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Please Read...New Grad PA in Elderly Urgent Care


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Hello fellow PA professionals,

 

I am a new grad working in an UC that sees almost exclusively 65+ year old patients with co-morbidities that never make anything a straight forward case. And to make matters even tougher, 80-90% of people are snow birds and do not have local PCPs to ensure proper follow up after they are discharged. Our urgent care sees anywhere between 50-70+ patients per day with two providers. Open 10 hours of the day. 

 

URI symptoms (runny nose, cough, sore throat, congestion, etc) that would typically take only a few minutes with young, healthy people take so much longer to work up, treat, and evaluate in this geriatric population. I end up getting CXR on people just to r/o heart failure as cause for their symptoms...I'd say half of the time, heart is enlarged and lots of pulmonary congestion. Hard to know if these changes are acute or chronic. I feel like my head turns with worse case scenario every time I see these patients. Every patient I don't send to the hospital, I have the "what ifs" going through my mind. 

 

I am afraid of using macrocodes or fluroquinolones because of potential cardiac side effects. I usually end up prescribing a penicillin, or if allergic, doxycycline.  I hesitate to use cephalosporins in those allergic to penicillin.  Many of the "DOC" regimens taught in school do not apply to this population because of their age and co-morbidities. 

 

Does anyone have any good references to help me become a more confident HCP for this older population? 

 

What is your favorite "go-to" treatment regimens for the most common urgent care complaints in the elderly?

 

Any advice is appreciated! Thank you!

 

C. Dorame, PA-C

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A few things.

 

This isnt urgent care. This is being a substitute PCP to a complicated population that doesnt usually have insight into how complex their own medical conditions are.

They use your place cause it is convenient and quick though for some of them, they dont need that. They need someone that can have a full understanding of their medical condition which doesnt happen in a short visit with any practitioner.

 

If these pts present with sob, cough and have pulmonary congestion on cxr, you have no choice but to assume this is new. If they have a PMH of htn, cad, hf, af, mi, then they have heart failure. Send them to the ED to at a minimum get diuresed.

 

Antibiotics. Even though this population may be at risk for a bacterial cause to their symptoms, it is more likely they have a virus just like anyone else. I would pursue abx in this pt population if they have a clear cut pneumonia or uti. If they have COPD and are wheezing more you could justify a short course of doxy along with some prednisone and increased albuterol. Otherwise stop contributing to resistance and c diff diarrhea. What I do now is reassure pts they dont need abx but symptomatic tx and give them a small amount of cough medicine.

 

Are there primary care clinics locally you can refer to? I think if you routinely care for someone whom truly would benefit from a more local PCP then tell them that, refer and document  the referral. You could also make the point to get the pts pcp's contact information and send the pts record to them and ask if there is anything else they would consider. You may think that is a lot, may think that is not your role in an urgent care. I am sure when there is a bad outcome, that pts family will wonder why the local urgent care didnt do a better job communicating about the condition of their loved one.

 

Finally here is my go to treatment for most elderly pts complaints. Do as little as possible unless there is a clear indication they need some intervention. 

Good luck, this does not sound like a fun gig.

G Brothers PA-C

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avoid ABX unless needed

 

Cdiff is no fun! and people get it

 

don't over medicate, don't miss something, make sure you don't screw up.....

 

 

 

so what to do?

 

do great exams, figure out how to "know" what the CXR is going to show you before you look at it, become a Dx master...

in order to do this, you need to slow down, think about it,, but don't think yourself into a corner - 

Review cases with the other provider

try your best, and try to have the f/u with local doc's or back to the clinic, chart well

 

 

 

simple right!?

 

Welcome to medicine - it is an amazing career and one that will never stop teaching you lessons

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Wow. That's a tough gig you're describing, particularly at the volumes you cite. I did internal medicine for many years and am now doing episodic care at a walk-in clinic with a population somewhat similar to what you describe and an average volume of about 25-27 pts/day for one provider - I don't know how I would have managed it as a new grad.

 

If I get flustered, I can't think or listen well. So I put a fair amount of effort into maintaining an even keel. I can tell you what I do to stay centered. I remind myself of the following:

 

one patient at a time

it takes as long as it takes

the waiting room is not my problem

the important problems are the lifethreatening ones, no matter what patients/staff/relatives/patient's employers think

my priority is that no one dies in my clinic

 

I have a mental note to always check the last creatinine, and have set my patient list to flag the people who are anticoagulated.

 

If I have an outlying piece of information that doesn't fit my diagnosis - a vital sign that doesn't seem right, for example - I strive to account for it.

 

My favorite reference is UpToDate, and I use it many times a day. It's quite good for most things, and includes a nice interaction checker.

 

If azithromycin or fluoroquinolones are the treatment of choice, you're stuck with them unless there's a contraindication. I completely understand your hesitation and often share it - I agree with what others have said about antibiotics, but if you do need to treat, undertreatment doesn't help either.

