Bernie Sanders just had an MI.....and went to Urgent Care....

[Cideous]

Family Practice guys....FFS PLEASE DO NOT SEND YOUR PATIENTS TO URGENT CARE FOR CHEST PAIN OR ABDOMINAL PAIN....!

 

Every single day a FP provider refers one of their patients to UC for abdominal pain or chest pain, and every single day I send them to the ER.  WE CAN NOT RULE OUT AN MI IN URGENT CARE AND WE CAN NOT RULE OUT A SURGICAL ABDOMEN IN URGENT CARE!.....

 

Please send them to the ER so they are not double charged!

 

/rant off

[Marinejiujitsu]

Family Practice guys....FFS PLEASE DO NOT SEND YOUR PATIENTS TO URGENT CARE FOR CHEST PAIN OR ABDOMINAL PAIN....!
 
Every single day a FP provider refers one of their patients to UC for abdominal pain or chest pain, and every single day I send them to the ER.  WE CAN NOT RULE OUT AN MI IN URGENT CARE AND WE CAN NOT RULE OUT A SURGICAL ABDOMEN IN URGENT CARE!.....
 
Please send them to the ER so they are not double charged!
 
/rant off

I think being double charged is the least of their worries.... but yeah send them to the ER[emoji50]

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[sas5814]

We do have a bit of a problem with that including PCPs right here in the building who send stuff over here that we can't handle. You would think after a year or two they would figure it out. I think most of the time its an easy dump and gets the patient out of their hair.

The majority of the people who come in with chest pain or an acute abdomen bring themselves. the ER is too far...the wait is too long etc etc. I sometimes ask how much time they have saved by going to the wrong place. I had one this evening with chest pain (known CAD, afib, congenital heart defect, can't take most anti-coags because of chronic Hep C) for the 3rd time in 5 months. Basically she comes here for us to call an ambulance. It boggles the mind.

[CAdamsPAC]

1 hour ago, sas5814 said:

We do have a bit of a problem with that including PCPs right here in the building who send stuff over here that we can't handle. You would think after a year or two they would figure it out. I think most of the time its an easy dump and gets the patient out of their hair.

The majority of the people who come in with chest pain or an acute abdomen bring themselves. the ER is too far...the wait is too long etc etc. I sometimes ask how much time they have saved by going to the wrong place. I had one this evening with chest pain (known CAD, afib, congenital heart defect, can't take most anti-coags because of chronic Hep C) for the 3rd time in 5 months. Basically she comes here for us to call an ambulance. It boggles the mind.

Stupidity exacerbated by laziness. My UC/WIC  experience with CP  patients was their electing to argue with me over receiving the best care was more the norm than exception!

[Mayamom]

My NP friend who works in urgent care calls 911 for most of the CP and acute abdomen scenarios.  She gets grief from the patients because they don't get why she can't manage them there.  Then she gets grief from her employer for sending them off to a higher level of care.  It's a no win situation.   

[Cideous]

Just to elaborate.....there is no damn way I am going to put my license and liability on the line to try and rule out a MI or acute abdomen in the UC.

Please....send them to the ER.  

Thanks.

[Boatswain2PA]

Troponin, ekg, and cxr rules out vast majority of chest pain patients.  Dont see why an UC couldnt do that.  Give em some aspirin while waiting for the troponin and you are doing what we do for most of ours in the ED.

[Marinejiujitsu]

Troponin, ekg, and cxr rules out vast majority of chest pain patients.  Dont see why an UC couldnt do that.  Give em some aspirin while waiting for the troponin and you are doing what we do for most of ours in the ED.

Some urgent cares have a crash cart and can do cardiac monitoring but most cant. Ive seen people crash with normal ecgs and a normal initial tropinin.

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[Marinejiujitsu]

My NP friend who works in urgent care calls 911 for most of the CP and acute abdomen scenarios.  She gets grief from the patients because they don't get why she can't manage them there.  Then she gets grief from her employer for sending them off to a higher level of care.  It's a no win situation.   

I'm assuming this is an urgent care that has a general surgeon as a collaborating physician?

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[ohiovolffemtp]

"Troponin, ekg, and cxr rules out vast majority of chest pain patients.  Dont see why an UC couldnt do that.  Give em some aspirin while waiting for the troponin and you are doing what we do for most of ours in the ED."

