Search for tag: "emergency room"

Interviewer: What is the thing you should be worried about if you end up with a dog bite? We're going to talk about dog bites next on The Scope.

Dr. Troy Madsen's an emergency room physician at University of Utah health care. And if you get bitten by a dog, what do you need to know? Dr. Madsen, go.

Dr. Madsen: So the biggest thing we think about with dog bites are infection. That's probably the first thing that comes to mind for me in any kind of bite dog, cat, whatever, but in particular with dog bites. So when I see someone with a dog bite, first of all, I'm looking at the wound itself. Are they moving their hand okay? Let's say they got bitten on their hand or on their forearm. Do all the tendons seem like they're intact? Can they feel? Are the nerves working okay? Is the blood flowing okay, making sure there's no damage to any of the vessels there? So anything I would do it any sort of laceration, that's what I'm doing with the dog bite.

But the big thing, I think, about say someone falls and cuts their arm or cuts their arm with a knife or something like that versus a dog bite would be the infection risk because dogs, like any other animal including humans, have lots of germs in their mouth. So typically what I'm thinking about there is getting the wound cleaned out really well, making sure it's washed out really well. And then often with these bites I'll put people on antibiotics. So I think if you're bitten by a dog that's the big thing you're thinking about is, number, one getting this cleaned out really well. Number two, was it a fairly deep wound or something where maybe you should be on antibiotics for a few days to prevent an infection there.

Interviewer: All right, so if you take a look at it and it's a deep wound then it's a no brainer, you probably should go to the ER?

Dr. Madsen: You really should.

Interviewer: The instant care would they be able to handle something like?

Dr. Madsen: Instant care would be fine.

Interviewer: They'll be able handle that as well and get that stitched up. But if it's just kind of a minor bite, they kind of broke the skin a little bit, then you need to watch out for infection.

Dr. Madsen: You do. And I think if it's a minor bite in those situations, if it were me, I would just wash it out really well.

Interviewer: Soap and water?

Dr. Madsen: Sure. You can use some soap and so might kind of might hurt. Quite honestly, if you just run the tap, just get a lukewarm water going, put your arm or whatever affected body part of was put it under there, let it just run for five or ten minutes, just wash that out really well, that's really going to do the job. And you can avoid putting a lot of soap on there, causing a lot of pain. I think just getting lots of water running through it, just flushing it out is going to be effective, and you know you can try some antibiotic ointment on there as well. But I think the big thing to watch for there is any signs of infection where it starts to get red, swollen, getting drainage from the wound, then absolutely in that situation, you need to get to an urgent care or an ER, get in and get on some antibiotics.

Interviewer: Some redness is normal though right after a bite like that?

Dr. Madsen: Some redness, yes, but I expect usually the redness is going to go down within 24 hours. If it's getting bigger after 24 hours, that's a sign of infection.

Interviewer: And get that taken care of immediately.

Dr. Madsen: Exactly.

Interviewer: All right. So if it's a dog that's known to you then I think we've covered it. But if it's a dog that's not known to you, then you've got people worried about rabies.

Dr. Madsen: So the big thing to know is if you know the dog, if it's your dog, if their shots are up to date, you can observe the dog after the bite, you don't need to rush in and get rabies shots. If it's a dog where this is some random dog, and you don't know whose dog it is and you don't know where the dog went, you need to think about rabies, and that's something to go to the ER for or an urgent care could handle this as well to look at getting the rabies vaccine to prevent rabies.

Interviewer: When a dog that's not known to you attacks you, would they be showing symptoms and signs of rabies? Or could they be asymptomatic, not showing those symptoms and signs and still have rabies?

Dr. Madsen: They could. It's hard to say and it may not be florid rabies where it's classically you know you hear foaming at the mouth as rabid dog. But just any time you're bitten by a dog and you just cannot track that dog afterwards or you just don't know if they've had their shots, you need really need to get the rabies vaccine in that situation.

Interviewer: And don't wait for, "I'll just see how I feel."

Dr. Madsen: Yes, don't wait to see if you get rabies and wait for that because there's not much you can do once you have rabies.

Interviewer: Is there anything else to keep in mind when it comes to a dog bite?

Dr. Madsen: I think the big things again are watch for infection, and use your judgment in terms of getting to the ER to get on antibiotics depending if this is a larger wound versus something you could just wash out treat at home. Again, always think about rabies if you don't know the dog, you don't know whose dog it is, get in, get the rabies vaccine.

updated: August 19, 2020
originally published: August 19, 2016

Interviewer: When is a fever bad enough that you should go to the ER? We'll examine that next on The Scope.

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

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health Care. When is a fever bad enough to go to the ER? Dr. Madsen, shed some light on that for us.

Dr. Madsen: Yeah. You know, it's interesting you bring that question up because I've had people ask me even recently. They've said, "At what point is the fever just going to cook my brain and how high does it have to be to cook my brain"?

Interviewer: That can't happen. Right?

Dr. Madsen: I can't say I've ever seen it happen and I told them that.

Interviewer: Okay.

Dr. Madsen: And it's something that's out there. I remember hearing that too, like people saying, "Wow, you got to keep your fever down, or you're just going to fry your brain." I can't say I've seen that. So when I think of fever I don't think of the absolute number with the fever. We define a fever as being 100.5 degrees Fahrenheit or greater. So I think of fever more in terms of what are the symptoms that you're having or what kind of medical problems do you have.

This is a child, a young infant, less than, say, 12 weeks old, and they have a fever of 100.5 or greater, you got to go to the ER because there, we get concerned about a serious infection. If this is someone who has an immune system problem, who's on chemotherapy, or maybe has HIV, or something that's affecting their immune system, again, another reason to go to the ER. I'm not concerned about is it 105, is it 100.5, if they have a fever, they need to have testing done.

Interviewer: If they are in that particular group?

Dr. Madsen: Exactly.

Interviewer: Okay.

Dr. Madsen: If they have immune system problems, if they're very young, and then, of course, if they're very old, people who are very old also. It's interesting because very old people really don't get high fevers like someone in their 20s might. So in them, a fever or a temperature of 100.5, that's pretty significant. And again, potentially a sign of something going on that's very serious. Whereas the average person walking along, who's healthy, who has really no medical issues, maybe they have a cough, maybe they have a fever up to 102, even 103, in my mind, that's not so concerning.

So when I think of fever, I think of more the whole person, what kind of medical problems do they have. And then, beyond that, I think of "Okay, what else is going on?" If it's someone who has a fever, who says the light bothers my eyes, my neck is stiff, I'm confused, or someone is reporting to me that they're confused, then I think of meningitis. Fever with a really severe cough, or a cough that has been going on for a week, and won't go away, I think of pneumonia or a sinus infection. Certainly, fever is with your unary symptoms, back pain, we think about kidney infections and issues there.

So again, you're taking that whole picture. So I think the big take home point would be that I don't even own a thermometer at home. I don't check my own temperature. I know if I'm hot, or I'm cold, or family member is hot or cold. I've heard some pediatricians say, "Get rid of your thermometer. Just don't use it on your kids unless they're the very young kids less than 12 weeks old," Because there, you are again looking at the whole picture. It's not just the fever.

Is the child lethargic? Are they feeding well? Are they eating? Are they still urinating, meaning that they're still having adequate fluids in their body? You're looking at everything there in addition to the fever.

Interviewer: That's kind of a tough paradigm for me to wrap my head around because I think a lot of people are just driven by "Oh, 103 fever. That's burning up. That's a major problem." But it sounds like you're saying to take that as an indicator to maybe assess, are there some other issues going on and those other issues are actually the reasons why you'd probably go to the ER?

Dr. Madsen: That's exactly it. You could have 103 fever with kind of a run of the mill cold, and you could feel absolutely miserable, but it doesn't mean you have to rush to the ER.

Interviewer: Okay.

Dr. Madsen: And you can. If you're at all concerned, never hesitate to call your doctor. Never hesitate to go to an urgent care or an ER. But in your mind, I want to think of it as like, "Okay. This absolute temperature means you're sick or something less than temperature means you're not." Like I said, some people with 100.5-degree temperatures who have other problems, that's really serious. Whereas another person on 103-degree temperature, probably very well, just could be a viral infection, and it isn't that big a deal.

