Getting ready, being ready, and having fun doing it (Proceedings)


Getting ready, being ready, and having fun doing it (Proceedings)

Apr 01, 2009

From the very first time I was faced with the responsibility of possibly having to respond to an emergency when I was a young boy scout (at age 11) to just yesterday when I was an emergency clinician at the Pet Emergency Clinic, the immediate goal was "to make everything ready". A pioneer in emergency care that coined the term "the Golden Hour." Dr. RA Cowley was emphatic on the carrying out of this goal because time is one of the things that can be manipulated and saved when faced with emergencies. It is a savings of time that can make a difference between life and death. The information presented here on practical readiness is provided to help clinicians and staff manage patients in the most efficient way possible. Some of the recommendations come from my experience and training as a surgeon and emergency and critical care specialist as well as a fireman and medic on the front lines...being the one to have to provide the initial care to critical patients whether 2 or 4 legged.

Readiness is also centered on being ready to perform those techniques that must be done immediately when critical patients are first seen

Readiness also involves the need to perform emergency procedures that one might not do very often when the crisis even occurs. The crisis can occur even during during "routine procedures" such as the adverse drug reaction leading to anaphylactic shock in which a tracheostomy may have to be performed prevent airway obstruction from the edema produced, to a rapid thoracotomy, aortic cross clamping, and cardiac massage, for the patient experiencing a sudden cardiac arrest secondary to a vasovagal response from moving the patient while under anesthesia. So the bottom line is that we must all be ready for critical life-and-death emergencies, all the time, even during a "routine" day.

Readiness involves being ready within the facility regarding equipment and supplies/drugs as well as knowing how to perform emergency procedures, operative techniques, and having the memorized knowledge of protocols that will need to be followed for the successful management of common emergency conditions

These include: patients presented with difficult breathing, collapse, severe hemorrhage, an acute abdomen, parvovirus like syndrome with diarrhea and dehydration/vomiting, gastric dilation-volvulus, acute poisoning, snake bite and spider bite-toxic envenomation, seizures, heat stroke, severe hypothermia or hyperthermia, severe sepsis, severe burns, acute paraparesis – paralysis, anaphylactic shock, aortic thromboembolism, severe hemorrhage, severe pancreatitis, peritonitis, severe wounds and fractures, and urethral obstruction, severe arrhythmias, head and spinal cord trauma, cardiac or near cardiac arrest from many causes and many others that may occur as a "routine" case in general practice and the procedures necessary to prevent a catastrophic even from occurring.

Prevention steps

Those steps necessary in the anticipation that something could go wrong are also important to do in readiness. An example is the older patient with dental disease that has renal and cardiac compromise that requires anesthesia for dental prophylaxis and the removal of a suspected tooth root abscess. The placement of an intravenous catheter while the patient is receiving blow-by oxygen and the injection of a "chemical courage" drug cocktail of ketamine, butorphanol and acepromazine are performed. These steps help preoxygenate the patient and decrease the patient's stress levels and provides a gentle and cardiovascular and renal protective strategy as a preanesthesia and the patient will accept, stress free, a mask for the delivery of 100% oxygen and assist ventilation with the BM (bag-valve) and reservoir attached.

Isoflurane is then added for induction after continuous arterial blood flow Doppler monitoring is added. This is accomplished by clipping the hair over the palmar arterial arch and adding ultrasonic jelly onto the ultrasound flat probe and the probe fixed in place tightly with adhesive tape on the central portion of the metacarpal skin above the metacarpal pad. This may sound complicated but is very easy to achieve.

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