Chapter 1 Introduction, summary, the system of care
Introduction
In the UK and in other countries there is a growing shortage of trained clinicians to meet the need for immediate assessment and treatment of urgent medical problems in primary care. Traditionally doctors have been the main providers of this care but already nurses, paramedics, and other healthcare professionals are extending their role to include clinical assessment, decision making, and treatment.1,2 Our aim is that this book will be a useful update for general practitioners experienced in this field and also serve as an introduction to those new to emergency clinical decision making.
This system will teach a method for the rapid recognition and treatment of immediately life threatening problems or conditions that require urgent hospital care. However, the focus of the book is the assessment of patients with less serious problems who can be managed without referral to hospital.
The book will use presentations rather than diagnoses as the starting point, for example the approach to the breathless patient rather than the treatment of asthma; the care of the disturbed patient rather than the diagnosis of specific mental illness.
Where possible we will try to make recommendations based on evidence. The field of emergency medicine is not rich in scientific analysis and community emergency care even less. We will interpret and transfer as much of the evidence as possible into the community emergency care setting.
Lastly and perhaps most importantly, the book sets the immediate management in the context of the start of the patient’s journey. The key principle (Box 1.1) is – what is right for this patient, in this setting, with my skills, at this time? There is evidence that some pre-hospital interventions may make patient outcomes worse. Just because a particular line of management can be practiced out of hospital it does not necessarily mean that it should be done.

Scope
The book outline is given in Box 1.2. This encompasses most of acute emergency medicine. Trauma is occasionally mentioned as it can be part of the presenting complaint (for example, in a collapse with an injury) or a possible cause (for example, in chest pain). However we will not deal with serious trauma as this is well covered in other texts.
Chapter format
The chapters will start with a list of objectives then go on to discuss the care of the ‘primary survey positive’ patient, identify the types of serious problems requiring hospital admission, and concentrate on describing the assessment and management of patients who might be treated at home.
The three step system of care
Overview
We will use a three step system of care (Box 1.3). The first step is to identify those patients with immediately life threatening problems, the second is to identify those patients who will need to go to hospital, and the third to fully assess that majority of patients encountered in community emergency care that will not require hospital referral. There may be no single ‘right answer’ to the immediate management of each of these problems. The variables in levels of training, distance or time to definitive care will influence the decision on the right management for this patient at this time and in this place (see below).
Figures from out-of-hours contacts to primary care in the UK indicate that only 1–2% of patients will require resuscitation. Most patients will have conditions that can be managed at home.


We will designate a patient as primary survey positive if a potentially life threatening problem is identified. In such cases the two major objectives are to administer those treatments or interventions that are absolutely essential and to prepare the patient for transport.
Step 1
The first step is to identify those patients who are ‘primary survey positive’. This process will usually take less than 30 seconds. If the patient is talking in full sentences, is fully orientated, the respiratory rate is between 10 and 29 breaths per minute, the pulse rate between 50 and 120, and the patient is not cold and sweating, then it is unlikely they need immediate resuscitation (Box 1.4).
Step 2
The next step is to identify the patient who obviously needs hospital admission, especially if the treatment needs to be given as soon as possible to reduce risk to life or limb (Box 1.5). Examples would be acute myocardial infarction, bleeding, suspected aortic aneurysm or imminent childbirth. In these patients essential treatment should be provided and transport to the appropriate hospital arranged.

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