Download 1430_Stiller_GF4E7

911:
What’s Your (phlebology office)
Emergency?
Sonja Stiller, MD
Center for Advanced Vein Care, LLC
Mentor, Ohio
ARE YOU READY?
Case #1
78 year old gentleman referred to you by his cardiologist for evaluation
of his leg edema. He is sitting in the waiting room with his daughter
filling out ‘new patient’ forms for his first visit.
You hear a commotion from the waiting area and someone yells
‘HELP!”.
• He is lying on the ground staring up at the ceiling
• Becomes agitated, starts reaching for something
above his head with his right hand and has garbled
speech
• He has a left facial droop and is not moving his left
arm or leg
ARE YOU READY?
Case #2
A 54 year old female, who is 5’2” and weighs 280lbs, is having her
initial vein mapping done by your ultrasonographer, while you are in
another room with a new consult.
Your office manager pokes her head into your room and says ‘You are
needed in the ultrasound room’ – and then she runs down the hall.
• She is sitting in a chair next to your ultrasound stand and is leaning
against your ultrasonographer
• She is listless, diaphoretic and her lips are cyanotic
• Her head droops down and she becomes unresponsive
• Next, her eyes roll back, she becomes incontinent of urine and has a
full body seizure that lasts approximately 20 seconds
• After the seizure, her breathing is sonorous and she appears even
more cyanotic
ARE YOU READY?
Case #3
A 49 year old female is at your office for her first ultrasound guided
sclerotherapy session for bulging varicosities after EVLA. She is
otherwise healthy, runs marathons ‘for the fun of it’, has a 10 year old
son at home, and is a lawyer. She is a bit nervous about the procedure.
After the first injection, she says “Hmmm, I think I’m getting some
chest pressure. Wow, I’ve never felt anything like this before…”
She starts rubbing her chest and becomes increasingly anxious.
ARE YOU READY?
Case #4
You step out of the office to grab a cup of coffee. When you return,
your staff is anxiously looking out the window. You ask “What’s up?”
and they tell you that a previous patient had just come in to deal with a
bill. He was apparently acting erratic and ‘out of control’. He slammed
the door as he walked out and now he is pacing in the parking lot,
yelling and waving his arms.
When you look out the window, you see him reach into his car, grab
something and put it in his pocket, and now he is walking back toward
your office door.
ARE YOU READY?
What makes EMERGENCY situations run ‘SMOOTH’ in the
hands of the ‘experts’?
• Planning
• Training
• Written Protocols
• Appropriate Tools
Planning and Training
Considerations:
1. Setting: Hospital? Free standing clinic? Medical Office Building?
2. Procedures performed and medications/anesthesia used
3. Requirements based on #1 and #2: BADGES required determined
by:
1.
2.
3.
4.
State regulatory agencies
Insurance companies
Hospital affiliations
Your legal friends (personal and patient lawyers)
4. Experience: your team is only as strong as your weakest link
5. Risk for non-medical emergencies in your practice area
Planning and Training
Medical Emergencies:
Potential BADGES that can be earned, and may be helpful:
First Aid
BLS/CPR
ACLS
Planning and Training
To Get or Not To Get?
Should you just call 911 and leave it to the ‘experts’?
Considerations:
1.
Setting: Hospital? Free standing clinic? Medical Office Building?
2.
HOW LONG WILL IT TAKE TO GET EMS OR A CODE TEAM TO YOUR LOCATION?
3.
Procedures performed and medications/anesthesia used
IF YOU ARE USING MEDICATIONS THAT PUT A PATIENTS BREATHING AND VITAL SIGNS IN
4.
BADGE Requirements required determined by outside sources
5.
Experience: your team is only as strong as your weakest link
YOUR HANDS – WHAT DO YOU THINK?
Non Medical Emergencies:
Violent individual (patient or non-patient)
Fire
Weather emergencies
The actions taken in the initial minutes of an emergency are critical. A prompt warning to employees to evacuate, shelter or lockdown can save
lives. A call for help to public emergency services that provides full and accurate information will help the dispatcher send the right responders
and equipment.
