This RMD Review comes from patient feedback regarding transferring care to the emergency room. Many of our patients feel the provider who sent them to the ER did not listen to them, evaluate them, or care about them as people or patients.
When it comes to CRH Healthcare clinics, there are two distinct categories of patients who need emergency evaluation.
The first category is the patient who simply needs more testing to definitively rule in or rule out an emergent condition. This patient’s risk is typically lower, but it is not negligible. The condition must be further evaluated due to the medical risk to the patient. The second category is the patient who is in an obvious emergency, such as a crushing substernal chest pain or facial drooping.
This article mainly pertains to the first category of patients. The second category of patients should receive expedited triage by calling EMS while the provider evaluates the patient’s safety and stability.
As healthcare providers, we understand that certain conditions cannot be fully treated in an urgent care facility. We know that a 70-year-old with a head injury needs a head CT; however, our patients often do not share this same level of knowledge or understanding. One of our responsibilities is to educate these patients so they understand the necessity of emergency workup and treatment.
The first point of this approach is to treat the patient as you would any other. Follow the AIDET guidelines. Take a complete history. Perform a complete physical examination. Perform any point-of-care testing. Then, present the treatment plan to the patient. This treatment plan may include a referral to an ER.
When you have a complete assessment, patients are more likely to feel heard and adequately cared for, which helps establish strong medical reasoning for ER referral.
A 42-year-old female with a past medical history of GERD and obesity presented to the clinic on Saturday at 8 a.m.
The patient reported abdominal pain that had been intermittent for two to three months. The pain previously lasted a few hours at a time. Now, the pain has become persistent for the past three to four days. Vital signs are within normal limits and stable.
The patient’s exam reveals tenderness to palpation of the epigastric and right upper quadrants. Murphy sign is further positive. Due to a complaint of abdominal pain in a woman of childbearing years, a UA and UPT were completed as a standing order. Both were negative.
The treatment plan was presented to the patient with an ER recommendation for a presumed diagnosis of gallbladder irritation, which was likely caused by a gallstone that had been popping in and out of the exit of the gallbladder for the past months causing the patient pain but was now likely stuck causing the buildup and irritation in the gallbladder.
It was further explained to the patient that the process of the condition could lead to infection and even death or that a gallstone can progress further into the shared tubes and lead to liver or pancreas backup and damage to the organs. The issue is that we don’t know what stage the patient is in the process, and the only way to learn for sure on a Saturday morning was with an ER evaluation.
The patient asked for other options, including outpatient evaluation and workup with in-house blood work and imaging, which would likely not be until Monday morning at the earliest. It was reiterated that there was a risk to this choice as the level and severity of the disease state are not known and could progress or worsen before that time.
The visit punctuated what the expected ER workup might involve, with a disclaimer that the ER will work it up as they see medically fit. There was also the addition that there was hope the ER workup was negative and the patient went home from the ER with a clean bill of health or the known diagnosis of GERD, as this would be the best-case outcome of an ER visit.
After being thoroughly informed and involved in the decision-making process, the patient opted to go to the ER for further evaluation. That evening, the patient underwent a cholecystectomy.
Do not delay a truly emergent visit, such as crushing chest pain or facial drooping, to provide this level of care.
If the example patient had opted for an outpatient workup, the appropriate response would have been to reiterate this decision goes against medical advice. The provider would have them sign the AMA form and treat them as best as possible within the bounds they have set with their patient autonomy.
In the example case, labs, an immediate right upper quadrant (RUQ) ultrasound, and a surgical consult as soon as possible would be needed. The patient may have been persuaded to visit the ER with a RUQ ultrasound, which demonstrated cholecystitis.
Don’t be afraid to tell a patient:
As a healthcare provider, I don’t ever want to miss something. The ER can do a more complete workup than I can do here in an urgent care setting. I would rather you go, and they find that your gallbladder is fine, than to miss a more serious problem. If they say everything is ok, then you have the best possible outcome. However, we don’t know for sure unless you go to the ER.
