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Suhad Hadi has nothing to disclose.
START OF CLIP
MALE SPEAKER: Now, I’ll ask Dr. Suhad Hadi to come to the podium. Dr. Hadi did her training at the University of Texas System. So, you know she’s a fabulous educator. Dr. Hadi is currently in practice at the Louis Stokes Veterans Affairs Hospital in Akron, Ohio. She is working with residence now at the VA. She serves as the Director of PAVE and she’s at the VA Hospital now. So, I’m going to ask Dr. Hadi to come up and she’s going to talk about office emergencies.
Please welcome Dr. Hadi.
SUHAD HADI: All right. So, we’re going to shift gears a little bit and talk about office emergencies. How many residents are still are in the audience? How many of you have had a first-hand deal with an emergency in the office? Cardiac arrest, syncope? No one? Two people? Okay.
I have no disclosures. We’re going to talk about, again, the importance of how you prepare your office. We had a great talk on building an office and some things you can do in your office to be prepared for emergencies, because when we look at the statistics, we’re going to see that they will happen.
My clicker is not working there. Okay.
So, how often do you think office emergencies are encountered? You’re going to see something at least once a year and on average, up to eight times a year. If I look back, I’d probably say it’s about five to six times a year that I have to deal with something… I don’t usually put syncope in my office emergency category, but it is. I’ve had to run one code in 22 years and that was plenty for me. But you will see these things. So, 95% of people in this study reported at least dealing with one office emergency within the past 12-month period.
When we look at children, those of you who… I’m in the VA. [00:02:00:05] I… when I was in private practice, I did see children. But when you do see children, the… it kind of... interesting studies. You’re going to see three to four office emergencies a year involving children. And the big thing with children is, about 60% of these patients are going to end up hospitalized because of the office emergencies. So, if you’re going to have an office that caters to all ages, you need to be prepared that this could happen to you when you’re treating these patients.
The other concern is that most offices are actually not prepared to handle emergencies, whether it’s not equipped, the training is not there, the team approach has not been established within the office, and that becomes really important. So, the big thing when you… again, I’m in the VA, but, of course, everybody is trained, BLS trained and we have a code team that comes to the rescue after you start initiating any treatment. But the big thing is, you’re going to want a team leader. And I look at you guys, if it’s your office, your practice, you’re going to be looked at as the team leader, the person who’s going to guide the emergency situation.
You’re going to want to designate somebody who is the event recorder. So, somebody should know that, “Okay, I need to record the time the event started and I need to record everything that we’ve done,whether it’s … we injected glucagon, we gave them a glucose tablet, we … the seizure started at such and such time and ended at this time,” you need a recorded.
You need to secure your area. So if you’re in your office and you have a waiting room, you need to secure that nobody’s walking back and, or disrupting the assessment of the emergency. If you’re in your office and somebody runs in from outside says “Somebody collapsed out front,” you need somebody who’s going to be directing the flow of traffic, directing flow of people.
These things need to be established amongst your group that what everybody’s role will be, and then you need to have somebody who’s in charge equipment, somebody that runs to get the AED, somebody that goes, and runs, and gets the EpiPens, somebody that runs, and goes, and gets, and knows where all of the stuff is.
The other piece of having a coordinated team so that this effort can go as smoothly as possible is to cross-train people, okay. [00:04:08:01] There shouldn’t be only one person who thinks to record or time keep, what if that person is not in the office that day? There shouldn’t be only one person who knows where we keep the EpiPens, or the glucose tablets, or things like that. So there should be cross-training amongst the teams so that everybody could fill every role. And remember, that team leader ultimately is going to be the person that says, “You’re going to do this, you’re going to that, you’re going to do this during this event.”
Practice protocol. Don’t wait until an event happens to see if everybody knows what they’re doing. Make it a priority to maybe once every quarter, twice a year, you run through protocol of emergencies. What are we going to do if there’s a seizure? What are we going to do if there’s a cardiac arrest, you know? Make sure everybody still knows their roles.
And then train and certify all your staff. I find it really interesting in a medical office when your front office staff is not BLS trained, or if they’re not… they do not know what to even do with an EpiPen or they don’t know what to do with glucose tablets. They should be adequately trained as well. Take the time to invest in your staff and it’s going to be the best thing for your patients. So, again, train and certify all of your staff.
