Is your code cart ready?

My schedule was pretty empty during my first few months in practice; it took some time for the word to spread that there was a new doctor in our small logging community. To relieve the boredom, I passed the time with whatever projects I could conjure up.

As I went about organizing the office, I came upon an object that was at first unrecognizable. Underneath a thick layer of dust, a pile of syringes and tubing, lay an ancient defibrillator. A brief survey of the drawers underneath this dinosaur revealed vials of epinephrine and atropine and a bag of IV fluid that had expired two years earlier.

None of the staff could remember the last time they'd been called upon to perform in a critical situation. Office emergencies are fairly rare events and the literature on the subject is very sparse. One study looked at the frequency of emergencies at pediatric primary care clinics in rural Vermont. There was less than one a year. Perhaps that's why many physicians don't consider it a priority to have a code, or crash, cart. While I haven't seen a study on the percentage of offices with code carts, two major cart vendors said that they limit their business to hospitals because many physicians aren't interested in buying. But even though office emergencies are rare, they do happen, and when they do, being organized and prepared is essential, especially in our extremely litigious society.

What's the goal of the care you'll provide?

First, determine whether your goal is to handle each emergency until the bitter end or merely to provide treatment until the EMTs arrive and the patient can be taken to an acute care facility. In evaluating how extensive your cart needs to be, consider proximity to the nearest hospital, the skills and training of your staff, and budgetary constraints. A dermatology practice in a large office building with an urgent care center down the hall will have different needs than a remote family practice an hour away from the nearest hospital or EMS. The dermatology practice may just need to do basic life support (BLS) where the remote family practice may need to prepare for the mega code.

Most practices probably fall somewhere in between, as does mine. The fire department is about a half-mile down the road, but small town resources being what they are, a 911 call from our office may not bring the most rapid response. The nearest hospital is about 10 miles away. With an office staff of two physicians and three LPNs, we have sufficient skill to do more than just BLS, but not enough to conduct a much more extensive code.

I decided that my goal of care would be to manage a high quality first 10 to 15 minutes of the most common emergency situations. Beyond that, we would need help and would likely have it by that time.

Survey the spectrum of potential emergencies

Next, I made a list of emergencies to prepare for based on our patient population. We care for patients from womb to tomb, so a variety of situations came to mind. In addition to the precipitous delivery of a baby, I determined that adult acute coronary syndrome, adult cardiac arrest, pediatric respiratory failure, seizure, and anaphylaxis were the diagnoses I would want to begin to treat within the initial 15-minute period. While airway management ranges from the basic jaw thrust to full endotracheal intubations, even advanced airway management could be needed prior to EMS arrival.

I considered but deleted rapid atrial fibrillation, florid congestive heart failure, and severe dehydration, reasoning that there would be time to transport the patient 10 miles away. A more remote office might want to prepare for these emergencies, while the office with an urgent care center close by may not want to treat an acute coronary syndrome or some of the other diagnoses that I included.

Don't feel restricted to the potential emergencies that may occur within your fairly narrow patient population. For example, you may need to treat parents or grandparents who have accompanied patients to your office.