Lauren Rothkopf, MD, and Mary Brennan Wirshup, MD

Medical emergencies may not be common in the office setting, but that’s precisely why you need to practice your response to them.





Certain emergencies elicit an immediate, conditioned response. When someone yells “Fire!” for example, most people look for an emergency exit or a fire extin-

guisher. However, emergency situations in medical offices do not engender the same type of Pavlovian reaction. Although most medical training, including family medi- cine training, involves learning how to deal with emer- gency situations, that education has a tendency to wane after graduation. Once physicians are in private practice, with the demands of seeing patients, maintaining emer- gency certification becomes a lower priority than dealing with day-to-day issues. Many primary care physicians do not invest time in maintaining active certification in car- diopulmonary resuscitation (CPR), much less advanced life support. However, medical emergencies do occur in physicians’ offices, including asthma exacerbations, chest pain, hypoglycemia, anaphylaxis, and impaired con- sciousness, among others.1 Outpatient facilities must be prepared to deal with these situations.

This article describes the emergency preparedness program that our practice, Community Volunteers in Medicine, designed and implemented. Our practice is a busy, mostly volunteer-staff clinic providing medical and dental care as well as ancillary services such as nutri- tion and diabetes education, and last year we conducted

26,000 visits. Given this patient volume, we felt that everyone on our staff needed to be prepared to deal with medical emergencies. In addition, because we have many volunteer staff who have retired from previous careers, are more than 60 years of age, and have medical issues, we felt it prudent to have measures in place to care for those who help us care for patients.

We recognize that our model may require adaptation for use in other offices depending on the number of staff (including physicians, other providers, and nursing staff), role assignment, proximity to an emergency department (ED), response times of local emergency medical services (EMS), the level of care providers are capable of adminis- tering (basic versus advanced life support), and state laws regarding who may provide emergency services. Still, we offer an emergency preparedness model befitting a family medicine office.

Condition C: An emergency preparedness program

We named our emergency preparedness program “Condi- tion C” to avoid the popularized term “code blue,” which could alarm patients in the office and waiting room. The algorithm on page 14 summarizes the steps involved in our program, which has two major components.

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Medical emergencies do occur in the physician office,

including asthma exacerbations, chest pain, hypoglycemia,

anaphylaxis, and impaired consciousness.

A scavenger hunt format engages staff members in the process of reviewing sup- plies that might be needed in an emergency.

Mock code situations allow physicians and staff members to practice their emer- gency response.

Scavenger hunt. The program begins with a review of all available emergency equipment in the office utilizing an engaging scavenger hunt format. Both nursing and medical staff participate in finding and reviewing the medi- cations and equipment that might be needed in an emergency situation (see the checklist of recommended emergency supplies). Because our office is staffed mostly by volunteers and not all items can be stored within a crash cart or emergency box, the scavenger hunt helps ensure that all staff members are able to access these items in an expedient manner and that the practice is fully equipped. Once staff identify the items, they inspect medications to make sure none have expired and review equipment use. It is imperative that staff know how to use oxygen tanks, injectable epinephrine, and other equipment correctly.

Additionally, Condition C cards with com- mon emergency situations and the appropriate interventions are located in each exam room and stored with the emergency equipment. The scavenger hunt confirms the presence of these cards.

Mock codes. The program also involves mock code situations followed by a debriefing to discuss staff members’ roles and potential issues that arose during the exercise. We do not inform staff ahead of time that a Condition C is going to be simulated. To mimic the most likely scenario in an office setting, we plant a volunteer in the waiting room or exam room and ask him or her to simulate shortness of breath or acute chest pain. This tests whether our office staff is alert to patients’ needs. The goal is to have someone call a Condition C in a timely manner, followed by a rapid response by staff with the appropriate emergency equip- ment. We try to perform these mock emergen- cies at least two times per year.


Obstacles addressed




emergencies do



One of the main obstacles to effective emer-


you see most



gency care that we identified through our


often in your



mock code situations was a lack of aware-








ness by front office staff of patients in









the waiting area. This was because of



the layout of our physical space. To


Algorithm for

What supplies

combat this issue, we installed sur-

the staff on

are available

veillance cameras throughout the area,


implementing an

vs. needed?



office emergency






Our emergency preparedness program








involves five key steps, depicted here.









Additionally, we orient all new staff mem-





bers to our emergency procedures upon hire,





and we review staff members’ CPR certifica-





tion regularly. Although this may seem like

Mock emergency


an overwhelming task to introduce into a busy

Scavenger hunt



clinic schedule, we believe it is worth the time




and effort. An alternative would be to incorporate all of these steps into a half-day session and to offer CPR certification on-site.