What’s your part? Stay calm, the basics. You need to stay calm. If you have an air of calmness, the whole situation will go that much better, especially if you’re going to be the team leader in the event. Call 911. There are situations where don’t necessarily have to call 911 and we’ll go over that. Assess the patient. Take the time to assess the situation, the patient. But, briefly, it should be a 5 to 10-second thing. When we say assess, you’re not going to spend five minutes assessing a patient that you should have probably started compressions on. And then act quickly. The quicker you act, the better the response, the better the recovery for the patient. [00:06:00:00]
All right, so let’s talk a little bit about syncope. So syncope is divided into three categories, so neurally mediated, cardiac syncope and orthostatic hypertension, adults and children, nobody is exempt from a syncopal episode. Essentially what a syncopal episode is is transient loss of consciousness due to reduced cerebral blood flow.
In the office, we’re going to deal with mainly the neuro… neurally mediated syncopal episodes, vasovagal or situational. So we’re going to focus on those. Again, these are the most common forms of fainting, so syncope is essentially fainting. It is still a frequent reason for ER visits, although, you know, it’s relatively benign. A lot of syncopal episodes, especially in the office, do not need to go to the emergency room or have 911 called. It actually happens more in children than adults. And I’m in the VA now, so I mainly see adults. But I can say that most of my syncopal episodes were children. You pull the needle out, you try to give them a shot, they get so worked up, the situational episode, they’re crying and they’ll just pass out on you.
There’s usually a trigger that results in a drop in the blood pressure. So we talked about the needle, the white coat syndrome, all of those things. I will say more men have passed out on me than females. And if I think about it, they fall harder too. Often preceded by symptoms and sensations and ultimately, in these situations, you want to recline the patient. If your chair allows you to put them in Trendelenburg, you can. If they fall into the ground, you want to prop their feet up.
Situational syncope falls under neuro… under this category as well and it’s usually certain physical functions, if somebody’s coughing real hard for a long time, if they’re laughing or swallowing, that can cause a syncopal episode as well.
So we talked about symptoms that precedes, so a lot of times you imagine yourself in the clinic, you’re getting ready, say, they’re doing ingrown nail procedure. [00:08:02:07] You pull that needle out to give the person a shot. And all of a sudden they say to you, “Doc, I’m just kind of feeling hot in here. Is the room hot? I’m dizzy.” and you look up and they look all faint and sweaty. Just stop everything you’re doing. That’s… you showed them the trigger. They saw the needle. They’re telling you their symptoms, you can anticipate that, they’re mostly likely going to pass out on you. So you’re going to want to lay them down, elevate their legs, possibly get a cold compress onto their forehead, monitor the vitals, get someone to do the blood pressure, if you have a pulse ox, measure their oxygen. You can do ammonia and try to rouse them if they do fully pass out on you.
But these are transient episodes, so one to three minutes these patients are going to rouse again. You can sit them up, give them a minute to kind of recoup and often times, we kind of just go on and complete what it was we were going to do. We’re still going to do the ingrown nail procedure, maybe hold their hand a little more, comfort them a bit.
But usually, this doesn’t require you to start compressions and rescue breathing and all of that stuff, okay. Some people have an underlying medical condition that may complicate a syncopal episode and they may, you may end up having to do that, that’s a rarity, that is not the norm. But you have to be prepared for that, should that happen.
Seizure patients. So, again, adults or children, nobody’s exempt. Usually, there’s a history of epilepsy in most of these patients. Sometimes, they’ll get febrile patients, especially children if the fever is high enough, they’ll start seizing on you, a stroke patient, hyperglycemic or hypoglycemic events. This is where we start thinking a little bit more, you know, 911 might need to be in the picture for these patients.
The big thing, the symptoms fall, you make see erratic movements, the tonic-clonic movements, the head jerk, the eye flutter, and then you have to raise your suspicion of a seizure. The big thing is to protect these patients. So if you’re anticipating that this patient is seizing or about to start seizing more aggressively, you want to clear the area. [00:10:02:29] You want to protect the patient. You want to get them to the ground. You want to stay with the patient. Do not leave the patient. Usually, a seizure episode is going to pass.
