Domain – Emergency medicine (case)

You are working on a Friday afternoon in your rural practice, along with a nurse and receptionist. Suddenly, the practice emergency alarm sounds and the call of ‘Help!’ comes from your nurse immunisation clinic. You run in to find an elderly patient collapsed, unconscious on the floor, with laboured breathing. The nurse quickly tells you that the patient and her husband have come in for their routine immunisations. Shortly after the patient was immunised, she complained of feeling short of breath and faint. She then collapsed.

Communication and consultation skills

The patient’s husband is in the room. How would you manage him in this situation? What if the couple did not speak English?

1. Reassurance and Calmness:
   • Approach the patient’s husband calmly and reassure him that we are taking care of the situation.
   • Explain in simple terms that his wife is being attended to and that help is on the way.
2. Assign a Role:
   • If the husband is visibly distressed but can still function, give him a simple task to help, such as holding his wife’s hand to provide comfort or moving to a safer area if necessary.
3. Non-English Speaking Couple:
   • Use any available translation services or apps if language is a barrier.
   • If there’s no immediate access to translation services, use non-verbal communication like gestures and maintain a calm demeanor to help the husband understand that care is being provided.
   • If the husband speaks some English, use simple, clear language and avoid medical jargon.

You need to call for help; who could you call and how would you do this? What if you were in a remote outreach clinic?

1. In the Practice:

   • Immediate Response: Use the practice’s emergency protocol to call for additional help.Emergency Services: Dial 000 for ambulance services, providing details about the patient’s condition.Nearby Medical Facilities: If other healthcare providers are nearby, call them for immediate assistance.

   In a Remote Outreach Clinic:

   • Remote Emergency Services: Dial 000, clearly stating that you are in a remote location and providing precise details about your location.Telemedicine: Use telemedicine services to get advice from a specialist or more experienced doctor if available.Local Resources: Identify any local resources such as community health workers or nearby clinics that might provide immediate assistance.

What are the important points that need to be relayed to any other helpers or emergency services that arrive? How would you communicate this information?

ISBAR Communication Format

I – Identify:

• Who you are: “This is Dr. [Your Name], a general practitioner at [Practice Name] in [Location].”Who the patient is: “I have an elderly female patient, Mrs. [Patient’s Name], who is approximately [age].”

S – Situation:

• Current situation: “Mrs. [Patient’s Name] collapsed and is currently unconscious with laboured breathing after receiving a routine immunisation.”

B – Background:

• Relevant medical history: “The patient and her husband came in for their routine immunisations. She has no known history of severe allergic reactions to vaccines. Shortly after the immunisation, she complained of shortness of breath and feeling faint before collapsing.”Immunisation details: “The vaccine administered was [name of vaccine], given at [time].”

A – Assessment:

• Patient’s condition: “The patient is unconscious with laboured breathing. Her vital signs are [include any measurements like pulse rate, breathing rate, blood pressure if available]. We have initiated basic life support measures.”

R – Recommendation:

• Immediate needs: “We need an urgent ambulance for immediate medical intervention and transport to the nearest hospital. Please send an advanced life support unit due to the patient’s critical condition.”Additional instructions: “We will continue monitoring her vital signs and providing supportive care until the ambulance arrives. Please advise if there are any specific instructions we should follow in the interim.”

Clinical information gathering and interpretation

What immediately important clinical information do you need to be able to manage this patient?

Primary Survey (ABCDE Approach)

1. Airway:
   • Patency: Is the airway open and clear?
   • Obstructions: Check for any visible obstructions or signs of airway compromise.
2. Breathing:
   • Respiratory Rate and Effort: Assess the rate, depth, and effort of breathing.
   • Oxygen Saturation: Measure with a pulse oximeter.
   • Breath Sounds: Listen for wheezing, stridor, or other abnormal sounds.
   • Chest Movement: Observe for symmetrical chest rise and fall.
3. Circulation:
   • Heart Rate and Rhythm: Check pulse for rate and regularity.
   • Blood Pressure: Measure to assess for hypotension or hypertension.
   • Capillary Refill Time: Assess perfusion status.
   • Skin Signs: Look for pallor, cyanosis, diaphoresis.
4. Disability:
   • Level of Consciousness: Use AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) or Glasgow Coma Scale (GCS).
   • Pupils: Check for size, equality, and reactivity to light.
   • Glucose Level: Check for hypoglycemia if a glucometer is available.
5. Exposure/Environment:
   • Full Examination: Look for any other signs of trauma, rashes, or allergic reactions.
   • Temperature: Check for hypothermia or hyperthermia.

