Search for tag: "appendicitis"

Interviewer: What are emergency rooms doing about opioids? That's next on The Scope.

Announcer: This is From the Frontlines with emergency room physician, Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health. And of course, by this point, most of us know that opioids are a major problem and it seems like taking that first one is what really lead you down that path. And for many people, they might have gotten them in the ER at one point. So I'm curious, Dr. Madsen, is that the case? Did you use to give out opioids for pain and has that changed?

Dr. Madsen: So I've absolutely given out opioids and we still do. I mean, there are cases where people need some kind of pain medication and, often, that's the only thing that's going to help them in the short term. But we've definitely seen the pendulum swing in the last few years. It used to be, in the ER we always talked about, "We're not treating pain adequately. We're not giving enough medication." And I think the response to that, 15, 20 years ago was to say, "Let's get more opioids. Let's prescribe more, let's give more IV medications."

Now, we've seen what's resulted from that. And it's not just the ER, it's primary care physicians, it's pain clinics, it's specialists. It's all across the spectrum of health care in the United States.

Interviewer: In the ER, was the opioid generally in pill form, or did you give it through IVs?

Dr. Madsen: We have often . . . and again, to say we don't do this, we do it because there is a role for opioids, and I think there's something we need to make sure we understand too is that there's a role for these medications people that have severe injury, long bone fractures, things like this, that's the only thing that's going to treat their pain adequately.

And so we do give at IV. There are IV forms of opioid medications like Morphine or Hydromorphone. And then there are pill forms as well that we can prescribe, hydrocodone, oxycodone, things like that. You've heard of Lortab, Norco, Percocet, all these sorts of brand names. So there are those two options that we use in the ER and that people use elsewhere as well.

Interviewer: So if I'm a patient, I find myself in the emergency department, and I'm told that my pain is such that you would recommend that I should have an opioid-based painkiller. Should I be nervous that I could possibly get addicted to it?

Dr. Madsen: I think the big issues with addiction come when we're taking medication not to treat the pain but often for the way it makes us feel. And if this is a new injury, if it's a serious injury, or if it's a serious issue like severe abdominal pain and that's the only thing that's going to control it, I think you need it. And I think you have to make sure you have some balance there and not just think, "Opioids are bad. I'm going to get addicted if I even have a touch of this medication." That's not the case.

So when people take it long term, they're taking it more for the way it makes them feel rather than, say, coming in for severe pain and I'm taking this because I need this pain in my abdomen treated right now because I've got a ruptured appendicitis or something like that going on.

Interviewer: So how have things changed in the ER?

Dr. Madsen: Yeah, so I think one of the biggest changes I've seen, so a couple of areas. Number one, we have a statewide database we can use and it's very useful. I can look up, if someone comes in and I can see have they gotten multiple prescriptions for opioids?

If they have and it's come from lots of different physicians, particularly lots of different ERs, I'll talk to that person and I'll express my concern, say, "We're seeing lots of different prescriptions from lots of different places. I'm concerned about the possibility of, maybe, addiction here. You need to go to one person, get this from one doctor so they can monitor what you're getting and make sure you're staying safe with these medications."

The second thing we've seen are just, like I talked about, decreased prescriptions for opioids for a lot of stuff that maybe we used to prescribe it for, for bumps and bruises and back pain because we wanted to make sure people's pain was taken care of. Now, I think it's more like saying, "Hey, try Ibuprofen. Ibuprofen, it's a great medication. Avoid opioids if at all possible."

Again, still there are cases where opioids are necessary. It's the only thing that's going to really adequately control someone's pain, but a lot of those kinds of gray zone areas. I think a lot more physicians are moving away from opioids altogether or are really limiting the number of opioids they're prescribing to those patients.

Interviewer: So this is a good first step, I would imagine. What else needs to be done?

Dr. Madsen: Well, I think we need to know a lot more about how we can better address pain and if there are other factors. Does anxiety really play into this, is something we studied in our ER. Patients who come in who are feeling very anxious, how much does that amplify the pain? If I address that anxiety, is that going to help with the treatment of pain?