14 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | March/April 2013

allowing the front office staff to see patients who are not directly visible from their desk.

Additional issues identified through our mock code exercises included slow response times among staff, diffi- cultly finding necessary items, poor documentation of the episode, and slow-downs in patient flow in other parts of the practice. We created the scavenger hunt to improve the ability to find needed items. To improve documenta- tion, we introduced an “Emergency Nursing Record” (see page 16). This flow sheet includes patient information, emergency type, vital signs, review of systems, necessary interventions, and medications. In the event a patient


requires transfer to the ED, we send a copy of this sheet with the patient. In general, this sharing of information helps streamline and improve patient care.

Immediately following mock emergencies, staff mem- bers meet to debrief and discuss problems in how the team responded. This allows all those involved to voice concerns and suggest improvements. Utilizing a debrief- ing form (see the “Mock Trial Evaluation Form,” page 18), we analyze each situation individually. These debrief- ing sessions help us troubleshoot the program. During a recent mock emergency, we discovered that multiple med- ications in our emergency box were expired. As a result,


The following checklist of recommended emergency supplies includes many expected items, such as oxygen and nitroglyc- erin, as well as several items not commonly found in family medicine offices, such as an automated external defibrillator (AED). In deciding whether to include a particular item in your practice, consider your staff members’ ability to use the item appropri- ately and your office’s access and proximity to emergency services.





  Automated external defibrillator (AED)


  Bag mask ventilator (two bag sizes and three

$19-$22 per

mask sizes for adult, pediatric, and infant)

mask and bag

  Blood pressure cuff (all sizes)


  Glucometer


  Intravenous catheter/butterfly needles


(18 to 24 gauge)


  Intravenous extension tubing and




  Nasal airways (one set)


  Nasogastric tubes


  Nasal cannula for oxygen


  Nebulizer or metered dose inhaler with


spacer and face mask


  Non-rebreather mask (three sizes)

$2.49 per mask

  Oxygen mask (three sizes)


  Oxygen tank and flow meter

Tank: $65 (empty)


Flow meter: $50-$150

  Portable suction device and catheters,


or bulb syringe


  Pulse oximeter for child and adult usage


  Resuscitation tape (color-coded)

$120 for a


package of five

  Universal precautions (latex-free gloves,

$12 per kit

masks, and eye protection)


  CPR barrier device


  Blood spill cleanup kit


  Eye wash


  Cardiac board



  Acetaminophen (rectal suppositories)

  Albuterol

  Aspirin, chewable

  Ceftriaxone (Rocephin)

  Corticosteroids, parenteral

  Dextrose 25% and 50%

  Diazepam, parenteral (Valium)

  Diphenhydramine, oral and parenteral (Benadryl)

  Epinephrine injection (EpiPen and EpiPen Jr.)

  Flumazenil (Romazicon)

  Lorazepam, sublingual (Ativan)

  Morphine (MS Contin)

  Naloxone (Narcan)

  Nitroglycerin spray

  Saline, normal

  Glucagon

  Atropine

  Lidocaine


  ECG machine

  Condition C cards

  Fire extinguisher

  Panic button

Note: Prices may vary depending on make, model, quantity ordered, and relationships with medical supply companies or hospitals. Med- ications are not priced here as quantities will vary based on needs assessment, office size, and proximity to an emergency department.

March/April 2013 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 15


Date ___________________  Time _________________  Time EMS called _________________  Time EMS arrived _________________________ 

Name of patient ________________________________________________  DOB _________________  Male ________  Female _________________ 

Allergies ___________________________________________________________________________________________________________________________

Describe events leading to emergency _____________________________________________________________________________________________


Historian/accompanied by _______________________________________________________________________________________________________

What type of emergency? (circle or check)

1. Chest pain How pain started _____________________________________  Nausea/vomiting | Shortness of breath 

Pressure | Tightness | Indigestion | Burning

Pain:  Sharp | Dull | Stabbing | Aching | Numbness | Location _________________________

Pain radiates to:  Jaw | Arm | Back

2.Shortness of breath

3.Asthma exacerbation


Allergic reaction Hives | Rash | Facial swelling | Difficulty breathing

5. Diabetic shock



Time ______________   Length ______________



Unresponsive | Visual disturbance | Headache | Incontinent



Tremors | Tonic-clonic seizure involving _____________ extremities



Eye gaze R | L

7. Other _____________________________________________________________________________________________________________________

