Urgent and emergent situations in the clinic

[Love2Sleep, BSN, RN]

I was wondering if you all could tell me about all the urgent and emergent situations that you have encountered in your clinics? I interviewed for a position in a family practice clinic, and if offered the position, I would like to prepare myself for all emergent situations that may arise, and how to handle them. Coming from inpatient nursing, I know these situations are handled differently in the clinic setting.

Thanks!

[Lemon Bars]

I've worked at a rural family practice clinic for the last five months. For emergencies, we call 911 and get the patient ready for transport by ground or air ambulance. We have epi, nitro, and a few other emergency meds. We put patients on oxygen, do EKGs and occasionally start IVs. It is 30 minutes drive to the nearest hospital where we are. Since I have been here we have dealt with anaphylaxis from a wasp sting, several abnormal urgent heart rhythms, indigestion that presented as chest pain, and some elevated blood pressures that won't come down with meds. Any type of real emergency is sent to the hospital either by ambulance or sometimes by private car if the patient has a driver and refuses the ambulance transport.

We also do minimal urgent care here, because our providers are generally booked up and we have no provider available for urgent care. We get people walking in asking for help, but if they are not established here as a patient they get sent to an urgent care clinic or a local emergency room. We will do some minor wound care, though. As the RN, I do triage for most of these situations, consulting a provider (MD, NP or PA) if they are available and if it's an urgent situation.

I would say that, in my clinic, good triage skills are more important than good emergency medicine procedure skills. But if you work at a clinic that offers urgent care, you may do more wound care, etc. I hope that helps.

[lpn164]

We don't have any alert system in our office but as a whole we have different teams, I am not sure how each team operates however my team (2 LPN's, and 1 MD) have an established plan if needed. We currently will have one person preferably the MD stay with the patient in distress while one calls 911, 1 LPN gets the AED & oxygen upon returning I am on chest compressions if CPRis needed, MD is on bag mask, while other is helping with 911/AED/family members/minutes/ with a plan to rotate every 2 minutes of chest compressions until 911 arrives. I have mentioned in the past a practice scenario and suggested each team also plan and practice this to avoid chaos and delaying CPR, however my management has done little to follow up which is why my team developed the plan we have as for-mentioned.

[2BS Nurse, BSN]

Call 911, alert staff and keep up on your BLS skills. We've done chest compressions and put on the AED more than once. It happens in the least expected areas.

On 12/22/2019 at 11:14 AM, 2BS Nurse said:

It happens in the least expected areas.

100% . We had a dad code in our waiting room while he was waiting for the baby's appointment. Terrifying. Thankfully he was OK in the end but very scary and of course totally unexpected.

[kholl]

When I started in Primary Care, I was really worried about being the only nurse around in an emergency and not knowing what to do, but I found that I was actually really well prepared by my training.

Just remember that your job is triage and, if needed, Basic Life Support. You're not there to diagnose the patient or do ACLS interventions. I see providers and nurses overthinking and throwing medications at the patient in code situations all the time, and it's really not appropriate. Start with ABCs, that should tell you if you need an epipen or AED. If those are fine, put on some O2 and check vitals, blood sugar, neuro assessment. You may decide the patient needs narcan or glucagon, otherwise get ready to handoff to the paramedic. Most of the time, it's that simple.

Don't sweat it, you're more prepared than you think.

[DinoNurse, BSN]

Anyone have any good resources for advancing triage skills? I recently switched from inpatient to ambulatory, and it's such a different world!!

For instance, a patient with 102 fever, vomiting, headache, cough, no abd pain. Is it the flu, something GI? I know I'm not diagnosing the patient, but Where should she go?! Telehealth visit, to avoid spreading flu if that's what it is? Urgent care? ER? Sigh. I feel like I should know this but I question myself all the time!

[2BS Nurse, BSN]

I would say "it depends on your urgent care". We are all so different. Some urgent cares are true walk in clinics that only accept colds, sore throats, etc. Others can place patients on cardiac monitors and accept chest pain, severe abdominal pain, etc. It's an ambiguous field and we dont communicate well with our ERs.

[T-Bird78]

We’re ENT so our big ones are uncontrollable nosebleeds. I had a child bleeding in one room, assisting the physician and trying to calm mom, and a coworker came to hold pressure as I updated the next room. The guy in that room yelled about the wait and I apologized, explaining we had a child who was bleeding uncontrollably and were waiting on the paramedics. The guy yelled that he didn’t care, he was tired of waiting, but refused to reschedule his appt. You’ll be fine with the emergency, just be prepared for the other pts in there because they’ll complain about having to wait. I tell people that I’d rather be delayed, than be the cause of the delay. Yes, you had to wait 30 minutes, but you could have been the person we were working on for that 30 minute time span. Oh, and to his credit, the guy did come back later and apologize. And the kid was okay.

[RN John]

at our urgent care clinic in Northern California we have 4 providers doing appointments and 1 provider doing walk in's.  Our response to emergent situations used to be that someone would yell down the hall and half the staff would come running.  I was able to help put together a rapid response protocol for our office that works very well.  We have 6 walky talkies given to specific staff with specific roles: Front desk, Walk in provider (leads the response), Nurse(responder 1 leads response in absence of provider), head MA(communicates with EMS or ER), and 2 other  MA's (responder 2 and runner) as secondary responders.

when an emergent situation occurs the rapid response is activated and nurse and walk in provider go to the location of the incident and assess the situation and call for backup if needed.  This keeps the response professional and prevents a clog up of people standing around.  It also communicates to the key staff who have walky talkies what is going on and equipment such as the crash cart or AED can be requested quickly and secondary responders can be activated as needed.  One important part of the protocol is to debrief all of the staff after an incident to find out how things went, what went well, what could go better and make improvements to the plan at that point.  

This has transformed how we respond to emergent situations for good.

[2BS Nurse, BSN]

First of all, I'm impressed that they would spend the money on walkie-talkies. Mostly, I'm floored that your organization would allow for debriefing time! Also, most of our providers would run in the opposite direction. ?

[RN John]

The walk talkies were about $50-60 on Amazon and work well. I'm the only nurse at the clinic and have been able to create some of the protocols, its been a real blessing to have the freedom to have input and transform the way we do some things.  Also our providers interact well with staff, I think better than most institutions. We only have 1 or 2 providers who would be uncomfortable running a response, in that case I try to talk through the response steps and assessments with them to help me keep my mind focused as well as theirs.