Interviewer: So this could be probably tough information for somebody to hear because I'm imagining if they're listening to this, they're concerned about somebody in their life with a fever. If they don't fall in one of those two groups, the very young, the very old, they're going to want to do something. But it sounds like what you're saying is a fever should only indicate that maybe you should look and see if there are other symptoms?

Dr. Madsen: That's exactly it.

Interviewer: Yeah.

Dr. Madsen: Yeah. I won't rush to get into the hospital based on a fever alone. Look at the whole picture. Look at all the symptoms. Look at how the person is acting. If they're acting fine, and they're eating well, and drinking well, and they're alert, and they're not confused, and they've got a temperature of 102, they're probably okay. You can give it some time. You can take some Tylenol, some ibuprofen, to bring the fever down and see how they're doing.

Announcer: We're your daily dose of health, sciences, conversation. This is The Scope, University of Utah Health Sciences Radio.

Interviewer: How to be sure you are safe when you're riding a horse or are around horses, that's next on The Scope.

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

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health Care. I thought it was interesting. Dr. Madsen told me that in August here in Utah that there tend to be more horse injuries that come into the ER than any other time of the month. Maybe it's because of the fair circuit, maybe it's because of the rodeos. But I thought it would be interesting to find out what are the common horse injuries you see so people could be wary of that and protect against those sorts of things. So what is it?

Dr. Madsen: Well, you w you're exactly right. It is something we do see and for whatever reason, maybe more in the month of August, like you said, because of fairs or different events, rodeos, things like that going on. It's interesting; several years ago we actually looked at the causes of more significant trauma in our ER, those people who stayed at least overnight in the hospital, and horses were on the top five in that list at University of Utah. So kind of interesting.

Interviewer: Wow, I never would have guessed that. I would think there are so many other things out there that would be so much more dangerous, but . . .

Dr. Madsen: Exactly.

Interviewer: . . . a horse can be pretty dangerous, apparently.

Dr. Madsen: Horses can. I mean, at least in terms of some of the injuries we see.

Interviewer: Yeah. Doing some serious damage. So kind of what's the most common horse injury that you would see that causes a lot of damage?

Dr. Madsen: The most common injury would be head injuries. You've got to think of it kind of like bikes or motorcycles. If you fall off a horse, the biggest risk is going to be your head and your spine. I think the biggest thing we see with horses is people who get bucked off a horse, who come down on their head, who then have a significant head injury. Maybe a skull fracture or lacerations, bleeding in the head being the most significant thing that we see.

Then they are either brought to the ER because they're unresponsive or maybe they lost consciousness, they regained consciousness. We do testing on them to make sure there's no bleeding or lacerations to repair or any of a number of things that can happen with the head injuries.

Interviewer: So it sounds like that could be just about as dangerous like a motorcycle or a four-wheeler and so forth or maybe even more so?

Dr. Madsen: You've got to figure the height you're up on a horse. You're probably up sitting at least 4 feet off the ground and when you fall from that height, that's certainly higher than you would fall off a motorcycle or a four-wheeler.

Interviewer: A lot of times, a motorcycle might go down sideways so you're even closer to the ground before the head hits. So when you fall off a horse, it's . . .

Dr. Madsen: Yeah, exactly. And you're 4 feet up and then, if a horse kind of rears up and throws you off their back, you're even higher. So you can come off a pretty good height, not necessarily at the speeds for four wheelers or motorcycles but still, there's definite danger there in terms of coming down and hurting your head. As I mentioned, the other thing too is spine injuries. When we think of head injuries, we also think of the head getting pushed forward or some sort of damage or something hitting the spine directly. And then that can cause some very serious issues as well. So that's the other big thing we see and we look for.

Interviewer: All right. So helmets for head injuries, even though it's not as cool as a cowboy hat

Dr. Madsen: That's right.

Interviewer: I mean, I guess if you want to be safe. Spine injuries, is there really anything one could do to protect themselves against that if you're getting on a horse?

Dr. Madsen: Not a whole lot.

Interviewer: Yeah. That just might be part of the deal.

Dr. Madsen: It is and there are actually some inflatable vests that people can wear. I'm not sure exactly how they work, if here's something that then attaches to the saddle where if a person is bucked off the horse this vest inflates and actually protects the person. I personally know someone, an older lady, who was wearing one of these vests when she was thrown from her horse and she had some pretty significant injuries, but nothing that was so serious. And she probably really benefited from this vest inflating and protecting her.

She swears by it and says it made a big difference for her. So it's something where I know that's something that's out there that people may be aware of that you can use as well that probably does provide some spine protection and protection to your chest and abdomen.

Interviewer: All right. So those sound like ones that are probably staying overnight. Are there other injuries that you tend to see horse related?

Dr. Madsen: We see kind of the full spectrum of orthopedic injuries. People who get scrapes and cuts on their arms and legs, broken forearms. You've got to figure if you come down from that height, you try and brace yourself with your forearm. There's a good chance you're going to fracture your forearm. Ankle injury is also very common, depending how you come down. You come down on your ankle, your lower leg can snap. So we do see those injuries as well.

Again, those are things, maybe they're an overnight stay, maybe it's something we can repair in the ER. But kind of the full spectrum. Everything we see with motorcycles, with ATVs, with bicycles, we see all those things with horses as well and maybe even compounded a little more just because the height the person is falling from.

Interviewer: Sure. It sounds like maybe the advice is to wear a helmet and then also just treat the horse, treat the animal with respect. I think it can be easy for a horse person to kind of forget.

Dr. Madsen: Exactly. You become comfortable with the animal. You think, "Well, this is safer than a motorcycle or an ATV." Again, it's on our top five list of things we do see injuries with. They do happen. It's something to be aware of.

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Interviewer: You get bitten by some sort of animal, whether it's a dog or a wild animal, the first thing you probably are starting to worry about is, "Did I get rabies?" We're going to find out more about that next on The Scope.

Dr. Troy Madsen's an emergency room physician at University of Utah Health Care. You get bit by an animal, I think the first thing a lot of people think after, "Ouch," is, "Ooh, do I have rabies?" Is that a real threat?

Dr. Madsen: It's a real concern. So, primarily, you're thinking about this with dog bites, cat bites, raccoons, foxes, and bats. And one of the really interesting about bats is, and this is something I've found kind of fascinating, the Centers for Disease Control, the CDC, actually recommends if you wake up and you look at the ceiling and there's a bat there, they actually recommend getting the rabies vaccine in that situation. The idea being that you may have been bitten by the bat during the night, you may not know you've been bitten, the bite marks are usually so small you can't see them. So the concern is that great.

There are certain animals that you may get bitten by and you may wonder about the concern about rabies, animals like rabbits, rats, mice. Those are not really concerns. The big thing I think about in my mind, typically, the animals that are going to transmit rabies are animals that are not necessarily vegetarian-type animals. So rabbits, those things, they don't really transmit rabies. It's more things like foxes, skunks, raccoons, these kinds of scavenger animals that may be eating some meat here and there. Those kinds of animals are sometimes those that carry rabies and those are the ones we get concerned about in saying, "Hey, if you've been bitten by one of these animals, we probably need to think about rabies."

In terms of dogs and cats, if it's an animal where you don't know the dog or you can't observe it, you don't know if it's had its shots, those are also animals where absolutely we worried about rabies and we treat you potentially to prevent a rabies infection.

Interviewer: So if it's a neighborhood dog, good idea to go talk to that neighbor, get that information and save yourself from the rabies shots, I suppose?

Dr. Madsen: Exactly.

Interviewer: If you find out, no, they haven't had their vaccinations, but they don't seem to be showing any symptoms, or you've been bitten by another animal where you're unsure, what would the next steps be?

Dr. Madsen: Then, that's a situation where you need to get the rabies vaccine. And what that involves, first of all, is giving them a medication at the site of the bite wound to prevent rabies infection. It's not necessarily the vaccine, but it's something that kind of neutralizes the virus if it is there. And then I start them on a series of basically four shots, where they'll come in, they'll get the shot that day, they'll come back in a few more days, get another shot. These are all vaccines to prevent a rabies infection.

And that's a precaution I'm going to take on anyone who comes in after a bite from any animal that could be carrying rabies. And the reason we're very, very cautious in that situation is because there's not much you can do if someone gets rabies. It's something you really want to prevent. You don't want somebody to catch it because if someone catches rabies and they actually develop the disease, it's almost universally fatal.