When I worked in an urgent care all labs outside of urine dips, strep and flu swabs were send outs.  So, turn-around on a troponin was about 24 hours.  So, the serial troponin trending that I do in the ED was totally impossible.  Also, I had no rooms where I could keep a patient for the 2-3 hours until the draw of the 2nd troponin.  Even more important, I had no heparin, plavix, etc. if the patient was having a STEMI.  So, the ED is the only place in my area with sufficient resources to manage a chest pain rule-out.,

[rev ronin]

4 hours ago, Mayamom said:

Then she gets grief from her employer for sending them off to a higher level of care.

What?  Why?  Evaluate and send them on, it's a 99204/99214 for about a 5 minute workup, unless the ED belongs to the same organization.  Money-grubbing management should be happy with the effort to revenue ratio.

[MedicinePower]

"An EKG, a diligent history/physical exam and troponin is all that is necessary to rule out acute coronary syndrome."

https://www.hippoed.com/urgentcare/rap/episode/bunnotintheoven/chestpain

[UGoLong]

"An EKG, a diligent history/physical exam and troponin is all that is necessary to rule out acute coronary syndrome."

https://www.hippoed.com/urgentcare/rap/episode/bunnotintheoven/chestpain

 

I’ve not heard of a free-standing UC that had the ability to do stat labs, outside of things like a rapid strep. If you process an MI, I feel that all you’re doing is delaying definitive treatment. If it’s a STEMI, that’s a delay in door to baloon time. If it’s an NSTEMI, it’s delaying a heparin drip you might start on suspicion while you await lab results.

 

So maybe you can rule out an MI with an EKG and troponin (if you can get it), but personally I feel keeping a patient away from definitive care for a time isn’t worth it.

 

The time to get resources mobilized is just before you think you’ll need them, not after when it could be too late.

 

 

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[mgriffiths]

The UC I cover every now and then has no in-house labs except rapid strep, flu, and urine dip.  We do NOT have an ECG because the physician oversight decided against it as they didn't want to risk someone doing an ECG and then not being proficient to interpret.  So while we don't send off literally every chest pain and abdominal pain, the vast majority do.

But our competitor hospital just instituted a new rule (2 days ago) for all PCPs (same hospital as I wrote about who fired the rheum NP).  PCPs are no longer allowed to send patients directly to the ED.  They are required to send them to the UC for initial evaluation and then the UC will send to ED if needed.  The UC is stand alone and about 10 minutes from the ED.  Guess who made that one up!  It's going over about as well as sour milk.

[Mayamom]

What?  A PCP cannot refer to an ER?  UC has to triage first?  What could go wrong with

that!

[Marinejiujitsu]

"An EKG, a diligent history/physical exam and troponin is all that is necessary to rule out acute coronary syndrome."
https://www.hippoed.com/urgentcare/rap/episode/bunnotintheoven/chestpain

But this maybe what 3% of the complainers of chest pain that it fits? But you also have spontaneous pneumos in young kids (17+ ive seen) ACS is not the only worry. And unless young with a low heart score, best to just send them.

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[Marinejiujitsu]

The UC I cover every now and then has no in-house labs except rapid strep, flu, and urine dip.  We do NOT have an ECG because the physician oversight decided against it as they didn't want to risk someone doing an ECG and then not being proficient to interpret.  So while we don't send off literally every chest pain and abdominal pain, the vast majority do.
But our competitor hospital just instituted a new rule (2 days ago) for all PCPs (same hospital as I wrote about who fired the rheum NP).  PCPs are no longer allowed to send patients directly to the ED.  They are required to send them to the UC for initial evaluation and then the UC will send to ED if needed.  The UC is stand alone and about 10 minutes from the ED.  Guess who made that one up!  It's going over about as well as sour milk.

I would put the organization on blast everytime. I would still send them and put in my chart, "I do not feel it is safe to send this patient to the urgent care and immediately go to the ER via ambulance or along with a family member or friend if refused."

Then if they cause issues I would report them.

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[ohiovolffemtp]

From the ED I can and do send low risk chest pain home, e.g. HEART score 3 or less.  However, to do a HEART score you need an initial troponin.  If at all possible, I'll keep them there for the 2nd troponin, even with a low HEART score.  So, unless your UC can get a stat troponin, and those UC's are rare, I wouldn't even attempt to manage a chest pain in a UC.

