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Dr. John Barrett is a family physician and the Executive Medical Director of the Community Physician Group for University of Utah Health. He reached his own health turning point over a decade ago.

Dr. Barrett found himself giving in to the anger and frustration that comes with being a physician. Like many men, this stress and frustration was actually a sign of depression. He was able to identify the symptoms in himself and seek help.

After reaching out to loved ones and working with professionals, Dr. Barrett was able to work through his mental disorder. It took over a year of talk therapy and medication to get his mental health back to a place where he could thrive.

"Down south I was what we would call 'a mess,'" says Barrett.

These days, Dr. Barrett is always on the lookout for signs of his own mental health. Whenever he notices a warning sign he focuses on self-care, focusing on his physical health, and reaching out to professional help before things get worse.

Like most health concerns, Barrett's mental health is something he's continually working on, but he feels more in control of his own mental health and wellbeing today than he did a decade ago. Telehealth: More Options for Medical Access

Dr. Barrett works with the Telehealth group at University of Utah Health, and he's seen first hand some of the applications emerging technology can have in the healthcare space. But first, what exactly is telemedicine.

Telemedicine is the means of providing healthcare access from a patient to a health professional using digital means like text or video chat through a computer or smartphone.

At University of Utah Health, in-state patients can call in via an app or web portal to speak directly to a general practitioner through a video call. For University of Utah employees and patients with a University of Utah Health insurance plan, these video calls are covered by insurance. For other patients in Utah, there's a flat $49 fee that will be refunded if the call is escalated to an in-person visit. What Can a Doctor Do Over Video Chat?

According to Dr. Barrett, the best way to think of a telehealth video call is like "virtual urgent care." Half of the patients calling in are given advice and counsel about whether or not they need to see a doctor in person. The other half are given a diagnosis of a relatively minor medical condition. And a very small percentage of patients contact telemedicine services with a concern that needs to be escalated to emergency care.

When a physician diagnoses a condition over a virtual visit, they can prescribe medications necessary for treatment. Dr. Barrett shares a story of a woman who was out on a camping trip in the Wasatch Mountains. After suspecting she had a urinary tract infection, she drove her car back down far enough to get cell reception. She was able to call a physician, get a diagnosis, and a prescription for an antibiotic right over the phone.

A large portion of the phone calls the telehealth team receives is from young new parents. When your kid is sick, it can be stressful. It can be difficult to determine if it's an emergency or if you can wait to seek help the following day. A quick video call to a physician can help to diagnose most pediatric concerns and help put a parent's mind to rest.

Other growing telemedicine fields include dermatology, where specialists can diagnose rashes and moles with pictures or videos. New services are also developing ways for people to access mental health services through text and chat. How Can I Access Telemedicine?

For Utahns, you can use the digital health services at University of Utah Health through the MyChart app if available, or visit healthcare.utah.edu/telehealth for more information. ER or Not: Broken Nose

Scot recently came across a skateboarder on campus whose face was covered in blood. There were no signs of a head injury, but the kid had broken his nose. Scot tried to help but he wasn't sure where to send him. Urgent care or ER?

According to Troy, a broken nose is no reason to go to an emergency room or an urgent.

As long as the person with the broken nose has not been knocked out, nor are dealing with a head injury, a broken nose is nothing serious. These days, if a patient comes to the ER with a broken nose, there's not much they can do to treat it. No big tubes of cotton stuck up the nose. No "setting of the broken nose." Nothing.

In most cases of a broken nose, the amount of swelling present limits the options doctors have for any type of treatment. The swelling must go down before any corrective measures can be taken.

Troy suggests that if you have a broken nose, wait a week for the swelling to go down, then go visit an ear, nose, and through (ENT) specialist. They will be able to better assess the damage and create a treatment plan after the swelling has gone down.

There is one caveat to this advice. If you look in the mirror up your nose and there's something on your septum that looks like a grape, you may need to go to the ER. This type of growth is called a nasal septal hematoma. It's essentially a big sac of blood that forms after an injury. When one of these hematomas grows in the nose, it can potentially erode the septum leading to potential structural problems. These hematomas are rare, but need immediate treatment if found. Housekeeping - We Have a Winner!

We announce the winner of the Who Cares About Their DNA Giveaway. For the last 6 weeks the guys at the Who Cares Podcast have been looking into the complicated issue of at-home genetics testing and calling for submissions for people interested in winning one of these kits and the opportunity to be on the show.

Our winner is listener Matt. Matt is thirty years old and he says this about wanting the test:

"I want to know more about my body, based on the things that are out of my control. A genetics test can help me understand what chances I have of developing certain disorders or what ones I could pass on to my children."

We'll be reaching out to Matt to speak with him about the aspects of these tests we've been exploring and have him on the show.