Interviewer: Really? So it's bad news, it's serious stuff.

Dr. Madsen: It's bad news if you get it, yeah. It's one of those things you can try and treat it and try and get them through it, but it's a horrible thing to get. So really, the treatment for rabies is prevention.

Interviewer: Gotcha. And these shots, they used to be in the stomach, right? And I heard they used to be really painful and there are a lot of them, but you're saying there's one at the site and then four more after that. Where are those four more?

Dr. Madsen: They're just in your arm or your leg. It's not in the stomach. I remember hearing that as a kid as well.

Interviewer: Has that ever been true?

Dr. Madsen: I don't know. That's . . .

Interviewer: Oh. Not since you've been in medicine.

Dr. Madsen: Not in the last 15 years that I've been in the medical profession.

Interviewer: Okay. All right.

Dr. Madsen: I don't know. I heard that too. I remember always hearing that you had to get a shot in the stomach and I thought, "Wow, if I got bitten by a dog, no way would I want to go get the rabies shot because that sounds miserable." But no, these are shots, you give them the same place you'd give a tetanus shot or something like that. They hurt a little bit, kind of like a tetanus shot would, but it's not something, like some really crazy shot that you're getting in your stomach.

Interviewer: Yeah. And better than the alternative.

Dr. Madsen: It's much better than the alternative. Exactly. You don't want to get rabies.

Interviewer: And is this an ER-only thing or could you do an Urgent Care for this?

Dr. Madsen: I think Urgent Cares can do this. I can't say I've looked into it specifically to see if they offer the rabies vaccine in most Urgent Cares, but it's a pretty straightforward thing. If you went there and they just said, "Hey, we don't have the vaccine here," then they're going to send you to the ER, but I think it's a reasonable place to start.

Interviewer: All right. And is there a time limit? After I get bit, is it a day? Six hours? Three hours?

Dr. Madsen: I would want to get in within the first 24 hours. Really, as soon as you can. I would not put it off, especially, like I said, because one of the vaccines, one of the injections we're giving, at the site of the wound is essentially neutralizing that virus if it's there, so the sooner, the better.

updated: March 10, 2021
originally published: July 22, 2016

Interviewer: You get bitten by a non-poisonous snake, ER or not? That's next on The Scope.

Announcer: Is it bad enough to go to the emergency room? Or isn't it? You're listening to "ER or Not" on The Scope.

Interviewer: It's the game where you get to decide whether or not you would go to the ER and then we find out the correct answer from Dr. Troy Madsen, emergency room physician at University of Utah Health Care. ER or not today, you are bitten by a non-poisonous snake. Is that a reason to go to the ER?

Dr. Madsen: Non-poisonous snakes, first of all, you want to know that it is a non-poisonous snake. So in Utah, we're thinking primarily about rattlesnakes being the poisonous snake here of concern. So if you know it's not a rattlesnake, if it's a little garden snake that was in your yard, you picked it up, it bit your finger, not necessarily a reason to go to the ER.

Interviewer: Okay.

Dr. Madsen: But there is kind of one little caveat here, with this. With any bite, and we always think about it with snakebites, you have to think about tetanus. Something we have to think about with any laceration, anything like that. So if you can tell yourself, "Okay. I know I had a tetanus booster. It's been within the last 10 years. I'm covered there." In terms of the bite itself, everything's moving okay, it's not like it affected any tendons, nerves, nothing like that, it's not a real deep bite, it's probably something you can just wash out at home and not go to the ER.

Interviewer: What about infection? Is that a worry in a snakebite as well? I know it's a worry with a lot of other bites.

Dr. Madsen: It is for a lot of other bites. And again, certainly, infection is something that you think about with snakebites. But if someone comes to the ER, they've got a couple little fang marks on their finger from a snakebite, and it looks clean, it's not like a real dirty wound where they were working in the garden and their hands were real dirty and then the snakebite pushed a bunch of dirt into their finger, I'm not really going to start that person on an antibiotic for that.

Interviewer: Fascinating. So like getting bit by a dog, more worry of infection than getting bitten by a snake?

Dr. Madsen: It is. And for me, it is just because the dog bites are usually deeper. There's usually more tissue involved. I don't know. I can't say I have ever looked to see what the germ content of a dog's mouth versus a snake's mouth is.

Interviewer: There's somebody out there that probably knows.

Dr. Madsen: There probably is, but for me, it's more just the fact that the dog bites are usually a much larger area, usually deeper, usually a lot more tissue involved.

Interviewer: Okay.

Dr. Madsen: That's why with dog bites, I am usually thinking more starting antibiotics to prevent an infection where with snakebites, typically, not such a concern, but something you have to watch out for to make sure nothing develops.

Interviewer: All right. So a non-poisonous snake bite, no need to go to the ER as long as you are sure you've had that tetanus booster within the past 10 years.

Dr. Madsen: Exactly.

Interviewer: Wash it out and just watch it, at that point.

Dr. Madsen: Yeah, wash it out. You can use some antibiotic ointment on it, keep an eye on it, make sure it doesn't develop an infection.

Interviewer: And if you have not had that tetanus shot, urgent care? Can they give you...

Dr. Madsen: Urgent care is fine, yep. You get in to see your doctor within the next day or two, that's fine as well.

Announcer: If you like what you heard, be sure to get our latest content. Sign up for weekly content updates at thescoperadio.com. This is The Scope, powered by University of Utah Health Sciences.

Interviewer: You come back from a hike and you find that you have a tick on you. Is that something that you need to go see a doctor for? We'll talk about that 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 Care. If you ever get a tick on you, is that something you need to go see a doctor about? Or is it something you can just kind of take care of on your own? Should I be a "do it myself" kind of guy with a tick or come see you?

Dr. Madsen: It's not an uncommon question. It's more of these questions where I may have a family member ask me this sort of thing, like, "I went out hiking. There's this tick."

Interviewer: Do you go to the ER for a tick?

Dr. Madsen: I wouldn't. Generally, not. It's probably something you could see your doctor for. But there are certain things you're looking for. When we think about ticks, we think about infections. We're fortunate in Utah that the more serious infections you think about with ticks aren't really such a big issue, like Lyme disease and Rocky Mountain spotted fever, which is funny. It's called Rocky Mountain spotted fever, but it's not so much in the Rocky Mountains. I think it was discovered in Denver and that's how it got its name. But it's more in the Southeast that that's an issue.

But regardless, if someone comes and they say, "Hey, I had this tick on me," I'm asking them, "How long was it on you?" They may not know exactly, but they may say, "Okay. I was camping. I've been home for two days." If that's the case, I'll say, okay, it's probably been on there at least 48 hours. Typically in those cases, we give antibiotics to prevent any kind of infection from the tick. Kind of the rule of thumb is if the tick's been there for 24 to 36 hours, we'll start antibiotics just to prevent an infection.

Now, if you've had a tick and it's been on you and you look at that spot where the tick was located and you start to see redness around there, like a circular sort of rash, maybe some puss in that wound that have kind of built up, then I'm more concerned, number one, about an infection from the tick, like a head being embedded in the wound. Or, number two, an infection that a tick has transmitted to you, like Lyme disease. Again, reasons to see a doctor.

But I think the bottom line is if you see a tick on yourself, let's say you're out camping, you pulled the tick off, you get rid of the tick, you don't need to feel like you need to rush right into the ER. Unless you're seeing some of these other things.

Interviewer: So is that the way to get rid of it? Just pull it out gently with tweezers? My dad used to go to the gas cans. I lived out on a ranch and he'd put gas in a a baby food jar and turn it upside down on the tick until it backed out. Or I've heard maybe nail polish. You put nail polish on them and they have to back out.

Dr. Madsen: Yeah, I've heard these things too. Some people have said to put petroleum jelly on it because the tick breathes through its body. I'm not a tick expert. There are probably tick experts out there that are cringing as I say this.

Interviewer: So we don't know if they breathe through their body or not, is what we're saying.

Dr. Madsen: I've heard people say that and then the tick will back out. I think one of the challenges with those is sometimes, it just makes the tick sit there and just makes it kind of moist. And then it becomes harder to pull it out. The thing I've learned is just to grab some tweezers, grasp down by the tick's head.

Interviewer: As close to the head as you can get, close to the skin, probably.

