Acute Medicine - on call, home visits & OOH
Bradford VTS Clinical Resources
- by Dr Sabah Malik
- Last modified: 22nd January 2024
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DOWNLOADS
path: ACUTE MEDICINE
WEBLINKS
- Urgent & Unscheduled Care super-condensed curriculum –
what you should know (RCGP) - OSCEs in Acute Medicine (BVTS)
- General Practice Emergencies on GP Notebook
- NEWS-2 by the RCP
- The Complete Resus Guidelines by resus.org.uk
- ABCDE approach by resus.org.uk
- Anaphylaxis by resus.org.uk
- Emergency drugs for the doctor’s bag (Nigel’s Surgery, CQC)
- Doctor’s bag contents by patient.info
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Information provided on this medical website is intended for educational purposes only and may contain errors or inaccuracies. We do not assume responsibility for any actions taken based on the information presented here. Users are strongly advised to consult reliable medical sources and healthcare professionals for accurate and personalised guidance – especially with protocols, guidelines and doses.
COME AND WORK WITH ME… If you’d like to contribute or enhance this resource, simply send an email to rameshmehay@googlemail.co.uk. We welcome collaboration to improve GP training on the UK’s leading website, Bradford VTS. If you’re interested in a more active role with www.bradfordvts.co.uk (and get your name published), please feel free to reach out. We love hearing from people who want to give.
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The Basics...
On-call and OOH can be busy, and after a while, it can start taking its toll on you, especially when it is flooded with what you might consider trivial or non-urgent problems. You can end up getting irate with patients, who then get angry with you. You only need one altercation to make the whole session feel horrible, and you’ll end up taking that home with you. Then you start resenting future sessions, and that subconsciously affects the clinical care you provide. It also has a detrimental effect on patient safety – as you end up overlooking important things in a patient who superficially looks well. So, here is my positively self-affirming statements that I say just before I start my on-call and actually, it almost always works! But of course, for it to work, you have to believe in it. I will sometimes repeat some of these statements until I feel I have internalised them and made them part of me.
Ram’s Mantra: Positive Self-Affirming Statements for On-Call and OOH
- I am okay
- I am going to have a good happy day today
- I am going to be nice and kind to all patients and staff, irrespective of how they are.
- I am going to dance with patients and staff
- Today is going to be a good day
- And you know it’s going to fly by, so let’s go….
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… (CASH-A)
- 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.
- 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!).
- 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.
- Hypoglycemia: there should be fast acting glucose available in the surgery.
- Asthma Attacks
Like meningitis, epiglottitis, leaking AAA, ectopic pregnancy and so on. Complete list available in the Downloadable resources section (see resource called EmAQ).
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).
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.
A good accurate but FOCUSED 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.
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..
- respiration rate
- oxygen saturation
- systolic blood pressure
- pulse rate
- level of consciousness or new confusion*
- temperature.
- 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?
Home Visits & Care Homes
Review notes
When you’re called out for a home visit to a nursing home or care home patient, before you set off to see them, REVIEW THE MEDICAL NOTES.
- Review previous consultations pertaining to the same presenting complaint as what you are visiting for. (Use the search box)
- Check last set of entries – from other GPs, OOH, community nursing
- Discharge summaries/hospital letters
- Are there any Outstanding recalls/CDM/Blood results
- RESPECT FORM AND RESUSCITATION STATUS – are these in place? Do you need to set one up?
Before you get there… think!
- Think of all the differentials
- And the questions you need to ask to hone down the differentials
- And all the possible things that you might have to do
- Don’t think too hard. Just mull things over in your head.
E.g. called out for swollen legs
On my journey…
- Is it one leg or two?
- If one – could be DVT (think D-dimer, Wells Score), bakers cyst, cellulitis (Rx antibiotics – have they got any allergies)
- If both legs – more likely CHF (review chest, make sure not in AF, do ProBNP, may need mild diuretics)
Different people say different things. So we have provided several articles for yo to consider on the right. Discuss with your GP trainer.
