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EMERGENCY CARE IN THE OFFICE

Emergencies occur in every type of medical practice. The dermatologist may not treat anaphylaxis as often as the emergency physician, but there is always the chance that a patient will react to a drug. All physicians must consider the types of emergencies that may arise in their practices and be prepared to deal with them. Some minimum standards for all physicians are set by professional organizations and hospital staff rules. Proficiency in basic life support at the level necessary to maintain certification with the American Heart Association or the American Red Cross has become such a common requirement for employment or staff privileges that it is arguably a standard of care for all practicing physicians.

The same general standards of care apply for emergencies as for routine care in the office or the hospital. Specialists are expected to work to the standards of their specialty and to have general competence in other areas of medicine. This can be a problem for subspecialists who were not trained as general practitioners before they did their specialty training. The law assumes that there is a core body of medical knowledge shared by all physicians. This includes the management of basic emergency conditions such as heart attacks and the management of iatrogenic complications of specialty practice, such as anaphylactic shock from a drug administered in the physician's office.

Physicians should have appropriate emergency equipment available where they practice, with the specific equipment needed tailored to the practice and the patient panel. For example, physicians who give injectable drugs should have all the equipment necessary to treat anaphylaxis. If the physician does not treat anyone under the age of 16, pediatric-sized airways are not necessary. If the physician does not treat anyone over the age of 10, a kit full of 18-gauge needles and liter bottles of fluid would not be appropriate. Physicians whose practices include older individuals should have the equipment and training to deal with a myocardial infarction. While the physician may not cause the patient's heart attack, heart attacks are an expected occurrence in the patient group.

The manufacturers of emergency kits are working to raise the standard of care for office emergency equipment. A bite block made from a tongue depressor and a syringe full of epinephrine taped to the wall is no longer acceptable emergency preparation. Oxygen, intravenous fluids, and steroids may be lifesaving. They are readily available in a suitcase kit that contains protocols for the use of all the equipment. Appropriate drugs and equipment should be readily available in usable form to treat a patient in a foreseeable emergency. Losing a patient to anaphylaxis because there is no oxygen available or the epinephrine is out of date is inexcusable.

Physicians should accompany patients to the hospital in the emergency transport vehicle if there is no proper paramedic service. Many helicopter transport systems, however, will not allow the attending physician to ride in the helicopter. These systems usually have a physician on the helicopter when it is sent out. The attending physician should call ahead while the helicopter is en route and talk to the staff physician at the receiving hospital.

Physicians rendering emergency medical care should recognize the limitations of the situation and of their skills. This is especially true of emergencies in the physician's office. Physicians should not hesitate to call an ambulance to transport a patient to an emergency room. If the physician cannot manage the emergency, it is negligent not to transport the patient to a proper emergency facility. The physician should never send a patient with a serious condition to an emergency room in private transportation. If the condition requires emergency care, the patient should be transported in an ambulance. (This may not hold true in rural areas without available ambulance service. In this case, the physician may need to accompany the patient.) The ambulance personnel may not be able to keep the asthmatic patient from dying, but a jury would never believe that the ambulance would not have helped.


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