[Marinejiujitsu]

From the ED I can and do send low risk chest pain home, e.g. HEART score 3 or less.  However, to do a HEART score you need an initial troponin.  If at all possible, I'll keep them there for the 2nd troponin, even with a low HEART score.  So, unless your UC can get a stat troponin, and those UC's are rare, I wouldn't even attempt to manage a chest pain in a UC.

That is true but if they are young and healthy we pretty much only get an ecg and cxr. At least at our county hospital and stanford university hospital.

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[UGoLong]

That is true but if they are young and healthy we pretty much only get an ecg and cxr. At least at our county hospital and stanford university hospital.

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Guess that wouldn’t be Bernie...


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[Cideous]

23 hours ago, Boatswain2PA said:

Troponin, ekg, and cxr rules out vast majority of chest pain patients.  Dont see why an UC couldnt do that.  Give em some aspirin while waiting for the troponin and you are doing what we do for most of ours in the ED.

For the love of gawd....this is exactly what I meant.

 

Good grief...and no a Troponin and one ekg doesn't rule out jack........

 

Have you ever done urgent care?

 

What field of medicine are you in Boats???

Edited October 12, 2019 by Cideous

[Boatswain2PA]

23 hours ago, Marinejiujitsu said:

Some urgent cares have a crash cart and can do cardiac monitoring but most cant. Ive seen people crash with normal ecgs and a normal initial tropinin.

Sure.  But they usually looked sick.  Someone comes in pale, diaphoretic, crushing chest pain and heaving with nausea I wouldn't work up in the UC.  I also wouldn't wait for EKG/Trop before calling cardiology.

21 hours ago, ohiovolffemtp said:

When I worked in an urgent care all labs outside of urine dips, strep and flu swabs were send outs.  So, turn-around on a troponin was about 24 hours.  So, the serial troponin trending that I do in the ED was totally impossible. 

Pre-HEART score validation I doubt any UC's had troponins.  With the HEART score validation I can certainly see some UCs getting I-stat troponin assays.

18 hours ago, UGoLong said:

If you process an MI, I feel that all you’re doing is delaying definitive treatment. If it’s a STEMI, that’s a delay in door to baloon time. If it’s an NSTEMI, it’s delaying a heparin drip you might start on suspicion while you await lab results.

I don't disagree with this, but reason should apply.  I don't call cards on patients I think have a high-pretest probability of MI until I get the EKG or Troponins, which technically delays the next step in "definitive treatment".  

Got the 50 year old with 1 risk factor who had three episodes of pain today, each lasting 30 seconds, one in left chest, one in right upper chest, and one in right lower chest who is hemodynamically stable and asking for a sammich?  Please just do the troponin, EKG, and CXR in the UC and not send him to the ED.

Got the 75 yo who is pale, diaphoretic, clutching his chest and saying the pain radiates to his shoulder?  Call 911, give asa, and do the EKG.

Unfortunately 9 out of 10 patients I get from UC/FP office is the previous.

 

1 hour ago, Cideous said:

Good grief...and no a Troponin and one ekg doesn't rule out jack........

Negative troponin and normal EKG, without a strongly suspicious history, actually DOES rule out MI/ACS (with a 0.9-1.7% miss rate) in most relatively young (under 65) patients with only a few risk factors and they can be sent home from the UC.

https://www.wikem.org/wiki/HEART_Score

Several months ago EMRAP had a great interview with the doctor who developed the HEART score, and has several episodes on the validation of it.

1 hour ago, Cideous said:

Have you ever done urgent care?

Yes.  For about six months.  It sucked terribly.

1 hour ago, Cideous said:

What field of medicine are you in Boats???

EM.  Single coverage provider in a 9000 annual visit ED two hours from tertiary care.

 

Oh, and it's God, not gawd.  And he loves you too! 

 

 

Edited October 12, 2019 by Boatswain2PA

[CAdamsPAC]

11 minutes ago, Boatswain2PA said:

Sure.  But they usually looked sick.  Someone comes in pale, diaphoretic, crushing chest pain and heaving with nausea I wouldn't work up in the UC.  I also wouldn't wait for EKG/Trop before calling cardiology.