Dr. Madsen: Yep. And then just pull directly back.

Interviewer: Pull straight out.

Dr. Madsen: Pull straight out and then drop the tick in some water, like a toilet or something like that so it's not climbing on someone else or climbing on your pet. Just so you're drowning the tick and getting rid of it.

Interviewer: And if you end up doing that, breaking the head off, then you need to go see a doctor? No?

Dr. Madsen: Possibly.

Interviewer: The body could handle that? Is that what you're . . .

Dr. Madsen: If you did break the head off and you came in, I would probably put you on an antibiotic for a few days and tell you to watch for signs of infection. But the reality is the head's probably not going to be that deep where it's going to cause any major issues. And it's probably just going to work its way out within a few days anyway.

Interviewer: So watch it for those other symptoms you talked about.

Dr. Madsen: Watch for those other symptoms, primarily. You're right. If you came in, I would probably say, "You've got the tick head still in there. Let's just put you on something for a few days just to prevent any infection from that."

Interviewer: But an urgent care could handle that?

Dr. Madsen: Exactly.

Interviewer: All right. Or a doctor the next day.

Dr. Madsen: Exactly, yeah. Not an emergent thing to get into an ER.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interviewer: A day in the life of an emergency room physician or in this case, a night in the life, 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 Care and I thought it would be kind of fun to go through a typical shift, the things that you encounter in an emergency room as one of your typical days. Is there even such thing as a typical day for you?

Dr. Madsen: I think you would probably say that the typical day is atypical because it always changes.

Interviewer: But you have a list. You keep track of everything you see every single night for whatever reason.

Dr. Madsen: I do. I keep track of it mostly because I need to remember to finish the charts to make sure I get those done but I do keep track of things. I also use my list of follow up with people, give them phone calls to make sure they're doing okay if it's someone I'm concerned about.

Interviewer: Got you. So let's just go down this list and see some of the things that you encounter and if any questions come up, I'll ask them but I think this should be really interesting.

Dr. Madsen: For sure. So this is a typical night shift and I'm certainly not going to reveal any protected health information or anything specifically about these individuals but these are the kinds of things we see in an emergency department.

So I walk into ER and the first thing I see is someone who is there with a fever. They've come with a fever as the first patient I go in and see, it may have been for whatever reason but their chief complaint, as we call it, the thing that's on the chart, on the board is that they have a fever and I have to try and figure out why they have that fever.

And then there's someone with a headache. The next room I go to and typically what I'm doing, I'm coming into a shift and there may be four or five patients waiting to be seen. Maybe they've gotten some testing going. So I'm saying, "Okay, fever, next one's headache."

Next thing I know someone's coming in who has had some burns. They've had some burns they sustained from flash burns where something exploded in their face. So I'm going in to see that person next, and then moving on from there to someone who has a laceration on their face. They were injured. They have a laceration I need to repair.

Interviewer: It's a cut?

Dr. Madsen: A cut yes.

Interviewer: Okay.

Dr. Madsen: Yeah a cut on the face, and so these are all of the things that are on my mind as I walk into my shift. I'm thinking okay, what do I need to address first? I've got this facial burn. I need to make sure this person is breathing okay, that it didn't affect their airway. Thinking on the laceration, okay I could probably wait on that. I'm going to check and make sure there are no other injuries.

Interviewer: So you have to make these decisions who you're going to see first. Somebody else doesn't do that for you.

Dr. Madsen: Oh, absolutely, I do.

Interviewer: Okay, so you've got a list of the things that are there and then you got to go oh, this is going to be the first thing I want to check out.

Dr. Madsen: Exactly.

Interviewer: Okay.

Dr. Madsen: I'm looking. I've got these patients I need to see and if someone there has chest pain or I can look at their vital signs, if their vital signs are abnormal I'm getting into that room first and I'm prioritizing all the time in the ER, who do I need to go see right now of those I've been seeing, of those who are new? Where do I need to go first?

Interviewer: So obviously somebody who is having difficulty breathing is going to be seen before I'm going to be seen with my broken arm.

Dr. Madsen: That is exactly right. We're going to go in to see that person first.

Interviewer: And the ABCs, let's talk about that just briefly.

Dr. Madsen: Yes.

Interviewer: Those are the three important things that you're looking for, go ahead and explain that.

Dr. Madsen: Yeah ABCs, we're always thinking airway first, making sure their airway is intact. They can move air through it. Breathing, making sure they are breathing. And then circulation, making sure they have a heartbeat, a blood pressure. Those are the three priorities I'm always thinking through. So if I look at someone's vital signs and their blood pressure is 70/40, I'm in that room immediately and the person with the facial laceration can probably wait.

Interviewer: Okay got you. All right, keep going.

Dr. Madsen: Yeah, so that's kind of what I start out with on the night shift. The next thing I see is someone who is pregnant, someone who is coming in with some pregnancy issues, maybe in the first trimester, the first third of the pregnancy, possibly having some bleeding during pregnancy, someone I would go in to see how are things going with their pregnancy. Are there any issues there we need to address?

And then someone who is confused, and this is a common thing we see in the emergency department.

Interviewer: Really?

Dr. Madsen: Yeah, it is and it's usually older people, often times someone who maybe in a care facility, who someone in the facility says this person is not acting quite right and the challenge there is it could be any of a number of things going on. So I've got to kind of throw out a net, as we say in that situation, often times running lots of tests to try and figure out what could be causing the confusion.

Interviewer: Could confusion be life-threatening?

Dr. Madsen: It could be, yeah.

Interviewer: That could be a symptom of something life-threatening for somebody.

Dr. Madsen: Oh it could be. I've seen cases where, and you just see them again and again so you kind of get programmed to think, oh maybe it's a urinary tract infection, maybe it's their medications, but I've seen cases of people who have had bleeding in their brain. Basically they're just saying, "Well, they're confused or not, acting quite right." They may have had a fall at some point and had blood that accumulated and no one knew they fell. So you've got to really look for heart attacks. You've got to look for infections. You've got to look for signs of trauma, all those sorts of things.

Interviewer: Okay.

Dr. Madsen: And then from there I again see someone else that has a headache. Someone else came in that also had a headache.

Interviewer: All right, so how often are headache's actually a good reason to go to the ER?

Dr. Madsen: That's a great question. A lot of people have chronic headaches and they know when to go to the ER for those because they just cannot manage their migraines at home. Big headaches that we worry about are those that are worse than previous headaches you've had or sudden onset severe headaches. If you had a headache plus a fever, we think about meningitis.

So those would all be reasons to go to the ER and all of the things that I'm thinking about is I see okay, the next patient I'm going to see has a headache. From there I saw someone who is suicidal, someone who actually came in saying they had had thoughts of hurting themselves, may not have made an actual attempt, but that's certainly a reason also to go to the ER and yeah.

Interviewer: I didn't know that.

Dr. Madsen: Yeah, we see that quite commonly and partly I think because our emergency department, because we work closely with the University Neuropsychiatric Institute. So a lot of patients who are admitted there will come through us, but I would say over the course of a shift, I very commonly will see at least one, maybe several people come in who are there for either a suicide attempt or thoughts of suicide.

After that I go in to see someone who is there for what we call a "crisis evaluation." This is addressing psychiatric complaints, psychiatric issues and not necessarily suicide, maybe they've been more depressed. Some people have chronic psychiatric issues. They may have had issues where they're not taking medications and have become very manic or had a lot of issues associated with that.

And then from there I saw someone with atrial fibrillation. So this is an issue where the heart's beating very rapidly, where it's just sometimes so quickly that we have to actually give them a shock to get it back into a normal rhythm and that's something very commonly we'll do in the emergency department.

Interviewer: Like a shock like "boo" or how do you shock them?

Dr. Madsen: We shock them with electricity?

Interviewer: Really? To get their heart going to where it should be again.

Dr. Madsen: Yeah, exactly and you may have seen on movies where people pull the paddles down. They're holding the paddles on their chest and then everyone says "Clear" and then they shock. It's not quite that dramatic but it's pretty close.

Interviewer: Really? So that's what it looks like.

Dr. Madsen: Yeah, you're actually delivering electricity to the heart to take it from an abnormal rhythm and try and shock it back into an organized rhythm, and I'm not just walking in the room grabbing paddles and putting it on their chest. These are people who come in, they're talking to me, they know when it started. It may be the first time it happened or they may be familiar with this from before. Maybe they've been shocked in the past. I make sure they would meet qualification to be able to undergo this procedure safely, but then I give them medication to sedate them and give them a shock.