The big thing with seizures too is you want to record the time; what time did the seizure start. This is where your staff comes in hand and they need to know if we’re dealing with a seizure, somebody start timing it. And the length of the seizure, how long it lasted.
You do not want to hold the patient down. Don’t try to forcibly hold the patient down and try to calm the movements. Okay? You want to lay them down. You want to protect them. Ideally, you want to get them on their side. You don’t want to put anything in their mouth. And you, again, no CPR here, okay? Do not do rescue breathing. Do not try to do compressions on these patients. The seizure is going to pass.
There are situations specific to a seizure that you do want to call 911. So… my H is gone in this first line but no prior history. If they’ve never had a history of a seizure, they arouse from the seizure, they’ve never had a history, they don’t know what caused this or why they seized, you really should get these patients to the emergency room and get evaluated.
If after the surgery they aroused but they’re having difficulty breathing, difficulty walking, they’re just not together there, you want to call 911. This is where your timing becomes important, if the seizure lasts more than five minutes, you should also have emergency services contacted. Say they seize, they sit down on the chair, they seem like they’re alert, they’re getting better and then all of a sudden another seizure kicks in. Your first impulse should also be to get these patients to the emergency room, or if they’re injured.
And the other thing is, if they have another underlying medical condition. So, these patients are diabetic, your seizure could be related to either hyperglycemic or hypoglycemic event so, you need to take that into account, and maybe even do a blood glucose stick once they are aroused, or if there’s pregnancy or some other condition that could complication the reasons for the seizure. [00:12:01:30]
I’m going to say that we all treat diabetic patients. So, I’m sure… I’m thinking in residency or in practice you’re going to get somebody who’s either hyper or hypoglycemic. I actually… it’s only went into hypoglycemia here. I don’t know what I was thinking, but hypoglycemic events are greater in type 1 patients than they are in type 2 patients, okay? The big thing is, too, is that up to 10% of deaths related to hypoglycemia and type 1 patients. So, it can be very serious and fatal for these patients to have multiple severe hypoglycemic events. When patients keep having repeated hypoglycemic events, their risk of a cardiovascular event increases to 80%. And then, so does their risk of cognitive decline or cognitive function decreases, dementia, all these risks increase.
And then, when a patient has a hypoglycemic event, we think, “Oh, we brought their blood glucose up. They should feel better. They’re going to go out and they’re going to function in society.” We see that with syncope. We actually see that with sometimes with seizures. But these patients, after a hypoglycemic event, their body has been taxed enough that it could take 24 to 48 hours for them to return to a normal level of daily function or really, they’re going to be fatigued and tired.
It’ll cost, on average, anywhere from $500 to $12,000 for the management of a hypoglycemic event. So, there is a socio-economic burden associated with not just hypoglycemic events. Any medical emergency to take into account.
So, with type 1, we do see some risk factors that are common with patients who have repeated hypoglycemic events. We see patients who’ve had history of that. Depression is a… has been found to be a factor of retinopathy and self-measurements. So, those patients who monitor like their own sliding scale, we all tend to see more of a risk of hypoglycemic episodes in these patients. [00:14:00:04]
In type 2, it’s usually food-related. So, you get that patient who has that early morning appointment, they’re used to taking their meds in the morning. So, they pop all their medications and they come to your office, but they were in such a hurry to not be late for your appointment because you’re going to turn them away if they’re late and they didn’t eat breakfast and they’re in your office and they are hypoglycemic. So, there are a lot of situations where food gets put on hold, but they always take their medication. So, that becomes a factor in type 2.
You get type 2 patients who… today, I’m going to exercise. I’m going to change my lifestyle. I’m going to go to the gym, go work out, go for a jog, and they take their medications and now, they’ve added something that’s burning the glucose in their body and what happens? They get hypoglycemic. Or patients who increase their insulin dose as well.
There are some commonalities between type 1 and type 2 in scenarios where we’ll see hypoglycemic events. And so, patients with chronic renal disease, the insulin in their body is… the clearance is slower or compromised. So, you might see hypoglycemic events in these patients. The elderly patients and patients who have co-prescriptions, so, somebody who’s on insulin and they’re also on oral agent and they aren’t quite juggling at well yet. And so, you will see hypoglycemic events in these patients.
