Are You Prepared?

"My brother, who's a bartender, may very well have a better chance of saving someone's life than some of my co-workers," says pediatrician Seth Toback. "That's because he's required to take a choking [prevention] course once a year."

Toback's experience is not uncommon and points out a weakness that many medical practices share. It's hard to estimate how many physician offices are sufficiently prepared for patients presenting with sudden medical emergencies, such as a heart attack, seizure, or severe asthma attack. Supplies and training requirements vary from state to state and among specialties. Chances are, upon closer inspection of your office, you'll discover that there are areas -- whether it be equipment, medication, supplies, or training -- that could use improvements.

According to a 1996 study in the Archives of Pediatric of Adolescent Medicine, there were an average of 24 emergencies per office, per year in New England. A 2000 Pediatrics study estimated between three and 32 emergencies per office, per year in Chicago -- and speculated that 50 to 67 percent of offices did not have emergency plans. An emergency is defined as any need to open the "emergency supply box" for masks, epinephrine, or other supplies not used on a routine basis.

"Some offices think they're ready because they have the equipment, but it's in 40 different places," says Elizabeth Wertz, a nurse and executive director of Pediatric Alliance, a 24-physician practice with nine offices throughout the Pittsburgh area. "In an emergency situation you don't want to have to go to different places because you need to be ready. The image the public has is that doctors should know what to do. [Patients] say, 'I'm in a medical facility and they can take care of whatever happens.' But that's not always the case," says Wertz.

Toback has been working with Wertz to improve Pediatric Alliance's emergency preparedness. "If you asked patients if they expected their child's doctor to be just as able to save their child's life as they would in diagnosing him I believe they would say 'yes.' Being prepared for emergencies in your office is as important as looking in ears and checking throats," he says.

Assess your needs

Wertz suggests beginning with a needs assessment. Review the supplies and equipment you have, and try to determine the most likely emergencies to occur in your office. The cost for properly stocking your practice will vary depending upon what provisions you want to make, but will generally run between $500 and several thousand dollars. Include items such as I.V. catheters and fluid, intraosseous needles, bag valve masks, a nebulizer, tubing, and medications -- or surf the Internet to purchase pre-made emergency kits and resuscitation systems.

During the needs assessment phase, begin keeping a log of very ill patients who present to your office. Ken Tegtmeyer, a pediatric intensive care physician at Oregon Health & Science University in Portland, says, for instance, that early intervention is critical when treating rapidly progressing meningococcemia, a disease more prevalent in children in the Pacific Northwest than other parts of the country. These patients require I.V. antibiotics, ventilator support, fluid resuscitation, and early transport to emergency and intensive care in order to survive.

One piece of equipment that is becoming increasingly common in doctors' offices as well as airports, malls, and stadiums, is an automatic external defibrillator (AED), which generally costs between $1,800 and $4,000. A 2000 New England Journal of Medicine study showed that the survival rate of 105 victims in ventricular fibrillation was 74 percent if they received their first defibrillation within three minutes of collapse; that decreased to 49 percent after three minutes.

Expense is an important consideration for many offices, particularly since supplies will expire and need to be replaced, says Wertz. "In my mind it's still worth it, but then I put my business hat on and it's expensive. I think, at $120 each for an Epi-pen in nine offices -- that's a lot. But if you save one life it's worth every penny."

Training and planning

"Everyone in the office needs to be trained in some capacity. A lot of times it might be the receptionist who initially sees there's a problem," says Wertz, who suggests that all employees become certified in Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS). Staff cannot rely solely on the doctors, she says. "Some offices say there's always a doctor available -- but what if there just isn't one available?"

Other practices rely on ambulances or on their proximity to the hospital. "What about that 10 minutes before the ambulance gets there?" Wertz poses. "If eight to 10 minutes go by, depending upon the emergency, you can kiss that person goodbye."

Despite being located within walking distance of the Susquehanna Health System, Daniel Glunk's internal medicine practice in Williamsport, Pa., doesn't depend on the hospital for emergencies: His entire office staff is BLS certified and the physicians are ACLS certified. "Even though we're right across the street we still have a responsibility to perform basic life support if someone should need it," Glunk says. The office is also equipped with basic life support supplies.

To make your emergency plan as effective as possible, assign specific responsibilities to each staff member -- even nonclinical types. Of course, much of this depends on who is certified to do specific tasks. "You need to know your own skills. If you haven't intubated since residency and you've been practicing medicine for a while, you need to know you can still do it. Having equipment will do you no good if you don't know how to use it," says Tegtmeyer.

Once tasks are assigned make sure nonclinical personnel understand the importance of their roles. Someone needs to be able to give good, easy directions over the phone to emergency personnel, especially in areas where 911 doesn't exist, says Toback. It's helpful for paramedics to know the best place to park, and to have one of the clerical staff meet the crew outside to show them the quickest path to the office door. Details on the victim's condition are also useful.

Running a code

When the pieces of an emergency plan are in place the best way to determine its effectiveness is to run a mock code -- practice a particular scenario -- and then critique it. Toback suggests asking local ACLS providers for expired medications and used equipment to practice with.

Wertz has organized several mock codes, runs them once a quarter, and plans to videotape them in the future. "Then [staff] can actually see what they did or didn't do. It's a good eye opener," she says. Wertz would eventually like to do unannounced practice codes, but for now the scheduled ones are best. "We tried to make it as nonintimidating as possible so staff have their own revelations and we aren't pushing it down their throats. We're not there to punish them. We're there to help them do their jobs better," she says.

For physicians who say they don't have time to prepare for emergencies, Toback points out, "If you do a couple mock codes that's only several hours for the year. There is no excuse for not having basic equipment or training." The next step for Wertz and Toback is to include EMS crews in the mock codes to determine response times to the office and to the hospital.

Zachary Goldfarb, who owns an emergency management consulting company in New York City and has been a paramedic since 1978, says that when an emergency response team is called, it can be very frustrating for the physician.

"When a paramedic comes through the office they're the ones that will do the follow through. The doctor will say, 'It's my patient and I'll take care of him,' but that's not going to happen," says Goldfarb. The physician may try to use the EMS crew's supplies and equipment or insist the paramedics take the patient to a certain hospital, he adds. "I have seen it happen on many occasions."

James Redka, a family practitioner in Williamsport, Pa., says in his 23 years in practice he has had several patients have heart attacks in his office and he has also started I.V.s while waiting for paramedics. The importance of being prepared for medical emergencies is not lost on him. "We're different from a department store and other businesses. We serve individuals with higher risks of having an event, and we have a responsibility to be prepared for it," says Redka.

Karen Gatzke can be reached at editor@physicianspractice.com.

This article originally appeared in the January/February 2002 issue of Physicians Practice.