Something else we're doing really new in our ER and one of the few places doing this is we have a physical therapist in our ER as well. So we're using our physical therapist to come in and see a lot of these people with back pain, work with them right there, get them set up with physical therapy to hopefully avoid the opioid prescription, to get them some treatment and say, "Hey, you don't need just to take pills for this. Here's some exercises, some strengthening, some stretching. It's going to give you a whole lot more relief than taking some sort of opioid."

Interviewer: So just like anything else, it's a useful tool. It's just that maybe we haven't been using it the best that we should up until this point?

Dr. Madsen: That's exactly right. I think the pendulum swung too far one direction and it's going back the other way. Hopefully, we can have some nice balance here and address this, what it really is, a nationwide epidemic.

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Interviewer: Food poisoning. How long after you eat it will it take to affect you? You're at a barbecue or a party or something and you ate a little something and now you're kind of wondering, "Oh, man. Maybe that chip dip was out a little too long." You're worried that you're going to get food poisoning. How long is it going to take until you actually know whether or not you did?

Dr. Troy Madsen is an emergency room physician at University of Utah Health. Food poisoning. How long after you eat something will it take to affect you?

Dr. Madsen: So food poisoning's going to take about six hours to hit you. And when I tell you this, I'm speaking from personal experience because I had some really bad potato salad once, that I knew was bad, and I still ate it and six hours later, I was as sick as I've ever been.

Interviewer: And what are those symptoms?

Dr. Madsen: So, typically, you're going to get some nausea, vomiting, maybe you get some diarrhea as well. Abdominal cramping, you might hurt all over, you might have a headache with it as well, but, typically, it's going to be those stomach, those GI symptoms. Just lots and lots of vomiting as your body is reacting to that bacteria that are in the food that made you sick.

Interviewer: So about six hours, normally. Does it vary from bacteria to bacteria?

Dr. Madsen: It does, but the most common one we see is Staph aureus, which affects thing like potato salad, mayonnaise-based sorts of foods. And that's usually what we're seeing, where you're at a barbecue, you're at a dinner, these things are left out too long, someone brought it from home and forgot it in their car and then goes out and gets it, you know. All these kinds of bad scenarios that are setting it up to really start to grow bacteria in there. And so, most of the time, it's six hours.

Interviewer: All right and how . . . does it automatically cause symptoms if you eat something that could be potentially bad, or do some people just react differently?

Dr. Madsen: I think some people it just depends, maybe . . . I don't know. You know, like I said, I had a personal experience with it and I knew this was not great potato salad, but I'm like, "I've got a strong stomach."

Interviewer: I guess you didn't, huh?

Dr. Madsen: I guess not. So I don't know if there's just, like, a certain threshold where if you eat X amount, you will get sick. If you eat less than that, you won't get sick. It's either really bad or it's not bad at all. Seems like most cases we see are people who come in who are feeling really sick from this.

Interviewer: Sure, which would make sense if they're coming into the emergency room, I suppose. So if some sort of food poisoning, or something I believe to be food poisoning, hits, you know, it's the six hours later after I ate something, maybe it was even at a restaurant, should I automatically be worried, or will my body kind of take care of it?

Dr. Madsen: Your body should take care of it. You know, if you've got other illnesses like kidney disease, heart problems, issues with dehydration, then I'd be more concerned because you're going to lose a lot of fluid. But if you're otherwise healthy and you think you can get through it, it's probably going to last six to 12 hours, and then you should feel better. You may want to go to the ER if you need to get some fluids, need to get some medication for nausea and vomiting, just to get through it. But the reality is most people are going to get through it okay. They're going to feel pretty crummy, but come out of it feeling weak, but feeling all right after 12 hours.

Interviewer: Would an urgent care be able to help you with those things, an IV and medication?

Dr. Madsen: They might be able to. The problem is if you go in an urgent care and you're just vomiting a lot, they might just get concerned enough, they might just send you straight to the ER. So it's kind of a tough call. Your doctor also might be able to call in a medication for you, some nausea medication, and maybe someone could pick it up for you. Because if you could just get that stuff in your system, you should be able to get through it okay.

