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Treatment tips in urgent care setting


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Hello,

 

I just started a part time job at a urgent care center. Since I only have experiences t family medicine,

I would like to know any treatment tips ( Some what aggressive treatment, symptomatic relief, etc) in urgent care settings.

Any suggestions would appreciated!

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That is a rather broad request. Would be helpful to have something more specific such as a patient acutely sprains a joint and is in pain, what can I give them by mouth for pain relief?

You could try reviewing this text:

Minor Emergencies: Expert Consult - Online and Print, 3e

Could also take a look at Brancel Urgent Care app for iPhone or iPad if you have that. There is an ortho trauma app too.

Another thing to keep in mind is the time of the year and the environment.

For example, I work in the Northeast.

In the summer, I see a lot of contact dermatitis, sunburns, lacerations and punctures.

In the fall, I see a lot of viral uris and sports and playground injuries with kids back at school.

In the winter, flu and winter sports injuries plus back sprains and contusions from falling.

Spring, allergic rhinitis and insect bites esp ticks.

This is just a subset of urgent care type things I will see in the context of a small ED setting but it helps to prepare for the seasonal influx.

Good luck.

G Brothers PA-C

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Thank you very much for your input, I will get these apps.

 

As what I am familiar is family medicine and as I am relatively new PA (licensed in 2013) and new to urgent care, my treatment plan tends to be not aggressive and viewed as not providing symptomatic relief as patients hoped. (my employer is also telling me to provide more aggressive care, fulfilling patient's expectation) 

I would like to know convenient use of Demerol shots, pain control, headache relief, throat pain relief other than promethazine with codeine, most common diagnosis with children at urgent care setting.

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probably should not ever use demerol in urgent care. for significant pain with objective findings, dilaudid would be a better choice.

narcotics are for fractures, burns, large lacs, etc, not minor sprains and strains. nsaids and muscle relaxants work fine for those.

reglan or compazine+ benadryl is a great h/a cocktail. once again, no narcs for most folks with h/a.

decadron and viscous lido can help with sore throat. also treating any post nasal drip with sudafed.

most kids have colds and OM.

If it is a work environment where you are expected to dole out narcs all day long you might want to look for another job.

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Thank you, EMDPA.

They are careful dispensing narcs, but "patient satisfaction" is very important to them. Most of the pt expect to get a "shot" to feel better or immediate symptomatic relief. As I am used to treating patient with medically necessary care only, this is kind of new for me. 

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I have used ketorolac injections for pain relief for back sprains and migraines.  Just know when not to use it and be careful in the elderly, dose for age, etc.  I've also used compazine/bendryl for migraines like EMED said, occasionally have used prednisone too as part of that.  I have seen several algorithims for migraines that were developed by different providers in UC/ED and yours might already have one developed that works well.  

 

Don't give narcs in urgent care except maybe Guaifenesin with codeine syrup with no refills.  I usually would give tessalon pearls first.  Be careful of overprescribing antibiotics for colds,bronchitis, sore throat and "sinus" infections.  Know the indication of when an ABX might be indicated.  

 

Know how to counsel parents about sore throat and the rapid strep vs. culture and decide when you will treat.  Check out rashes..you will get bunches of them and take a good history to find the cause.  I've used decadron too for sore throat.  Works for viral pharyngitis (like a mono infection) when you see patients with enlarged, red tonsils and order appropriate tests for the things you will encounter.

 

You will get plenty of UTIs so review treatment for them.   My former UC had plenty of patients who came in with STDs.  

 

Know when to order CXRs too for cough.  Inhalers were a common prescription I wrote for those with bronchitis/asthma exacerbations along with a course of prednisone.

 

Check out those apps recommended....they sound good.  I've never used them for UC but I'm sure they will be helpful.  

 

Once you get our groove on and learn appropriate ways to treat the stuff that comes in to UC your patients will be happy and so should admin. 

 

Just stay away from narcotics and controlled substances as much as possible.  You do not want to be the candy man and when you are new the community sometimes tests you out to see if you are weak willed or if you practice great medicine. 

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Dont. Give. Demerol. Shots.

When you do, every drug seeker in several counties will show up at your place.

It is a terrible drug and a terrible precedence to set.

If you find yourself giving and writing for controlled substances for patient satisfaction at an increased rate, you are working at place you dont want to be at. 

