Saturday, December 22, 2018

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solution for getting immediate care that won't break the bank.
Most are open after hours and on weekends and they provide a good and needed service for urgent small problems.

The key word here is "Small".  Or said another way; "Minor".   Most Urgent Care facilities are staffed by one or two nurses.  They can provide minimal immediate testing and sometimes a quick Xray.  They work with protocols to treat simple problems.  They can give immunizations and do rapid strept tests.  They can check urine for pregnancy or infection.  They can treat a new cough. They can remove splinters, tape a broken toe and treat a rash.  These are minor problems for most people and do not need to be seen in an Emergency Department.  The best place is your doctor's office but Urgent Care is a good alternative.

It's hard to know what is "minor" and what needs a higher level of attention so here are some tips.  You may not need them now, but when you have an urgent medical problem I hope you will remember and head to the ED instead.

Don't Go to Urgent Care If:

  • You have serious underlying medical problems like heart failure, insulin dependent diabetes, cancer,  just out of surgery,  frail elderly, or an illness that has been getting worse over weeks.
  • You have sudden dizziness or chest pain
  • Your baby is lethargic and not drinking
  • You have severe abdominal pain or are vomiting with pain
  • You have been sick for days and have taken a turn for the worst
  • You have a head injury
  • Your vision has suddenly changed
  • You cant walk and don't know why
  • You cant breathe and don't know why

Most Urgent Care will simply divert these patients to an Emergency Department for evaluation but you would waste precious time and money when you should just go to the ED directly.  Urgent care does not have the clinical expertise or the equipment to treat serious problems.

If you have a primary care physician, a phone call to him/her is usually the first best bet to get advice and direction about next steps.

Monday, November 12, 2018

Nutty Thanksgiving ICD-10 Codes

Ahhh, the things doctors have to go through to get paid by insurance companies and Medicare. Every patient encounter has to have a diagnosis code for each problem or procedure.  The book of codes is larger than a huge phonebook. ( Note:  I do understand that readers under age 30 may not have ever seen a phonebook but use your imagination - it's thick and big)

Here are a few of the wacky codes we are required to use for these conditions. Please don't ask me who thought these up:

W61.43 - Pecked by a turkey.  (Who knew they were so dangerous?  Another reason to go Vegan?)
W60.0   - Contact with sharp leaves. (That leaf pile will decompose naturally so be safe. No need to rake)
Y92.72  - Place of occurrence-chicken coop. (Yes we also have to show where the injury occurred)
Y91.71  - Place of occurrence- barn.  (Please make it stop...)
Z63.1    - Problems in relationships with in-laws (This will be a common one this season)
Y93.E2 - Injury due to activity-laundry (Women, protect yourselves. Leave it alone)
W29.1   - Contact with electric knife (Oops)

And finally for after the meal: 
R14.1   - Gas Pain,   (followed byR-14.3 - Flatulence (accompanied by) K-30 -indigestion (and)
R-12    -  Heartburn

For Black Friday we have a code also:
W-52  -  Crushed, pushed or stepped on by crowd. (Amazon by mail anyone?)

For the Doctors and other providers of care during the holiday season there is a special code:
Z-56.6 -   Mental and Physical stress related to work.

Please forgive your Doctor for being hunched over her computer.  She has to remember or look up all of these codes.

hat tip to MedScape for the wacky codes.

Sunday, November 11, 2018

Ruptured Plantar Fascia

Many people have experienced plantar fasciitis.  It is a painful bottom (plantar surface) of the foot that often comes on after athletic exercise, prolonged hiking or running or just for no reason at all.
The plantar fascia is a band of tissue that connects the heel bone to the toes.  This wide ligament covers the entire bottom of the foot and acts like a elastic band under the arch and helps absorb shock when you walk.  Inflammation and tiny micro tears are the culprit in plantar fasciitis.  Most patients can diagnose it themselves and it rarely needs imaging or any special tests.

Bruise indicating a ruptured plantar fascia
Ruptured plantar fascia is relatively rare and the snap occurs suddenly, usually with exercise.  The force of jumping or stepping can cause a tear that causes sudden pain and inability to bear weight on that foot.  The injured athlete often feels a "pop" when the fascia snaps.  Within 24 hours the blood from the tear forms a bruise on the bottom of the foot.

So what should be done for a torn plantar fascia?  Like any muscular injury, ice is the first treatment.  It not only limits further bleeding and swelling, it also provides pain relief.  Elevation and compression (ace wrap) are also first treatments.  An ultrasound is usually as effective as an MRI for seeing the ligament but the diagnosis does not require any imaging.  Physical therapy and using a walking boot are helpful for the first few weeks of healing.  It is very rare that surgery is needed.  The fascia forms a scar and heals itself.  Sometimes shoe orthotics are used to support the arch during healing.

The best way to keep your feet healthy and prevent plantar injuries are:

Weight control
Never get a steroid injection into the plantar fascia (it is a risk factor for rupture)
Stretching the toes and feet before activity
Stretch the arch of your feet
Stretch the achilles tendon (it's all connected)
Wear good athletic and walking shoes with arch support
Use heel cups or shoe inserts (over the counter is fine)
Flex your feet/toes upward when you are in bed and before you get up in the morning.

Thursday, April 26, 2018

Tick Paralysis

 We spotted a Coyote in our backyard, laying near some outdoor lawn chairs.  When we approached she did not jump up and run, as would be expected, but attempted to crawl up the side of the yard.  She was clearly unable to walk and did not respond like a wild animal would.

