommends this, but it’s not necessary; just bag and call 911. Dachs explained that bagging a patient is just as good as intubating. Besides, if a family physician hasn’t intubated in awhile he/she will be a little rusty, so it might be a good idea not to. There was one physician who raised her hand after Dache asked if anyone tried to intubate. She said, “Yes. I nailed it,” upon receiving a round of applause. Should a physician experience an out of the hospital arrest, Dache stressed the key phrase: “Push hard, push fast,” and avoid interruptions when performing chest compressions. He said not to worry about breaking ribs; if it saves a patient’s life, he/she won’t care.
3. Ensure you have the ability to insert large bore IVs and to use isotonic saline, which is the best to use.
4. Using either a defibrillator or automated external defibrillator (AED) will be successful. When consider what type to buy, Dachs recommends buying an older defibrillator from a hospital; new physicians might want to consider buying an AED at www.aedsuperstore.com.

When considering what medication to use during cardiac arrest—epinephrine or vasopressin—it doesn’t really matter. In 2000, ACLS was pushing vasopressin, but in 2004 and 2005 ACLS says it doesn’t matter and that either or will be fine. Dachs said that either lidocaine or amiodarone should be available on the code cart. However, the ACLS has found no evidence that antiarrhythmic medicine works.

There were some other emergencies that Dachs touched on including:

Diabetic emergencies — Hopefully a family physician has a glucometer. It’s also a good opportunity to use glucagon, especially in patients experiencing hypoglycemia who could get combative. Glucagon works in about 5-10 minutes and can really get a physician out of a bind.

Seizures — When a patient has a seizure, the office gets chaotic, similar to a cardiac arrest. The best way to stop seizures is using benzodiazepines. It doesn’t matter how a physician does it (IV/rectal/etc), he/she needs to get it into the patient any means necessary. What’s interesting is that most times a patient will stop seizing before the physician can administer the drugs. Dachs also cautioned physicians not to confuse seizures with convulsive syncope. There are 12% of people who pass-out and have a seizure that don’t need to be sent to the ER.

Acute asthma — If a patient is wheezing a physician should start them on a nebulizer at once. There are some physicians who might say that a patient is just a little jittery and will want to wait five minutes—Dachs says, “Just give them the drug.”

Chronic heart failure — Physicians should be aggressive with nitrates to turn off the preload and consider administering an ACE inhibitor. If a patient has elevated blood pressure, Dachs said that some residents will send the patients to the ER, which drives him crazy. He cited the rumor that elevated blood pressure produces a headache. According to the International Headache Society, this is not true.

Pediatric vomiting — Should a child start vomiting in a physician’s practice, Dachs recommends that he/she should administer oral ondansetron—an oral dissolving tablet. He acknowledges that it is relatively expensive, but that it’s better than connecting the child to an IV in the ER.

Simply put, family physicians should be prepared when all hell breaks loose if and when an office-based emergency occurs, and to create an exit strategy to hopefully keep the chaos at bay.