Paula and E gave you some good guidance. The question is when you give that toradol for back pain and the guy who usually gets the demerol shot says to you: "toradol doesnt work, only demerol does, it has the last 4 times I have been here", what is your response and plan?

Good luck.

G Brothers PA-C

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Guest Paula

Several of the EDs I worked at stopped stocking demerol back in about 2010.  It was a facility wide decision with the CAHs that were in the same region. 

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"Fulfilling patients' expectations" and prioritizing "satisfaction" are - in the abstract - respectable and positive things. The problem is that without the administration and leadership helping you to influence those expectations appropriately, it's a trap.

 

I've been doing Urgent Care almost exclusively for over 4 years now, and a big part of what makes me good at it, and my boss happy with me, is the ability to have a positive and productive patient-centered encounter where everybody walks away happy, and yet the care was appropriate. In our organization, we know that "giving people everything they ask for" is not good care.

 

Handing out abx and pain meds is easy. It might or might not result in happy marks on surveys. What's actually good for the bottom line and good for the organization is when your clinic gets a reputation for quality care and people who know their stuff while being nice to patients. The billing for UTI workup labs, xrays for ankle injuries, and lac repairs is where you make your money, not becoming known as a good place to score pain meds.

 

If the people running the joint actually steer you toward unnecessary prescribing, take a good look at whether you want to keep working part-time for them. Check into the other Urgent Cares around - the ones that drug-seeking patients have been turned away from before they come to you - and maybe hook up with the group with better long-term priorities.

 

Just my two cents, mind you, but life is too short to work for shady operations.

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Oh, and the other thing: according to my boss and collaborating MD, the basic, fundamental, 100% vital rule of Urgent Care medicine is the ability to think quickly and clearly about the one big question:

 

Is this a problem that we are going to be able to solve, right now, at this visit?

 

UTI: yes it is. We can diagnose a UTI and start treatment. We can prescribe an antibiotic and talk about whether the patient wants phenazopyridine too.

 

Sinus infection: Maybe. If there have been symptoms for 2 days and the patient hasn't tried Sudafed, saline nasal spray, and plenty of fluids, we can get them on track with proper education and instruction about how to treat the congestion aggressively with OTC methods, and avoid a need for antibiotics.

 

...You'll notice that while just writing a Z-pack gets the encounter over slightly faster and might or might not make the patient "happy," it doesn't provide better care in any way at all. So again, I challenge the idea that "Rx = good care / no Rx = care that isn't aggressive enough." Too many patients think this way; we shouldn't perpetuate it too.

 

Abdominal cramping for 2 months, with some bowel changes now and then, plus this weird rash that comes and goes: No. Here, let me make sure you don't have an acute abdomen, and then help set you up with an appointment with someone in Primary Care.

 

So if it's not an issue that can be addressed in one visit, they're not even in the right place. If you're being asked to make patients happy with "aggressive" care even in situations where they presented to the wrong practice setting in the first place, then I don't understand what the heck the people in charge are even doing.

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  • 4 weeks later...

Aggressive care or customer service does not always equate to over-prescribing, but I agree there is a fine line.  Steroids for a truly painful sore throat is probably fine, but someone getting this 2-3 times a year, or a diabetic getting steroids for a viral pharyngitis, are not appropriate.  Treating a painful sprain or strain with a short course of ultram can be okay, but T3 for anything viral is not appropriate. Often in the ED we will give a shot of toradol or get a "thereuptic X-ray" when time allows so the pt feels better about their visit, when time allows, so long as it is safe to do (eg no NSAIDs in elderly or renal impaired, etc).

 

I think a big part of this is not going to be over-treating, but involving patients in their care.  Eg viral sx wanting abx - explain to them you perhaps are willing to post-date an abx rx if they are not better in x amount of days, if they are willing to accept all ADRs with a couple explained to them - at this point some pts will still take it but many will ultimately not fill the rx because they are better by the time the date hits.  I don't think there is a big harm in doing this from time to time, but that is very different from handing out abx for clearly viral illnesses in healthy patients all day.  Tessalon pearles are a great cough medication relatively safe in the elderly.  I will give eye drops to viral conjunctivitis no problem if patients want - no real harm in this in most cases - after explaining I think this is viral and won't help, but truly there is no way to definitively say whether it is bacterial or not, etc.  Sometimes we do this even without them asking.