So ultimately, these patients that you may treat the episode in your office, you definitely also want to them to follow-up with their primary care doctor so that the underlying ideology is addressed as well.
What symptoms are you going to see when a patient is hypoglycemic? They’ll come in, they’ll be clammy, they’ll be pale, they’ll be... they may express that they’re suddenly hungry, or they just look fatigued in the chair. I can tell you, every time a patient has been hypoglycemic in my office, it’s because I trained at UT, and we saw tons of diabetics, but I can tell you that, a patient sitting in my chair, and I can tell that they are hypoglycemic, because if you’re used to these patients, these patients become your regulars, you know how they normally look, even on their bad days. So if they look worse than that, you need to worry about a hypoglycemic event. [00:16:02:01]
I’m lucky we have a diabetes nurse who’s right next door to me, I just call her name and she comes in, and she is already checking the sugar, has everything that she needs for these patients.
The biggest thing when I was in charge of working with the residency program is when residents and students would come in and say, “Oh, I think Mr. so and so drunk today. I can’t even get the words out of his mouth.” And if I know the patient, or if I don’t know the patient, first thing is, are they diabetic, did you ask them if they took their medications today, did they eat?
And sure enough, when symptoms become severe in a hypoglycemic event, that’s the appearance these patients might have. Their speech is slurred, they’re confused, there are visual disturbances, they could lose consciousness on you, they could start having seizures. But a lot of times, these patients, they’ll talk to you like… literally, like they’re drunk or on something because they are just not themselves and they’re not together. And so your red flags need to be raised.
So what are you going to do? You’ve determined it’s a hypoglycemic event, you want to ideally raise the blood sugar level. So whether it’s an adult or a child, and then like we said, ultimately, get them to their primary care doctors so that the underlying cause can be adequately addressed.
Your goal is to dose what we call rescue carbohydrates in the clinic. So your clinic should have… I mean, we have peanut butter, we have crackers, we have glucose tablets, we have little cans of orange juice for them, and so these are things that are easily stackable in your clinic so that you have them.
So, ideally, 15 to 20 grams of a fast acting carb, you don’t want to give them something that is fatty or protein because that’s actually going to slow the absorption, if not, inhibit the absorption of the glucose into the patient’s system. So you’re going to… it’s going to take longer to see a response. Because, ideally, in 15 minutes, you want to recheck that patient’s sugar and you want to see that they have gone above 70, okay, on the glucometer. [00:18:05:16] but if they haven’t, after 15 minutes, you want to re-dose again, and then check again in 15 minutes.
When it’s children, you can easily employ the rule of 15s. And the rule of 15s, literally, you can give them 15 Skittles, you can give them 15 plain M&Ms, something that has sugar, give them 15 of them, kids will be happy to eat 15 Skittles, my kids would, or 15 M&Ms, and you’re going to get their sugar up. But, again, you’re going to re-check in 15 minutes and make sure it comes up.
If it doesn’t come up fast enough, again, you’re going to call EMS. But another good thing to have in your office is a glucagon kit, okay. These things will cost… any of these devices that we talk about today are going to put out about $500 to $1000, but they’re an investment in your office and your patient.
So a glucagon kit, if you don’t see the sugars coming up, say, you tried glucose tablets or orange juice and you check two times and they’re still not above 70, you’ve called 911. If you have a glucagon kit, in adults, you’re going to give them one milligram injection, and in kids, you’re going to give them a half milligram and keep monitoring about every 15 minutes to see that their sugars have gone up. These are already pre-loaded. All you have to do is draw the syringe and fill it and give the injection. And you’re going to inject it in either the buttock, the thigh or the upper arm for these patients. And, again, monitor every 15 minutes.
