Planning for the Unexpected: How Veterinarians Can Prioritize Emergency Situations
Picture this: It's Friday afternoon and you're wrapping up the last veterinary cases of the day when an emergency walks through the door. You've been practicing the art of setting boundaries so that you can leave work on time. But, it's clear that this pet needs immediate care.
This scenario happens more and more often these days making it imperative that general practitioners and specialty clinicians work together to facilitate timely, optimal care for veterinary patients and ease the stress of everyone involved.
Here's how you can prepare for a transfer to a veterinary emergency or specialty clinic in a way that helps ensure your patient receives the best care possible.
Identify Emergent Veterinary Issues That Need Urgent Attention
When preparing a case for transfer to the ER, the goal is not to fix all problems. Instead, it's to provide enough initial treatment to stabilize the pet for safe transportation. Although the list of potential scenarios is lengthy, here are some common situations that require more urgent intervention.
1. The Veterinary Trauma Case
Whether it's a vehicular trauma, dog attack, or high-rise syndrome, the initial assessment of the trauma should be the same. When evaluating a case that you'll be transferring, always consider scenarios in which treatment should not be delayed, including but not limited to hypovolemic shock, hemorrhage, wounds, pneumothorax, head trauma, or pain.
- Hypovolemic shock: Signs of hypovolemic shock may include pale gums, weak or thready pulses, weakness, tachypnea, and tachycardia. If possible, obtain a blood pressure reading to assess the level of hypotension and a PCV/TS to assess for acute hemorrhage as a contributing factor. If the patient is hypotensive, an intravenous (IV) catheter and an initial crystalloid bolus are warranted.
- Pneumothorax: Three-view thoracic radiographs are helpful for assessing pneumothorax, pulmonary hemorrhage, or fractured ribs. If a pneumothorax is present, and it's severe enough to cause hypoventilation, thoracentesis should immediately be performed.
- Head trauma: Signs may include cranial nerve deficits, seizures, or Cushing's reflex. A single dose of hypertonic saline or mannitol 20% solution can help to temporarily relieve intracranial pressure while you prepare the patient for transfer. Hypotension should be addressed prior to the administration of mannitol. The patient's head and neck should be elevated 30 degrees from the ground during transport to help alleviate increased intracranial pressure. Keep in mind that steroids are contraindicated in these cases.
- Open wounds: Clean and bandage wounds to prevent nosocomial infection and staunch bleeding, and consider starting antibiotic therapy early to prevent sepsis—for example, in treating major bite wounds.
- Pain: If a patient has been appropriately stabilized but has a clearly defined source of pain, such as a fracture, and treating pain will not impact the next veterinarian's examination, pain should be addressed in a timely fashion. This can include an opioid injection and a temporary stabilization of any fractures. Typically we avoid using corticosteroids or nonsteroidal anti-inflammatories in trauma patients.
2. The Patient in Respiratory Distress
Veterinary treatment options depend on the source of respiratory distress; however, obtaining a full three-view radiographic series can sometimes be detrimental to these patients. Offer flow-by oxygen and consider mild sedation, such as a single intramuscular (IM) or IV injection of butorphanol, and always weigh the risk versus benefit of obtaining diagnostics. If there is enough evidence on exam or available radiographs to suggest pleural effusion or a pneumothorax, emergency thoracentesis should be performed to provide immediate relief and allow for safer transport.
Thoracentesis should be performed between the seventh to ninth intercostal space at the cranial aspect of the rib, keeping in mind that air travels dorsally and fluid ventrally. Ultrasound is helpful for guidance, but rarely necessary. If the patient has evidence of pulmonary congestion, or there is a concern for heart disease, a single IM dose of Furosemide (2 mg/kg IM) is also a reasonable treatment to initiate.
3. The Dog With Gastric Dilatation and Volvulus
Gastric dilatation and volvulus can be easily diagnosed, and these patients have a very good prognosis if treated in a timely manner. However, patient status can decline rapidly due to poor perfusion. Obtain a right lateral radiograph and send a copy of the image along with the owner. Then, consider either trocarization or placement of a temporary orogastric tube to remove excess gas, improve patient comfort, and buy some time to get the pet where it needs to be. Have your team members place an IV catheter to administer a single fluid bolus to maintain perfusion during the transfer process.
Prepare the Pet Owner
It may go without saying, but this is a stressful situation for any client. Remember that you are the veterinarian they know and trust. Even a brief conversation about expectations, estimated cost of specialty care, and patient prognosis can go a long way to support your client and prepare them for what's next. Providing your veterinary client with the appropriate resources to make an educated decision will only serve to benefit their pet in the long run.
Communicate With the Veterinary ER Facility
You can support a successful transfer by first calling ahead to confirm the ER clinic is not at capacity and will be able to take the patient, and then sending relevant records. One way to get records over to the emergency veterinarian as quickly as possible is to print a hard copy and send it along with the client. Another option is to consider an online portal where valuable data, such as radiographs, can be shared in real time. Pertinent information to pass on will include any major exam findings, prior medical issues, diagnostics performed, and treatments given (including dose and time).
Your colleagues at the nearby emergency facility are fully aware that seeing these patients at a general practice can be a challenging, often overwhelming, task. So, if you have specific questions regarding a difficult case, consider reaching out directly to the ER facility. Good communication is key to facilitating a seamless transfer and providing the best possible care for your patient.