Interviewer: Okay.

Dr. Madsen: Yeah. From there I saw someone who is short of breath and who came in saying they just weren't breathing well. After that an allergic reaction, a severe allergic reaction. We had to give medication for it to treat it. And another fever patient, someone else with a fever and I finished up the night with another case of a rapid heart rate and atrial fibrillation.

Interviewer: That is quite a night. How long is your shift?

Dr. Madsen: The night shift's scheduled for eight hours. I usually plan I'm going to be there about ten hours, just wrapping things up and taking care of patients at the end of the shift. So that's a pretty typical day or night in the ER.

Interviewer: And from that typical day or night, I don't even know if I should ask this question, how many of those people actually made the right choice coming in?

Dr. Madsen: As I look back on these, I can't really say that any of these, I would say don't come in. These were all, as I'm looking back specifically at these, and again it's been a while ago. I'm not going to say when all this happened because I don't want to tie this into any potential health information on anyone but these all seem like fairly legitimate reasons to go to the ER.

The other issue at night is there are no urgent cares. So it's not like you can go to an urgent care or call your doctor and be seen in the middle of the night for your facial laceration and things like that.

Interviewer: Sure. Well that's very, very interesting. So I think the interesting thing for me was, my perception always was you'd see a lot of broken bones, a lot of cuts, a lot of that sort of thing, but there's quite a variety of reasons somebody might come to the ER.

Dr. Madsen: There is. You see a little of everything and that's what's fun about it. Like I said, you go from the room of someone who is pregnant to someone who is having a heart issue, to someone who is having trauma, to someone who is having a psychiatric issue, kind of the full spectrum.

Interviewer: That's really interesting insights on things that I wouldn't have expected in your list there. What are some things that weren't on the list that you do tend to see typically but maybe just not that night?

Dr. Madsen: One thing we didn't see a lot of that night was trauma. Lot of people coming in injured and the most common sort of trauma we see is motor vehicle accidents and injuries from that. We also see penetrating trauma like stab wounds or gunshot wounds. Occasionally we see that. We didn't see any of that that night either.

Another common thing we'll often see are infections, things like pneumonia or people just coming in with upper respiratory infections. I didn't see a lot of that that night either. So it's kind of funny in the ER, that's the fun thing about it that you never know what you're going to get. There are some nights where it seems like you just cannot get out of the trauma room. It's just one accident after another. Other nights, you may not even go in the room.

Interviewer: Yeah and other nights, it might just because lot of people that are confused.

Dr. Madsen: Exactly.

Interviewer: Like confused old people coming in for whatever reason.

Dr. Madsen: That's exactly right. We didn't have a lot of that that night either but there are some days where that seems like that's all you see are older people coming in confused and not sure what's going on and then you have to really kind of look for a lot of different possibilities in those scenarios.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Dr. Miller: What happens in a level 1 trauma center? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. David Rothberg. He's an orthopedic surgeon specializing in trauma surgery. He's also a professor of orthopedic surgery.

David, tell us a little bit about what it means to work in a level 1 trauma center as an orthopedic surgeon.

Dr. Rothberg: Well, we're a member of the team that takes care of patients on their worst day generally. A lot of the patients that come to a Level 1 trauma center are patients who have been in a car accident or have fallen from an extreme height or some sort of accident along these lines. And we're a member of the team along with the general surgeons and neurosurgeons that take care of all sorts of trauma. Anything you can think of, from head trauma, spine trauma, belly trauma and extremity trauma.

Dr. Miller: So these could include industrial accidents. It could include automotive accidents. Just about any type of traumatic injury that would involve, what, multiple organs or just orthopedic injuries?

Dr. Rothberg: Really multiple organs. Orthopedics tends to take a lead role, often times in the operative care of these patients. But we're a member of a huge team and what it means to be a level 1 trauma center is that we can take care of anything.

Dr. Miller: Give me some examples of the types of injuries you particularly take care of.

Dr. Rothberg: In orthopedic trauma, we take care of just about any broken bone or soft tissue injury, but our specialty has evolved around the care of pelvic and acetabular fractures and fractures into people's joints.

Dr. Miller: Do you see these types of injuries mostly in automobile accidents?

Dr. Rothberg: They can be in automobile accidents but we see them ranging from recreational activities, like rock climbing to industrial accidents like you mentioned.

Dr. Miller: Now in a patient who's being sent to a level 1 trauma center, how far away are they coming to our center from? What is our outreach or ability to take care of these patients in terms of geography and distance?

Dr. Rothberg: Well, we're fortunate to have an incredibly large geographic catchment that involves Idaho, Montana, Nevada, parts of Northern Arizona, Wyoming and occasionally people from all around the United States who may be here.

Dr. Miller: Would the patients who are injured then be sent directly to us by helicopter or fixed wing or would they come from another hospital usually?

Dr. Rothberg: It's really variable. We have an incredible active helicopter service because of how large the geography is. But we also consult with physicians and outside hospitals who have patients that are above and beyond what they can take care of. And so we are commonly talking with them on the phone, brining patients here to help with their definitive care.

Dr. Miller: Tell me a little bit about the families of these patients. How are they directed to our hospital to follow up on their loved ones and be sure they're being taken care of?

Dr. Rothberg: That's an incredible process. So in the very beginning it's really patient-focused but as soon as that level 1 trauma activation, which can vary in time but usually is quite quick, somewhere in the ballpark of 15 to 30 minutes, we're already involving the patients. They've been in the ER talking with our social workers and then our surgeons and other providers are already talking to them as soon as possible.

Dr. Miller: Now you work with other types of specialists outside of orthopedics. Could you talk a little bit about that team approach? I mean, what happens when a patient hits the emergency department and they come in with a trauma? How do you begin to take care of them in conjunction with other specialists?

Dr. Rothberg: What happens is the general surgeons are usually kind of the quarterback of the football team. They're really in charge of what's going on in the trauma bay, along with the ER doctors and the anesthesiologists.

But when they come in, it's an incredible amount of people that are there on the spot, so orthopedics and neurosurgery and EMT and plastics. They're all there so that all injuries can be identified and taken care of in a timely manner. But we end up being involved with the vast majority of these because of the amount of extremity injuries that are involved in these traumas.

Dr. Miller: Sounds like chaos.

Dr. Rothberg: It can be but it's a pretty incredible process that we review and have almost a script that we follow each time so that nothing is missed.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interviewer: You get a crazy severe headache out of nowhere. ER or not? That's next on The Scope.

All right. It's time for ER or Not, where you play along and decide whether or not something that happened is worth going to the emergency room or not. We're with Dr. Troy Madsen. He's an emergency room physician at University of Utah Hospital. Today's ER or Not, you get a crazy severe headache out of nowhere. Just, bam, it hits you. Should I wait a few minutes, or should I think about going to the ER? ER or Not?

Dr. Madsen: I'm going to ask you a little more about this. Have you had a headache like this before?

Interviewer: No. This was just something, never experienced anything like this.

Dr. Madsen: Nothing?

Interviewer: No.

Dr. Madsen: Severe headache?

Interviewer: Yeah.

Dr. Madsen: All of a sudden?

Interviewer: Maybe mild headaches before, but nothing like this. It just all of a sudden, bam.

Dr. Madsen: Did it make you pass out or cause you to feel sick to your stomach?

Interviewer: It did not make me pass out. Caused somebody to feel sick to their stomach, sure.

Dr. Madsen: Okay. Yeah. These are typical questions I'm going to ask someone. Again, I'm imagining you're a family member calling me on the phone telling me, "I've had this severe headache. It just came out of nowhere. I've never had headaches before. Otherwise, feel okay." I'm going to say, "Go to the ER."

Interviewer: Okay. So severe headache out of nowhere, no other symptoms, still go to the ER?

Dr. Madsen: Yes.

Interviewer: Put a little nausea on top of that or passing out, then definitely.

Dr. Madsen: Absolutely.

Interviewer: I'd imagine go to the ER.