Initial goal: Preserving life – of patients, visitors, staff and yourself
Second goal: Stabilization of your environment
Third goal: Minimize damage
https://www.ready.gov/business/implementation/emergency
Planning and Training
Other Training:
1. Drills – learn by reading, talking, doing, PRACTICE
2. Make sure NEW HIRE’S know about this!
3. Establishing roles - cross training!
4. De-escalation training, crisis intervention training
5. Developing protocols
- if you are not GIVEN a protocol, work as a team to make protocols that
work for your scenario. This will allow incorporation of ‘lessons learned’
and ‘best practices’ built off the experience of the team.
-samples of protocols
Intersocietal accreditation commission: http://www.intersocietal.org/vein/seeking/vein_standards.htm
American Heart Association: http://www.heart.org/HEARTORG/
Homeland security website: https://www.ready.gov/business/implementation/emergency
Written Protocols
Why have WRITTEN POLICIES (of any kind!)?
1. All employees – including new employees – need to understand
that there is a process to ensure proper steps are taken in any given
task.
2. Ensures consistency in practice
3. Sets an expectation for employee behaviors and should provide an
outline of step/actions expected.
4. Serves as a training tool
5. Gives your staff a ‘safety net’ (remember your team is only as strong as your weakest link!)
Law #3
“At a cardiac arrest, the first procedure is to take
your own pulse”
The Fat Man
The House of God, by Samuel Shem
Written Protocols
What do you do with those protocols?
A) put them in the dust covered policy and procedure manual on
the top shelf in the staff lounge?
B) put them in easily seen locations (posted next to work
stations, computers, crash carts…) in staff work areas
C) post laminated, colorful post-its of steps of action (that can’t
be missed) in key locations in the office
D) review and practice the protocols with your staff on a regular
basis
E) all of the above
Written Protocols
Tools
What Should be in your ‘tool chest’, aka Crash Cart/kit?
IAC Standards for Vein Center Accreditation (section 2.2A):
Emergency equipment and supplies must include, but not be limited to:
i. emergency cart/kit;
ii. oxygen;
iii. defibrillator/automated external defibrillator (AED);
iv. emergency drugs (including a master list with verification of expiration date).
All emergency equipment must be clearly labeled and be for emergency use only.
Emergency equipment and medications must be secured with a disposable plastic lock
Intersocietal Accreditation Commission: http://www.intersocietal.org/vein/seeking/vein_standards.htm
http://www.intersocietal.org/vein/standards/iacveinstandardsaug2015.pdf, accessed September 2016
Tools
Oxygen must be inspected by authorized personnel every six months.
Defibrillator/automated external defibrillator(AED) testing and maintenance per the
manufacturer’s specifications, which must be documented.
Required supplies must include at a minimum, but are not limited to:
blood pressure cuff(s);
stethoscope;
A flashlight/extra batteries;
bag-valve-mask (AMBU) for resuscitation;
oxygen
nasal cannula for oxygen administration
oxygen mask
nasal airway
needles and syringes
http://www.intersocietal.org/vein/standards/iacveinstandardsaug2015.pdf, accessed September 2016
Tools
Listed suggested supplies:
Intravenous solutions and supplies.
Required minimum medication(s):
Epinephrine 1:1000, 1 mL (2 ampules) OR Epi-Pen (pre-dosed)
(2 pens);
Diphenhydramine 50 mg/mL (2 ampules);
(Optional) Diphenhydramine elixir/solution 12.5 mg/5 mL (1 bottle);
(Optional) Diphenhydramine HCl 25,50 mg caps (1 bottle of each);
Methylprednisolone 125 mg (2 vials);
Aspirin (325 mg, uncoated).
http://www.intersocietal.org/vein/standards/iacveinstandardsaug2015.pdf, accessed September 2016
Other Tools
• Emergency Contact lists (non-911 numbers)
• Evacuation Plans/Disaster Plan
• Panic Buttons
• Door bell/intercom system
• Code words (aka, code Adam, code Blue, code Violet, code Hercules..)
• Generator
• Battery Back-up for equipment
• Fire extinguisher
“By Failing to Preparing,
You are Preparing to Fail.”
- Benjamin Franklin
Thank You!