Thank you to everyone who participated! Just Going to Leave This Here

On this episode's Just Going to Leave This Here, Scot has made a serious caffeine mistake. Troy muses about the first dog in space. Talk to Us

If you have any questions, comments, or thoughts, email us at hello@thescoperadio.com.

Interviewer: It's another edition of "ER or Not" with Dr. Troy Madsen. All right, go ahead and play along, and see if you can figure out the answer to today's situation. Dr. Madsen, today's "ER or Not" a panic attack. Is that a reason to go to the ER or not?

Dr. Madsen: That's a tough one, because I think, for some people they absolutely feel they need to go to the ER, and typically, what's going to happen is, in the ER, is you might get some medication to help calm you down, give you a little bit of time to relax, but it's probably not something you absolutely need to go to the ER for. If you've had a history of anxiety before, you may have some medication at home you could take that can kind of help calm you down. You know, take 30, 45 minutes before you make that decision to go to the ER.

Of course, the big reason to go to the ER would be if you're having other issues, as well. Let's say you're having thoughts of hurting yourself, you know, any thoughts about suicide, absolutely you need to get to the ER. And that would be the biggest thing I'd say. You know, when someone comes in saying, "I'm just feeling really anxious," they're hyperventilating, that's my first question. "Well, are you having thoughts about suicide, any attempts, anything like that, that we need to be worried about?"

Interviewer: But the panic attack itself and the hyperventilation, that's not a breathing issue, generally?

Dr. Madsen: Well, that's a great question, and I think there are kind of two things here. There may be a person who's had panic attacks before, they've been diagnosed with anxiety, they're familiar with this feeling. If you're in that situation, you may have medication, you may know how to kind of control things at home. Maybe you've tried some deep breathing, things to calm yourself down.

Now, on the other hand, if, just out of the blue, you've never experienced this and you suddenly start to feel extremely anxious, you're hyperventilating, you know, you may think to yourself, "Well, maybe this is just a panic attack," but something like a blood clot in the lungs can cause a person to feel very anxious, very short of breath. It gives you that feeling like you're going to die, something that a person with a panic attack might feel. So you've got to be careful there, and if that's something you haven't experienced before, then absolutely, I would say you need to get to the ER.

updated: May 6, 2020
originally published: September 29, 2017

Interviewer: What should you do if someone you know has a very severe asthma attack? We're going to find out next on The Scope.

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

Interviewer: Dr. Madsen, I want to do a scenario here. If somebody has a very severe asthma attack, and I'm there, what should I do? I would imagine that that person knew they had asthma, and I'd hoped they had an inhaler. Would that be the first place I'd start?

Dr. Madsen: Probably so, but you also have to think, is this someone you just need to call 911 for and get them to the ER. And in my mind, the way I really judge the severity of an asthma attack is, first of all, can the person talk to me? If a person cannot breathe well enough, where they can't really get out more than say a one word answer, that's really severe. And in that situation, before I go looking for their inhaler, I'd say call 911. Get the ambulance there, get them to the ER, because even if they take a couple of puffs of their inhaler, it's probably not going to do much in that situation.

Interviewer: All right, so super severe like that, don't even mess around with it, don't hesitate, call 911, get the professionals there.

Dr. Madsen: I would.

Interviewer: And if they're not quite that severe, they're able to get some sentences out, they're able to talk to you, what would you do at that point?

Dr. Madsen: Usually in that situation, if they have asthma, they have an inhaler somewhere, and so they might say "Hey, can you go grab my inhaler for me?" Maybe they're feeling kind of winded, they just want to sit down, try and relax a little bit. But they're talking to you, they're not breathing so fast they just can't get anything out. You look at them, they look like they're working a little bit to breathe, but it's not like when they breathe you see all of their neck kind of sucking in because they're trying to get air in. So it's not a real severe case, so certainly I think an inhaler is going to help there.

Even in those situations, if it's that bad they might take a couple of puffs of their inhaler, they might feel a little bit better. But I often find even in those scenarios, they may need some more treatments in the ER, including possibly steroids which are going to help out as well, which typically they don't have at home.

Interviewer: All right, one of the ABCs is breathing. And any time that somebody is having trouble breathing, that is one of the rules that you use that you should go to the ER. So it's crucially important. What should you do at that point, while you're waiting for help to arrive, whether it's the inhaler didn't work, maybe they didn't have one, they ran out, they are struggling breathing. Is there anything you can do to help them at that point?

Dr. Madsen: Really the best thing you can do is whatever you can do to just keep them calm, because if someone is having trouble breathing, that's going to make you feel anxious. You can just imagine that drive you have to breathe, and when you're struggling with that you're going to feel incredibly anxious. The problem with asthma is that anxiety is going to make it even more difficult to breathe, it's just going to compound the problem.