Secondary Survey

1. History (using AMPLE):
   • Allergies: Any known allergies, especially to vaccines or medications.
   • Medications: Current medications, particularly those affecting cardiovascular or respiratory systems.
   • Past Medical History: Relevant medical conditions (e.g., history of anaphylaxis, cardiovascular disease, respiratory conditions).
   • Last Meal: Time and contents of the last meal, if relevant.
   • Events Leading to Present Illness: Detailed account of symptoms and events leading up to the collapse, as reported by the nurse or husband.
2. Focused Physical Examination:
   • Head-to-Toe Examination: Look for any additional signs that might indicate the cause of the collapse (e.g., rash, swelling, trauma).
   • Neurological Exam: Assess motor and sensory function if the patient regains consciousness.
3. Further Investigations:
   • Electrocardiogram (ECG): If available, to assess for any cardiac abnormalities.
   • Blood Tests: If facilities allow, check for basic metabolic panel, complete blood count, and any markers of anaphylaxis or infection.

Immediate Management Steps Based on Findings

• Airway Management: If airway obstruction is present, use appropriate techniques to clear it (e.g., suctioning, positioning, airway adjuncts).
• Breathing Support: Administer high-flow oxygen if oxygen saturation is low or if there is significant respiratory distress.
• Circulatory Support: Initiate IV access if possible, prepare for fluid resuscitation if hypotension is present, and consider medications like adrenaline (epinephrine) if anaphylaxis is suspected.
• Neurological Monitoring: Continuously monitor the patient’s level of consciousness and neurological status.
• Prepare for Transport: Ensure that the patient is ready for transfer to a higher level of care as soon as emergency services arrive.

By systematically using the primary and secondary survey approach, you ensure that no critical steps are missed and that the patient receives prompt and appropriate care.

What other information do you need to help you make a diagnosis?

Making a diagnosis, decision making and reasoning

In this situation, what are the possible causes for the patient suddenly collapsing?

1. Anaphylaxis:
   • A severe allergic reaction to the immunization.
   • Signs: Rash, urticaria, angioedema, difficulty breathing, hypotension.
2. Vasovagal Syncope:
   • A common cause of fainting due to a sudden drop in heart rate and blood pressure.
   • Signs: Dizziness, nausea, pallor, sweating before the collapse.
3. Cardiac Event:
   • Myocardial infarction, arrhythmias, or other cardiac issues.
   • Signs: Chest pain, palpitations, previous cardiac history.
4. Hypoglycemia:
   • Low blood sugar levels, especially if the patient is diabetic or fasting.
   • Signs: Confusion, sweating, shaking, weakness before collapse.
5. Hypotension:
   • Could be due to various causes, including dehydration or a reaction to medications.
   • Signs: Lightheadedness, dizziness, pallor.
6. Stroke or Transient Ischemic Attack (TIA):
   • Sudden neurological event affecting blood flow to the brain.
   • Signs: Sudden weakness, difficulty speaking, facial droop.
7. Pulmonary Embolism:
   • A blood clot in the lungs causing sudden respiratory distress and collapse.
   • Signs: Sudden shortness of breath, chest pain, tachycardia.
8. Seizure:
   • An abnormal electrical discharge in the brain.
   • Signs: Aura, convulsions, postictal confusion.

Would knowing the diagnosis change the way you immediately manage this patient? Why or why not?

Yes and No – The initial steps of managing an unconscious and collapsed patient focus on stabilizing their vital functions and preventing further deterioration, regardless of the underlying cause.

This approach ensures that the patient’s basic life needs are met (airway, breathing, circulation) while preparing for more specific treatments once the diagnosis is clearer.

Immediate Management Regardless of Diagnosis:

1. Airway, Breathing, Circulation (ABC):
   • Airway: Ensure it is open and clear.
   • Breathing: Provide oxygen if needed.
   • Circulation: Check pulse, initiate CPR if no pulse.
2. Positioning:
   • Place the patient in a supine position with legs elevated if no spinal injury is suspected (to improve circulation).
3. Vital Signs Monitoring:
   • Continuous monitoring of heart rate, blood pressure, respiratory rate, and oxygen saturation.
4. Emergency Call:
   • Call emergency services (000 in Australia) for immediate medical assistance and transport to a hospital.
5. Basic Life Support (BLS):
   • Initiate BLS if necessary.

Diagnosis-Specific Interventions:

If Anaphylaxis is Suspected:

• Adrenaline: Administer intramuscular adrenaline (epinephrine) immediately.
• Antihistamines and Corticosteroids: Administer as secondary treatment.
• IV Fluids: To treat hypotension.

If Cardiac Event is Suspected:

• Aspirin: Administer if myocardial infarction is suspected and not contraindicated.
• Nitroglycerin: Administer if there is chest pain and no contraindications.

If Hypoglycemia is Suspected:

• Glucose Administration: Give oral glucose if the patient is conscious or IV glucose if unconscious.

If Seizure is Suspected:

• Seizure Precautions: Protect the patient from injury during the seizure, monitor airway and breathing.