 

Don't hesitate to consult - with colleagues, with your SP, with local specialists when appropriate. 

 

Remember that speed is less important than accuracy, for the big picture. In five years, you won't even remember that someone waited 3 hours to see you, or that you didn't see as many patients as your colleagues. What you will remember is whether you felt good about the medical outcome. That's what the patient will remember too.

 

I guess what I'm trying to say is don't let other people or your own expectations of yourself push you into moving too fast. A slow provider is better than a dead patient.

 

I have to say that your trial-by-fire position is fabulously educational.

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If I get flustered, I can't think or listen well. So I put a fair amount of effort into maintaining an even keel. I can tell you what I do to stay centered. I remind myself of the following:

 

one patient at a time

it takes as long as it takes

the waiting room is not my problem

the important problems are the lifethreatening ones, no matter what patients/staff/relatives/patient's employers think

my priority is that no one dies in my clinic

 

If I have an outlying piece of information that doesn't fit my diagnosis - a vital sign that doesn't seem right, for example - I strive to account for it.

 

 

Remember that speed is less important than accuracy, for the big picture. In five years, you won't even remember that someone waited 3 hours to see you, or that you didn't see as many patients as your colleagues. What you will remember is whether you felt good about the medical outcome. That's what the patient will remember too.

 

I guess what I'm trying to say is don't let other people or your own expectations of yourself push you into moving too fast. A slow provider is better than a dead patient.

 

I have to say that your trial-by-fire position is fabulously educational.

this. every day. emergencies come first. some folks will leave without being seen. I consider that self triage to common sense. if you want to wait 4 hrs for me to rx sudafed feel free. it's always busy now. it is what it is. my previously slow night shifts with 12-18 pts/12 hrs are now 24-36/12 hrs. with low staff and me doing a lot of the IVs, injections, discharges, splints, etc

just a note about abx in the elderly. vantin is a great drug. our I.D. folks love it for elderly urinary and pulmonic infections. it's basically oral rocephin. gotta love that.

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That sounds like a tough gig.

From the clinical side, most of the sx you described are not really life threatening.  Rhinitis/rhinorrhea, congestion, sore throat, cough by themselves aren't a big deal.  I would minimize workup unless the patient was frail, febrile, etc.  Remember you're working as an UC not as a PCP, there's just some workups that are impractical in a UC setting.

As for abx, plain ol' amox (and doxy) is great and covers a lot.  Bacteria quickly go resistant to azithro and the macrolides (I read a study that there was 50% resistance after the 1st course).  

Anyways, make sure you bill for those 99214/04 and 205/215's instead of 99213's if you're spending a lot time and working with complex pts.

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Everything CByersPAC said. I can't add much to that. Geriatrics is my very favorite population but it ain't for wimps. Everyone has multisystem disease and polypharmacy. Learn the Beers criteria and get very comfortable with your physical exam. You sound like you have a pretty good head for pharm--that is mandatory for this group. Safety first. Be comfortable sending the folks who need the ED to the ED. Insist on med lists from pharmacies and make sure your staff reviews them to be sure they're current. The American Geriatrics Society had a super awesome app free on iTunes--iGeriatrics. Download it. Also highly recommend their publication Geriatrics at Your Fingertips (I think around $40).

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"What is your favorite "go-to" treatment regimens for the most common urgent care complaints in the elderly?"

 

Makes me nervous. It suggests to me that you're looking for cookbook solutions rather than having a deeper understanding as to why you practice the way you do. I sense this is also what is driving your  lack of confidence when dealing with certain patient populations. I would advise that you start with a list of presenting symptoms in this population that make you feel uncomfortable and start studying! Why are you "afraid" of macrolides? Get an EKG and check their QTc.  But, prescribing an antibiotic to a patient who doesn't need one is a dubious proposition and simply not good medicine. Furthermore, when you "usually" just end up prescribing Penicillin or Doxycycline, how is the alcoholic patient with klebsiella gonna respond to that? He ends up in the ER in ARDS and Sepsis. I would really advise you breakdown your most common presentations and become a Jedi in understanding your approach. The 'what if's' and worrying you have is simply gaps in your knowledge. The good news is that by dedicating yourself daily, you can improve your approaches and walk out your shift feeling good. I wish you all the best!

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Where I work our biograms and cultures have shown that ceftin is the most effective choice for UTI's in the elderly.  We have increasing resistance to Cipro and Bactrim.  Macrobid doesn't seem to do well.  So, if the patient says they are PCN allergic it's a trigger to probe a bit more on what the "allergy" is.  If it's known anaphylaxis, I avoid cephalosporins.  However, if it's "my mother told me I had a rash once", I'll educate on the S/S of anaphyllaxis and risk the 0.5-3.0% cross allergy since what I'm reading recently pushes that to the low end of the range.

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