So realistically, the only thing you can do there besides say having them take some puffs of their inhaler, would be to do whatever you can do to help them calm down. Turn on the TV, turn on some music, something just to help them relax a little bit, while you're waiting for the ambulance. Reassure them they're going to be fine, tell them you're breathing okay, you're talking to me, this is great, ambulance should be there hopefully within 5 to 10 minutes. And at that point, they're going to get them on some continuous breathing treatments and get them where they need to be.

Interviewer: So in summer, it sounds like if somebody is having a severe attack like that, just call 911 because there are things that you can do in the emergency room to help them, and just a breathing problem is not something you want to mess with.

Dr. Madsen: That's exactly right. Like you said, we talk about the ABCs, that's what B stands for. Once you talk about breathing, you've got to address it, and usually you're not going to be successful at home. Keep in mind that asthma is a very serious disease. It kills thousands of people every year, so you have to take it seriously to get them the help they need.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Interviewer: Sepsis. What is it, how do you get it, and what should you do about it? That's next on The Scope.

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

Interviewer: Dr. Troy Madsen's an emergency room physician. I wanted to learn a little bit about sepsis today. What exactly is sepsis? Let's start there.

Dr. Madsen: Well, sepsis is, you know, a word you may have heard, but the best way to think about sepsis is it's just an infection that started somewhere, either in the lungs or the urine or on the skin, like a urinary infection, a skin infection, that then works its way through the entire body. So it's basically just a full-blown form of stuff that otherwise might not seem like that big a deal, that you could just take some antibiotics for.

Interviewer: All right, so a localized infection is not sepsis?

Dr. Madsen: No.

Interviewer: It's when that infection somehow gets into the bloodstream. How common is that that that's going to happen?

Dr. Madsen: It's not super common. It's more common in people who are older who have immune system problems. That's where we often see cases. But I mean, I've absolutely seen people who have come in with urinary tract infections, young, healthy females, who it works it way up to their kidneys. From there, you start to see the effects throughout their body.

And really, the effects we're looking for to call it sepsis are high temperature, so they're coming with a fever, they're breathing rapidly, their heart rate is going fast. We check blood work on them. Their white blood cell count, which is a sign of infection more throughout the body, is elevated. And then, sometimes in severe sepsis, their blood pressure even drops, just because that severe infection can cause the blood vessels to dilate. So that blood pressure's going to drop, and that's where it gets really serious.

Interviewer: So it could happen to anybody, even if you're healthy, more likely if you have a compromised immune system. Something to avoid, nonetheless. Are there ways to avoid getting sepsis?

Dr. Madsen: So really, the key to avoiding sepsis is to catch infections early. If you look at your arm, it looks like you have a skin infection. Let's say you have an area of a lot of redness, warmth. You touch it, you just say, "Wow, this is really hot here." You need to get on some antibiotics, because those are the things that can then progress to sepsis as that infection spreads. You're having urinary tract symptoms.

The times I see these cases of sepsis are people who might let it go for a couple of days, and then it works its way up. They start having back pain, fevers. That's when it becomes urosepsis, so starting from the urine and then that infection working its way through the body. Or pneumonia, the other common thing, people who are coughing a lot, high fevers. Things get much worse there. So if you can catch these things early, get on antibiotics, you can generally avoid that really severe form of the infection that we call sepsis.

Interviewer: All right, and if sepsis does kick in, what's the treatment for that?

Dr. Madsen: So sepsis, it requires hospitalization. So in these patients, and we've done a lot of studies in the ER, how do we best treat these patients, but the key is getting on top of it early. And what that means is getting IVs in, giving fluids. Just because people can be very dehydrated, they can have a lot of fluid loss from this. And then getting antibiotics early. I'm going to start antibiotics very early on these patients who come in who are septic and admit them to the hospital, often admitted for several days on IV antibiotics while trying to figure out exactly what caused the sepsis and making sure it's treated appropriately.

Interviewer: And why the long-term hospitalization on that? Why not just give antibiotics and let them treat it at home?

Dr. Madsen: Well, one of the challenges, they often need additional IV fluids, and they often need that IV form of antibiotics. Some of the IV forms are much stronger than what we could give at home, and so that's why they're in the hospital, monitoring them. This can be a life-threatening condition. I mean, some studies that were done on sepsis several years ago even showed that, you know, in these cases, they were finding 30% of patients with sepsis were dying. Maybe it's not that high now. I'm sure it's not now that we've improved our care, but this is a big deal. So these patients are often admitted and for several days.

Interviewer: So to me, it sounds like, if you experience some sort of an infection, especially some of the ones that you mentioned, that you should get on top of that and treat that so the sepsis doesn't ever become a problem. But then, if the symptoms start happening, you absolutely need to go to the hospital.

