Abstract
The purpose of this article is to review the ‘RCGP emergencies in general practice’ course held on 7 December 2019. The course was led by emergency medicine consultants from the Royal Berkshire NHS Foundation Trust. It consisted of updates of relevant clinical guidelines and interactive scenarios based on urgent and unscheduled care.
In our role as future GPs, the ability to deal with patients with urgent needs and recognise the acutely unwell is of paramount importance. Referring the patient to the correct location for prompt hospital assessment is a key part of our role. Many trainees have attended simulation days as part of their foundation and GP training – often with a focus on the airway, breathing, circulation, disability, exposure (ABCDE) approach (Resuscitation Council (UK), 2020). These courses help develop valuable skills but are often focused on management in secondary care. Managing an acutely unwell patient in primary care can be daunting. There may not be enough resources or an immediate team nearby to help. Emergencies are thankfully few and far between but are frightening for any trainee when they happen.
The course involved rotating through multiple scenarios with a clear focus on primary care. The clinical presentations were realistic. The course leaders were aware of the realities of working in a GP surgery and the likely resources available. The cases included a variety of presentations, from paediatrics to older adults, and from sepsis to seizures. Each scenario was led by one of the delegates with a small group observing and then assisting, taking on the roles of reception staff or nursing colleagues, for example. The delegate was able to ‘tap out’ and ask for help from others if they felt stuck or unsure of where to go next. The group reviewed the implemented management plan and offered feedback. The latest guidance for the clinical case was reviewed, updating us on new guidelines, such as the ‘sepsis decision support tool’ (The UK Sepsis Trust, 2018). Each scenario was followed by a summary presentation, including relevant guidance and take-home messages.
Key learning points from the course
Be prepared
When next entering your surgery consider the following.
Develop techniques to improve documentation in acute cases
The importance of robust documentation to support clinical decision-making was strongly emphasised. One suggestion was the use of scoring systems to help support and rationalise decisions. For example, the pulmonary embolism rule-out criteria (PERC) rule (Kline et al., 2004) was highlighted. This may be helpful in assessing patients who are low risk for venous thromboembolism (VTE). Another scoring tool discussed was the NEWS2 score, which stratifies severity of acute illness based on observations and specific parameters (Royal College of Physicians, 2017). This may be a helpful, objective measure to support decisions about patient admission or a certain ambulance response time. Multiple other scoring systems were also discussed, which trainees may find helpful when starting in general practice to aid clinical management and documentation.
Comparing primary and secondary care management
The consultants provided techniques and tips on how to provide immediate care while waiting for an ambulance to arrive. For example, for a patient who is hypotensive in septic or anaphylactic shock, simply implementing passive leg raising, if there is no access to intravenous fluid therapy, will significantly increase fluid return and may be lifesaving. Other suggestions included use of on-the-spot tools, such as the AliveCor Electrocardiogram (ECG) devices, which can generate an ECG in seconds, enabling quicker diagnostics and therefore referral to the right secondary care team.
Co-ordinating care effectively with other services and professionals is essential
Referral to other specialities is something many trainees may find daunting when starting in general practice. Referral using the SBAR technique was practised, providing clearer, more succinct communication. SBAR has been shown to improve patient outcomes and patient safety (Müller et al., 2018). The method involves describing the clinical situation in a systematic approach: S – situation; B – background; A – assessment; and R – response or recommendation. Hospital colleagues, as we know, are also extremely busy and being able to succinctly refer and state why or what is needed in a few lines can be beneficial.
Key learning points.
I would highly recommend the course to any trainees as it improved my confidence managing these patients and refreshed my knowledge, supplementing it with added guidance. The beauty (and sometimes terror) of general practice is that your next patient could have a ruptured abdominal aortic aneurysm, a stroke or cauda equina… the list is endless! The week after attending the course, a patient presented with sudden onset of central, crushing chest pain with low oxygen saturations and hypotension. I felt much more confident bringing the patient into the treatment room, asking for help and delegating certain tasks while implementing immediate care. This course helps equip trainees with the skills to successfully deal with such cases and any practise of these can only be helpful!
