Management of emergencies (Initial assessment and unresponsive patient care)

General rules for emergencies

A medical assistant will face two types of emergencies in an ambulatory care practice: office emergencies and home emergencies. Common office emergencies and their management are discussed later in this chapter. Besides dealing with actual emergency situations on site, a medical assistant frequently is the first person to interact with patients facing potential emergencies at home. It is estimated that one third of the telephone calls received in a provider’s office involve some type of problem that requires attention. An immediate decision must be made on how to manage that problem: by giving home care advice, scheduling an appointment, or, in life-threatening cases, notifying EMS. Many facilities, under the direction and approval of the provider, create a reference list of appropriate questions for specific patient complaints.

Regardless of how emergency phone calls are managed in the facility where you work, consider the following general rules when faced with an emergency:

• It is most important to stay calm. Reassure the patient and make him or her as comfortable as possible.
• Assess the situation to determine the nature of the emergency. Decide whether the need is immediate. This decision requires calm judgment and medical knowledge.
• Obtain as much information as possible to determine the appropriate action.
• Immediately refer any concerns to the office supervisor or provider.

Telephone screening

Each time the phone rings in a healthcare facility, a person with a possible life-or-death situation may be on the other end of the line. One of the most important tasks performed by medical assistants every day is answering the phones and managing patients’ needs efficiently and appropriately. The following emergency action principles serve as a guide for managing emergency phone calls in an ambulatory care practice.

• If the patient’s situation is life-threatening, activate EMS/911.
• Never put a caller with a life-threatening emergency on hold, and always be the last to hang up
• Remain on the line until help arrives and you have talked to EMS personnel.
• Immediately record the names of the caller and the patient, the location, and the phone number in case the connection is lost.
• If you are unsure how to manage the emergency situation, contact the provider.
• If the patient is referred to an emergency department (ED), call the ED to notify the staff of the patient’s arrival, and make a follow-up call to determine the patient’s condition.
• Gather as much information as possible about what is wrong with the patient and when the problem started.

Obtain details about the patient’s condition, including the following:

• What is the patient’s level of consciousness? Alert, responsive, lethargic, or confused? Did the patient lose consciousness at any time? If so, for how long?
• What is the character of the patient’s respirations (and pulse, if the caller is able to determine this): normal, rapid, shallow, or difficult?
• Is there bleeding? If so, how much and from where?
• Is there a suspected head or neck injury? If so, has the patient been moved? Is there a suspected fracture? Where
• Does the patient have a history of this problem?
• Any there other symptoms, such as fever, vomiting, diarrhea, or pain?

Obtain details about what has been done for the patient. For example:

• Medication—What, when? Dose, effectiveness? Current allergies?
• Thoroughly document the information gathered and any actions taken, including notification of EMS, whether the patient was sent to the ED or an appointment was scheduled, all home care recommendations, and whether the provider was notified and when.

Based on the outcome of the telephone interaction, a decision is made on when the provider will see the patient. Emergency calls require activation of EMS or immediate attention as soon as the patient arrives. Urgent calls require a same-day appointment if the patient has an acute condition or is in severe discomfort. Such cases would include a young child with a high fever or a patient who complains of moderate to severe abdominal pain. A new patient will have to be worked into the day’s schedule, which may cause a delay in currently scheduled appointments. Patients with other, less urgent problems can be scheduled for appointments within the next 3 to 4 days.

Management of on-site emergencies

An emergency can occur at any time to anyone. Always follow Standard Precautions when you are at risk for coming into contact with blood or body fluids. When an emergency occurs, it is impossible to determine the level of infection. All body fluids must be considered infectious, and appropriate precautions must be taken to prevent cross-contamination. If the situation is life-threatening, notify EMS and stay with the patient until you are relieved by the EMS provider or the provider in your office. It is important to document all details of the incident in the patient’s health record.

Documentation of an on-site emergency

1. Patient’s name, address, age, and health insurance information
2. Allergies, current medications, and pertinent health history
3. Name and relationship of any person with the patient
4. Vital signs and chief complaint
5. Sequence of events, beginning with how the problem occurred, any changes in the patient’s overall condition, and any observations made about the patient’s condition
6. Details about procedures or treatments performed on the patient

Life-threatening emergencies

If a patient in the facility shows any signs of unresponsiveness, the provider must be brought to the patient immediately. If no provider is available in the facility, EMS must be activated. Even when a provider is present, the provider may order you to call 911 for immediate emergency care. Put on gloves before you begin to assess the patient, because any emergency situation may involve exposure to blood or body fluids.

Unresponsive patient

If a patient is able to talk to you, he or she has an open airway. If the patient does not respond to a simple question (e.g., “Are you OK?”), gently shake the person’s shoulder to check responsiveness. If the patient does not respond, you must assume that the patient is unconscious. Immediately call for help and activate EMS if that is office policy.

To care for an unresponsive patient, first assess the patient’s respirations to determine whether the person is breathing. When the patient collapsed, the tongue may have gone limp and occluded the trachea. Just by changing the individual’s position and opening the airway, you may provide all the assistance the patient needs to breathe independently.

If the patient is face down, roll the victim onto his or her back while supporting the head, neck, and back. Apply the head tilt–chin lift movement to open the airway. The tongue is attached to the lower jaw, so moving the jaw forward automatically opens the patient’s airway. If a head or neck injury is suspected, the neck should be manipulated as little as possible; therefore, the airway should be open with the jaw-thrust maneuver. Both of these actions relieve possible obstruction of the trachea by the tongue.

Check for breathing or only gasping for breath while checking the carotid pulse at the same time for 10 seconds. Look for a rise in the chest while listening or feeling for air exchange. Breathing may stop suddenly for a variety of reasons, including shock, disease, and trauma. If no breaths are detected but there is a pulse, artificial ventilation must be started immediately because death can occur within 4 to 6 minutes. Barrier devices should be kept on hand for artificial respiration, and these should be used if rescue breaths are required. Administer one breath every 5 to 6 seconds (about 10 to 12 breaths per minute). Check the carotid pulse about every 2 minutes. If there is no pulse, begin chest compressions immediately at a ratio of 30 compressions to 2 breaths with about 100 to 120 compressions per minute.

The AHA uses the acronym CAB (compressions, airway, breathing) to help people remember the order for performing the steps of CPR.

When both breathing and pulse stop, the victim has suffered sudden death. Sudden death has many causes, including heart disease, choking, drowning, poisoning, suffocation, electrocution, and smoke inhalation. CPR must be started immediately to attempt to revive the patient and to prevent permanent damage to body organs, especially the brain. Continue CPR until the victim begins to move, an AED is available and ready to use, professional help arrives, or you are too exhausted to continue. If the patient has a pulse but is not breathing, continue rescue breathing and occasionally monitor the pulse until help arrives.

For specific procedures and precautions in the management of respiratory and cardiac emergencies, refer to the Standard First Aid Manual of the American Red Cross or the American Heart Association CPR Manual, or those organizations’ websites. As stated earlier, all healthcare workers should have a current Certification for the Professional in CPR.