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We have compiled our tips in a single document if you prefer that format. The PDF can be downloaded here.
ER Tips and Tricks are a series of hands-on, focused guidelines intended to assist community FPs in making decisions about which patients should be referred to the ER. The tips help FPs make ER referrals more effective or avoid them entirely by providing protocols for treating and assessing patients in the community first. Tips and Tricks subjects are determined by a group of ER and community physicians, based on the experiences of both.
When your patient has an imaging test showing a new serious abnormality (i.e., cancer), they will be directed to the ED to have the results reviewed by the ED physician.
This often means your patient will be told about their new serious health issue by a complete stranger in a loud, rushed environment, which is not a great experience for either the patient or the ED physician.
What can you do? Write “Patient to follow-up with FP for results” on the imaging requisition if you are concerned about a serious result in a NON-life threatening situation.
If you have a patient in atrial fibrillation of unknown duration, take a step back and ask yourself, “What can I do for them right here, right now?“
TIP: Send your patient to the ED if they are UNSTABLE:
Everything else can be handled by you and your friendly neighbourhood cardiologists! Don’t forget that the Atrial Fibrillation Clinic provides a very thorough service for patient education and management. You are not alone!
TRICK: Read the UpToDate section on New Onset of Atrial Fibrillation available through the VDFP website (an excellent resource), or check out this video.
Did you just get a call from the lab about a critical INR while you were heading out the door to have dinner with your family? Here’s a quick guideline to get you started
TIP: Critical INRs made easy:
If there is any bleeding with an INR >3.6 your patient needs assessment at the ED.
Haven’t been able to get vitamin K in the community? Call any Shoppers Drug Mart and order vitamin K 2.5 mg (1/4 ampule) orally.
Useful resources:
Community family physicians can often deal with minor lacerations and minor I+Ds of infected cysts or abscesses in the office, even in children. It can throw your schedule off kilter, but it’s a good chance to keep up those procedural skills!
Don’t be afraid, and make use of your office staff to support you!
TIP: If you think the patient needs sedation for the procedure, keep them NPO and send them in to the ED.
TRICK: If you feel you would like to improve your skills in lacerations and I+Ds (we all get a little rusty on some things), check out St. Paul’s CME courses on ED or Rural Family Practice – they often have hands-on sessions dedicated to improving procedural skills.
Ever had a situation where your day is packed and someone in the waiting room is REALLY sick?
Your full assessment, including vitals and physical findings, is valuable – it helps the patient to know they are being cared for and is very helpful for the ED doc.
TIP: Put your diagnosis on the referral form to help the ERP know what you’re thinking.
TRICK: If you already know the diagnosis and think they need a specialist, contact the on call specialist directly (through the switchboard) to avoid a lengthy wait in the ED.
For those of us who don’t do obstetrical medicine, seeing a woman with a first trimester bleed can be stressful and perplexing. Sometimes, the ED is just the right place for her to go, but often FPs can safely manage the initial evaluation, which is especially important to patients at a highly emotional time.
If the patient is in their first trimester and has light or moderate bleeding with cramping similar to a period:
TRICK: During regular office hours, the Vancouver Island Women’s Clinic takes referrals to evaluate, monitor and manage miscarriages. They usually see patients within 1-2 days of your call.
Who to send to the ED?
TIP: You really need the ultrasound for dates to properly evaluate bHCG. A serial bHCG that does not rise by at least 50% after 48 hours is concerning PRIOR TO 8-9 weeks GA, when the levels can plateau and slightly decrease.
TIP: Rh factor should be done at the HOSPITAL lab, as Life Labs results can take up to a week. RHIG (WinRHO) should be administered within 72 hours through the Vancouver Island Women’s Clinic, the VGH CFAU, or the ER if required.
What about On Call?
If you get a call from a patient after hours, this workup can be arranged for the following day when you are back in the office, with instructions to go to the ED if things worsen.
Helpful resource:
We’ve all had the awkward and frustrating experience of trying to look UNDER someone’s eyelid. There are several available techniques – grab the eyelashes, flip the lid over a Q-tip/stick, etc. – with varying degrees of success.
Check out this minute long video on lid eversion techniques created by UBC Medicine.
True story: Our main boat motor had broken down so we had to putt along for 4.5 hours on our little motor with a nine and six year old squeezed somewhere in between a week’s worth of gear. At the fairly squirrelly four-hour mark, I looked over at our six-year-old son, who was silently grinning from ear to ear with two brown almonds just barely protruding from his nostrils….