One thing is for certain – you should all be give a Doctor’s Bag with all equipment and drugs in it necessary for home visits and in surgery. When you complete training, you will of course then need to provide your own.
If you have not got a doctor’s bag or there are items missing (compared with the (say) ashcroft list on the right), then again raise this with your GP trainer and Practice Manager.
- Try and issue prescriptions when you come back from surgery unless it is super urgent.
- There is less likely a chance that you will make with an electronic prescription compared to a handwritten one.
- Let the patient know you are doing this and when they can go and collect the item.
Most practices print of a Home Visit Summary Sheet for you.
This is to help you with your consultation – in case you need something like
- a list of repeats
- recent bloods
But please log into the Electronic Medical Record (EMR) for a more comprehensive review of the patient – like the last set of consultations. Don’t just rely on the printed sheet.
Please destroy any physical paperwork that has a patients information on it.
- This is your responsibility.
- Do not throw it in a bin.
- Do not leave it in your car.
- Instead, put it through the practice’s shredder (every practice has one).
- It is a serious breach of confidentiality if you leave the home visit patient summary sheet lying around! Destroy it when you are done with it by shredding (tearing it up is NOT enough).
PS Many practices now offer electronic access to patient records securely via you phone – apps like Brigid. Ask your practice! Or research it if they don’t know and help improve your practice (a leadership project perhaps?)
BEFORE YOU GO
- Use ARDENS template: care and residential home. This can help you focus.
- Review notes
- Check last entries – anything fromGP/= or community nursing teams?
- Outstanding recalls/CDM/Blood results
- Discharge summaries/hospital letters (look at the last few)
- RESPECT FORM AND RESUSCITATION STATUS – anything in place? Does it need to be?
- Look at QOF markers and Chronic Diseases
- can you review and do these? (Dementia, CVD, DM (foot check) etc)
WHEN YOU GET THERE
FIRST – acute problem
- Deal with the acute problem that they have called you out for
- Always look at vitals – P, BP, Temp, Sats
SECOND – the 9 Geriatric Giants
There are now 9 Geriatric Giants are remembered by the mnemonic MANIC MOLD
- Mobility – including balance problems, sarcopenia and falls – decide what to do if deteriorating
- Stop certain meds – like benzodiazepines or antipsychotics if unnecessary (speak with psych?)
- Trial to reduce opioid medication if pain is okay?
- Refer to pharmacy team to optimise medicines.
- Physio for sarcopenia (weak muscles)?
- Elder Abuse – including self-neglect
- Ask the patient on a 1-1 when alone “How are you doing here?”, “How are they treating you here”
- Unusual brusing?
- Look at the feet – often tells you if the patient is being looked after or not!
- Poor Nutrition –
- Look at the mouth for any oral problems – poor dentures, ulcers (beware oral cancer), thrush
- Look at the rest of body – anorexia of ageing?
- Ask about patient’s oral intake
- Ask for the patient’s weight (MUST score if falling).
- Incontinence
- Ask if they are incontinent. All the time or some of the time? Any increasing confusion with it?
- Are they drinking enough? (ask about oral intake)
- Is there a strong smell indicating UTI?
- Dipstick urine/Send off for MSSU
- Confusion or impaired Cognition
- Is it dementia or delerium?
- Dementia – do a memory assessment score.
- Sometimes “bad behaviour” is because of
- an infection (Hx, Ex, urine dip, bloods),
- pain (ask about grimaces, calling out on moving),
- constipation, or
- depression.
- Medication Problems
- Review medications and take off medication that is not needed. Ask if patient not taking or refusing any.
- Reduce polypharmacy
- Avoid creating polypharmacy.
- Osteoporosis
- FRAX score?
- DEXA Scan if appropriate
- Lonliness
- Ask patient “Often, as people age, they feel more lonely. Are you experiencing that too”? “How bad is it my dear?”
- Discuss with Nursing/Care home what to do. e.g. Any befriending services, encouragement at home/nursing home community events (e.g singing on a Thursday afternoon)
- Depression
- Ask patient “You seem a bit down to me. Do you find that you are down in your spirits a lot?”