Dr. Madsen: Yes, absolutely. These are cases where the big thing I'm worried about is what's called a subarachnoid hemorrhage, which is bleeding in the brain. So you can have an aneurysm. Maybe 1% to 2% of the population, of all of us, just have possibly little brain aneurysms, just something we have and we may not know it. But these individuals that have severe, sudden headaches like this, the big thing I'm worried about is something rupturing with that aneurysm, bleeding out, and that's what's causing the severe headache.

Classically, what will happen is someone will say, "Out of nowhere I had the absolute worst headache of my life." They describe it as a thunderclap headache, just like that thunder just hitting you all of a sudden. Sometimes they may pass out. Sometimes they may feel very nauseated. They may have other symptoms as well with it, if the bleeding is severe, like difficulty speaking or weakness. But really, if you have that severe, sudden onset headache, you need to go to the ER to get that checked out.

Interviewer: So these aneurysms, otherwise completely healthy people could have them?

Dr. Madsen: They might, and that's the thing. It's not something where I'm going to recommend that people just go and say to their doctor, "Hey, I heard this guy say that maybe 1 or 2 out of every 100 people have these aneurysms. I want to get checked for this." Because most people go through their whole lives and it's never an issue. But in some cases, for whatever reason, there may be something about it, either it's large or it's been weakened for some reason, these aneurysms can rupture, and then can cause these severe symptoms.

Interviewer: Are there instances where you could have this sudden severe headache and it is something else? What I want to say first of all, if you do have this go to the ER.

Dr. Madsen: Yes.

Interviewer: But in the interest of not freaking everybody out, could there be other reasons?

Dr. Madsen: Oh, absolutely.

Interviewer: Okay.

Dr. Madsen: Just because you have this doesn't mean you've had a ruptured aneurysm. When studies have looked at it, they've found that about 10% of people who describe these thunderclap headaches, these very severe, sudden headaches, do end up having some sort of bleeding in the brain. That means the other 90% just had it. For whatever reason, it just came on. The big thing I'm thinking about in the ER is ruling out the bad stuff. Oftentimes, that means getting a CT scan of the head to look for any sign of bleeding there, making sure there's no sign of that, and we may have to do some additional tests as well.

But at the end of the day, 90% of the time or more, I'm telling people, "Hey, you had a severe headache. I don't have a great explanation as to why. I may look for other causes as well, but at least we know it's nothing very serious like this."

Interviewer: Then, that buys you some time to maybe look into the other reasons.

Dr. Madsen: Yes, exactly.

Interviewer: But definitely, those thunderclap headaches, go to the emergency room.

Dr. Madsen: Absolutely. Yep. I've seen cases of people who have come in, young, healthy people who have come in and said, "I've had this severe, sudden onset headache." We start the testing. Within 30 minutes they are not responding, because the bleeding has gotten so severe. We're getting the neurosurgeons down there emergently. So one of those things that I don't want to scare you with this, but severe, sudden onset headaches you want to take seriously.

updated: September 23, 2020
originally published: May 13, 2016

Interviewer: Common ways that people cut themselves that lands them in the ER. That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health Care. What are some of the ways that you see that people come into the ER that they've cut themselves that lands them in the ER? The whole point of this is to maybe make us all a little bit aware.

Dr. Madsen: Sure.

Interviewer: When we're doing one of these things that, you know, this is a common way that somebody could cut themselves.

Dr. Madsen: Yeah, it is, and we do see lots of lacerations. Probably when you think of the ER, you think of going there because you were cut at some point and maybe had to have stitches. One of the common ways I often see people cutting themselves is cooking. This is something where I oftentimes see people who work in restaurants, who cook on a regular basis and are slicing and cutting things up and they'll catch a finger.

That's the most common site. They'll sometimes cut off the end of the finger, just the tip of it, not through the bone but slice off a piece there or cut down through the fingernail and then it seems to stop once it hits the bone. That's not an uncommon thing I see just from rapid cutting and just getting their finger in the wrong spot and getting that knife right through it.

Interviewer: Yeah, restaurant workers. What about just regular people? Not quite as much?

Dr. Madsen: Oh, sure. We see it with regular people, too.

Interviewer: Yeah, sure.

Dr. Madsen: But I guess for me it's always a surprise when you see the restaurant worker where they're doing this all the time and then they cut themselves and they always say they feel stupid, but it happens quite often.

Interviewer: Okay, so kitchen accidents. Watch those kitchen knives.

Dr. Madsen: For sure.

Interviewer: Be careful.

Dr. Madsen: Watch the kitchen knives and watch your fingers when they're near the kitchen knives.

Interviewer: Because that's the common kitchen cut, is a bit of finger.

Dr. Madsen: Exactly.

Interviewer: More so than a [makes cutting noise].

Dr. Madsen: Oh, yeah, for sure. I usually don't see someone who sliced down through their hand. It's almost always on the finger.

Interviewer: Okay. All right, what's the second kind of most common cut that you might see?

Dr. Madsen: The next common cut I see is someone who falls. They either land on their elbow and that will split the elbow open causing a laceration there, or they hit their knee and slice their knee open, or sometimes they'll fall and hit their head.

These head injuries, when it hits the scalp, that's where you really see a lot of bleeding. A lot of times they'll just come in with all sorts of bandages or holding towels on their head and just saying, "I must have a huge laceration on my scalp because it's bleeding like crazy." We'll pull these towels off and it's maybe only an inch long.

Interviewer: Oh, no.

Dr. Madsen: But scalp lacerations bleed like crazy. That's the bottom line. That is probably the next most common thing I see.

Interviewer: So they look much worse than they really are?

Dr. Madsen: They really do.

Interviewer: Generally?

Dr. Madsen: I think they really scare people and it's something you've got to go to the ER for typically, or maybe an urgent care because you do have to have it repaired, but a lot of times it looks much worse than it actually is.

Interviewer: All right. So I guess I didn't even consider a cut caused by blunt trauma.

Dr. Madsen: Sure.

Interviewer: That's interesting.

Dr. Madsen: Not an uncommon thing.

Interviewer: What are some other common ways that you see people with cuts?

Dr. Madsen: So another common thing we see is power tools. I've got to throw this one in here because probably the biggest surprise for me when I started working in the ER was all of the table saw injuries I saw. It's funny because at the time I had this old table saw in my garage. I'm not an experienced woodworker, but I thought I'm going to pull that saw to make some stuff with it.

Within the first month I probably saw four people who came in who had had their fingers amputated, cut off, from table saws. So I immediately got rid of the table saw. These were experienced carpenters and woodworkers that just said, "You know, it just happened." As they were pushing the wood through this table saw it just jumped or whatever, it hit a knot and their finger jumped forward, just cut right through the finger. So household equipment, power tools, table saw injuries, we do see a lot of those.

Interviewer: Watch those sorts of things. You've got experienced people that are cutting their fingers. Is there anything you can do to avoid that?

Dr. Madsen: Well, there are certain techniques you can use. I know there actually are some power tools and table saws that, I don't know how they're designed to do it, but somehow it's able to sense if that saw hits flesh. I don't know how it knows this. It's pretty remarkable.

Interviewer: I know, I took a woodworking class and the guy said you could take a hot dog and go to run it through this blade and it would stop it without cutting that hot dog.

Dr. Madsen: Yeah, it's amazing, but apparently you don't want to try the hot dog because if you do that, the way the mechanism works it just throws some steel right up into the blade and pretty much destroys the tool. Apparently, that's an option. I think there are other techniques where you're just not getting your hand close to . . . like, using a piece of wood or something to push that wood through rather than getting your hands right in there.

Interviewer: So three ways that people tend to cut themselves. Is there kind of a fourth category that you could lump in, two or three of the more minor ways?

Dr. Madsen: Yeah there are always knives. People who have pocket knives or maybe something where they're using their knife or some kind of tool to try and use it in a way maybe it shouldn't be used. Something slips or . . . you know I've got to tell you a personal story. I once made the mistake of trying to separate several frozen hamburgers using a butter knife. The butter knife slipped and went right into my hand.

Interviewer: A butter knife?

Dr. Madsen: Yeah, a butter knife. It was not good. I threw a little suture in that and tried to sew it up myself. It actually worked okay, but that's the kind of stuff we see, too. People with different household items, maybe screwdrivers, things like that, trying to use them in certain ways and something slips and cuts themselves.

Interviewer: Using them in a way that they weren't intended.