Interviewer: Got you. And other than my own personal health, could it be something else that's more insidious than just food poisoning that would cause concern? I suppose if it doesn't stop in 12 hours, that's when . . .

Dr. Madsen: Yeah. It absolutely could, and that's the tough thing with food poisoning. We have people come in all the time that say, "I've got food poisoning," and honestly, I have no way to know unless they tell me, "Yeah, this other person was there and they got sick too and ate the same thing." Could be a virus, could be appendicitis, could be a bowel obstruction. There are lots of things that go through my mind so, definitely, if you're not feeling better after even six hours, you may consider getting checked out. And if you're having lots of abdominal pain, bloating in your abdomen, like your abdomen just feels like it's really distended, like it's sticking out, or you're really tender in the right, lower side of your abdomen, those are all things that might suggest something else going on.

updated: December 26, 2022
originally published: February 3, 2017

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: All right. Here's a question. How can you reduce the use of imaging tests for patients that you are evaluating for appendicitis? That's what Dr. Eric Glissmeyer's research focused on. Thank you for coming to help answer that question. First of all, why did you want to answer that question?

Dr. Glissmeyer: Well, particularly when we're evaluating children that are being seen for abdominal pain and they may have appendicitis, we like to not do dangerous things or harmful things to children. It's not uncommon that a CT scan, a test with ionizing radiation that exposes the child to potential risk of harm, is done, especially in uncertain cases. So we wanted to try to set forth the protocol with the support of our surgeons and our radiologists that helps us one, standardize our approach and two, reduce CT use and that was our primary objective.

Interviewer: How have people tackled this problem before?

Dr. Glissmeyer: Well, there are a number of places around the country that have done great work in establishing protocols that many times have been just developed iteratively in a quality improvement kind of way, that have had the focus of reducing CT use.

I think that one unique approach that we took here is we didn't want to just know when is CT scan used in patients who are ultimately proven to have appendicitis, but when is it used in that larger demographic, that larger denominator of patients who are evaluated for suspected appendicitis? The doctor goes and feels their belly and says, "They may have appendicitis. I better rule them out for appendicitis."

What do you do next? We have a lot of tools at our disposal and there's a lot of variability in what people do. We wanted to standardize that with that objective of reducing advanced imaging tests like CT scans.

Interviewer: All right. Here's the moment of truth. What do you do?

Dr. Glissmeyer: What we believe the best thing to do is to take a standardized approach driven by physical exam and utilizing a scoring scale. We use something called the Pediatric Appendicitis Score and there are a number of other scores being used. We don't really think it matters exactly what the score is. We don't think there's any magic in one particular lab value or one particular physical exam finding.

Appendicitis is sneaky and it likes to present many different ways. What we've found though is with the support of our surgeons and our radiologists all working together to determine an algorithm, that as we go down and we do a blood count and we do an exam and we see what some of those initial results come back as, we can either put the patient into a category of low risk and, "Gosh we're done." We really don't need to have much worry about appendicitis unless things get worse, intermediate risk, where perhaps an ultrasound test and certainly you have to have an organization that does ultrasound well.

Pediatric ultrasound for appendicitis is not an easy test. Our ultrasonographers have been doing this a long time at primaries and are very good at it. We actually know based on what they see on the ultrasound there are four different grades for the ultrasound result. We know what the likelihood of appendicitis is for those different grades.

So we've got some great data to drive our decision making out of the results we get. You know what? There are some patients who don't even need an imaging test to diagnose their appendicitis. If it's a classic case, straightforward, the labs support it, you're done, call the surgeon, take the appendix out. This was done 20 to 25 years ago with no imaging tests regularly because they didn't have any. So we kind of need to go back to that in some ways.

Interviewer: And in your research, how accurate was this method?

