Guest Editorial: Today's Residency Insight is presented by guest editor, Christopher Browning, DPM. Dr. Browning has worked in multiple facets of healthcare for over 20 years including critical care/emergency nursing, emergencency pre-hospital care, fire fighting and podiatric medicine and surgery. In this issue of Residency Insight, he shares his expertise on Office Emergencies and how to best prepare for them.
—Ryan Fitzgerald, DPM, RI Associate Editor
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Christopher G. Browning,
DPM, FACFAS,CWS
Private Practice,
Belton, Texas
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Are You Prepared for an Office Emergency?
It Will Happen to You
When was the last time that you had to deal with an emergency situation in your office? Were you prepared to handle it? Was calling 911 enough? What did you do to stabilize the patient/situation while waiting for the paramedics? Do you have an emergency kit in your office? Are the drugs expired? Are you or one of you staff trained in basic life support or advanced life support? Did the patient die in your office? These questions are real and I will share with you a real life situation that happened to me a few weeks ago.
It Happened to Me
A 75 year old debilitated wheelchair bound patient presented in a motorized chair with her son. The patient's
history included Type 2 Diabetes (non-insulin requiring), HTN, S/P CVA with left sided hemiparesis, Diabetic peripheral neuropathy, and mild PVD. This was a "routine diabetic foot care visit", but she had a complaint of an ingrown nail to the medial aspect of both great toenails.
Case Presentation
After performing my clinical assessment of the patient, she was noted to have normal blood pressure, pulse and respirations. She was an ill appearing woman who appeared much older than her stated age but she was cooperative and non-toxic. The patient was found to have chronic, non-infected appearing ingrown nails with ungula labia hypertrophy to the medial aspect of bilateral great toenails.
Treatment
I easily removed the ingrown nails with a nail nipper and #61 blade and held pressure as she bled mildly due to her legs hanging dependently and also because she was taking a post-stroke anticoagulant. No anesthesia or local was even needed due to her neuropathic state. The procedure and visit were uneventful and I gave the patient and her son a copy of my standard post-nail procedure handout on how to care for her toes.
Emergency!
While typing my note on the EMR system, after the patient had rolled up to the check-out window, I heard some commotion. I heard the patient’s son say in a concerned and panicked tone, “Mom, are you ok?” I immediately got up and approached the window. I had just conversed with this patient less than 15 seconds prior and she was doing “fine.”
The patient was lifeless and completely unconscious, slumped over the chair. Her muscle tone was completely limp. She was diaphoretic and had a faintly palpable carotid pulse. She was breathing shallowly and I immediately instructed the receptionist to call 911. Having worked as a paramedic and ICU/ER nurse for several years prior to becoming a podiatrist, my primal instinct kicked in.
My Response
I immediately performed the “ABC’s” of basic life support outlined by the American Heart Association: Airway, breathing, and circulation. She was so limp that I held her head erect as she was in a wheelchair to support her airway (the head-tilt chin-lift would work on the ground or a modified jaw thrust in this situation.
One of my check-out personnel was trained as an emergency medical technician intermediate (not for this job!) and she quickly took over the airway while I listened for breathing and checked circulation. How many of you actually keep a stethoscope nearby ? The patient was breathing shallowly about 10 times per minute and had distant heart tones with a slow pulse rate of 60 per minute.
I instructed another staff member to take a manual blood pressure which came back as 80 systolic. What was wrong with this lady? Was she having another stroke or a myocardial infarction? Within seconds I performed what I consider the ‘fourth vital sign” regarding patients with diabetes, finger-stick glucose. How many of you have a glucometer in your office? We keep a disposable type from Walgreens that is about the size of a pill bottle, requires NO controls and is disposable. This model is about $10-20 at Walgreens. It is simple and quick to use and is accurate.