Vital signs




Pulse ox

Blood glucose




































































General appearance


_____  No acute distress

_____  Mild | Moderate | Severe distress

_____  Alert

_____  Anxious | Decreased level of consciousness

_____  No barriers

_____  Learning barriers:  Cognitive | Language | Emotion | Other



_____  No respiratory distress

_____  Mild | Moderate | Severe distress

_____  Normal breath sounds

_____  Wheezing | Crackles | Stridor


_____  Decreased breath sounds



_____  Regular rate

_____  Tachycardia | Bradycardia | Irregular rhythm

_____  Pulses strong

_____  Pulse deficit

_____  Skin warm and dry

_____  Cool | Diaphoretic


_____  Pale | Cyanotic | Flushed

16 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | March/April 2013


An obstacle to running mock emergencies in a busy practice is pushback from staff who say it interrupts patient flow.

we revised our system of monitoring medications used for emergencies and assigned a staff member to this task.

An additional obstacle to running mock emergen- cies in a busy practice is pushback from staff who say it interrupts patient flow and disrupts those working in the clinic. This was the case at our practice, and getting buy-in was difficult at first. Attitudes changed, however, after a true medical emergency transpired, and our staff witnessed that things went smoothly. In this instance, a patient presented with chest pain and was having an acute myocardial infarction. Condition C was called. The patient was given aspirin, nitroglycerin, and oxygen. The electrocardiogram and flow sheet were copied and sent with the patient to the ED. The emergency physician subsequently called to compliment our clinic for the pre-

hospital care. By the time the patient reached the ED, the ST elevations were already resolving.

Worth the effort

Although implementing an emergency preparedness program is challenging, we believe it is a worthwhile and necessary addition to all family medicine offices. While infrequent, emergency situations do occur in office set- tings, and this program equips us to provide the best possible care for our patients. Implementing an office emergency preparedness program removes the anxiety of dealing with unusual issues, keeps necessary medications and equipment current and in working condition, and identifies problems prior to an actual emergency so that







_____  Oriented


_____   Disoriented to Person | Place | Time


_____  Cooperative


_____  Agitated | Confused | Memory loss


_____  Speech appropriate


_____  Nonverbal | Speech slurred | Facial droop


_____  Moves all extremities


_____  Weakness | Sensory loss | Which extremity __________________________________







_____  ECG


_____  CPR started



_____  AED used


_____  CPR stopped



_____  O2 at 2L-nasal cannula

_____  Assisted ventilation with bag valve mask





_____  IV access _________________________________
































































Discharge instructions _________________________________________________________________________________________________________


Signature of person in charge of record keeping__________________________________________________________________________________

Medical provider________________________________________________________________________________________________________________

Developed by Community Volunteers in Medicine, West Chester, Pa. Copyright © 2013 AAFP. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. http://www.aafp.org/fpm/2013/0300/p13.html.

March/April 2013 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 17

A mock emergency evaluation form can help practices identify problems in their response prior to an actual emergency.

Creating an emer- gency prepared- ness program takes time but is worth the effort.

Having a program in place can reduce the anxiety associated with emergency


Date of mock emergency: ___________________________________




Comments and other information





Placed mock call to EMS immediately








Airway assessed








Breathing assessed



Respiratory rate:




Description of respiration:





Oxygen started for respiratory












Circulation assessed












Any other initial interventions used








Patient reassured frequently until



At 5 min:

mock EMS arrived



At 10 min:








Head to toe examination








All supplies required for management




of the patient were available








Supplies requested were found quickly








Emergency nursing record form was




available and/or used








Personnel knew how to use equipment












Condition C cards were available




and/or used








Leader communicated effectively and




roles were assigned








Events were recorded accurately
















situations and ultimately improve patient care.

they can be resolved. It also reduces the risk of malpractice suits arising from poor emergency care in an office setting.

The old adage “practice makes perfect” seems applicable. Though perfection is impos- sible, all clinicians and staff members must practice their response to medical emergen- cies in the outpatient setting so they are pre- pared should an actual emergency arise. Your

patient’s life may someday depend on it.

1.Toback SL. Medical emergency preparedness in office practice. Am Fam Phys. 2007;75(11):1679-1684.

Send comments to [email protected], or add your comments to the article at http:// www.aafp.org/fpm/2013/0300/p13.html.

About the Authors

Dr. Rothkopf is currently pursuing a master’s degree in public health at Temple University in Philadelphia. Dr. Wirshup is vice president of medical affairs at the Community Volunteers in Medicine clinic, West Chester, Pa., and a clinical adjunct professor of family medicine at Temple Medical School. The authors would like to thank Edith Condict, CRNP, for her development of the Condition C cards, which led to the inception of the Condition C program. Author disclosure: no relevant financial affiliations disclosed.

18 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | March/April 2013