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Acute Medicine

Know your emergencies

The curriculum for General Practice is massive.  It’s almost impossible to cover in an 18 month GP placement.   You will have been told by others how the most important thing is that you practice SAFE medicine and not put patients at medical risk.  But how do you do this when you’re starting off?  You cannot possibly know everything all in one go.   

A way forwards is to know your GP emergencies.  If I asked you to write a book on all medical presentations that can come to General Practice – that book could go on and on and on!   However, if I asked you to write a book on GP medical emergencies, you could probably do it in less than 25 pages!   And at the end of the day, the risk of harm to patients is higher if you don’t manage emergencies optimally than in the less urgent routine presentations.   So… know your emergencies.  Make it one of the first things you do.   The downloadable resources above should help pave the way.

Be Prepared For 5 Common Medical Emergencies…

  1. Asthma Attacks
  2. Seizures: not all seizures require intervention, and most will progress through tonic/clonic into post-ictal and then recovery. There are cases, such as status epilepticus, where a benzodiazepine intervention is appropriate as it is the fastest way to end a seizure. High-flow oxygen should also be administered after the tonic/clonic phase to expedite recovery.
  3. Anaphylaxis: even a minor allergic reaction can sometimes become severe. Adrenaline auto-injectors should be available in every GP surgery.  Be careful – make sure you inject the right way round (some docs have been known to prick their own thumbs thinking the protected need end is the button!).
  4. Cardiac Arrest: it’s critical to respond immediately before the aid team arrives. It is important to have an Automated External Defibrillator (AED) and be trained in its use.
  5. Hypoglycemia: there should be fast acting glucose available in the surgery.
But know how to recognise and treat others too 
Like meningitis, epiglottitis, leaking AAA, ectopic pregnancy and so on.    Complete list available in the Downloadable resources section (see resource called EmAQ).  

It starts with knowing where the emergency equipment is

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.  If you are not shown in induction where everything is – ASK to be shown… ASAP.   The nursing staff are good at going through it all with you.  

Make sure you know your drug doses or have a quick handy easy to get hold of reference guide.   Know you anaphylaxis protocol. Know your doses of benzylpen and alternatives for suspected meningitis.

And also make sure you have your own set of emergency drugs for your doctor’s bag (for instance, in case you need them on home visits etc).

Know your BLS and Defib protocol

Go through and remind yourself of the BLS protocol.  Then try and book onto a BLS course – most GP training schemes will have one scheduled.  Alternatively, ask your GP practice when they are doing their next annual routine one.  Did you know all GPs have to do mandatory BLS training every year?  If your practice’s next BLS training date isn’t for a while – ask around neighbouring GP practices and find the next available and seek permission to attend.   Different GP practices do their annual updates at different times throughout the year.

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

Is the patient unwell or not?

A basic approach is to simply work out whether the patient is unwell or not.  If they are, then ask yourself how unwell you think they are.  Are they a little off colour, severely off colour or somewhere inbetween?  Sometimes it is obvious just by looking at them (the young gentleman very short of breath, can hardly speak).   Other times, it becomes more clear on good history taking and examination.  

Take a good history

A good accurate history is dependent on you truly listening to th story and slowing down to clarify things when parts of the story are either unclear or don’t make sense.   I had a patient who came in with a few niggles in his chest that he said he wasn’t worried about but thought he would just get them checked before he was flying off to Pakistan.  He kept brushing it off as nothing, and that his wife was just being fussy.  But I made him slow down and tell me the story very carefully.  He had been getting chest pains 5-6 times a day for the last 5 days (crushing, exertional).   I sent him to A&E for unstable angina – turned out he had an MI.

Examination - always do the vitals

The vital signs will always come to your rescue, especially when you’re a bit baffled as to what is going on.   The vital signs are..

  1. respiration rate
  2. oxygen saturation
  3. systolic blood pressure
  4. pulse rate
  5. level of consciousness or new confusion*
  6. temperature.
  7. Capillary refill
If these go off, then something is seriously going off.   Use the NEWS-2 charts (see Weblinks section) to work out whether these vitals are giving an early indication of a medical emergency.   I was once called to a nursing home about a patient who just “wasn’t himself”.    He was a bit drowsy, and I could not get much of a history from him or the nursing staff.  They said “he doesn’t speak much anyway”.   But his BP was very down and his pulse rate high.  He looked pale and clammy and did not report any pain anywhere.  Because of his low BP, high pulse, confusion – I admitted him.   It turned out he had a leaking AAA.   See how vitals can help you out?

Spotted a mistake?  Have a top tip to help others?  Leave a comment below…
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