It remains a mystery WHY kids put things in their nose, but it is no longer a mystery how to get it out! Check out this family-involved technique for removing a foreign body from a child’s nose using a parent’s “kiss.” It works about 60% of the time, but should always be done under medical supervision due to the risk of aspiration (as with any removal of foreign body) and the theoretical risk of barotrauma to the ears and lungs.
How to perform the ‘parent’s kiss’:
TRICK: If the parent cannot perform the procedure, you can perform the same process with a bag-valve-mask. Ensure the mask covers only the childs’ mouth.
See www.racgp.org.au/afp/2013/may/mothers-kiss/ for more information.
Who knew the ubiquitous alcohol swab could help nauseous patients feel better! How easy is it? Sit your patient down with an emesis tray at the ready. Have the patient do three nasal inhalations (in through the nose – out through the mouth) from an opened alcohol swab every 15 minutes, with 2 repeats if necessary.
The use of inhaled isopropyl alcohol has been well-studied in anesthesia literature showing at least a 50% decrease in the severity of nausea within 10 minutes, which is 20 minutes faster than IV ondansetron! Even a 2012 Cochrane Review concluded that isopropyl alcohol was effective in reducing the need for rescue anti-emetics; but it is NOT RECOMMENDED IN CHILDREN as it just too noxiously stinky for kids. With no reported adverse reactions in adults, this inhaled vapor is extremely cheap and readily available.
Want to know more? Visit www.aliem.com/2015/trick-trade-isopropyl-alcohol-vapor-inhalation-nausea-vomiting/
Head injuries in children have to be one of the most upsetting situations for parents and caregivers; making assessment, accurate treatment and giving appropriate instructions for observation extremely important.
GCS following head injury is typically the parameter used to assess severity. A child presenting with GCS under 13 or declining GSC should be sent to the ED and will likely undergo further work up with imaging. For a child with GCS 14 or 15, providers must use clinical reasoning to decide whether the risk of radiation from CT head outweighs the risk they of developing a significant traumatic brain injury. It should be noted that children under the age of 2 are assessed on different parameters given differences in presentation, anatomy/physiology etc.
Patients with minor head trauma who meet all of the following criteria may resume normal activity:
What defines minor head trauma?
If <2 years old
If > 2 years old
If you have classified your patient as having a minor head injury, you must now decide whether they can be safely discharged, require further observation or should be sent to the ED for a CT head and possible intervention.
There are 3 clinical decision making tools with different sets of criteria that can aid in that decision making:
The PECARN rule was tested to have the highest sensitivity (100%) and the CHALICE rule with the highest specificity (85%), therefore encouraging PECARN to be incorporated into practice to limit missing significant TBIs.
Based off the decision tool and combined clinical gestalt, if the recommendation is no imaging or observation, the following resources are recommended for caretakers
Here are some helpful resources for managing head injuries in children:
‘Tis the season of the ABCs – Asthma, Bronchiolitis and Croup.
Our ED colleagues have shared a GREAT Canadian website for assessment and treatment of pediatric medical conditions: www.trekk.ca. You don’t need to log in – just type and search for great, concise recommendations.
Here are a few highlights from the Trekk website:
TIP: For kids with a moderate ASTHMA exacerbation, consider adding a single dose of oral dexamethasone (0.15-0.6 mg/kg) to their inhaled regimen. This has been shown to significantly decrease respiratory distress within 2-6 hours and decrease admissions to hospital. (Link to a scoring tool for mild-moderatesevere also on the website).
TIP: BRONCHIOLITIS most commonly hits your really young patients – mostly under age two, but especially under 12 months. If you have a child less than 12 months old, with a first episode of wheeze in the winter months, it’s likely bronchiolitis and should NOT be treated with Ventolin, Atrovent, inhaled steroids, antibiotics, hypertonic saline or systemic corticosteroids. SUPPORT a to ensure adequate oxygenation and hydration is the main treatments.
TIP: For that youngster with acute onset of barky cough, CROUP is the likely cause. New recommendations state that ALL kids with croup should have a single dose of oral dexamethasone at 0.15-0.6 mg/kg (max 12 mg). Nebulized epinephrine is only required if stridor, modsevere increased work of breathing, or agitation. Red flag features: drooling, significant pain, low O2 sat, outside normal age range, not improving with treatment.