Dr. Madsen: Exactly.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interviewer: What will an emergency room physician do if you have a severe stomachache? Can you go into the ER? That's next on The Scope.

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

Interviewer: One of our most popular pieces on TheScopeRadio.com is "I have a severe stomachache, ER or not?" And in that particular episode, we were told that if you have a severe stomachache, you should go to the ER and have a look at because it could be a couple of things. One of the comments on that is what do emergency room doctors do if you go in with a bad stomachache? Dr. Troy Madsen is an emergency room physician at University of Utah Health. Bad stomachache somebody comes in, what do you start doing?

Dr. Madsen: This is a really great question because you may think to yourself, "Okay, my stomach hurts. I'm going to go to the ER and they're going to look at me and say, 'Why are you here?' They're going to send me home."

So the first thing I'm going to do of course is find out more about the stomachache, when did it start, where does it hurt. Have there been any other symptoms with it like fever or any pain elsewhere, nausea, vomiting, diarrhea, pain with urination, any blood in the urine or in the stool. So these are all kind of things I'm doing to try and figure out, "Okay, what could be causing this sort of pain?"

The next thing often that I'm doing is, not often always, is a physical examination. So I'm examining this person trying to push on their abdomen and I really focus on certain areas because these areas will make me think of different things. If I push on the right lower side of their abdomen and it hurts, I'm thinking of appendicitis.

On the right upper side I'm thinking of the gallbladder, maybe a gallstone or an infection there. Just in the upper part of the abdomen, just kind of down below the ribs there where you feel a little notch that little bone there. Thinking about the pancreas there. It could be causing some symptoms.

And then in the left lower side of the abdomen. In older people you can have an infection in the intestines there called diverticulitis, that often causes pain there. So those are some of the things that are going through my mind as I'm pushing around saying, "Hey, does it hurt here? If I let go, does it hurt worst when I let go?" That can be a sign of a more severe infection. Is the pain just everywhere or does it really localize to one spot?

Typically in the ER, you'll get an IV. We'll put an IV in, which is giving you medications. So if you're having severe pain we'll give you a pain medication. If you're having nausea we'll treat that. Often times we're giving fluid for dehydration, especially if a person has been vomiting a lot, "I've had a lot of diarrhea." And then I'm thinking about testing. What do I need to do to figure this out?

In some cases someone may come in, I may push on their abdomen and in doing that I pretty much have an idea of what's going on, but those cases are rare. A lot of times with abdominal pain we are sending tests and so typically there I'm doing blood work, looking at their white blood cell count, that's going to show me signs of infection.

Also, looking at their liver function test to see if there's anything there that suggests a liver problem. Look at something called the lipase, which is something that they have an issue in the pancreas. I'm going to see things that are abnormal there. Looking at the kidneys, electrolytes. So all sorts of different blood tests.

And then beyond that I may do an ultrasound, an ultrasound to look at the gallbladder. Maybe we end up getting a CT scan to look at the appendix or the other organs in the abdomen. So it's going to be more testing guided by where this person hurts.

There may be cases where we do an examination, push on the abdomen and we don't have to do tests. Maybe we'd say, probably gastroenteritis, probably a virus or something like that. But often times we are doing some sort of testing in the ER.

Interviewer: So a lot of the times it sounds like it's a very complicated thing. That's even difficult for a physician to figure out what the real problem is?

Dr. Madsen: It really is and this is one of the most common things we see in the ER is abdominal pain. So you've always got to be thinking of all these different things. There's really not just a certain way we go about it. We're going to be guiding that by how their symptoms started, where they hurt, but typically it does involve some blood work, may involve an ultrasound, maybe a CAT scan. Trying to sort through this and rule out the bad stuff to see what's going on.

Interviewer: To most people that come in, have a pretty good sense of the difference between kind of regular stomach pain that might be caused from something they ate or a gas bubble and one of these issues you've talk about?

Dr. Madsen: It's tough. At the end of the day the large majority of the time we send people home saying, "We're not finding anything really serious. It's probably something you ate, probably a virus or a gas bubble or something." So it is really tough for an individual to tease that out and so I can't say that most people really are sure exactly what's going on.

Interviewer: If the pain subsides after five minutes or so, would you recommend somebody still going to the ER? Is it that more pain that lasts longer that should worry somebody or not really?

Dr. Madsen: Yeah, I think probably pain that lasts longer and it depends on the individual and what other medical issues they might have. But typically if it's something that comes on and goes away, you can watch it, see what happens, see if things come back if they get worse. Most things that are serious, in pretty much all cases if it's going to be something that's really significant, it's going to get worse. It's not just going to come on and then go away and then you feel fine.

Interviewer: But it sounds like that it can be a difficult thing to figure out and if in doubt, really you should go see somebody.

Dr. Madsen: Sure, absolutely. Have someone at least take a look at you, examine you, see where you hurt. Get a better sense of what's going on.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 22, 2018
originally published: April 22, 2016

Interviewer: What are some of the common lawnmower injuries that an ER doc might see? We'll find out next on The Scope.

Announcer: Health tips, medical news, research and more for a happier healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Troy Madsen's an emergency room physician at University of Utah Hospital. It's that time of year again when you get out the lawnmower and start mowing. What are some of the common lawnmower injuries that you see? I mean, the first thing I think of when I think of lawnmower injury is cutting something, like you get your foot under there, you get your fingers under there. Do you see a lot of that?

Dr. Madsen: Not a lot, but we do see it.

Interviewer: Okay.

Dr. Madsen: Either from people for whatever reason they, like you said, may get a foot under there. Who knows exactly how that happens sometimes. Maybe they got their hand under there and the lawnmower is on.

Interviewer: Yeah, some of those lawnmowers can continue to run, you can take the bag off, empty it. Maybe there's a little . . . and you think you can clean out a little bit of . . . I mean, I don't know. You would think most people wouldn't do that and most people don't, it sounds like.

Dr. Madsen: Most people don't, but occasionally, it does happen. And that's kind of the obvious thing. You think, "Okay. Lawnmower. The blade's spinning." You don't reach in there, you don't reach into the shoot and try and clean grass out while it's running. Just don't do it. It might catch a finger or maybe you're moving and you get your foot under it.

Interviewer: What you're seeing are those things that we don't expect. Dr. Madsen: Yes.

Interviewer: I'm thinking, "Like what?"

Dr. Madsen: Yes. Kind of the interesting things we see are, okay, I'm a conscientious lawnmower, I tell myself do not run the mower when I'm cleaning grass out from the shoot. So I turn the lawnmower off and then I reach into the shoot and I've got all this grass, this wet grass stuck in there. I'm pulling it out. Well, that wet grass, you've got a blade in there with a spring on it, it may have really tightened that spring up. It may have a lot of tension, I pull that grass out and then that tension releases and the blade gets my finger. And I have seen that happen. We see it with snow blowers and we see it with lawnmowers.

Interviewer: So the smart thing to do: turn it over and use a stick?

Dr. Madsen: Use a stick. And I wouldn't even turn it over. If it's stuck in the shoot, get a stick in there, just pull that stuff out and just try and clean it out as well as you can before trying to put anything in there that's going to cause any tension release if there's tension in that blade.

Interviewer: All right. What are some of the other things you see in the ER when it comes to lawnmower injuries?

Dr. Madsen: Well, the other thing would be that occasionally happens is you're mowing a lawn and you hit a rock or something in the grass and then it just flicks it. Occasionally, we will see people who have been hit in the leg by something like that. You do have the other lawnmower, the weed whackers or whatever you call them, that have the little kind of cable that spins around that obviously puts you at higher risk for things getting flicked into your eyes. We do see things in people's eyes either in the eye or hitting the eye and causing a scratch or an abrasion on the eye. That's the other thing you obviously have to watch for as well.

Interviewer: All right. Some good tips for some things to look out for when you're mowing your lawn. Any final thoughts? When you mow you lawn, eye protection?

Dr. Madsen: Yes, absolutely, eye protection.

Interviewer: Cargo shorts?

Dr. Madsen: Long pants and wear good shoes. Don't go out there in your flip-flops.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Announcer: Is it bad enough to go to the emergency room or isn't it? You're listening to "ER or Not?" on The Scope.

Interviewer: It's time for "ER or Not," where you get to play along and decide whether or not something that happened is worth going to the emergency room. We're with Dr. Troy Madsen, Emergency Room Physician at University of Utah Hospital.