- Antidepressant? Behavioural activation?
- Ask if patient has a DoLS in place – ensure this is coded in the notes – add to problem list and summary.
- RESUS STATUS/RESPECT FORM to be considered for all. Use template
- Palliative care register/review if appropriate
BACK AT THE PRACTICE
- Write up your home visit and the reason why you were called
- Tidy up the repeat medication list – reduce polypharmacy.
- Remember to use appropriate clinical templates (e.g. Ardens, S1, EMIS) for all the other stuff you reviewed and looked at (e.g. medication reviews, CDM, bloods)
- Move on recall dates. Keep recalls to a minimum.
- Liaise with community phlebotomy and observation team for follow up bloods if needed.
- Liaise with Community Matrons/Care Coordinators/District Nurses of other issues that need follow up.
END OF LIFE CARE
- If at the end of life, start anticipatories?
- Stop unnecessary meds
- Get Palliative Care involved? Gold Line?
- DNACPR/RESPECT Forms – discuss with patient/relatives and complete.
- Keep care home staff in the loop.
Tell the patient
When you are unwell with any of the following…
- Vomiting or Diarrhoea (unless only minor and mild)
- Fevers, sweats and shaking (unless only minor and mild) – this can often happen with common cold/flu, chest infections, water infections
Then
- STOP taking the medicines I have written down for you
- Restart these when you are well (after 24-48 hours of eating and drinking normally)
- If you are in any doubt, contact the pharmacist, doctor, nurse or call 111.
Also
- Take some rest
- Drink plenty of sugar-free fluids. Aim to drink at least three litres (five pints) a day, UNLESS YOU HAVE HEART FAILURE – in which case ask your Heart Failure nurse or GP or ring 111 (you may need to stick to around 1.5-2 litres). If you have Heart Failure, weigh yourself every day. If you suddenly gain more than 2Kg in 3 days, contact the emergency doctor or call 111.
- Try to keep to your normal meal pattern, but if you are unable to, for any reason, you can replace some or all of your meals with snacks and/or drinks that contain carbohydrate such as yoghurt, milk and other milky drinks, fruit juice or sugary drinks such as Lucozade, ordinary cola or lemonade. You may find it useful to let fizzy drinks go flat to help keep them down
- Avoid too much caffeine as this could make you dehydrated.
- Take painkillers in the recommended doses as necessary.
- Contact your GP to see if treatment with antibiotics is necessary.
- If you are vomiting uncontrollably, contact your GP or call 111
- Keep taking your insulin or diabetes medications even if you are not eating. HOWEVER, stop metformin and blood pressure medication if you are dehydrated.
- Test your blood four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
- Test your urine four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
- Testing for ketones
- When diabetes is out of control as a result of severe sickness, it can lead to a condition called diabetic ketoacidosis or diabetic coma if you have Type 1 diabetes. The body produces high levels of ketone bodies causing too much acidity in the blood.
- If you have Type 1 diabetes and your blood glucose level is 15 mmol/l or more or you have two per cent or more glucose in your urine, you will also need to test your urine or blood for ketones. They are a sign that your diabetes is seriously out of control. Ketones are especially likely when you are vomiting and can very quickly make you feel even worse. If a ketone test is positive, contact your GP or diabetes care team immediately.
Medicines to STOP on sick days (mnemonic SADMAN)
- SGLT-2 inhibitors: medicine names ending in “flozins” like canagliflozin, empagliflozin, dapagliflozin
- ACE inhibitors: medicine names ending in “pril” like ramipril, lisonopril, enalapril, captopril, perindopril
- Diuretics: e.g. medicine names ending in “ide” like furosemide, bendroflumethiazide, bumetanide
- Metformin (which is a medicine for diabetes)
- ARBs: medicine names ending in “sartan” like losartan, candesartan, valsartan, irbesartan
- NSAIDs: anti-inflammatory pain killers like ibuprofen, diclofenac, naproxen, ketoprofen