Dr. Madsen: Exactly. Once you get fevers, chills, you know, just things getting much worse, the back pain, like an infection in the kidney, just a cough that is just not getting better and you're bringing stuff up, lots of phlegm, yeah, get to the ER. This may be something more serious that requires some IV antibiotics.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

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.

Announcer: Want The Scope delivered straight to your inbox, enter your email address at the thescoperadio.com and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Interviewer: Flu season 2016-2017 update. 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's an emergency room physician at University of Utah Health Care. And a lot of times, he's going to see things happening in the community before the rest of us really even hear about it. And from what I understand, it's a pretty bad year for the flu this year.

Dr. Madsen: It sure is, and, again, I'm speaking from my perspective in the ER where we see the sickest of the sick. But I have seen some incredibly sick people who have had the flu. These are people who have come in. I've seen them. I assume they some sort of just severe pneumonia, some sort of sepsis, where the infection from a bacteria has spread through their body. I'm not finding any source besides the flu. And these are individuals where I ask them afterward, I say to them, "Well, did you get the flu shot this year?" And they say, "Absolutely, I did."

So we're seeing a resistant strain out there. We're definitely seeing people who are getting very, very sick with this who we're admitting to the hospital and I'm seeing quite a few people. And as I talk to other ER doctors, as I talk to our pharmacists in the emergency department, they say that's been pretty much reflective of what we're seeing across the board right now.

Interviewer: All right. So the flu season, you just never quite know when it's going to hit, but you're saying it's hit.

Dr. Madsen: It has absolutely hit.

Interviewer: And if you got the flu shot, you're going to want to take some other precautions as well because it could be a strain that wasn't vaccinated for.

Dr. Madsen: That's exactly right. And I don't have all the data to note how many of these strains that we're seeing now are going to be prevented by the flu shot versus how many of these are not. Again, I'm seeing a lot of cases of people who had their flu shot who are getting very sick from the flu.

But don't assume because you had the flu shot you can just walk around anyone who's sick and walk away just fine. You've got to wash your hands. You've got to try and avoid contact with people who are sick, if you can, certainly if they're family members, just practice basic health hygiene. Try to stay well, but know that you may have the flu, even if you had the flu shot and you get sick.

Interviewer: So as an emergency room physician, how do you not get the flu then? Because, I mean, you're around all these really sick people with the flu.

Dr. Madsen: Yeah, it's a challenging thing. If people come to the ER with flu-like illnesses, in the triage area, they automatically put a mask on them because it's spread by droplets when they're coughing and sneezing. That's one thing you can certainly do at home. We wear masks in the room as well. Certainly hand washing, making sure we're doing that frequently. You know, it's basic hand washing and basic sanitation practices you'd do at home as well.

Interviewer: All right. And probably can't predict this. Do you think it's going to get worse?

Dr. Madsen: I do. I mean, given the increase that we've seen just in the last couple of weeks, I expect we're going to see this get worse over the next month And it could be a pretty significant flu season for us.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign me up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Interviewer: Oh, the bells are jingling somewhere, there's a Santa Claus ho-ho-hoeing. It's Christmas time and in the emergency room, Dr. Troy Madsen celebrating the holidays, busy at work. This is a special episode of The Scope that we want to call "Christmas in the ER."

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

Interviewer: Welcome, Dr. Madsen.

Dr. Madsen: Thank you. I feel like this should be a song. Isn't there like a country song "Christmas in Dixie." Christmas in the ER kind of song.

Interviewer: Yeah.

Dr. Madsen: Kind of a melancholy song, you're working in the ER.

Interviewer: If we were to sing that song, what would we sing about, Dr. Madsen? What does Christmas look like in the ER?

Dr. Madsen: Well, I tell you, I'm going to be working Christmas morning at 7 a.m. I will be there to greet you if you come in the ER. As all the kids are opening their toys from Santa, I'm scheduled to work 7 a.m. Christmas Day. So Christmas in the ER, it's one of those days where, it's a lot like working on night shift when it's snowing and I find when you work those nights or if you work Christmas Day, basically, if anyone makes it into the ER, they usually have something seriously wrong with them.

It's not the kind of day that the person walks in that's had abdominal pain for two years or a person walks in with a splinter in their finger something like that. People put those things off. If people come in the ER on Christmas morning, you know that it's probably something you better take seriously because no one's going to leave their home or just go in Christmas Day unless it's something they're really concerned about.

Interviewer: So you know some serious stuff is going to come through the door. Is there anything typically you see on Christmas Day?

Dr. Madsen: In terms of typical stuff Christmas Day, once in a while you can, I know this sounds kind of funny but you can see some sorts of injuries from opening presents, and I know that sounds a little silly, but there are.

