Originally published January 2013
Medical emergencies can occur anywhere, at any time, including physicians' offices and clinics. When emergencies arise in these settings, physicians and their staff will be called upon to assist patients and trigger an emergency response. Conducting an appropriate emergency risk assessment, followed by planning, preparation, and practise will contribute to an effective response and can improve the outcomes for patients.
What types of emergencies are being seen?
It is not hard to imagine a patient arriving for a scheduled medical appointment, suffering from severe chest pain, and being urgently transported to the nearest emergency department. Cardiovascular events, including cardiac arrest, are among the most common emergencies in medical offices and clinics, as documented in studies from Canada, the United States, and Australia.1, 2, 3 The Canadian study looked at the frequency and types of emergencies seen by Canadian family physicians in an urban setting and found cardiovascular emergencies were followed by general illnesses such as trauma, infectious diseases, hypothermia, or exposure; and respiratory distress such as asthma. The other frequent emergencies were strokes, seizures, fainting, allergic reactions, anaphylaxis, diabetic distress, abdominal illnesses, back pain, hemorrhages, gynecologic and obstetric issues, and pharmacologic problems such as poisoning or toxic exposure.
What are physicians' responsibilities in an emergency?
Certainly, physicians who perform specific procedures in their offices or clinics — for example, allergy or immunization injections, drawing blood, performing surgical procedures such as vasectomies — owe a duty of care to their patients, and the courts and the provincial and territorial regulatory authorities (Colleges) expect physicians to be prepared for urgent complications that might arise as a result of the medical interventions they provide. In a clinic where allergy injections are given, for example, it is reasonable to anticipate that a patient could suffer an anaphylactic reaction. The courts and Colleges expect physicians and staff to have a prepared emergency response to treat patients suffering from this type of emergency.
Although some medical emergencies can reasonably be anticipated or foreseen in an office or clinic, others cannot. Individuals can experience an emergency at any time. They could suffer an asthma attack or a stroke, or a parent may bring in a sick child unaware that the child is acutely ill. The individual may or may not be a patient of the office or clinic. They could be a caregiver accompanying a patient, or even a person walking in off the street in search of urgent medical help.
While a clinic or office cannot reasonably be prepared for every possible, unexpected emergency, Colleges view physicians as having an ethical obligation to do their best to attend to individuals in need of urgent care. The Canadian Medical Association's Code of Ethics states that physicians should: "Provide whatever appropriate assistance you can to any person with an urgent need for medical care."
In unexpected medical emergencies, physicians should focus on practising medicine to the best of their ability. They should treat individuals requiring care with the goal of preventing prolonged suffering and addressing imminent threats to life, limb, or health. The care physicians provide in an emergency situation may be far different from what is expected of them under normal circumstances and is more basic than what can be provided in an emergency department. Physicians and their staff in an office or clinic may consider having a response plan to address basic emergency care, including providing basic life support until emergency services are available. Once emergency services arrive, the physician can transfer care to emergency responders. The physician should document the care that was provided, which will be valuable in the individual's ongoing care.
How to prepare for an emergency
There are a number of resources to assist physicians in planning and preparing for an emergency in their office or clinic. Physicians may first turn to their College for any policies, guidelines, or recommendations for emergency preparation. The Collège des Médecins du Québec, for example, has published a booklet, Procédures et interventions en milieu extrahospitalier, which includes information on preparing for an office or clinic emergency; it is available in French on the College's website at www.cmq.org/fr.aspx. The Ontario College of Physicians and Surgeons also has a booklet that includes guidance on preparing for emergencies, Safe and Effective Office-Based Practices, available at www.cpso.on.ca. In addition, there are articles2, 4 on the topic and a website created by a young British Columbia doctor at www.OfficeEmergencies.ca.
The resources suggest offices and clinics prepare by carrying out a number of activities — determining the office's level of risk and types of emergencies that are most likely to occur, assessing the training and equipment needed to respond to those emergencies, developing a plan, and conducting practice drills.
Physicians should begin preparing their office by assessing the level of risk in their practice. Doctors should examine the practice's characteristics such as the patient population (whether patients include children or the elderly), the volume of patients, whether it is in an urban or rural location, the distance to the closest emergency room, the types of procedures performed in the office, the access to emergency response services such as 911, etc. A family physician's office or clinic will have different characteristics and a different level of risk from that of a physician who, for example, specializes in psychotherapy. Knowing the level of risk will help physicians determine the equipment and training needed to respond efficiently and effectively to a medical emergency.
Organizing equipment and training
The equipment and supplies required in a physician's office should correspond to the level of risk in the practice, the procedures performed in the office, and how much medical intervention physicians feel they and their staff can appropriately provide. For instance, offices or clinics that are a significant distance from a hospital or emergency department may have a higher level of risk and so may have equipment that allows the physicians and staff to provide basic life support for an extended time. Physicians should use their clinical judgment to determine the equipment and supplies most appropriate for their practice.
Those physicians who offer pediatric care should take into consideration the special treatment requirements of children in an emergency. Equipment, supplies, and medications must be specifically tailored to infants and children.
Staff training is a critical part of preparing an office for an emergency. By knowing the types of emergencies the office is at risk for and the current skill levels of each staff member, physicians and staff can identify and address skills or knowledge gaps. Physicians in a small office may consider having all staff trained in basic life support, while in a larger office only clinical staff may require such training. All staff should be aware of the role they are to play during an emergency and know the availability and location of equipment and supplies. Specific staff members could be trained and assigned to inspect, replace, and order equipment and supplies.
Having a written plan clarifies how the office will respond to a medical emergency. It details the role each staff member will play, where the equipment is located, and how the patient will be transferred to the next level of care, typically a hospital or emergency department. To maintain the level of preparedness, physicians should practise the plan with their staff. Drills allow staff members to test their knowledge, become comfortable and efficient with each step, and notice problem areas and make improvements. Knowing the plan thoroughly will make it easier for staff to remain calm and attend to the patient when an emergency does occur.
As soon as possible after the emergency, physicians should document the encounter in a medical record, even if there is no previous doctor-patient relationship. The documentation provides a record of the medical reasoning and the steps taken, facilitates any further investigations and treatments, and is valuable if there are questions about the care.
The bottom line
Physicians have an ethical obligation to attend to individuals who require urgent care while in the office or clinic, whether or not the individual is a patient. By carefully examining the characteristics of their practice, physicians can try to anticipate the emergencies that are most likely to occur, and prepare their office or clinic by stocking the necessary equipment, training their staff, and developing a response plan. As soon as possible following the emergency, the steps that were taken to care for the patient should be clearly, completely, and legibly documented in a medical record. Planning and preparation will allow physicians and their staff to calmly and effectively respond to medical emergencies.
- Liddy, C, Dreise, H, Gaboury, I., "Frequency of in-office emergencies in primary care," Canadian Family Physician, (October 2009) Vol. 55, p.1004-1005.
- Sethe L. Toback, "Medical Emergency Preparedness in Office Practice," American Family Physician (2007) Vol. 75, no.11 p.1679 – 1684.
- Johnston, C. L., Coulthard, M.G., Schluter, P.J., Dick, M.B., "Medical emergencies in general practice in south-east Queensland: prevalence and practice preparedness," Medical Journal of Australia, (July 16, 2001) Vol. 175, p.99-103.
- Sempowski, I.P., Brison, R.J., "Dealing with office emergencies, Stepwise approach for family physicians," Canadian Family Physician, September 2002, Vol. 48, pages 1464-1472.