Dr. Glissmeyer: For patients who come in and we see for having appendicitis, I want to first say how do we know when we were looking at this retrospectively that the patient was actually being evaluated for appendicitis? How did you crawl into that doctor's mind and determine, "Well, did they actually suspect appendicitis or were they just coming in for gastroenteritis?"

We developed a surrogate definition, whether they had an ultrasound done, whether they were coming in for a chief complaint or abdominal pain and the word appendicitis was used in the note and a CVC was obtained that 95% of those patients were evaluated for appendicitis.

It had a sensitivity and a specificity of 95%. We're confident that we could evaluate the patients or rather identify the patients that were being evaluated for appendicitis. So in that group, I think the real question people would want to know is what were you doing before you did this protocol and what did you achieve after in terms of the CT use?

Interviewer: Yeah, did it reduce it?

Dr. Glissmeyer: We were one of the lower utilizers in the country in CT. Our baseline data showed we were doing CT scan only 15% of the time in this cohort of patients being evaluated for appendicitis. If you look nationally, it's more around 30%. So we were already a low utilizer of CT.

But what I was so pleased to find was that as we instituted this protocol that has not just the standardization but this follow up option that we'll talk about too, we were able to drop that low rate in half again, from 13% to 6%, from 13% to 6%. So we were really pleased to see we were even able to cut that in half further.

Interviewer: Is there an ability to even cut that more, do you think?

Dr. Glissmeyer: I think potentially. But I think you achieve a certain baseline minimal rate where you get your unclear cases, you get your cases where your patient has been having pain for a week or so and you really suspect that this is a ruptured appendicitis and CT scan is really the optimal test to use. I think around 5% or so is probably about the minimum you want to achieve.

Interviewer: All right. Explain the follow up option you were talking about.

Dr. Glissmeyer: Probably somewhere around a third of patients who have abdominal pain are being evaluated for appendicitis. It's not totally clean, a third, a third, a third, but let's talk about it in those terms because it makes it easy.

If a third of patients come in and it's pretty obvious after your exam and some labs they don't have appendicitis, you're done. You don't need imaging tests. About maybe less than a third, somewhere around 15-20% and they come in and they have pretty clear evidence of appendicitis, labs support it, you call surgery, they get their appendix taken out, no imaging tests needed there.

Then there's this larger middle where the fall into an intermediate range of a Pediatric Appendicitis Score that we have called between 4 and 7. If they have that score, you do an ultrasound scan first. Boy, when it shows the appendix and it shows it's normal or it shows the appendix and it shows it's not normal, that's really helpful. Then you can make your decision based off of that, but if it doesn't see the appendix, what do you do then.

The patient still has some tenderness, you're still a little uncertain. Do you just go stick them in the CT scanner to get your answer? That's what I think historically has been done, when the ultrasound fails to give you the answer you want, we go and scan them. We work with our surgeons to say, "You know what? We've observed this patient for a couple of hours here in the ER. Their pain is not really getting worse. It's not a clear cut appendicitis. Why don't we have them come see you tomorrow morning in clinic?"

So if it's Sunday night between Sunday night or Thursday night where they could go the next morning, that being between Monday and Friday, they can show up at about 7:30, 8:00 a.m., come into surgery clinic, get their belly pushed on, be examined, get lab tests repeated if they need to, perhaps do another ultrasound if necessary and find themselves in the hands of another expert the next morning also with not a second ER charge, which is nice, but being able to come into the clinic.

We thought, "Are we going to go and be doing surgery clinic follow up now? Are people going to just be like all the time overrunning the surgery clinic the next morning?" Actually it's only about one patient every ten clinic days that utilizes this resource. But the fact that you can offer it to them in the emergency department the families love and the docs love because in the faces of uncertainty, it gives them a plan. That's been the magic of the approach.

Interviewer: What's the next iteration then of this research? Where do we go from here?

Dr. Glissmeyer: We've been pleased with what we've been able to achieve at Primary Children's Hospital. It's to take it to other hospitals within Intermountain Healthcare, University Healthcare, having the support of surgeons at those other hospitals is key and radiologists as well, we're working on that. But only half of the appendix case present to the tertiary children's hospital here, Primary Children's Hospital. We want to address that other important half and that's where we're going next.