We called our local wildlife rescue ( and they immediately responded, threw a sheet over the animal to keep her calm and took her to the rescue facility.  A vet examined her and found she was a young female and was covered in ticks.  Tests were done and the diagnosis was Tick Paralysis.

Tick Paralysis rarely affects humans but it is well known in dogs, sheep, horses, pigs and other animals when a feeding tick produces a neurotoxin. It is most common in the Spring from April to June. The toxin travels through the lymph system and can affect respiration, vocal cords, limbs and results in inability to walk.  It is fatal, usually due to respiratory failure.

The incidence in humans is unknown and it usually affects only children.

Our little Coyote patient had all the ticks removed at Wildcare and the paralysis resolved within 24 hours.  She was given Frontline to protect from future ticks and released back to the wild.

Because Coyotes are solitary during the day but join their pack at night, the experts try to release them back to the area she was picked up.  The animals don't do well if they are released to a new, strange area.  I hope that doesn't mean my backyard but nearby is just fine.  We were also told that Coyotes rarely attack cats and dogs (unless they are there for easy access) and their diet is usually small rodents, berries and roots.

As we continue to build in wild areas, we need to co-exist with wild animals.  We were glad we could save this little female Coyote.

Wednesday, March 28, 2018

Preventing Skin Cancer

Spring is here and that means sun.  Who doesn't like the feeling of sun shining down on a warm day, especially after a gloomy, cold winter.  But skin cancer incidence is rising worldwide and we must protect from too much sun exposure.

Skin cancer is the most common type of cancer.  We break skin cancer into two major types; melanoma and non-melanoma.  Melanoma is the least common (2%) but is responsible for the most skin cancer deaths (80%).  The non-melanoma cancers are squamous cell and basal cell and it is rare for them to cause death.  All of these types are linked to sun exposure.  Here is what the evidence shows for skin cancers:

1. Sun Exposure: All skin cancers are linked to increased total and recreational sun exposure.  The more sun exposure, the more risk.  Avoiding midday exposure when the sun is strongest, especially in children, is advised but there are no studies that look at this exposure by itself.
Peeling means bad sunburn-avoid

2. Indoor Tanning: Evidence shows indoor tanning is associated with increased melanoma, squamous cell and basal cell carcinoma.

3. Sunscreen Use: The risk of melanoma and non-melanoma cancers are lessened in people who routinely use sunscreen compared to those who do not.  The minimum age for sunscreen use is 6 months. Babies younger than 6 months need clothing protection and hats/shade. Other studies show the benefit of educational programs to ensure people use hats and shirts as sun protection.

4. SPF in Sunscreens:  The Sun Protection Factor shows the amount of time one can be in the sun without burning from UBV rays.    Higher SPF provides slightly more protection but an SPF of 45 gives about 98% protection so going higher than that is not needed.  It's more important to apply the sunscreen more often as it diminishes with sweat, water and time.

Enjoy the sun with a wide brimmed hat, sunscreen and the shade between 2-4 PM. 

Tuesday, March 20, 2018

Rural Nurse Diagnoses and Treats His Own Heart Attack

Here is a remarkable feel good story as reported in the letters section of The New England Journal of Medicine. 

A 44 year old male nurse was working alone in a rural part of Western Australia when he developed severe chest pain and dizziness.  He knew these were symptoms of a heart attack and he was over 90 miles from the nearest medical facility and 600 miles from Perth, where advanced care could be obtained.  He got an EKG on himself and sent it electronically through the Western Australian Department of Health which was started in 2012 for rural community practitioners.

Sure enough, the electronic read came back and showed he was in the middle of a massive myocardial infarction (MI).  Did he panic?  Hell no!
This remarkable nurse proceeded to chew an aspirin, take sublingual nitroglycerine and start an IV on himself.  He administered the right drugs; intravenous heparin, opiates and another blood thinner called clopidogrel. He got him self ready for thrombolysis and received this "clot buster" when the Royal Flying Doctor Service arrived and transported him to Perth.

The next day a stent was placed in the mid right coronary artery and he was discharged home within 48 hours.

I'm trying to imagine starting an IV on myself while in the middle of a heart attack and keeping this cool.  It's such a great story and EverythingHealth hopes this guy goes on to help lots of patients in rural Australia.

Saturday, March 17, 2018

Rectal Exam-Is it Needed?

Medical practice is constantly changing and this is a good thing.  As evidence comes forth, we change how we care for patients to ensure "evidence-based" quality. We no longer bleed patients or deliver caustic enemas.  We understand that ulcers are the result of H pylori bacteria and that autism is not caused by bad mothering.  It took 20 years for hand washing to be accepted for infection control after Ignaz Semmelweis made the connection of why 1/3 of hospitalized women died after childbirth in 1850.

Our newest evidence is that digital rectal exams (DRE) looking for prostate cancer in men is probably not effective for diagnosis.  In fact is might even be harmful if it leads to biopsies and further studies.

As an Internist, I was trained that a digital rectal exam (DRE) was needed and essential for every male physical exam after the age of 40.  And my male patients have come to expect it.  The March-April issue of Annals of Family Medicine reports that in 7 studies with 9241 male patients, the DRE is not sensitive or specific for evaluating prostate cancer.  This means there are more false-positives and more men sent for biopsy and further studies that prove to be not needed.  It is not an effective test for screening or diagnosing prostate cancer.

Digital Rectal Exam for screening of prostate cancer is no longer recommended.  In fact, in 2016 a large study in a little read journal, Current Medical Research and Opinion, also spoke against DRE as a recommended test.  I don't know if Medical Schools are still recommending DRE in physical exam.  Since 81% of doctors perform this test and patients expect it to be helpful, I suspect it will take time before this medical practice changes.  

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...