Tip: Do you have a young child in your clinic who does not seem to want to use their arm after a pulling injury? Maybe they were with a caregiver who grabbed the child’s hand to prevent them from falling or maybe they were playing with a parent who was swinging the child. They might have a radial head subluxation (A.K.A. “nursemaids elbow”)
Trick: If the accident was non-traumatic and there is no neurovascular compromise, bony pain, or edema, you might have all the tools you need to get the little one back on with their day! In a radial head subluxation, some of the annular ligament is displaced into the radio-humeral joint space. Scan this QR code on your phone to watch this quick video for an example of how to quickly and easily reduce the dislocation.
An asthmatic comes to your office wheezing and struggling to breath! Yes, the ED is the best place for one of these patients who may be suffering from a life-threatening asthma attack. While you wait for EMS to arrive, here is what you should do:
Tip:
Trick:
Long before any asthma patient arrives at your office experiencing respiratory difficulties, it is important to take stock of what you have on hand to rapidly relieve their symptoms. Be sure to have Ventolin with a chamber, oral corticosteroids and controlled oxygen (tubing and nasal prongs) in the office. It is much better to have them at the ready and never need them than to NOT have them when your patient with asthma arrives in distress!
Printed instructions for all types of inhalers are found on the asthma.ca website:
https://asthma.ca/gethelp/treatment/how-to-use/
Signed up for Pathways? Inhaler education videos are available on pathwaysbc.ca/ under Resources -> Patient Information -> Respiratory. You can email the videos directly to your patient from the Pathways website.
Looking for other personal/patient resources?
Your MOA has just fit in an 8 year old patient and her parents, stating that the child appears anxious with very swollen lips and eyes. When you see her, you note wheals and redness on her neck and chest. You are certain she is having an allergic reaction and are now on high alert for anaphylaxis. She complains that her tongue feels tingly and she is having some difficulty breathing.
Tip: Prepare Ahead!
This is when you jump into action and quickly grab the emergency kit you have prepared for events just like this. Ask your MOA to call 911.
Trick: You did it!
While your patient is improving and you are waiting for the ambulance to arrive to transfer your patient to the ED for observation, prepare and discuss a prescription for 2 EpiPens to have available for immediate use if this situation occurs again. It’s a good idea to have a practice kit in your office to let patients see and feel how to use it. Free kits are easily ordered at: www.epipen.ca/en/epipen-resources/epipen-starter-kit-and-organization-kit/order-your-starter-kit-or-org-kit
Book a follow-up appointment to review the proper use of the EpiPen and explore what allergen may have precipitated this event.
Here is a video demonstration that will help you teach your patient and her parents how to use an EpiPen.
Do you have a patient who is 15 years of age or older, needs once daily IV antibiotics but is not requiring hospitalization? The OPAT clinic might be the perfect spot for them!
OPAT is also the contact point for outpatients who may be eligible for home IV therapy. This program provides assessment, education, and support for patients undergoing intravenous therapy who could recover at home.
Does the patient need to be seen TODAY (which may mean a first dose through the ED if outside clinic hours) or can they wait until the next morning to be assessed at the OPAT clinic?
The clinic is open seven days a week from 7:30 am-1:00 pm; however, new referrals are not taken on weekends or statutory holidays. Patients need to arrive at the clinic at 7:30 am for their first appointment but subsequently are given scheduled appointment times.
Frazzled and frustrated trying to figure out which specialties have clinics you can refer your patients to? It’s hard to remember which services have to be arranged through an inpatient MRP and which community FPs can refer to regardless of what privileges they hold.
Well, good news! The Victoria Division’s Pathways site lists over 20 outpatient clinics that you can refer to directly. All you have to do is log on to Pathways and search the word “outpatient”. Easy!
Clinics include:
Trick: You can also find these clinics by searching for a specialty under the ‘Select Specialty of Service’ (e.g. find the Pulmonary Function Lab under Respirology).
Tip: Pathways contains information about clinics that are physician-led. Allied health clinics, such as the Tall Tree Concussion Program, are not included (for more information on that program and to access their resources, you can visit their website at concussion.talltreehealth.ca/doctors).
So how do you access Pathways? If you don’t already have a log in, you can contact Cherith Golightly at [email protected]. She will get you set up!
Physician Connectors (250-519-5282) is another great resource that provides a single point of access for FPs to help patients get connected with Island Health programs and community health programs and services.
Truth, or myth? “ED Physicians can get any imaging studies done sooner than physicians outside the ER.”
