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Is your doctor's bag up to date?

Dr Peter Holden answers questions from GP Dr Alastair Bint on what GPs should carry in their bag in light of recent changes to out-of-hours

Dr Peter Holden answers questions from GP Dr Alastair Bint on what GPs should carry in their bag in light of recent changes to out-of-hours

1. How has the doctor's bag changed since many GPs dropped out-of-hours work?

The GP's responsibility is now limited to 08.00-18.30 hours, Monday to Friday only. During these hours GPs still have to deal with emergencies or do home visits if the patient's condition dictates. Therefore the contents of a GP's bag should have changed little, except for the range and quantity of continuation medication carried.The purpose of the doctor's bag is to equip a doctor to give proper, efficient and timely care when working outside surgery premises.

The bag should therefore contain:·equipment for diagnosis·drugs for immediate administration where the patient's condition dictates·stationery including statutory forms·other items of convenience or reference. Whether you use an attache case or a backpack, give serious consideration to fixing your diagnostic equipment into foam cut-outs as this not only protects it, but gives immediate visual confirmation that you have replaced the equipment in your case after use.

2. Which common emergencies should GPs still be prepared for?

Many sources of information list the recommended drugs for specific emergencies. One of the most authoritative and recent is Drug and Therapeutics Bulletin. The September 2005 edition carries information on drugs for use in adults and November 2005 carries the information for children. It may be necessary to carry both oral and parenteral preparations of the same drug.

Essentially you need to be able to diagnose and treat the following:

  • acute pain
  • nausea and vomiting
  • asthma
  • infection
  • diabetic emergencies
  • myocardial infarction
  • angina
  • left ventricular failure
  • seizures
  • psychiatric emergencies
  • shock and haemorrhage
  • anaphylaxis·drugs to support adrenal action
  • croup
  • dehydration

In addition to injectable and oral therapeutic preparations, diagnostic tools are required: stethoscope, auriscope, thermometer, peak flow meter, sphygmomanometer, tendon hammer, tape measure, tongue depressors, blood sugar measuring kit, lancets, syringes, hypodermic needles, cannulae, dressings and a pocket face mask.

Essential stationery includes: FP10, Med3/5, laboratory and X-ray forms, Mental Health Act forms, envelopes, headed professional notepaper and the BNF.

Special points to consider:·If you carry opiates you should also carry an opiate antagonist such as naloxone; likewise you should carry flumazenil to reverse benzodiazepine overdose.·Beware that adrenaline (epinephrine) comes in two concentrations; one in 1,000 for intramuscular/subcutaneous administration in anaphylaxis and one in 10,000 for intravenous use in cardiac arrest. Both have short shelf-lives of under a year.

Wrap ampoules/vials of glucose in several layers of kitchen towel as, if they break, the contents will wreck foam inserts and ophthalmoscopes.

3. Given the tightening of controlled drugs rules and the extended administering abilities of paramedics, is there still any need for GPs to carry diamorphine?

Yes. Other non-controlled analgesics are inferior to morphine or diamorphine for severe pain. Quality general practice dictates that severe pain from, for example, burns but especially in myocardial infarction, must be adequately treated. The correct initial treatment for myocardial infarction is MONA ­ Morphine, Oxygen, Nitrates and Aspirin. The administration of an opiate is not simply for humane reasons but sound physiological ones as it lowers the massively elevated arrythmogenic catecholamine levels.

Take great care that you only carry one strength of opiate. Fatalities have occurred from inadvertent overdosage because there is little to differentiate 30mg ampoules from 10mg ampoules of diamorphine. Opiates should always be given intravenously and diluted so that accurate aliquots can be titrated slowly.

There is no place for IM administration of opiates.The circumstances under which paramedics can administer controlled drugs are strictly defined by protocols which do not cover all the indications where a GP might use such a drug.

4. Is there any place for GPs to carry thrombolysis medications?

Half of all cardiac deaths from coronary thrombosis occur within 75 minutes of onset. Prompt administration of thrombolytics improves 30-day survival by 6-8 per cent if given within 60 minutes of onset and by 3-5 per cent if given within three hours.

The national service framework standard 6 requires a call to needle time of 60 minutes to be achieved. The current consensus is that of the three time variables (call to needle, transport time to hospital, hospital door to needle time) only the third can be reliably reduced by better organisation.

Proper safe administration of thrombolytics requires a 12-lead ECG to be reliably interpreted and possession of a defibrillator as reperfusion dysrhythmias are common. So there are significant logistical and skill issues to be addressed as well as the revenue consequences of the thrombolytic exceeding its shelf-life before use.