ER or Not? Electric shock. Here's the scenario. You're unplugging an extension cord. Maybe you're doing some wiring around the house and you get bit and maybe it lasts for about five seconds, which actually happened to me once. I was unplugging an electrical cord and I couldn't let go of it as soon as the electrical shock started hitting. I looked and I watched myself not being able to get rid of this thing and then eventually, after about five seconds, I was able to release my fingers and throw it down.

Dr. Madsen: That's really scary.

Interviewer: It was scary.

Dr. Madsen: So what did you do?

Interviewer: I think I was 16.

Dr. Madsen: You walked it off?

Interviewer: I was 16. I didn't feel any adverse effects afterward so I didn't do anything. Apparently, it's worked out all right for me. Dr. Madsen: You survived to talk about it.

Narrator: Yeah, but should I have done something?

Dr. Madsen: That's tough.

Narrator: ER or not?

Dr. Madsen: I guess you're right. I think a large majority of us would do exactly what you did. I remember having a similar scenario too when I was a young kid and reaching . . . it was an outlet then touched something and just felt this shock and it was so strong, but I didn't go to the ER. But the reality is you should. You should go the ER.

Interviewer: Even for something real brief or short like that?

Dr. Madsen: For a household shock like that, you should go to the ER.

Interviewer: Okay, and why?

Dr. Madsen: The reason is because when you get that electrical activity . . . and certainly there are things about it that could put you at higher risk. If it's a high-voltage injury, not a household injury, that's another thing entirely, but the issue is that it can affect your heart's rhythm. Now, if it's going to put your heart into a really dangerous rhythm, it's probably going to happen immediately, but it can still do things to your heart's rhythm. The reason to go to the ER is to get an EKG. That's something that can tell us, did this affect your heart? Are we seeing anything there that's concerning that could then make you at higher risk in the next few hours of going into a life-threatening heart rhythm? If the EKG is okay, we might watch you for a couple of hours just to make sure things are okay, but that's what you worry about.

Interviewer: Really? So you would say if somebody gets an electric shock whether it lasts a second, five seconds, there don't appear to be any other symptoms, no burns, none of that sort of stuff, you really should go to the ER?

Dr. Madsen: You should. And we're not talking about static electricity here. We're talking about something like you had. Let's say you're having a shock from an outlet, you're doing some electrical work at home, something like that where it does shock you. Certainly if you're someone who has some medical issues like you've had abnormal heart rhythms in the past, any sort of medical problems, that would put you at higher risk. If you're standing in water at the time that happens, that puts you at higher risk for that current going through your body. If you feel the shock in your right hand and you're touching metal in your left hand, and you feel that shock also in your left hand, that puts you at higher risk as well.

The challenge with it is, I can't tell you again. I'm thinking like someone calling me and saying, "Hey, I just got this shock. A pretty insignificant shock where I could not let go of an extension cord for five seconds because of this." And they say, "Am I going to be fine?" I'll tell them, "You probably are. I'd put the odds at 98% that you're going to be fine, but there's that 2% chance of something serious and the only way we're going to see it is on an EKG."

Interviewer: And I can't do that at urgent care?

Dr. Madsen: They could run an EKG at an urgent care if you wanted to go there. My suspicion is, when you went there they would say go to the ER because they may not feel comfortable just getting an EKG and sending you home. One thing we can do at an ER is put you on a monitor, a heart monitor, just to watch that heart rhythm. The EKG is going to give us a snapshot of your heart. The monitor is something we can watch over, say, 30 minutes to an hour just to make sure there is nothing unusual going on there.

Interviewer: So don't feel bad if I get an electric shock and go to the ER?

Dr. Madsen: Do not feel bad at all because here, we're talking about something potentially very serious. Probably not, but potentially serious.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: October 16, 2018
originally published: April 7, 2016

Interviewer: All right, it's time to play the game ER or Not, where you get to play along and decide whether or not something that has happened is worth going to the emergency room. We're here with Dr. Troy Madsen, emergency room physician at University of Utah Hospital.

ER or Not? You're eating a chicken wing and you accidentally swallow a bone.

Dr. Madsen: This is tough one, Scot, so I want to know, what do you think?

Interviewer: All right, so I'm going to say that we did one on toothpicks before . . .

Dr. Madsen: Yes.

Interviewer: . . . that if you swallow a toothpick and it goes into your abdominal area it could puncture through.

Dr. Madsen: Sure.

Interviewer: I'm going to guess based on the kind of chicken wing or the chicken bone, that could be a problem here.

Dr. Madsen: Yes.

Interviewer: A bigger, duller bone, I don't know. It could be painful coming out, but it probably could pass through. I don't know. I don't know. I don't know.

Dr. Madsen: See? I'm going to put you to work in the ER. Look how much you've learned and how much you know. I'm so impressed. Those are the exact processes that are going on in my mind. I'm imagining myself having a family member call me and say, "I'm having chicken wings tonight. I was watching a game and I don't know what I did, but I swallowed a chicken bone."

My first question for them is, "Are you sure you swallowed it? Are you sure it's not in your airway?" If it's in the airway, that's an entirely different issue. Absolutely, you need to get to the ER if it feels like it's stuck in there, you're having a hard time breathing, maybe there's like a high-pitch wheezing sound, that's ER, absolutely.

Interviewer: Anytime there's an airway issue, ER.

Dr. Madsen: Yes, ABC; A stands for airway. If it affects the airway, get to the ER.

Then the next question is, let's say, okay, it's not in the airway, what are we talking about in terms of a chicken bone here? I'm thinking number one, is it something that's going to somehow puncture their intestines as it's passing through? Was this a piece of a chicken bone that splintered, and then they swallowed it down? Or is it a really big chicken bone? And by a big chicken bone, I'm talking about something usually longer than about three inches.

Interviewer: Okay, so it would've been really hard to swallow something like that.

Dr. Madsen: It would have been, exactly. If you're talking about something three inches or longer, that's really tough to swallow, and a chicken wing isn't the sort of thing that's going to do that. If they tell me, you know, I don't know why they would do this but if somehow they were chewing on this chicken wing while watching a game and swallowed a big sharp piece down there, that would be a reason to go the ER because there you do worry about possibly causing some sort of a puncture wound in the stomach or in the intestines.

Or if they said, "This was not a chicken wing. This was a chicken thigh and this was a big bone," and again, I don't know why they would have done that or swallowed it, but that's another reason to go to the ER.

Interviewer: All right, so the grey area is a dull kind of bone that's not that big.

Dr. Madsen: Exactly.

Interviewer: Maybe a half-inch long, not very big around, is that going to pass through?

Dr. Madsen: It should, yeah.

Interviewer: Do you take the chance?

Dr. Madsen: If you're concerned you can always go to the ER. We can get an X-ray, we can look at it. It's a bone; we're going to see it on an x-ray. We can call the GI doctors and ask them to look at it. My suspicion is they would not go in and put you through anesthesia to go down and fish that out and pull it out. If it's a small chicken bone, maybe half an inch long, an inch long, it should pass through okay.

Interviewer: Okay. I'm nervous now. I mean, this is one of those things where in a couple of instances, you know absolutely what the answer is, but then there's that grey area.

Dr. Madsen: It is definitely a grey area.

Interviewer: Is there a chicken wing hotline I could call, like poison control that can give me some advice?

Dr. Madsen: It's funny, if you call poison control they probably would give you advice.

Interviewer: You think so?

Dr. Madsen: Yeah, they would. And then they would get people on the phone if they needed to. So of it is a grey area and you're not sure, and it's something you've ingested like that, they would probably be able to help you out there.

Interviewer: If it's the grey area, is there a period of time or something that would make you more concerned that this might be an issue?

Dr. Madsen: That's a tough one because some things, you swallow it and it's just going to sit there or it's going to work its way into your intestines. Once it gets in there, you may have no symptoms but it may be too far down to really fish it out. If it is a concern and you're just saying to yourself, "Hey, what do I do about this?" it's worth at least talking to someone, calling your doctor, and you can always go to the ER. It's not a big deal, but certainly talk to someone if you're just wondering, "What do I need to do about this?"

Interviewer: One of those nurse hotlines or something of that nature, perhaps.

Dr. Madsen: Exactly.

updated: July 22, 2020
originally published: April 3, 2016