Interviewer: It does.

Dr. Madsen: One of the kind of the things that is notorious for potentially causing lacerations and injuries in opening gifts are kind of these clam shell plastic cases.

Interviewer: Oh, yeah, really?

Dr. Madsen: Yeah, have you tried to cut into one of those things? Like I've done it. I've even cut myself on it because you cut the thing open, then you get your hand in there to try and pry it open, and those edges it's thick plastic, it can kind of cut into your finger. I know it sounds a little silly but sometimes you do see stuff like that from people opening things.

Interviewer: Yeah, I didn't think of you using a knife to open boxes and stuff if you're not paying attention or and there's probably . . .

Dr. Madsen: Yeah, keep using knives, box cutters, things like that.

Interviewer: I shouldn't have been so quick to laugh, I apologize.

Dr. Madsen: It does sound so clichÈ that it's Christmas morning, you're opening gifts and you get injuries from that. But occasionally, you do see stuff like that. Later in the day, there's sometimes kind of the overeating stuff, people with some belly pain or just feeling a little bit uncomfortable. Again, maybe not such a big deal on Christmas but sometimes you get that. But like I said, it's really typically a very slow day in the ER and I'm probably going to jinx myself now by saying that because I'm working Christmas Day.

Interviewer: Here, quick, jingle these bells.

Dr. Madsen: Yeah, exactly.

Interviewer: Instead of knock on wood, you can jingle some bells.

Dr. Madsen: Yeah, exactly. But it is a day when people come to the ER, it's usually serious stuff and heart attacks, asthma problems, maybe a car accident as they're driving somewhere, things like that.

Interviewer: Do you guys celebrate Christmas at all in the ER? Is there a picture of Santa Claus up or Christmas cards around anywhere? I mean, do you decorate?

Dr. Madsen: Christmas in the ER there are usually some decorations up. I can't say that Santa has ever come to the ER. But usually, everyone will bring food in and kind of have a potluck dinner or potluck lunch in the ER, something like that.

Interviewer: That sounds kind of cool. I suppose there's a lot of camaraderie in there anyway and then when you're all working on a holiday even more so probably.

Dr. Madsen: Yeah, exactly. Like I said, it's usually slower days so you usually have some more time to get everyone together and have some food together. So it's not everyone's favorite place to be on on Christmas Day, but like you said, there's a lot of camaraderie there, people there. we're kind of in the same boat together just enjoying it together.

Interviewer: What do you bring to the potluck?

Dr. Madsen: What do I bring to the potluck?

Interviewer: Yeah, what's the Troy Madsen special Christmas dish?

Dr. Madsen: See, I am a horrible cook so usually anything I bring is going to be like already prepared food, usually a bag of chips or something like that.

Interviewer: Come on.

Dr. Madsen: I'm sorry to admit that but it's the truth. I don't really cook well, so it's usually what it is.

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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: Three symptoms that don't seem serious but could be. We'll talk about that next on The Scope.

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

Interviewer: Dr. Troy Madsen's an emergency room physician at University of Utah Health Care. Today, three symptoms that don't seem serious but could be. We're talking about signs that you might have a serious medical condition that a lot of people ignore because we're kind of numb to these things.

What are the big three? Let's start with number three. In no particular order, or is this in order?

Dr. Madsen: This is in no particular order at all.

Interviewer: Okay.

Dr. Madsen: Just the three things I thought of as we talked about this that people often don't take very seriously but when they come in sometimes we can find serious things going on.

First one on the list is headaches. And when we're talking about headaches, I think a lot of us are used to headaches. We work, we get tension headaches, sometimes we just don't feel quite right, a little nauseated. But I oftentimes find that people with headaches just feel like "I've just got to tough it out," just get through it and it will go away.

Interviewer: Right, it's a headache, everybody gets them.

Dr. Madsen: Exactly. And, sometimes headaches are a sign of something very serious going on. A lot of times, the red flags with headaches are, headaches that come on very suddenly, very severe, maybe make you feel more nauseated then maybe you've been with previous headaches, certainly if you're passing out because of headaches. Another interesting thing with headaches that's more serious is if it wakes you up in the morning, like you get a headache and you wake up and this headache is the thing that woke you up.

Interviewer: Okay.

Dr. Madsen: And that's often a sign of something going on in the brain, maybe a brain tumor or something like that that can be a more serious thing. So a reason to, certainly if it's a sudden onset severe headache, get to the ER, if it's a headache that's waking you up in the morning, something to talk to your doctor about, they may want you to come to the ER or get some sort of imaging of your brain to see what's going on there.

Interviewer: And it might not be a bad idea if you just kind of always have headaches to talk to your doctor about it because that's not a fun way to live.