If Stroke is Suspected:

• Positioning: Keep the patient’s head elevated slightly if possible.
• Avoid Aggressive Treatment: Avoid administering any medication that could worsen bleeding in the case of hemorrhagic stroke.

Clinical management and therapeutic reasoning

What interventions may need to be performed to manage this patient? What if the patient were a child?

ALS guidelines…

• Immediate Management: Use the ABCDE approach to stabilize the patient, regardless of age.
• Diagnosis-Specific Interventions: Adjust treatments based on the suspected underlying cause.
• Pediatric Considerations: Use age-appropriate techniques and dosages for interventions.

Do you know where to find resuscitation resources in your clinic? If you were in an alternative place of work (eg a nursing home or local hospital) would you know where to find the resuscitation resources? What if this occurred outside of your practice?

Specific Actions for Various Settings:

1. In the Clinic:
   • Immediately locate and bring the emergency trolley/crash cart to the patient.
   • Utilize available oxygen supply, masks, and AED as needed.
   • Administer emergency medications from the trolley.
2. In a Nursing Home or Hospital:
   • Quickly access the nearest emergency trolley/crash cart.
   • Use the institution’s protocols for emergency situations.
   • Collaborate with the nursing and support staff to manage the emergency.
3. Outside the Practice:
   • Call emergency services immediately (000 in Australia).
   • Locate the nearest AED if available (e.g., in shopping centers, sports complexes).
   • Perform basic life support (BLS) until professional help arrives.

Preventive and population health  

Does your community have access to publicly available automated defibrillators? If not, is this something you could advocate for?

Access to AEDs in the Community:

• Many communities, especially urban areas, have publicly available AEDs located in places such as shopping centers, schools, sports facilities, and public transport hubs.
• In rural or remote areas, access may be limited.

Advocating for AEDs:

• Assessment: Determine the current availability and distribution of AEDs in your community.
• Community Needs: Highlight the importance of AEDs in improving survival rates from sudden cardiac arrest.
• Stakeholders: Collaborate with local health authorities, government officials, and community organizations.
• Funding and Grants: Explore funding options from government grants, non-profit organizations, or community fundraising events.
• Education and Training: Promote community training programs on the use of AEDs and basic life support.

Who should be involved in the decision to continue or cease resuscitation efforts? Attitudes towards death can vary based on culture; what if this occurred in an Aboriginal or Torres Strait Islander patient?

Decision to Continue or Cease Resuscitation Efforts

Who Should Be Involved:

1. Medical Team: Doctors, nurses, and other healthcare professionals who are directly involved in the resuscitation efforts.Patient’s Family: Family members should be involved in the decision-making process, taking into account the patient’s previously expressed wishes and advanced directives.Ethics Committee: In complex cases, the hospital’s ethics committee may be consulted to provide guidance on ethical considerations.Cultural Liaison Officers: For Aboriginal or Torres Strait Islander patients, involve cultural liaison officers or representatives to ensure culturally sensitive decision-making.
Cultural Considerations

Attitudes Towards Death in Aboriginal and Torres Strait Islander Communities:

• Respect for Elders: Elders hold a significant place in the community, and their care is given high priority.Cultural Practices: There are specific rituals and practices around death and dying that need to be respected.Communication: Use culturally appropriate communication methods, involving Indigenous healthcare workers or liaison officers to facilitate discussions.

If This Occurred in an Aboriginal or Torres Strait Islander Patient:

1. Involve Indigenous Health Workers: They can provide insights into cultural practices and help communicate with the patient’s family.Family and Community Involvement: Engage the patient’s family and community leaders early in the decision-making process.Respect Cultural Practices: Ensure that any cultural rituals or practices are respected and facilitated as much as possible.Document Preferences: If the patient has an advanced care directive or has expressed preferences regarding end-of-life care, ensure these are followed.Cultural Sensitivity Training: Ensure that all healthcare providers involved are trained in cultural sensitivity to provide respectful and appropriate care.

Professionalism

If this situation makes you feel anxious or nervous, what steps can you take to improve your confidence?

What are the possible issues with confidentiality and consent in this case? What if this were a child with an aunt/uncle or grandparent?

Confidentiality and Consent Issues

1. Confidentiality:
   • Patient Information: Ensure that the patient’s medical information is shared only with individuals directly involved in their care.
   • Emergency Situations: In an emergency, it may be necessary to share critical information quickly. Ensure that this information is communicated discretely and professionally.
2. Consent:
   • Implied Consent: In life-threatening emergencies, implied consent is assumed if the patient is unconscious or unable to provide consent, as immediate intervention is necessary to preserve life.
   • Advanced Directives: Check if the patient has any advanced directives or documented wishes regarding resuscitation and emergency care.