That Was It – she was critically hypoglycemic and dehydrated
The patient’s glucose was “low” which corresponds to less than 25mg/dl on this model. I could not give her orange juice, coke, or candy as she was unconscious. Without intravenous access, Dextrose 50% solution was not possible and was not in my emergency kit. This kit contained no intramuscular Glucagon. What I did have was a deteriorating patient in my presence who appeared very unstable and looked like she was circling the drain. In my emergency kit was a tube of instant glucose. I squeezed the contents onto a gloved finger and massaged the thick solution in the patient’s buccal mucosa, taking care not to choke her. Surprisingly, the patient “woke-up” within 5 seconds and was talking. A recheck of the glucose after one minute was 158mg/dl. Her blood pressure improved to 110/70, pulse: 80, and respirations: 18/minute.
She was certainly not 100% but no longer looked to be on the verge of respiratory or cardiac arrest. I was preparing myself to remove this woman from the chair and lay her on the floor just seconds prior to perform CPR with a pocket mask.
EMR Took Over
The ambulance arrived in about 10 minutes and transported her to a local hospital, where she was admitted for dehydration, uncontrolled diabetes and syncope. She was treated and released.
Follow Up - Again
Ironically, the patient came back in two weeks for ingrown nail removal follow-up and once again, “looked well.” I bent down to remove the Band-Aids from her toes and she projectile vomited a bucket of pink substance across the room. She had what appeared to be a seizure but remained normotensive, euglycemic, and conscious as we once again called 911. She was admitted for gastroenteritis. Other than vasovagal episodes in children, we luckily seldom experience these types of emergencies in the podiatry office.
Action Steps for You
Nonetheless, one must be prepared and have staff that is competent and able to participate during such an episode. There are several companies on the market that produce a first aid kit or you can make your own. The one that I have comes from a company which sends refills yearly for a fee to replace the expired drugs. One could argue that it is cost prohibitive as we have only had to break the seal a couple of times.
I would recommend that the podiatrist and at least one staff member maintain training in basic life support. I would have a stethoscope/sphygmomanometer, pocket mask, thermometer, pocket flash light and glucometer at minimum. Emesis basin is helpful as patients frequently vomit. Dallas type mechanic suction devices are cheap and can aid in clearing an airway of vomit or other debris. An oropharangeal airway and a nasal trumpet are also usually included in these kits. As far as advanced kits like the one that we keep in my office, most have sublingual Nitroglycerin, Valium for seizures, inhalers for the asthmatics, Tigan for nausea, instant glucose for the diabetics, etc. A solution of 1:1000 epinephrine is also included for allergic reactions and anaphylaxis (although I believe that commercially available Epipens are great) which occurs far more commonly than you might believe, even in the instance of putting Silvadene cream on the wound of a patient with a sulfa allergy or Triple antibiotic ointment on a patient with a neomycin allergy. The bottom line is having a verbal and written plan of action, i.e.….who does what, who calls 911, who manages the airway and crowd control.
Emergencies May be Rare, But You Must Be Prepared
Although relatively uncommon, emergencies including diabetic coma, insulin shock, myocardial infarction, hypertensive episode, stroke in evolution, fall, shock, seizure, cardiac arrest (how many of your older patients have an implanted defibrillator), and asthma attacks do occur in doctor’s offices. It used to amaze me when I was working as a paramedic and would get called to the waiting room of a busy internist’s office to find a patient rolling around in the lobby having a seizure while the doctor and even staff was behind the glass watching and doing nothing to help the victim.
Take vital signs!
I cannot stress the importance enough. We have seen patients with 250/130 blood pressures and even had one patient suffer a stroke due to undetected hypertension. We had warned this patient on every office visit to seek immediate care for his blood pressure problem, but he failed to take heed.
Being prepared for office emergencies will benefit you and the patients you treat and will leave a positive image of you in the eyes of the bystanders (other patients) who watch “their doctor” help someone in need. Don’t cancel the ambulance if the patient gets better, as you need to transfer care to the paramedics so that the patient can be transported to the hospital and receive proper and complete work-up.
Christopher G. Browning,
DPM, FACFAS,CWS
Private Practice,
Belton, Texas
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