Dr. Madsen: Yeah, you're exactly right. We do see cases like that, too, of people who come in the ER who say "I just get migraines all the time" and they could be on medication to prevent that, to prevent that ER visit and make their life much more comfortable.

Interviewer: All right, number two on three things that don't seem serious but could be.

Dr. Madsen: Yeah, so number two is back pain. And back pain is another one of these things you figure "Tough it out, I get pain in my back, maybe I was doing some lifting, something like that." But one of the really, really serious things with back pain is an aortic aneurysm, or a tear in the aorta. And classically with that, people will have pain that starts in their chest and goes though to their back and it's like a tearing pain, maybe it's down in their abdomen and they feel some pain in their back as well with that.

Interviewer: So upper or lower back it sounds like.

Dr. Madsen: Exactly.

Interviewer: Doesn't have to be just back from where the heart is.

Dr. Madsen: No it doesn't.

Interviewer: Even though it's a heart thing you're describing.

Dr. Madsen: Well it's related to the heart. The aorta is the main vessel that delivers blood from the heart to the body. So yeah, it is related to the heart. The heart is squeezing blood through there, so people sometimes just have just severe back pain with an aortic aneurysm or a tear in the aorta and that's something that's extremely serious, you've got to get to the ER, get that checked out. And typically with that, they just have sudden onset severe pain. That's how they describe it. Just a sudden onset pain feels like a tearing or a ripping sort of pain.

You know with back pain as well, you can have issues like cancer, tumors in the spine, things there that will cause you pain that's often more severe when you're lying down or certain positions. It's a little more rare, but that would be something to see your doctor about. They could get an x-ray of your back, sometimes they'll get an MRI to take a look there and see what's going on.

Interviewer: So if it's something you've lived with for a while, there again, go see a physician because why should you live with that. If it's something that comes on very suddenly, for no real apparent reason, that's the trip to the ER time.

Dr. Madsen: Exactly.

Interviewer: All right. Number one on the list of three symptoms that don't seem serious but could be.

Dr. Madsen: And number one is abdominal pain. And we see lots and lots and lots of people with abdominal pain, and we see lots of people with abdominal pain who don't have anything wrong. But then we see people with abdominal pain who come in and say "I've had this pain in the right lower side of my abdomen for five days now. I just figured it was gas and it would go away." We get a CT scan and they have a ruptured appendicitis. And that's just not good.

So there are things in the abdomen that can go very wrong, and it generally happens over time. Typically in the abdomen, it's not something that's going to happen all of the sudden, but if you're having abdominal pain and it's not going away after a few hours, it's progressing, especially on the right side of your abdomen. If you're a typical young, healthy person, the right lower side is your appendix, the right upper side is your gall bladder.

Those are the most common things I see in young healthy people who are just like "I've had abdominal pain before. This will go away." They come in, they have a ruptured appendicitis, or they have a very serious case of cholecystitis, which is an infection of the gall bladder, and they have to go to the operating room to get these things repaired, which they would otherwise but often it's a much more complex case because the infection there is so advanced.

Interviewer: So it sounds like the first two, sudden symptoms. The third one, symptoms that have lasted for a while.

Dr. Madsen: Exactly. Things that came on more gradually and then progressed but people just keep thinking "This will go away" and it's not going away.

Interviewer: That's for the abdominal pain. How many days, if I kind of have a consistent abdominal thing going on, what should my line be, where I'm like "I better go see somebody"? Five days? Is that it, or sooner than that?

Dr. Madsen: I would do sooner than that. With the appendix, with the gallbladder, most things if you got a little bit of food poisoning or some gas in your stomach it's going to get better within six hours. If it's going on beyond that, if you're getting more toward 12 hours with this sort of thing, that's definitely I think a reason to at least see your doctor about it.

Interviewer: And I think it's also interesting too because I know a lot of people from some previous podcasts talk about very sudden abdominal pain like waking up in the middle of the night, sudden abdominal pain. From what you just told me, that doesn't sound like necessarily the thing to worry about. It's if it continues over time.

Dr. Madsen: Well, and again it becomes challenging because I mention that thing to you about the aortic aneurysm, like the back pain, that's also in the stomach that is a sudden thing, so it comes a little bit more challenging.

Interviewer: How do I know if something happens suddenly if I should be concerned? I mean, how do I parse this out?

Dr. Madsen: I think you have to base it on the severity of the pain, how it compares to your previous pain. But these are things where people kind of ease into it, it's like "Oh this isn't so bad. I've got a little pain in the right side of my abdomen. I'm used to having a little bit of abdominal pain." But then they gradually get worse and worse. Maybe some of these other serious things in the abdomen, they come on suddenly, and they're severe.

And so, you base it on the severity, and then those things that aren't so severe, you base it on well, what's it been doing over time, has it just been gradually getting worse, that's a sign often of something more serious.