Pre-HEART score validation I doubt any UC's had troponins.  With the HEART score validation I can certainly see some UCs getting I-stat troponin assays.

I don't disagree with this, but reason should apply.  I don't call cards on patients I think have a high-pretest probability of MI until I get the EKG or Troponins, which technically delays the next step in "definitive treatment".  

Got the 50 year old with 1 risk factor who had three episodes of pain today, each lasting 30 seconds, one in left chest, one in right upper chest, and one in right lower chest who is hemodynamically stable and asking for a sammich?  Please just do the troponin, EKG, and CXR in the UC and not send him to the ED.

Got the 75 yo who is pale, diaphoretic, clutching his chest and saying the pain radiates to his shoulder?  Call 911, give asa, and do the EKG.

Unfortunately 9 out of 10 patients I get from UC/FP office is the previous.

 

Negative troponin and normal EKG, without a strongly suspicious history, actually DOES rule out MI/ACS (with a 0.9-1.7% miss rate) in most relatively young (under 65) patients with only a few risk factors and they can be sent home from the UC.

Yes.  For about six months.  It sucked terribly.

EM.  Single coverage provider in a 9000 annual visit ED two hours from tertiary care.

 

Oh, and it's God, not gawd.  And he loves you too! 

 

 

All of this is predicated on having STAT LAB SUPPORT , no UC Clinic I've worked in ever had this. If I am concerned enough to order a troponin for a CP  pt, I am sending them to the ED.Call me weak, inept or whatever, but reckless or flippant won't make the list.

Edited October 12, 2019 by CAdamsPAC

[Boatswain2PA]

18 minutes ago, CAdamsPAC said:

All of this is predicated on having STAT LAB SUPPORT , no UC Clinic I've worked in ever had this. If I am concerned enough to order a troponin for a CP  pt

The UC I worked in had an Istat.  While they didn't do troponins (this was pre-HEART score validation), we did BMP/CMPs and got the results in a few minutes.  CBCs (without diff) took about 10 minutes.  Actually much faster than I get them in the ED.  And you can purchase the troponin assay for the IStat.  

This shop used the IStat exactly BECAUSE it came back in a few minutes, and then we could turn the room over.  Better/worse yet, most of the time the UA, chemistry, CXR and/or EKG was already done (all ordered by protocol) before the patient was even roomed, let alone by the time I saw them.  This place was a money-making MACHINE!!!!!  
 

 

18 minutes ago, CAdamsPAC said:

If I am concerned enough to order a troponin for a CP  pt, I am sending them to the ED.Call me weak, inept or whatever, but reckless or flippant won't make the list.

I was not trying to infer that any UC provider is weak or inept for sending CP to the ED, my apologies if I came across that way.  Please chalk it up to incomplete communication inherent with written discussion.

But IF your UC has (or can get) stat Troponins, EKG, and CXR, then a good H&P can rule out CP emergencies in many (most?) patients without sending them to the ED.

Edited October 12, 2019 by Boatswain2PA

[CAdamsPAC]

1 hour ago, Boatswain2PA said:

The UC I worked in had an Istat.  While they didn't do troponins (this was pre-HEART score validation), we did BMP/CMPs and got the results in a few minutes.  CBCs (without diff) took about 10 minutes.  Actually much faster than I get them in the ED.  And you can purchase the troponin assay for the IStat.  

This shop used the IStat exactly BECAUSE it came back in a few minutes, and then we could turn the room over.  Better/worse yet, most of the time the UA, chemistry, CXR and/or EKG was already done (all ordered by protocol) before the patient was even roomed, let alone by the time I saw them.  This place was a money-making MACHINE!!!!!  
 

 

I was not trying to infer that any UC provider is weak or inept for sending CP to the ED, my apologies if I came across that way.  Please chalk it up to incomplete communication inherent with written discussion.

But IF your UC has (or can get) stat Troponins, EKG, and CXR, then a good H&P can rule out CP emergencies in many (most?) patients without sending them to the ED.

The Suits and Medical Directors wanted volume and  quick turn around of pts. The idea of keeping exam rooms filled with CP awaiting labs would make their heads explode We didn't even have a Crash  Cart in the clinic, which BTW was 200 yards from the Fire Station we called for true "emergencies".

Edited October 12, 2019 by CAdamsPAC