Emergency care in general practiceBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6971.6 (Published 07 January 1995) Cite this as: BMJ 1995;310:6
- Anthony Avery,
- Mike Pringle
Doctors need to maintain their knowledge and skills and carry the right equipment and drugs
Life threatening emergencies do not occur every day in general practice: some conditions such as anaphylactic shock may occur only a few times in a professional lifetime. Rarity makes the task of keeping up to date a challenge. How should general practitioners respond?
Firstly, the use of protocols—regularly discussed and updated—should help maintain the essential knowledge. Secondly, regular attendance at practical courses helps sustain skills. The Royal College of General Practitioners has taken an important step by making it a requirement that candidates show their competence at cardiopulmonary resuscitation before they can pass the MRCGP examination. Nevertheless, more skills based courses are needed for established principals.
Thirdly, general practitioners need to be properly equipped for emergency care. The traditional black bag should now be accompanied by a range of items, which may include a nebuliser, intravenous fluids, an electrocardiograph machine, and a defibrillator. While a nebuliser (or large volume spacer) is essential for the successful management of acute severe asthma,1 the need for the other items is more debatable. For example, when visiting a patient with suspected myocardial infarction a general practitioner might waste precious time by performing electrocardiography. Higher priorities are to arrange urgent admission to hospital, to give adequate pain relief, and to administer aspirin (when appropriate). Nevertheless, there are circumstances in which an electrocardiograph machine might come in useful—for example, in recording a cardiac arrhythmia.
A defibrillator may be life saving in a patient with ventricularfibrillation, and studies have confirmed the value of automated external defibrillation outside hospital.2 3 Defibrillators carried by general practitioners are known to be effective4; the earlier defibrillation is performed after cardiac arrest the better the outcome.2 3 While first line ambulances can provide a rapid response in many cases of cardiac arrest there will be situations in which general practitioners can save lives if they are first on the scene with a defibrillator. The decision to carry this equipment will be influenced by local ambulance response times and provision of appropriate training. Reimbursement of equipment costs would help general practitioners to purchase defibrillators.
Next, general practitioners must carry a suitable range of drugs for the emergencies they are likely to face.5 Recent attention has concentrated on aspirin and penicillin. In a questionnaire survey two fifths of general practitioners reported that they did not carry aspirin6—yet this drug reduces the death rate in myocardial infarction if given in the first 24 hours.7 It makes sense for general practitioners to give aspirin in suspected myocardial infarction as this will help to ensure that all suitable patients are given the benefits of this drug. In a study by Colbridge et al nearly a fifth of general practitioners from the north west of England did not carry benzylpenicillin (p 29)8—yet this drug should be given immediately to patients suspected of meningococcal infection.9 These results suggest that a substantial minority of doctors need urgently to review the drugs they carry.
Drugs for use in emergencies should be checked regularly to ensure that they have not passed their expiry date. Controlled drugs should be stored in a locked bag, and a careful record should be kept of their use. Another issue is the temperature at which emergency drugs are kept.10 11 For example, the datasheet for benzylpenicillin recommends storage below 25°C.12 The internal temperature of a traditional black bag can reach 40°C in the boot of a car.10 One cannot assume that the drug will remain active until its expiry date if the recommended storage temperature is exceeded.11 Options for storage include keeping drugs in cool conditions out of the car except when on visits, spraying a black emergency bag silver,10 or using a “cool bag.”
Emergency care in general practice is important. All general practitioners should examine this aspect of their work to ensure they can deliver a high quality emergency service.