Interviewer: 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 or somebody you know suddenly seems very confused. Confusion as a symptom, what could that possibly mean?

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

Interviewer: Dr. Troy Madsen is an emergency physician at University of Utah Healthcare. Dr. Madsen, as far as symptoms go, if somebody seems confused all of a sudden, whether it is myself or somebody I'm with, what could be the underlying cause of that? For example, with elderly people I know a urinary tract infection can cause confusion, which blew me away.

Dr. Madsen: Right. You know, the average person, and we'll try not to get into the elderly people too much here because that's . . . anything, just a urinary tract infection, like you said, can cause issues.

Let's say we've got the average person out there. Let's say it's a 40-year-old male who normally, has no health issues and just suddenly seems confused. This can be very challenging but for me this is where vital signs are vital. I'm looking at the vital signs because that's what is really going to point me in one direction or another.

First of all, I talk to the person. Yeah, let's say they just seem like they're not quite there. They're not answering questions appropriately. Of course I want to know, did they have anything happen? Were they injured? Did they have a head injury? Are they using any drugs or medications? Anything like that, but in looking at the vital signs that's going to push me in one direction or another.

If they have a fever, I'm thinking possibly meningitis. This person might need a spinal tap or a lumbar puncture to look for some kind of infection around their brain that's causing this. It could be another infection maybe like pneumonia, less likely to make someone just suddenly confused who's normally health, but a possibility.

I'll look at their heart rate. If their heart rate's really fast, and this is something I see quite commonly, heart rate up above 150, up to 200, they might be having an abnormal heart rhythm, something we have to treat either with medication or with a shock to the heart to get that back in a normal rhythm because that really rapid heart rate can make them confused. They're not getting as much blood to their brain.

Maybe their blood pressure is low, and if the blood pressure is low I'm thinking about maybe they're bleeding somewhere. I've see people who have had some kind of internal bleeding either in their stomach or in their intestines that causes their blood pressure to drop down suddenly. They seem confused and weak. That's a very serious thing but I have absolutely seen that happen in young people. Very serious cases of bleeding in someone who maybe is taking a lot of ibuprofen for some pain and it causes some stomach irritation and bleeding.

So those are the primary things I'm looking at, and then I might look at their oxygen level as well. I have seen cases of people with low oxygen levels who have had suddenly a blood clot in the lungs and it goes to the lungs, it causes their oxygen level to drop, their heart rate's up. That causes confusion as well.

For me, again, it's one of these things where it could be any of a number of things, but if you're with someone who is normally healthy, really doesn't have a lot of health issues and suddenly they're confused, that's someone absolutely I would get to the ER and then as an ER doctor there I'm going to be going one direction or another based on what's happened to them prior to that and also really looking at those vital signs to see, okay, is there one direction I need to go here either with infection or with the heart or something in the lungs, something that's causing this confusion to happen.

Interviewer: So it sounds like the cause of confusion is just the brain's not getting enough of something.

Dr. Madsen: Exactly.

Interviewer: Whether that be oxygen, blood. What else would it need?

Dr. Madsen: Well, the blood is delivering the oxygen so typically it's something that's decreasing the blood flow there. Maybe there's just not enough oxygen getting in the body. Certainly young people it's less common but you have to think about strokes or bleeding in the brain.

I have occasionally seen cases of people who seem confused but it's because they're just not speaking correctly. Either they're not pronouncing words correctly or they can think of the right words in their brain but they can't get the words out. That's from either some sort of a stroke, from something breaking off and causing decreased blood flow to the brain or actual bleeding in the brain that's affecting that. Again, these are all things that are emergent issues.

Interviewer: Yeah, sudden confusion is not a good thing, I'm gathering.

Dr. Madsen: Not a good thing.

Interviewer: Go to the ER.

Dr. Madsen: It's not, and it could be any of a number of things, and yes, you should go to the ER.

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: August 2, 2019
originally published: June 17, 2016

Scot: Is it bad enough to go to the emergency room, or isn't it?
Find out now. This is ER or Not on The Scope. Time for another addition of ER or Not with Dr. Troy Madsen, Emergency Medicine at University of Utah Health Care. Here's the scenario. Decide if you need to go and then we'll get the answer from Dr. Madsen. I cut myself, do I need stitches? ER or not?