 

Patients with dental pain - learn to do dental blocks and offer these.  Many pts will refuse because they don't want a needle in their gums, but others will appreciate the few hours of relief, and either way then you have given them a choice.

 

For chronic back pain, you should never, ever give narcs.  Consider PT if they haven't had it.  Acute back pain can get flexeril and motrin when appropriate - this is done in the ED all the time.  Also you can try Medrol dosepak in back pain in appropriate pts.

 

HA - go to is Compazine and Benadryl; and add on some decadron which has been shown to give longer relief of migraines.

 

I think a big thing is making patients feel they have been listened to their chief complaint adequately addressed.  This can be as simple as sitting when talking to the pt, laying hands on the pt beyond just a quick exam, and taking half a minute to get to know where the pt is from or just having a little bit of idle talk with them.  This is not so much a priority in a busy ED (although it can and should be when time allows) but in an UC setting with these type pts may be appreciated more.  Explaining to pt's why you are, or are NOT, going to do some test or tx, can go a long way.  Ultimately, if you feel you are just writing rx's to make your pts and your boss happy, then it is time to start looking for a new job before you get totally burnt out.

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  • 1 month later...

You have received some good advice from folks who have been in the game. UC can be tricky. I have worked it for >6 years and what I have learned from folks who are better at it than me is "First do no harm". #1 priority in UC setting is r/o if you are dealing with an emergent problem. If so send to ER. #2 Is r/o if you are dealing with a PCP/chronic problem. If so, give appropriate education, initiate tx and refer to PCP or appropriate specialty for continuity of care.

Remember, in UC setting for some patients you are the 1st provider they see for their issue, so your first responsibilty in patient education. Teach them how to help themselves with there runny nose, back pain flares, RICE for sprains/strains/ simple fx's. I promise you, If you focus on those areas there is NO COMPANY & NO PATIENT that can accuse you of practicing bad medicine.

Just my 2cents.

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  • 4 weeks later...

Learn to be an "Antibiotic Nazi" - the CDC has some Rx forms for viral illnesses that you date, name, tick off and sign, just like a real script.  People feel better if they walk out of the office with something in their hand rather than just some advice - makes them feel like they've waited for something.  I used to have some personalized sticky notes that I'd do my OTC suggestions on - again, people walk out with something in hand AND a reminder of how to use it.  See http://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/viral-rx-pad-bw.pdf   

 

As mentioned, dental blocks can be a Godsend to someone with a pulpitis or fracture with exposed dentin or even a minor abscess, to tide them over until they see a tooth fairy.  I've used them countless times - I explain that it might be short lived, but will let them get ahead of their pain management.  I usually do it with some lidocaine /c and bupivacaine.  They're also great for doing suturing in some facial zones to prevent field distortion.  Also, high dose ibuprofen and Oil of Cloves are great for dental pain.

 

Demerol BAD...Toradol GOOD, as long as it's not contraindicated.  We have no Demerol in any ED's in the province I work in and haven't for about 8 years. 

 

Sinus rinses are wonderful things to clean out people's heads and post nasal drip - a problem with Sudafed stems from it drying up the snot but also thickening it so it gets sticky and they gag on the post nasal drip.  Rinses are a great adjunct or plain old first line treatment option for sinus issues.  It's also a "Non-Pharmacologic" tool ;-D.

 

There are oodles of migraine cocktails here and in other threads - jmj11 is a great mind to pick about HA's.  Have a couple of cocktails that you get very comfortable with, as well a couple of backups.  I'm in the habit of adding Benadryl to cocktails with  agents like metoclopramide, prochlorperazine, chlorpromazine, promethazine, etc to keep them from getting squirrely...helps them sleep a bit too.

 

Get good at quickly making slabs, splints and basic casts.

 

Have a gooder.

 

SK

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  • 2 weeks later...

Adding norflex to your migraine cocktail is very helpful if the patient is also experiencing neck stiffness, e.g. tension HA.  Just r/o and document the r/o of meningismus.  Another thing to ask about is sudden reduction in the patient's caffiene consumption - another sure HA trigger.

 

Soaking an extremity in ice water with betadine combines cleaning and local anagesia.  This is especially helpful prior to doing a wedge resection or draining a subungual hematoma.  It can also soften severely calloused skin needing sutured, e.g. soles and palms.

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