Interviewer: Getting that feedback from the surgeon afterwards for the patients that didn't get the imaging but had the operation and you find out how successful you've been or haven't been. Have these tools proven to be pretty successful?

Dr. Glissmeyer: That's a great question. You wouldn't want to be going and admitting to the surgery service a lot of patients who you as the ER doc are convinced have appendicitis and then they go in there to take it out and then, "Uh-oh, it looks normal." That happens on a rare occasion. Nationally about 5% is the rate of negative appendectomy. You go in and, "Oh, we thought it was appendicitis and it's not."

Our rate here is about 2-3% and it's not increased since the use of the protocol. So going in and taking out patients' appendix without ultrasound test or any imaging test, it still is successful and doesn't increase that negative appendectomy rate.

Announcer: Discover how the research of today will affect you tomorrow. The Science and Research Show is on The Scope.

Host: Now a shorter hospital stay and a faster recovery for children that need an appendectomy. We'll examine that next on The Scope.

Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Skarda: Traditionally, in pediatric surgery and, in particular, with younger patients who have appendicitis, we were very worried about the potential for complications and, in particular, infection inside the abdominal cavity. Because of that high degree of concern, we essentially created protocols for treating these patients after their appendectomy, which included relatively long durations of IV antibiotics lasting 7, 10, 14, sometimes 21 days and associated in-patient, in-hospital stay for that entire period. This did decrease the rate of infections, we think, but we just treated patients for a very long time with in-patient IV antibiotics.

Host: So at one point, that was a solution to a problem that somebody saw.

Dr. Skarda: That's correct.

Host: And then you kind of started reexamining it. What caused you to think, "Well, maybe we can actually shorten these stays?"

Dr. Skarda: We noticed here at Primary Children's that a fairly large percentage of these patients were ready to go home two or three days after their appendectomy. Because of the protocol that we had in place, they were required to stay in the hospital well beyond that point.

Host: Yes. So they were feeling fine, and everything looked good as far as you were concerned. But they had to stay.

Dr. Skarda: They had to stay because they were on IV antibiotics.

Host: Yeah. And because that's what the protocol was.

Dr. Skarda: And that was consistent, I think, with most children's hospitals across the United States.

Host: All right. And then what made you think, "Maybe we can shorten this"? I mean, how do you go through that process of suggesting that this is a better way to do it, maybe?

Dr. Skarda: Well, we had talked about it as a group of surgeons for some time. Looking at that issue very closely, we realized that there was a very high likelihood that these patients who are ready to go home probably no longer needed antibiotics. And I think that the critical issue here was that not all patients with appendicitis necessarily respond the same way, and there are may be some that do not need antibiotics as long as others. If we can identify who they are, stop their antibiotics, and get them out of the hospital, they'll likely do better.

Host: Yeah. And actually, the data showed that.

Dr. Skarda: Yeah. Once we initiated our new protocol, which is clinical response based, meaning from the moment of the operation, we monitor patients every two hours at the bedside to see if they're drinking enough, eating enough, their pain is well controlled, and if they don't have a fever for 24 hours, they're ready to go home. Once they meet those criteria, then we send them home. We do check labs on their way out the door, basically, to see whether or not they need any oral antibiotics at home. Some of them do. Some of them don't. Then we follow them back in clinic in one week and make sure that they're doing well.

Host: And the hospital stay is shortened how much?

Dr. Skarda: This protocol decreased our hospital stay on an average of two days. So from 7 days to 5 days, and this decreased the cost of care by about $5,000 per patient with appendicitis and improved their outcome in terms of abscess rate from about nine percent to about five percent.

Host: Awesome. So it just went all the way around. Shorter hospital stay, less money, and better outcomes.

Dr. Skarda: That's correct.

Host: All right. And this was just all the post-operative procedure?

Dr. Skarda: That's right.

Host: But there's more to this story? You actually said, "Can we maybe do more?"