Dr. Troy Madsen: So cuts are tough. It's one of those things that I always think to myself, "Man, if I were out traveling and I had to go to the ER for a cut for stitches..." You know, it's not a fun situation to be in because usually you're waiting for three or four hours to get in. You know it's really a great question, "Do I really need stitches on this?"
If you look at the wound and you look at the cut and the edges are gaping, or they're not together, then that's a sign you need stitches. The big thing stitches do is they just pull the wound together. They hold it together to make sure that it heals up nicely.
It becomes a much bigger concern if it involves the face. There we worry much more about cosmetic outcomes and making sure things look okay. If the wound is open, if you're seeing tissue coming out of it, maybe things you know that look a little bit deeper than the skin, those are all signs that you probably are going to need stitches.
Otherwise, if that's not the case, you can try a bandage on it at home. There are some things I've seen at the store; actually, liquid bandages they call them. It's kind of similar to some stuff we use in the ER. It works pretty well for holding these lacerations and keeping dirt and things like that getting in there if it is something more minor that doesn't need stitches.

Scot: Is this an Instacare thing maybe?

Dr. Troy Madsen: Sure. Absolutely. Instacare is the perfect place for this kind of thing. A great place you can usually get in a little more quickly than the ER. Get that sewn up. If there are a lot of big concerns with bleeding, a lot of blood coming out of that or if you are having trouble feeling in your hand... Let's say you've got a cut down further on your wrist and you lost sensation. That's a reason to come to the ER because we might need to get a hand specialist to see you. Urgent Cares are a perfect place for these things otherwise.

Announcer: We're your daily dose of science. Conversation. Medicine. This is The Scope, University of Utah Health Sciences Radio.

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

Interviewer: It's time for another From the Front Lines with Dr. Troy Madsen, emergency physician at the University of Utah Medical Center. As an emergency room physician you see things first-trends, what is happening right now? What is it we need to be aware of?

Dr. Madsen: So right now the big thing we're seeing and the big thing people are talking about is air quality. As the temperatures go up in Utah we get ozone that develops. This is stuff in the air that can then get in your lungs; if you have lung problems like asthma or emphysema, it can really make things worse.

Interviewer: So in the E.R. you're seeing increased cases of this?

Dr. Madsen: We are. We're seeing more cases of people coming in who are having trouble breathing, definitely just in the last few days.

Interviewer: And that's attributed to air quality? No doubt about it.

Dr. Madsen: It is. I hadn't seen the numbers we've had recently until just now and just looking at the ozone levels and the fine particulate matter, this is all the stuff that's released from forest fires and different range fires. We are seeing our numbers up, associated with that.

Interviewer: So what's going on exactly, you've got the bad air, somebody breathes it in, and what's going on at a physiological level?

Dr. Madsen: Yeah, so the big thing that's going on, for people who have asthma or emphysema, there lungs are already sensitive, so when you get this stuff in your lungs, if you get this ozone in there or these particles in the air, it just causes the lungs to get inflamed. They produce more mucous, they just get really inflamed and red, if you were to look at them and see them, and then they get really tight. So these are people who already are more likely to have their lungs just tighten up, where their airways just can't get air through them. This just makes things that much worse.

Interviewer: So what can you do for a person like that?

Dr. Madsen: So the big thing is if you already know you have asthma or emphysema, make sure your medications are refilled, make sure your inhalers are full, and make sure you're using them. Do you have preventive medications? Be sure to use those on a daily basis. If you start to have trouble breathing, use your Albuterol or whatever you're using to help you out. And if things get really bad, come to the E.R. A lot of these people we're having to keep overnight on breathing treatments and on steroids to try and get their lungs opened up.

Interviewer: What about healthy people, is it going to affect somebody that's healthy as well?

Dr. Madsen: So the big thing we're seeing with healthy people is a lot of times they're getting what feels to them kind of like allergies or a cold, clearing their throat a lot, having a lot of congestion maybe runny nose, stuff that feels kind of like allergies, maybe their eyes are watering a little bit, so it's causing some of these issues with them as well. So I would say if you're younger, if you're healthy, get outside, exercise, enjoy it but try and do it more in the morning when it's not quite so hot, because as the day gets hotter, that ozone, that stuff in the atmosphere builds up more and can be more of a problem.

Interviewer: How long are we going to have to endure?

Dr. Madsen: Hard to say, yeah, in terms of what we have in line and in store for us, I think it's really going to depend on what happens with fires. I sure hope that we don't see forest fires and issues like we had last summer. I can say I've never seen a summer in the E.R. like last summer, in terms of the number of cases we had of people with trouble breathing. It was worse than what we see in the winter, which is usually pretty bad, so let's just hope it doesn't get to that point.

Interviewer: So it's really the fire particulate matter more than the heat and the ozone that's causing the problems?

Dr. Madsen: Well I think what happens, the ozone is there, it's always there with the heat, we know about it, people who have asthma kind of know what to watch out for but then you throw that smoke in on top of it, for the bad forest fires, and that's when things really get bad. People usually aren't prepared for that and that's when we start to see a lot of problems. It kind of pushes people over the edge who already have some issues.

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