Myth!
The TRUTH is that aside from truly life-threatening situations (ask yourself: is my patient going to DIE TODAY if I don’t get this imaging done?), ED physicians have the same access to x-rays, ultrasounds, CTs, and MRIs that community physicians have.
TIP: DON’T send patients to the ED to “get your imaging test done more quickly,” because all it will give your patient is a very long wait ending in frustration and distrust.
TRICK: SAME-DAY CT is available for life-threatening conditions without sending your patient to the ER. Fill out a regular CT requisition, give it to your patient, and make sure they arrive at either hospital before 3pm -they will be slotted in when a spot is available.
Ouch! A patient presents to your clinic with a sore, throbbing finger due to a subungual hematoma after slamming it in the car door this morning.
TIP: If the patient has intact nail folds and the injury occurred in the past 48 hours all you need is an 18-gauge needle and 5 minutes to have that patient feeling a whole lot better!
TRICK: The trick to relieving painful pressure caused by the subungual hematoma is to make a small hole in the nail to allow blood to escape. This is called nail trephination. To create the hole twist a large bore needle with gentle pressure into the nail above the lunula. You will know that you are in the right spot when blood begins to escape and the patient feels some relief. Typically a digital block is not required for this procedure.
Don’t forget to consider if tetanus prophylaxis is required for this injury. If you are concerned about a possible fracture order an xray as prophylactic antibiotics may be required.
For more information:
Nosebleeds can be scary for patients… Fortunately they are usually not serious and with the right care most will stop on their own.
TIP: How to manage an active nosebleed:
Assess ABCs. If unstable seek immediate emergency care and urgent ENT consult. If stable, attempt conservative measures: Have patient clear clots by gently blowing nose Have them lean forward Next, they should pinch the cartilaginous portion of their nose for 20 mins x 2 If ongoing bleeding after 2nd attempt perform rhinoscopy to identify the source (90% are anterior — little’s area) Anterior bleed likely? Consider cautery or nasal packing Posterior bleed likely? Send to ED for urgent ENT consult.
TRICK: The pressure applied when pinching the cartilaginous portion of nose should be hard enough to blanch the patient’s fingernails. Ensure patient does not release pressure as this disrupts the clot and prevents hemostasis.
Click here for pdf
You have just seen a young patient with frequent vomiting and diarrhea and you suspect they may be dehydrated.
Approach to Pediatric Dehydration and Fluid Replacement: Perform physical exam to determine degree of dehydration.
Want to more resources?
If you are concerned that a patient’s mental illness puts their safety or the safety of others in immediate danger, call 9-1-1 and have the patient transported to the ED.
Tip: Consider if a referral to Urgent Short-Term Assessment and Treatment (USTAT) might be a good option to get support for your patient. Trick: USTAT Provides short-term psychotherapy for patients in crisis, at risk, or in severe distress. A team of psychiatrists is available as needed for consultation and follow-up. Access is through MHSU Intake. While awaiting an appointment make sure the patient has access to Vancouver Island’s Crisis Line – see below. If you have a specific question in regard to treatment options consider contacting the Rapid Access to Consultative Services (RACE) line to speak with a psychiatrist. Check out: https://divisionsbc.ca/south-island/race/aboutrace
Patient resources
Hypertensive Emergency is when an acute elevation in blood pressure (>180/120) causes target organ damage. These patients should be sent to the ED immediately for management. S+S that may signify acute target organ damage include: generalized neurologic symptoms (agitation, delirium, visual r), focal neurologic symptoms, flame hemorrhages, cotton wool spots, papilledema, nausea or vomiting, chest pain or discomfort, severe back pain, or acute dyspnea.
Hypertensive Urgency or Severe Asymptomatic Hypertension, often associated with a mild headache in office, is much more common.
TIP! In the absence of symptoms, there is no proven benefit from rapid lowering of blood pressure. Those with imminent cardiovascular risks from known aortic or intracranial aneurysms should be considered for BP reduction over a period of hours and should be sent to the ED. The reduction goal for these patients should be to <160/<100 without reducing the map greater than 25% over a matter of hours.
The Victoria Division of Family Practice acknowledges with great respect and appreciation that our office is located on the traditional, ancestral, and unceded territories of the Coast Salish nations. We are privileged to be working on the lands of the Lək̓ʷəŋən (Lekwungen/Songhees) and WSÁNEĆ (Tsartlip, Tsawout, Tseycum) Peoples.
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