Our patients want to be heard, validated, examined, and cared for, as we all desire. When they enter our clinics, some of them know they likely should have gone to the ER, and they are scared.
We often see people on what may be the worst day of their lives, so remember to listen carefully, evaluate thoroughly, and treat them with the kindness and professionalism you’d want to be shown to yourself or a family member—even when you know they require a higher level of care.
Daniel Ralston, MD
Regional Medical Director
Peachtree Immediate Care
E-mail: dralston@peachtreemed.com
Herpes zoster is a reactivation of the varicella-zoster virus (VZV), more commonly known as shingles. It can occur with natural infection or after immunization to varicella, although immunization-mediated zoster is less frequent. The reactivation can occur in any age group or demographic.
The primary risk factors for herpes zoster are increasing age and immunosuppression.
The clinical manifestations are typically a painful, one-sided, and dermatomal rash that begins with erythema or erythematous papules, progresses to erythematous vesicles or bullae, and can then become pustular. Pain is often described as burning, throbbing, or stabbing and may be present before any skin manifestations.
The thoracic dermatome is the most common location for this rash to present. The approximate breakdown for commonly involved dermatomes: thoracic (53%), cervical (20%), and trigeminal (15%), including ophthalmic and lumbosacral (11%). While rarer, multiple, usually contiguous, dermatomes or sides can be affected.
Herpes zoster should be on your differential diagnosis for any one-sided and dermatomal rash, and even a consideration should be made if it crosses the midline or is in two contiguous dermatomes. If it is in your differential diagnosis, then because of the complications that can happen from shingles it needs to be ruled in or out and accounted for in your treatment. This can be done with a viral culture of the rash, treating with one of the approved treatments, or ideally doing both when possible. The goal is to prevent or lessen any complications.
It should be noted that herpes zoster, especially in early disease presentation, can mimic cellulitis. It is thus sometimes necessary to run a bacterial culture, viral culture, and treat for both a cellulitis and herpes zoster while cultures are pending and then narrowing coverage based on culture data. This is especially true in high-risk areas, such as the ear or face.
The complications of shingles depend partially on location but can be devastating. Post-herpetic neuralgia occurs in 10-20% of cases. Other complications include, but are not limited to, herpes zoster ophthalmicus, herpes zoster oticus (Ramsay Hunt syndrome), aseptic meningitis, encephalitis, and Guillain-Barre.
The above paragraph discussed the use of viral cultures for the rash in the evaluation of shingles. Additionally, if a rash is noted in the first or second branches of the trigeminal nerve, a fluorescein stain should be performed in the clinic to exclude dendritic involvement, and the patient should follow up with an ophthalmologist. Similarly, lesions of or near the ear require otoscopic evaluation and close ENT follow-up.
Treatment is one of three approved agents: valacyclovir, acyclovir, and famciclovir. Most providers prefer valacyclovir and famciclovir for fewer daily doses, but some patients find that acyclovir carries a lower financial burden. The goal of treatment is to lower the duration and severity of illness and the risk of complications. For uncomplicated zoster, the evidence does not currently support a role for any adjunctive therapy such as gabapentin, TCAs, or glucocorticoids. It is still utilized in complicated zoster cases such as Ramsay Hunt or herpes zoster ophthalmicus, although the evidence behind this and which dosing to use is contested.
The prevention of shingles is done via vaccination. The only vaccine currently on the market in the United States is Shingrix. The vaccine is indicated for all patients age 50 and older and can be given, even if the patient has had a herpes zoster outbreak before. The vaccine reduces the incidence of shingles and post-herpetic neuralgia. In the two largest trials, Shingrix reduced the risk of developing herpes zoster by 90-97% and post-herpetic neuralgia by 89-99%.
Daniel Ralston, MD
Regional Medical Director
Peachtree Immediate Care
E-mail: dralston@peachtreemed.com
