Introduction, summary, the system of care

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Chapter 1 Introduction, summary, the system of care

Jim Wardrope, Colville Laird, Peter Driscoll

Introduction 2
Scope 3
Chapter format 3
The three step system of care 3
Overview 3
Primary survey positive 6
Which treatment does the patient need now? 6
Do I need to transport immediately? 6
Do I need back up? 6
Patient obviously requires hospital treatment 6
Secondary survey 7
Patient stable, no immediate reason for hospital transport 7
Subjective information gathering: the history 7
Objective information gathering 9
Analysis – differential diagnosis 10
Plan – treatment and ongoing care 10
Communication – patient and carer 11
The variables in community emergency care 11
The patient 11
The disease (or co-existing diseases) 12
The level of competency/the level of empowerment 12
The emergency care system, the environment, distance to definitive care 12
Summary 13

Introduction

In the UK and in other countries there is a growing shortage of trained clinicians to meet the need for immediate assessment and treatment of urgent medical problems in primary care. Traditionally doctors have been the main providers of this care but already nurses, paramedics, and other healthcare professionals are extending their role to include clinical assessment, decision making, and treatment.1,2 Our aim is that this book will be a useful update for general practitioners experienced in this field and also serve as an introduction to those new to emergency clinical decision making.

We will describe the management of non-traumatic emergencies commonly encountered in community emergency care. The objective is to provide a clear and easily followed system of assessment and management of the ill patient.

This system will teach a method for the rapid recognition and treatment of immediately life threatening problems or conditions that require urgent hospital care. However, the focus of the book is the assessment of patients with less serious problems who can be managed without referral to hospital.

The book will use presentations rather than diagnoses as the starting point, for example the approach to the breathless patient rather than the treatment of asthma; the care of the disturbed patient rather than the diagnosis of specific mental illness.

Where possible we will try to make recommendations based on evidence. The field of emergency medicine is not rich in scientific analysis and community emergency care even less. We will interpret and transfer as much of the evidence as possible into the community emergency care setting.

Lastly and perhaps most importantly, the book sets the immediate management in the context of the start of the patient’s journey. The key principle (Box 1.1) is – what is right for this patient, in this setting, with my skills, at this time? There is evidence that some pre-hospital interventions may make patient outcomes worse. Just because a particular line of management can be practiced out of hospital it does not necessarily mean that it should be done.

Box 1.1 Key points

image Immediate treatment is often only the first part of the patient’s care. The immediate management must be seen as part of the continuum of care.
image Just because an intervention can be carried out does not mean that it is always in the patient’s best interests to do so.

Scope

The book outline is given in Box 1.2. This encompasses most of acute emergency medicine. Trauma is occasionally mentioned as it can be part of the presenting complaint (for example, in a collapse with an injury) or a possible cause (for example, in chest pain). However we will not deal with serious trauma as this is well covered in other texts.

Box 1.2 Book outline

image Introduction
image The system of assessment and the resuscitation of the primary survey positive patient
image Airway and breathing problems
image Chest pain
image Neurological abnormalities and poisoning
image ENT/dermatological conditions
image Falls and the elderly population
image Gynaecology and obstetrics/abdominal pain
image The acutely disturbed patient/mental health
image Fever/nausea and vomiting in the unwell adult
image The assessment of the unwell child
image Paediatric presentations
image Musculoskeletal problems
image Systems design, communications, ethics

Chapter format

The chapters will start with a list of objectives then go on to discuss the care of the ‘primary survey positive’ patient, identify the types of serious problems requiring hospital admission, and concentrate on describing the assessment and management of patients who might be treated at home.

The three step system of care

Overview

We will use a three step system of care (Box 1.3). The first step is to identify those patients with immediately life threatening problems, the second is to identify those patients who will need to go to hospital, and the third to fully assess that majority of patients encountered in community emergency care that will not require hospital referral. There may be no single ‘right answer’ to the immediate management of each of these problems. The variables in levels of training, distance or time to definitive care will influence the decision on the right management for this patient at this time and in this place (see below).

Box 1.3 The system of care

Figures from out-of-hours contacts to primary care in the UK indicate that only 1–2% of patients will require resuscitation. Most patients will have conditions that can be managed at home.

image Step 1 – identify those patients with immediately life threatening problems, provide essential initial resuscitation and transport
image Step 2 – identify those patients with conditions requiring immediate hospital care, provide essential treatment and transport
image Step 3 – fully assess all other patients and decide on the appropriate management of the patient

We will designate a patient as primary survey positive if a potentially life threatening problem is identified. In such cases the two major objectives are to administer those treatments or interventions that are absolutely essential and to prepare the patient for transport.

Step 1

The first step is to identify those patients who are ‘primary survey positive’. This process will usually take less than 30 seconds. If the patient is talking in full sentences, is fully orientated, the respiratory rate is between 10 and 29 breaths per minute, the pulse rate between 50 and 120, and the patient is not cold and sweating, then it is unlikely they need immediate resuscitation (Box 1.4).

Box 1.4 Quick assessment of the primary survey in adults

Patients fulfilling all these criteria are unlikely to have an immediately life threatening problem:

image can talk in complete sentences
image fully alert
image respiratory rate is between 10 and 29 breaths per minute
image pulse is between 50 and 120 beats per minute
image patient is not cold, clammy, or sweaty

Step 2

The next step is to identify the patient who obviously needs hospital admission, especially if the treatment needs to be given as soon as possible to reduce risk to life or limb (Box 1.5). Examples would be acute myocardial infarction, bleeding, suspected aortic aneurysm or imminent childbirth. In these patients essential treatment should be provided and transport to the appropriate hospital arranged.

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