Dr. Skarda: Yes. Exactly. So although we accomplished a lot with the post-operative component of this, we realized that there are other areas where we could potentially improve. In most children's hospitals, there are many different surgeons performing appendectomies, and each of them perform their appendectomy in a slightly different way depending upon where they were trained, who trained them, and what seems comfortable for them.

Oftentimes, though, the instruments used to perform the appendectomy are relatively expensive. Given this variable nature of a lot of ways to make a taco or do an appendectomy, what we figured out is that there's probably a good way that we can perform appendectomies. We can essentially standardize the procedure so that everyone's doing it the same way. I then spent a lot of time and identified a specific set of devices and a specific way to do the appendectomy that was cost-effective and efficient. I then got all of my partners to agree to do that at Primary Children's.

Host: Was that hard to do?

Dr. Skarda: You know, it actually wasn't. I think once they saw the data, they saw the variability, they saw the cost involved, and they saw what was possible in terms of doing it all the same way, they actually agreed to it fairly quickly. Then once the procedure itself was standardized, we were able to decrease the cost per appendectomy at Primary Children's from about $800 or $900 in disposable devices that would never be used again to about $150 to $200 of disposable devices and, quite frankly, reusable devices. We've had this in place now for more than a year, and given our rate of appendectomies here at about 500 per year, that ends up being a cost savings of around $200,000 to $250,000 a year.

Host: Not an insignificant amount of money, especially in today's day and age when everybody's talking about healthcare costs and insurance premiums.

Dr. Skarda: Right. Well, it's really all about value, which incorporates the importance of having good outcomes. We monitor those as we made these changes, and, again, our outcomes have actually improved. We're having fewer abscesses, shorter duration of hospital stay, shorter operative times, and our physicians are happy. And more importantly, the parents and our patients are happy.

Host: Yeah. That's exciting stuff. Is this kind of a common thing, that procedures are standardized and we don't necessarily look at the equipment used as closely as we should throughout medicine, or was it just kind of unique to this procedure?

Dr. Skarda: I suspect there's been some drive towards standardizing procedures in other countries. However, in the United States, to my knowledge, this is the first successful attempt to do that.

Host: Well, that's exciting. Are other hospitals finding out about this, asking you how you did it? Is this something you're passing along, paying it forward?

Dr. Skarda: Yeah. There's no question there. Other facilities are very interested in this. This data will be presented this fall at the AAP Conference in San Diego, and we anticipate that as this information and this idea is disseminated throughout the United States that there will be a significant degree of adoption. There's a great deal of interest, of course, in value, improving care, and decreasing cost. And this certainly fits into that category.

Host: Where are you looking at fixing next?

Dr. Skarda: We've also standardized cholecystectomy, or removal of gall bladders at Primary Children's. And we're considering moving onto other procedures.

Host: And final thoughts?

Dr. Skarda: I think there's an enormous opportunity in medicine and, in particular, at Primary Children's Hospital to standardize and improve care and improve value.

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Interviewer: Top five reasons people might end up in the ER. Think about what you think they might be, and you'll find out next on The Scope.

Intro: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: One of the top five reasons people come in the ER. We're with Dr. Troy Madsen, University of Utah Hospital Emergency Room Physician. Let's go over the top five reasons somebody might end up in the ER. Number five.

Dr. Troy Madsen: This is based on actual research we've done. So we looked at patients who come into the Emergency Department, and we try to quantify why did they actually come in. The number five reason on that list was back pain, and oftentimes this was an acute back injury. Maybe they twisted their back or just stood up wrong or something happened. Or sometimes it's chronic back pain. It's pain they've had for years, and they come into the ER for this.

Interviewer: Let me ask you one question further. Is that a reason to go to the ER? Should you go to urgent care?

Dr. Troy Madsen: It is a reason to go to urgent care. The reason to come to the ER is if you're having any bladder or bowel something, like, where you just cannot urinate or you can't hold it, like, you just urinate on yourself because then we actually worry more about spinal cord compression.

Interviewer: Okay.

