Surviving out-of-hours emergencies: clinical tips for recent graduates

In my last blog post we looked at what can be done from a non-clinical perspective to improve our case management and stress levels when dealing with emergencies. This doesn’t require clinical knowledge or experience so hopefully will reassure those new to night duties that clinical acumen isn't the only part of the service we deliver to our clients. That being said, we do still need to also be able to treat these cases competently and advise the owners of treatment options, prognosis, costs, and so on.

As you build up your bank of clinical experience, managing emergency cases becomes thrilling, but for new graduates going home alone with a pager and a sense of dread, waiting for experience to be gained can be quite a daunting prospect.

I don’t know where to start with emergency cases

You just have to take the first step, you don’t need to know every step of the process! So, start at the start – a good clinical examination and a decent history will get you to the next step. It’s important to remember that it is common in emergency practice to not reach a diagnosis in the first few hours so having an approach for dealing with the most common presentations such as collapse, dyspnea, seizures and trauma can help you get closer to the definitive diagnosis.

Oxygen, pain relief and IV access

Providing oxygen, appropriate pain relief and gaining intravenous (IV) access are valuable first steps that need to be completed for many of the serious emergency cases that present.

Fluid therapy

The next step is working out whether fluid therapy is necessary and if so whether it is appropriate to give a bolus. If you have identified hypovolaemic shock then a bolus is necessary to fluid resuscitate the patient. This can be life-saving and your focus should be alleviating shock symptoms whilst working out the cause.

Usually boluses are administered over a set time frame (for example 10-15 minutes) and one of the essentials of giving a bolus is to reassess the patient at the end of the bolus. The aim of this is to work out whether another bolus is needed or whether clinical parameters, such as heart rate, pulse quality, mucous membrane colour and capillary refill time (CRT) have improved sufficiently to now employ a lower ongoing rate.

Diagnostics

Finally, which diagnostics should be prioritised given the presenting signs of the patient? Diagnostic lab options include haematology, biochemistry, electrolytes, blood gas as well as blood smears. Diagnostic imaging utilising ultrasonography and radiography are also helpful depending on the case presentation

I’m terrified of surgical emergencies

Surgical emergencies are few and far between so when we face them, it can induce panic. Informed consent is paramount so it is crucial that the client understands the procedure, along with any risks or complications prior to the surgery taking place.

Breaking the surgery down into the anaesthetic part and the surgery itself can help. Is the animal stable enough to cope with an anaesthetic or do you need to fluid resuscitate it prior to the procedure? Most emergency patients will require some form of fluid therapy prior to surgery so getting an IV line in place is essential, both for the fluids and induction of general anaesthesia.

Breaking down the steps of 'big' emergency surgeries

Essentially, when we think about the 'big' emergency surgeries it can be really helpful to break these down into the steps needed. All abdominal surgeries will start with opening the abdomen and finish with closing the abdomen. Timewise, this may take up a decent proportion of your surgical time and is something you will already be comfortable with from routine elective surgery, for example bitch spays. This leaves the bit in the middle…

Exposure is everything and although you will have heard this a million times before, making a large incision is really helpful, so make sure your surgical clip is extreme! Hair should be generously clipped from cranial to the xiphoid region to the pubis. You might not need to make such a large incision but if you do, you will be prepared.

Cutting into the abdomen is usually straightforward but remember a gas-filled stomach, a gravid uterus, an enlarged spleen or any other large abdominal mass should prompt extra care, in order to avoid unintentional damage. Removing the falciform fat is also a great tip in terms of improving exposure, particularly in obese dogs. Many emergency surgeries have common themes. For example, a gastrotomy, cystotomy and caesarean section are similar versions of each other utilising similar suture patterns and suture types/sizes. If you have experience of one, then you can use what you have learned with the others.

Relieve suffering

If you think about it, the real stress of veterinary practice is not the collapsed dog, the cat that's been hit by a car, the haemoabdomen or the Gastric Dilation and Volvulus (GDV) case. An animal presenting with an emergency condition is already compromised so remember that anything you do is likely to improve the situation and relieve suffering. It is essential to remember that those emergencies that can cause the most worry, such as GDV, are already on a pathway to certain death, therefore interventions performed can only make this situation better although in some cases euthanasia is all we can do to relieve suffering.