Improving Confidence in Emergency Situations

Feeling anxious or nervous in emergency situations is natural, but there are steps you can take to improve your confidence and competence:

1. Regular Training and Drills:
   • Participate in and organize regular emergency response drills in your clinic.
   • Attend advanced life support training courses, such as ACLS (Advanced Cardiovascular Life Support) and PALS (Pediatric Advanced Life Support).
2. Continuing Education:
   • Stay updated with the latest guidelines and protocols from relevant medical bodies (e.g., Australian Resuscitation Council).
   • Engage in continuous medical education (CME) programs focusing on emergency medicine.
3. Simulation Exercises:
   • Use simulation-based training to practice managing various emergency scenarios in a controlled environment.
4. Peer Support and Mentorship:
   • Seek mentorship from more experienced colleagues.
   • Engage in peer discussions and debriefings after emergencies to learn from experiences.
5. Mental Preparation and Stress Management:
   • Practice mindfulness and stress reduction techniques to maintain calmness during emergencies.
   • Visualize successful management of emergency scenarios to build mental preparedness.
6. Familiarity with Equipment and Protocols:
   • Ensure you are familiar with the location and use of all emergency equipment in your clinic.
   • Review and memorize emergency protocols regularly.

Confidentiality and Consent Issues

1. Confidentiality:
   • Patient Information: Ensure that the patient’s medical information is shared only with individuals directly involved in their care.
   • Emergency Situations: In an emergency, it may be necessary to share critical information quickly. Ensure that this information is communicated discretely and professionally.
2. Consent:
   • Implied Consent: In life-threatening emergencies, implied consent is assumed if the patient is unconscious or unable to provide consent, as immediate intervention is necessary to preserve life.
   • Advanced Directives: Check if the patient has any advanced directives or documented wishes regarding resuscitation and emergency care.

Managing a Child in Emergency Situations

Confidentiality and Consent for a Child:

1. Parental or Legal Guardian Consent:
   • Typically, consent for treatment is obtained from a parent or legal guardian.
   • In emergency situations, if a parent or guardian is not available, implied consent applies, similar to adults, as the priority is to save the child’s life.
2. If the Child is with an Aunt/Uncle or Grandparent:
   • Temporary Guardian: If the parent is not present, the aunt, uncle, or grandparent may provide consent if they are acting as the child’s temporary guardian.
   • Legal Documentation: Ideally, there should be legal documentation authorizing them to make medical decisions for the child.
   • Contacting Parents: Efforts should be made to contact the parents or legal guardians as soon as possible to inform them of the situation and obtain consent.
3. Confidentiality:
   • Maintain the child’s confidentiality by discussing medical details only with authorized individuals.
   • If a relative is not the legal guardian, share only necessary information for immediate care while attempting to reach the legal guardians.

General practice systems and regulatory requirement

What are the regulatory requirements for resuscitation resources in a clinic setting? Is your clinic prepared? What resources are available in other settings, or on home visits?

1. RACGP Standards for General Practices:
   • The Royal Australian College of General Practitioners (RACGP) provides standards that outline the necessary resuscitation resources and equipment for general practices.
2. Basic Resuscitation Equipment:
   • Oxygen Supply: A reliable oxygen source with masks and nasal prongs.
   • Airway Management: Basic airway adjuncts such as oropharyngeal airways, bag-valve masks, and suction devices.
   • Defibrillation: Automated External Defibrillator (AED) readily accessible.
   • Emergency Medications: Adrenaline (epinephrine), antihistamines, aspirin, and glucose.
   • Monitoring Equipment: Blood pressure monitors, pulse oximeters, and stethoscopes.
3. Training and Preparedness:
   • Regular training for all staff in Basic Life Support (BLS) and use of emergency equipment.
   • Regular maintenance and checking of all resuscitation equipment to ensure functionality.

Is there a system to quickly call for emergency help in your practice?

Procedural skills

Do you feel confident with managing airway, breathing and circulation? If not, how could you improve your understanding and skills?

Do you know how to use a defibrillator? If not, how could you learn to use one and become competent?

What equipment is there in your clinic? Would you feel confident in using this equipment? If not, how could you improve your confidence?

Managing uncertainty

It is possible that this is a case of anaphylaxis related to the immunisation. What strategies would you use to make sure that other life-threatening diagnoses are not missed?

Strategies to Avoid Missing Other Life-Threatening Diagnoses:

• Use a systematic approach (ABCDE) and thorough history and physical examination.
• Monitor vital signs and perform diagnostic tests if available.
• Consider a wide differential diagnosis and consult with colleagues or specialists.

Reflect on the chances of causing harm with life support interventions when you are unsure of the diagnosis.

• Basic life support interventions are generally low-risk and essential in emergencies.
• Advanced interventions should be guided by clinical judgment, evidence-based guidelines, and continuous reassessment.
• Prioritize interventions that offer the greatest benefit while being mindful of potential risks.