In Scotland the drug is obtained under stock order whereas in England and Wales the GP bears the financial risk under para 44.5. So in summary, GPs practising in rural or remote areas may wish to consider thrombolysis administration as part of a co-ordinated response from the ambulance service utilising the Immediate Care/First responder NES to fund the process. However, most GPs practise in locations where the ambulance service paramedics can deliver thrombolysis in the required timescale.

5. It is common practice for GPs to carry antibiotics, painkillers, anti-emetics and such like and to give a limited supply until patients are able to get their prescription. Are there any pitfalls to dispensing in this way?

The issue of supplying drugs 'from the bag' has become much more complex, particularly in this era of product liability. If the manufacturer or product licence holder of the drug issued cannot be identified the GP assumes all the risks of product liability.Therefore GPs issuing drugs must keep meticulous records of purchase and supply, names of the wholesaler and product licence holder, batch numbers and expiry dates and keep them for seven years in the case of an adult and until the age of 25 in the case of a child.

Strict labelling regulations apply to any drug dispensed and the container must be appropriately marked with a typewritten label. Department of Health guidelines state that to prevent antibiotic resistance, complete courses of antibiotics should be dispensed.

6. When carrying drugs and equipment in your car are there any insurance, safety or legal considerations?

There are no insurance issues as long as your car is insured for your business use. Drugs should be in a locked receptacle in a locked boot. Controlled drugs are supposed to be in a locked container bolted to the car in a locked boot. Only if carrying over 500l of compressed gas (oxygen or Entonox) is a green diamond compressed gas symbol required.

7. How should GPs ensure medicines in their bags are up to date and are there any special considerations, for example car temperature?

The easiest way to ensure that items are in date is to create a list of bag contents on a spreadsheet, detailing their name, batch number, source of supply, reorder codes, etc, and their expiry date. I keep this on my PDA and set the warning for 30 days prior to expiry but your practice nurse or manager could keep spreadsheets and note expiry dates in a diary.The internal temperature in vehicles in the UK can vary from -15°C in winter to 60°C on a hot day with a black car. Drugs are supposed to be kept at 2-25°C.

Gas cylinders should also be kept at similar temperatures. So when the temperature is outside this range the bag and gas cylinder should be stored indoors.

8. Beyond the normal equipment used in day-to-day surgery, what additional equipment would a GP be expected to take on home visits?

Individual GPs are expected to demonstrate no greater skill than GPs as a class and therefore to use equipment generally used by GPs.

GPSIs in immediate care are expected to deliver to the higher standard. Some GPs will take a nebuliser to an asthmatic, others may also administer oxygen. The evidence of benefit for prompt administration of oxygen in so many clinical emergencies, coupled with readily available rented cheap integrated oxygen cylinder/reducing valve systems, dictates that in the near future there will be little excuse for GPs not carrying oxygen.

The trend to manage more patients at home means that in selected cases many GP will perform home ECGs.

9. Will GPs ever be expected to carry an automatic defibrillator?

In less than five years a 'shock box' Automated External Defibrillator (AED) will cost less than a fire extinguisher. Currently AEDs cost between £1,000-£2,000.

The training and maintenance requirements are minimal. The GP looks pretty inadequate when the local first-aider produces and uses one.The successful use of an AED does wonders for your self-esteem, the patient's outcome and the practice's reputation. Why doesn't every practice have one right now?

10. What does the future hold? The future of the doctor's bag will depend on patterns of care delivery.

Although an increasing amount of visiting and emergency work is being performed by paramedics and emergency care practitioners, when the GP is called it will be to the more complicated cases. Coupled with an increase in domiciliary care fuelled by practice-based commissioning and more sophisticated near-patient testing and analysis techniques, the doctor's bag is likely to become more complex.

Peter Holden is a GP in Matlock, Derbyshire; he is the honorary secretary of BASICS (the British Association for Immediate Care) and is a medical aircrew member on the Lincolnshire and Nottinghamshire Air Ambulance ­ he is a GPC negotiator but the views expressed in this article are his own and may not reflect official GPC policy.Competing interests None declared

What I will do now

Dr Bint responds to the answers to his questions·

I suspect the average GP doesn't carry even half the amount and variety of medications suggested here.

I expect each GP has to make a balanced judgment about the amount they could carry and the amount they feel is justified.· Although I appreciate the benefits of carrying morphine, I suspect the legal complexities and bureaucratic hurdles will continue to put many GPs off.

I didn't realise the complexities around dispensing from the doctor's bag. It has certainly persuaded me to keep a more careful record of medications I carry and expiry dates.

Alastair Bint is a GP in Reigate, Surrey

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