All right, this is my worse one, cardiac arrest. How many of you had to run a code, give compressions, do an AD device? Yeah. That wasn’t like my scariest emergency, but I was a… I was a resident, so that’s back in the 90s, so I’m older. But we were in the OR, doing a case and the patient coded, the anesthesiologist looked at me and said, “Start compressions.” My attending and co-resident ran out of the room and they’re watching from the window, the OR door and I’m doing compressions and anesthesiologist is running the code, we’re following his lead, the nurses are there recording. [0:20:06:07] And, luckily, the patient resuscitated, but, you don’t know.
I have a friend who happens to be an ER doctor, it’s actually my cousin, out jogging one day, a guy collapsed in front of him, he is running a code, send someone to get the AD, you don’t know where you’re going to encounter these emergencies. And they will walk in your office a lot of times as podiatrists. Our population is a sick population.
So every 90 seconds, somebody dies from a cardiac arrest and 360,000 deaths per year. Remember, cardiac arrest is a rhythm problem, so essentially no blood is pumping to the heart or… through the heart and to the body and to the brain, versus an MI where you have a blockage and there is some degree of pumping going on, but a section of the heart is not receiving blood flow. This is a medical emergency, you call 911, you don’t even think about it.
So with these patients, you’re going to check the patient’s breathing and pulse, call and send for help. And you… the first thing you want to do is start compressions right away. So it’s actually important to get the blood, get into the brain and have it pumping. The key with compressions is the depths, so it’s two inches, depth compression and important piece is the recoil. If you don’t allow appropriate recoil, the heart’s not going to fill, your next compression is not going to send as much blood as it can to the brain and to the rest of the body. And then you give two breaths and you repeat the cycles.
Now what do you do if you see the person collapse in front of you and you have help, you’re going to send somebody to call 911 and you’re going to start CPR. They’re going to come back and you’re going to two a two-person rescue until your EMS arrives.
What if the person’s collapsed then you walk in? Are you torn? Do you call 911 first? Do you address the patient first? You always assess the patient first and you want to do at least two minutes of CPR before you leave the patient because you don’t know how long they’ve been down and you want to get the blood moving. [00:22:00:00] Two minutes of CPR and then you can go leave the patient, call 911, come back and then resume CPR.
Okay, so, this came up yesterday AED devices. They’re so self-explanatory and if you have if you have access to one, you have a 40% greater chance of saving a person’s life, okay? So, this is another worthwhile investment, $1,500 in your office to have because you’re going to increase the chance of saving a life by 40% by using this.
All you’re going to do is keep it charged, you’re going to turn it on. Hit the on button when it comes and it’s essentially following the prompt after that. It’s going to talk to you and tell you what to do. Because you’re going to… it’s going to tell you to apply the pads. The pads come with pictures so you know exactly where to place them. And once it tells you that it’s analyzing the patient, you’re going to stop the CPR you’re doing, while if you have two people rescue going on, you can actually put the pads on while you’re still giving compress… actively giving compressions so you’re keeping the process going. But once, the AED starts to analyze, you’re going to step back, let it analyze. And it’s going to tell you, shock the patient, you’re going to clear and shock the patient or no shock is necessary and you’re going to resume CPR. It’s going to pretty much guide your whole rescue effort. And again, I can stress the 40% chance if you do CPR and an AED together of increasing… of saving their life.
After every emergency, ideally, you want to get the patient to recovery position. Seizure patients, you want to get them immediately on their side. But after they’ve recovered and if they’ve rebounded, you want to… if they’re lying flat, you simply bend the knee through the same side arm over the chest and roll the patient gently over to their side. And just stay with them until EMS arrives, or until they can get up on their own. So, I think that’s it.
So, when you call 911, make sure you have… give them your name, location. Make sure you give them the patient’s name. Make sure when they arrive, you are able to tell them because you have a recorder in your office, recording the events. How many glucose tablets did you give them? [0:24:02:16] Or what time did the seizure start? When did it end or, you know, how many chest compressions have you given? How many shocks did you give them? Be… everything gets recorded. The whole event, from beginning to end because it’s going to make the work on the other side that much easier for the EMS when they do arrive if it is a situation where you had to call for EMS services.
So, again, be prepared, stay calm, call 911, assess, act, and prepare your office for this because one emergency per year and anywhere up to eight, you’re going to see it. All right. Or you could do what my kids do, just call mom. [Laughs]
All right. Thank you.
END OF CLIP