Dr. Troy Madsen: The other reason to go to the ER is if you've had an injury to the back, like, direct trauma to the back, something that could cause a fracture.

Interviewer: All right.

Dr. Troy Madsen: Again, another reason to go to the ER.

Interviewer: But just a pain or an ache?

Dr. Troy Madsen: Yeah. Just aches and pains, especially these chronic aches and pains. It's probably a better reason to see your primary care doctor.

Interviewer: All right. Number four. Reasons people might end up in the ER.

Dr. Troy Madsen: Number four reason is coughing and congestion. A lot of upper respiratory symptoms. So they just got a cold. They're just feeling kind of miserable. Maybe they have a fever along with this, but this is a very common thing we see in the Emergency Department.

Interviewer: Just the kind of coughing that doesn't stop? I could never imagine going just because I'm coughing.

Dr. Troy Madsen: Yeah. And one thing you're going to find as we go through this list, you'll find a lot of things here that maybe you could not imagine going to the ER for. But when I think I started working in the ER, that was the biggest thing that surprised me. It was a lot of the kind of more minor things that we see on a regular basis, but, you know, I think people get very concerned. They may just have really, quite honestly, just a cold. But for whatever reason, they're concerned that something more serious may be going on.

Interviewer: Again, coughing. Is that a reason to go to the ER or is it more of an urgent care situation?

Dr. Troy Madsen: That's a great thing to go to an urgent care for or see your primary care doctor.

Interviewer: All right.

Dr. Troy Madsen: The exception being is if you have underlying immune system disorders or if you're on chemotherapy, anything there where you have a fever is going to be more concerning and is a reason to go to the ER.

Interviewer: Or you just can't breathe.

Dr. Troy Madsen: Exactly. Yeah.

Interviewer: All right.

Dr. Troy Madsen: If you're just not breathing, your lungs are really tight with asthma or something like that.

Interviewer: Top five reasons people come into the ER. Number three.

Dr. Troy Madsen: Number three is chest pain. We see a lot of chest pain, and this is definitely something to come to the ER for. This is something that's very concerning, especially in older adults. Once people start to get into their 50's or even older, and especially if you have risk factors for heart disease. If you have high cholesterol, high blood pressure, any family history of heart attacks, it's absolutely a reason to come to the ER, and it's one of the more common things we see.

Interviewer: Number two.

Dr. Troy Madsen: Number two is trauma and orthopedic injuries. We certainly see a lot of people after car accidents, people who were brought in by the ambulance and then people who walk in themselves either were seen at the scene of an accident and released by the ambulance but drove themselves in for some pain. Or people who have traumatic injuries from falls, from orthopedic injuries such as twisting their knee, hurting their legs, you know. So here we're talking about a full spectrum of traumatic injuries, you know, very serious. The things that, you know, maybe are kind of more sprains or strains. Things like that.

Interviewer: Is there a way that a patient could make the determination whether, again, they should go to urgent care or the ER for something like that?

Dr. Troy Madsen: You know, my general rule of thumb is, "If it's something that's from a car accident, and it involves your spine, your chest, or your abdomen, these are things to go to the ER for. If it's something where you've twisted your knee but you can put some weight on it, and even if you're having some trouble putting some weight on it, still, it's a great thing to go to an urgent care for."

Interviewer: All right. Top five reasons people come into the ER. Number two.

Dr. Troy Madsen: It works up to number one.

Interviewer: Oh. Top five reasons people come into the ER. Number one.

Dr. Troy Madsen: Number one. The top reason we see people and the most patients we see are abdominal pains, surprisingly. It's up to maybe about 25 percent of patients we see are there because their stomach hurts. They may have had some nausea, some vomiting, maybe some diarrhea, maybe just some cramping, or maybe it's something more serious like an appendicitis or cholecystitis, which is their gall bladder being infected. So we see kind of a full spectrum of things there as well, but that is the number one thing we see in the Emergency Department.

Interviewer: And the same question, how do I know if it's maybe just an urgent care or primary care physician issue versus coming into the emergency room?

Dr. Troy Madsen: Yeah, and this is always kind of a tough one, but I often, you know, think of the more serious concerns in the abdomen being on the right side. So the right lower side is your appendix. The right upper side is your gall bladder. If you're a lot of pain in those places, if you push in there and it hurts, and even more concerning if when you release, it hurts even worse, those are signs that you should probably go to the ER.
But, again, there are things where they could probably see you in urgent care, or if your doctor could get you in that same day, they can probably see you and evaluate you.

Interviewer: Is there some place you could call before you maybe make that call if you're on the fence?

Dr. Troy Madsen: Usually, calling your doctor's office might be helpful. Sometimes it's a little tough because you're probably not talking to your doctor. You're probably just talking to someone answering the phones. So it's a little bit tough, but see what you can do there.

Interviewer: All right. So just use your best judgment?

Dr. Troy Madsen: Yes. Use your best judgment. If you're concerned, come into the ER. And I think the biggest take-home point from this list is if you come into the ER and you think it's not that serious, trust me, there have been people there with much less serious things than what you have. So err on the side of caution, and don't feel ashamed if you need to come to the ER.

Outro: We're your daily dose of science, conversation, medicine. This is The Scope, the University of Utah Health Sciences Radio.

Dr. Troy Madsen: I'm Dr. Troy Madsen, emergency physician at the University of Utah hospital, today how the ER works.

Announcer: Medical news and research from University of Utah physician and specialists you can use, for a happier and healthier life. You're listening to The Scope.

Dr. Troy Madsen: So one of the questions I get asked a lot as an ER doctor, is how does and ER work? Well the biggest thing to keep in mind, is when you go in the ER, number one, you're seeing an emergency physician. So we're the doctors that work in the ER, that's what we do on a day-to-day basis. We work there, we treat patients, and if anyone would ask what is our specialty, it's treating emergent conditions. So I know a little bit about a lot of things, and in another sense, I don't know a lot about a few things. So it's kind of a trade-off, but that's who you're seeing. So I'll come in the room, I'll see you as an emergency physician, and then we'll go through, what are you here for? Are you having abdominal pain, chest pain, have you been injured? And then kind of sort through it from there. And once we get some test results back, if we find something that's concerning, that's when we get specialists involved.
So in a sense, you know we do kind of triage things, you hear about triage nurses, who kind of distill things down or sort through things, and decide what's really serious and what's not. That's kind of what were doing as ER doctors is sorting through, okay what you have wrong, who we need to get involved? If you come in with the abdominal pain, and we do a CT scan and you have appendicitis, I'll call the surgeon once we get the results back. Now let's say you have an arm that's injured or it looks like it's broken, we'll get the x-rays, once we know it's broken we'll call the orthopedic surgeons. So in that sense, you're coming in the ER, you're seeing us, then we're bringing the other people down to get you the help you need. There are a lot of other people you see on the way there, we have nurses that will see you, sometimes you'll see a triage nurse at the front desk.

In our emergency department we actually have one of the doctors that sits out front, so we can see you more quickly, and try and get you treatment more quickly as well. But you may see EMTs, these are technicians in the ER who may start your IV, you may see radiology technicians, who are taking you to x-rays. So there's a lot of support staff their, but we're all kind of working toward that same goal, under the guidance of the emergency physician, try to figure out what's wrong, is it something we can treat in the ER and send you home, or is it something that we need to get someone else involved. So nurses are absolutely integral part of the emergency department. And I can tell you, having worked a lot of different places, what a huge difference great emergency department nurses make. And I can say in our emergency department they truly are the best nurses I've ever worked with, and we're really fortunate to have them.
The nurses are really responsible, they're kind of my eyes and ears in the ER. I may be taking care 15 different patients at once, I may be stuck in a trauma, I really rely on these nurses to come to me and say, hey this patient in bed ten, is really sick, we need you in there right now. The nurses are the ones that are at the bedside, who know what's going on with the patient, they're starting the IV, giving them medication, sending off the laboratory results, giving really the treatment these patients need, under my direction, and they really are the key to a successful emergency department.