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Emergency Minute - ER vs. Urgicare

Writer's picture: drjparentedrjparente


Welcome ​back, ​everyone. ​Another ​episode ​of ​Emergency ​Minute. ​This ​is ​John ​Parente. ​I'm ​here ​with ​you ​today ​to ​discuss ​where ​do ​I ​take ​my ​sick ​child? ​We're ​going ​to ​talk ​about ​pediatrician's ​office ​versus ​the ​urge ​of ​care ​versus ​the ​emergency ​department. ​But ​before ​we ​get ​started, ​I ​wanted ​to ​reference ​an ​upcoming ​podcast ​that ​I ​did ​with ​my ​good ​friend ​doctor ​Dustin ​Portella, ​everyone's ​favorite ​dermatologist ​from ​Idaho ​who ​trained ​with ​me ​many ​years ​ago. ​Andhe ​and ​I ​talk ​about ​emergency ​medicine. ​We ​talk ​about ​dermatology ​because ​that ​is ​his ​specialty. ​And ​we ​talk ​about ​a ​very ​important ​issue ​that ​I ​think ​all ​of ​you ​want ​to ​know ​more ​about, ​which ​is ​manscaping. ​Yes, ​that ​actually ​happened. ​So ​look ​forward ​to ​that. ​It ​won't ​be ​on ​this ​particular ​channel, ​but ​it ​will ​be ​pretty ​much ​plastered ​all ​over ​the ​earth ​with ​his ​tremendous ​following.


Healthcare is broken. There's no question about it


All ​right, ​so ​speaking ​of ​followings, ​don't ​forget ​to ​follow ​me ​on ​social ​media at Drjparente. ​You ​can ​follow ​me ​on ​TikTok, ​Instagram, ​Facebook ​and ​YouTube. ​None ​of ​you ​guys ​are ​following ​me ​on ​YouTube. ​Kind ​of ​hurt ​my ​feelings. ​So ​today ​we're ​going ​to ​kind ​of ​sort ​out ​the ​gray ​area. ​And ​I've ​gotten ​a ​few ​listeners ​that ​have ​contacted ​me ​and ​said, ​we ​need ​to ​talk ​about ​do ​I ​take ​my ​child ​to ​the ​pediatrician's ​office? ​Do ​I ​take ​my ​child ​to ​the ​emergency ​department? ​Or, ​God ​forbid, ​the ​urge ​of ​care, ​the ​dreaded ​urge ​of ​care. ​So ​now, ​there ​are ​some ​obvious ​things ​that ​I ​think ​people ​probably ​know. ​Most ​people ​know, ​like ​if ​your ​kid's ​arm ​is ​falling ​off, ​you ​know, ​you're ​not ​going ​to ​the ​pediatrician, ​you're ​going ​to ​the ​emergency ​room. ​If ​your ​child ​needs ​acheckup ​or, ​you ​know, ​their ​immunizations ​or ​just ​something, ​that's ​very ​simple. ​Of ​course ​they're ​going ​to ​go ​to ​the ​pediatric, ​the ​pediatrician. ​So ​we're ​going ​to ​sort ​out ​some ​of ​this ​stuff ​here ​today, ​kind ​of ​the ​stuff ​in ​between ​there. ​Now, ​a ​couple ​of ​things. ​You ​know, ​first ​of ​all, ​I've ​said ​this ​a ​billion ​times ​on ​this ​show. ​Healthcare ​is ​broken. ​There's ​no ​question ​about ​it. ​But ​even ​this ​here ​today, ​even ​at ​its ​entry ​point, ​• ​is ​broken. ​People ​don't ​know ​where. ​Where ​do ​I ​take ​my ​child? ​Should ​I ​call ​a ​pediatrician? ​Should ​I ​call ​the ​ER? ​No, ​don't ​call ​the ​ER, ​because ​we ​don't ​give ​medical ​advice ​over ​the ​phone, ​and ​we ​say ​that ​783,000 ​times ​a ​day. ​But ​the ​other, ​you ​know, ​piece ​of ​that ​is ​that, ​you ​know, ​urgent ​care ​is ​popping ​up ​all ​over ​the ​place. ​Like ​Medspas. ​everybody ​wants ​to ​have ​an ​urgic ​care ​and ​staff ​them, with ​people ​that ​have ​almost ​no ​training. ​So ​• ​• ​there's ​obviously ​a ​lot ​of, in ​between ​here. ​But ​even ​when ​it ​does ​work, ​it's ​still ​far ​from ​perfect. ​Right? ​Like, ​I've ​talked ​about ​that ​before. ​• ​But, ​the ​biggest ​thing ​here ​is ​that ​people ​have ​to ​understand ​• ​limitations, ​and ​not ​just ​in ​ER ​or ​the ​system, ​but ​just ​healthcare ​in ​general. ​But ​unfortunately, ​they ​don't. ​Everybody ​wants ​to ​drive ​through ​McDonald's ​and ​get ​their ​meal ​served ​to ​them ​very ​quickly, ​very ​cheaply, ​and ​economically, ​and ​then ​go ​about ​their ​business ​five ​minutes ​later, ​and ​they ​kind ​of ​approach ​healthcare ​the ​same ​way. ​And ​that'd ​be ​great ​if ​it ​worked ​that ​way, ​but ​it ​doesn't. ​We ​don't ​often ​get ​our ​answer ​in ​the ​emergency ​department. ​I ​say ​this ​all ​the ​time, ​and ​nobody ​likes ​to ​hear ​this, ​but ​the ​vast ​majority ​of ​patients ​that ​present ​to ​an ​emergency ​department ​with ​abdominal ​pain ​leave ​with ​a ​diagnosis ​of ​• ​abdominal ​pain, ​which ​means ​that ​we ​don't ​find ​anything. ​And ​that's ​okay. ​That ​doesn't ​mean ​that ​there's ​nothing ​wrong, ​but ​people ​have ​to ​understand ​and ​sort ​of ​gauge ​those ​expectations ​that, ​like, ​look, ​we ​may ​not ​find ​everything ​we ​need ​in ​just ​a ​couple ​of ​hours. ​In ​the ​emergency ​department, ​you ​know, ​these ​things ​sometimes ​take ​time ​to ​present, ​and ​they ​take ​days ​or ​weeks. ​Like, ​neurologic ​things ​can ​take ​weeks ​or ​months, or ​years ​sometimes, ​before ​people ​actually ​arrive ​at ​a ​diagnosis. ​So ​understand ​that ​there ​are ​limitations. ​That, ​doesn't ​mean ​that ​someone's ​done ​something ​wrong. ​We ​live ​in ​such ​a ​society ​that ​is ​just ​this ​blame ​culture. ​You ​got ​to ​point ​the ​finger. ​Something. ​Something ​bad ​happened ​to ​my ​kid, ​therefore, ​it's ​someone's ​fault. ​Well, ​no, ​it ​may ​not ​be. ​It ​could ​just ​be ​the ​disease ​process ​and ​progression. ​So ​it ​is ​a ​broken ​system, ​but ​we'll ​touch ​base ​on ​that ​a ​little ​bit ​as ​we ​get ​down ​into ​the ​weeds ​here ​of ​some ​of ​these ​topics.


The requirements for nurse practitioners in Ohio are absolutely abysmal


Before ​we ​get ​started, ​though, ​I ​wanted ​to ​do ​a ​couple ​of ​disclaimers. ​The ​first ​disclaimer ​is ​this. ​This ​is ​not ​meant ​to ​be ​medical ​advice. ​If ​you ​feel ​that ​you ​or ​your ​loved ​one ​or ​your ​child ​needs ​to ​go ​to ​the ​emergency ​department, ​by ​all ​means, ​please ​do ​so. ​Do ​not ​take ​this ​podcast ​as ​me ​saying, ​do ​not ​go ​to ​the ​ER, ​because ​that ​is ​definitely ​not ​the ​case, ​especially ​with ​children. ​Like, ​you ​know, ​I've ​got ​three ​kids. ​I ​get ​it. ​You ​know, ​people ​get ​nervous, ​people ​get ​scared. ​We ​always ​talk ​about ​pediatrics ​is ​treating ​not ​just ​the ​patient, ​but ​the ​parents. ​Right? ​I ​mean, ​that's ​a ​big ​part ​of ​it. ​But ​that's ​okay. ​That's ​our ​job. ​You ​know, ​we're ​supposed ​to ​educate ​people ​on ​whatever ​that ​disease ​process ​is ​or ​why ​patients ​and ​parents ​should ​be ​reassured ​that ​there's ​not ​anything ​too ​horrible ​going ​on. ​The ​second ​disclaimer ​is ​that ​I ​do ​not ​want ​to ​offend ​any ​of ​my ​mid ​level ​colleagues, ​specifically ​nurse ​practitioners. ​I've ​talked ​about ​this ​very ​openly ​on ​numerous ​podcasts ​before ​nurse ​practitioner ​training, ​at ​least ​in ​the ​state ​of ​Ohio ​and ​presumably ​the ​rest ​of ​the ​country, ​although ​I ​did ​not ​take ​the ​time ​to ​look ​at ​the ​other ​49 ​states ​and ​what ​the ​requirements ​are. ​But ​the ​requirements ​for ​nurse ​practitioners ​in ​the ​state ​of ​Ohio ​is ​absolutely ​abysmal. ​Absolutely ​abysmal. ​You ​can ​become ​a ​plumber ​with ​far ​more ​training ​than, becoming ​a ​nurse ​practitioner. ​The ​number ​of ​hours ​is, ​is ​absolutely ​abysmal. ​You ​can ​do ​it ​online, ​you ​can ​do ​it ​without ​any ​training ​by ​a ​physician, ​which ​is ​crazy. ​And, ​you ​know, ​you ​don't ​even ​get ​procedural ​training, ​you ​know, ​laceration ​repairs, ​etcetera. ​A ​lot ​of ​urgicares ​are ​going ​to ​be ​staffed ​with ​nurse ​practitioners. ​So ​that ​is ​something ​that ​you ​have ​to ​kind ​of ​keep ​in ​mind. ​And ​again, ​disclaimer, ​there ​are ​good ​nurse ​practitioners ​out ​there. ​They ​do ​exist. ​I'm ​not ​taking ​any ​shots ​at ​any ​particular ​person ​or ​anything ​like ​that. ​I'm ​just ​overall, ​the ​system ​is ​absolutely ​broken, ​and ​the ​vast ​majority ​of ​nurses ​I ​know ​are ​all ​becoming ​nurse ​practitioners ​because ​it's ​so ​simple ​to ​do. ​What's ​not ​so ​simple, ​then, ​is ​taking ​care ​of ​people ​without ​any ​sort ​of ​supervision ​on ​the ​other ​side ​after ​the ​fact. ​But ​that's ​a ​whole ​other ​discussion ​for ​another ​day. ​So ​my ​apologies ​if ​I ​offend ​anyone. ​That's ​not ​my ​goal. ​My ​goal ​is ​to ​simply ​be ​very ​honest ​and ​factual, ​and ​the ​training ​right ​now ​is ​just ​very, ​very ​pitiful ​when ​it ​comes ​to ​requirements. ​So ​talk ​about ​the ​three ​levels ​today. ​Obviously, ​the ​pediatrician, ​I guess ​you ​could ​throw ​a ​family ​doctor ​into ​that ​urgent ​care ​versus ​the ​ER. ​You ​know, ​obviously ​a ​pediatrician ​is ​going ​to ​be, ​you ​know, ​for ​the ​most ​part, ​they're ​going ​to ​be ​board ​certified. ​They're ​going ​to ​go ​through ​all ​of ​medical ​school ​for ​four ​years, ​then ​they're ​going ​to ​go ​through ​their ​pediatric ​residency ​as ​well ​for ​several ​years. ​This ​is ​very extensive ​training. ​Right. ​And ​then ​you ​have ​your ​ear ​doctors. ​I'm ​not ​going ​to ​belabor ​that ​point. ​We ​have ​at ​least ​a ​three, ​if ​not ​four ​year ​residency ​on ​top ​of ​medical ​school ​as ​well, ​just ​literally ​hundreds ​of ​thousands ​of ​hours. ​And ​then ​you ​have ​nurse ​practitioners ​who ​I ​think ​in ​the ​state ​of ​Ohio, ​it's ​like ​four ​or ​500 ​hours ​are ​required, ​and ​then ​physician ​assistants ​who ​end ​up ​doing ​several ​thousand ​hours ​of ​training ​and ​their ​requirements ​are ​a ​lot ​higher. ​And ​also ​they're ​taught ​by ​physicians ​for ​the ​most ​part, ​not ​other ​mid ​levels. ​So ​that's ​kind ​of ​your ​breakdown ​of ​the ​three ​levels ​now. ​So ​the ​pediatrician's ​office ​I'm ​not ​going ​to ​speak ​to ​very ​much ​because ​I, ​I'm ​not ​a ​pediatrician. ​I ​don't ​work ​there. ​But ​I ​do ​tell ​you, ​I ​see ​plenty ​of ​kids ​in ​the ​emergency ​department. ​So ​I ​think ​the ​vast ​majority ​of ​those ​visits ​that ​you ​should ​go ​and ​take ​your ​child ​to ​the ​pediatrician ​is ​going ​to ​be, ​you ​know, ​checkups, ​immunizations, ​you ​know, ​your ​annual ​physical ​follow ​ups ​from ​the ​emergency ​room. ​If ​you ​do ​happen ​to ​end ​up ​in ​the ​emergency ​room ​and ​you ​need ​a ​follow ​up ​appointment, ​like ​they're ​there ​for ​you. ​And ​some ​places ​do ​walk ​ins ​and ​things ​like ​that. ​But ​we've ​talked ​about ​this ​before, ​that ​healthcare ​is ​very ​broken. ​It's ​very ​difficult ​to ​get ​in ​to ​see ​your ​doctors. ​But ​I ​think ​the ​one ​area ​that ​sort ​of, debunked ​that ​are ​the ​pediatricians. ​Pediatricians ​actually ​usually ​do ​a ​pretty ​good ​job ​of ​taking ​some ​walk ​ins ​or ​some ​same ​day ​appointments ​because, ​you ​know, ​things ​happen ​to ​little ​kids ​and ​then ​parents ​get ​anxious ​and ​they ​want ​to ​take ​them ​in, ​and ​that's. ​And ​that's ​fine. ​I ​think ​there's ​a ​place ​for ​that. ​You ​know, ​a ​lot ​of ​family ​physicians ​and ​internal ​medicine ​docs ​and ​obviously, ​you ​know, ​cardiologists ​and ​specialists. ​I ​mean, ​you ​know, ​you'll ​be ​dead ​and ​buried ​by ​the ​time ​you ​get ​to ​see ​one ​of ​those ​guys. ​So ​that's ​going ​to ​be ​kind ​of ​like ​the ​office ​setting ​type ​of ​appointment ​that ​you're ​going ​to ​be ​taking ​your ​child ​to ​now. ​We'll ​talk ​about ​later ​on ​in ​the ​show, ​just ​kind ​of ​very ​specific ​complaint ​specific ​visits, ​age ​specific ​visits ​as ​well. ​But ​for ​the ​most ​part, ​that's ​kind ​of ​the ​pediatric ​office. ​Now, ​the ​urge ​of ​care, ​you ​know, ​obviously, ​I ​have ​a ​personal ​bias ​here, ​is ​pretty ​much ​run ​almost ​exclusively ​by ​nurse ​practitioners ​or ​pas. ​It ​can ​also ​be ​by ​resident ​physicians ​• ​or ​physicians ​who ​are, ​like, ​retired ​or ​they're, ​you ​know, ​psychiatrists ​on ​the ​side ​trying ​to ​make ​extra ​money. ​So ​understand ​that ​if ​you ​go ​to ​an ​urgent ​care, ​there ​is, ​like ​a ​0% ​chance ​that ​you ​are ​going ​to ​see ​a ​board ​certified ​emergency ​medicine ​physician. ​Now, ​you ​know, ​to ​the ​average ​person, ​you're ​like, ​I ​don't ​care. ​I ​don't ​care ​who ​I ​see. ​Well, ​there's ​a ​difference ​there, ​I ​promise ​you. ​That's ​like ​saying, ​I ​want ​to ​play ​in ​the ​NFL, ​andyou ​know, ​I've ​that ​expectation, ​but ​really, ​it's ​m ​more ​like ​pee ​wee ​football. ​I ​mean, ​there's ​a ​difference ​between ​• ​someone ​who's ​board ​certified ​versus ​someone ​who's ​just ​sort ​of, ​you ​know, ​kicking ​the ​tires ​on ​the ​side. ​So ​we ​see, ​unfortunately, ​these ​disasters ​in ​the ​emergency ​department ​all ​the ​time, ​and ​that's ​part ​of ​the ​reason ​why ​I'm ​somewhat ​jaded ​in ​this ​regard. ​There's ​this ​sort ​of ​national ​movement ​that, ​oh, ​you ​know, ​pas ​and ​P's ​are ​cheaper ​than ​docs, ​so ​we ​should ​just ​replace ​all ​of ​them ​or, ​you ​know, ​cut ​back ​on ​ours ​for ​physicians. ​And ​this ​is ​happening ​across ​the ​country, ​and ​nobody ​even ​knows ​it, ​except ​for ​people ​that ​are ​in ​healthcare. ​So, ​obviously, ​I ​have ​a ​personal ​bias ​here, ​but ​it's. ​It's ​based ​on ​what ​I ​see ​and ​what ​I ​do ​every ​day. ​There's ​literally ​websites ​out ​there, ​specifically, ​like, ​Facebook ​groups ​and ​things ​like ​that, ​that ​keep ​track ​of ​just ​absolutely ​disaster ​cases,and ​just ​completely ​mismanaged,patients. ​Obviously, ​it's ​not ​open ​to ​the ​public ​and ​things ​like ​that, ​but ​it's ​very ​eye ​opening ​to ​see ​what ​happens ​when ​you ​put ​people ​who ​have ​very ​little ​training ​in ​charge ​of ​people's ​lives. ​We ​just ​had ​a ​case ​this ​week ​that ​was ​sent ​over ​by ​one ​of ​my ​good ​friends. ​I ​don't ​want ​to ​mention ​the ​name ​because ​I ​don't ​want ​to ​get ​anybody ​else ​in ​trouble ​here, ​but ​this ​was ​a ​nurse ​practitioner ​that ​had ​done ​an ​outpatient ​workupfor ​chest ​pain ​on ​this ​individual ​and ​had ​ordered ​all ​these ​random, ​weird ​tests ​that ​have ​absolutely ​no ​bearing ​on ​chest ​pain ​whatsoever ​for ​blood ​work. ​Then ​proceeded ​to ​order ​a d ​dimer ​to ​check ​for ​a ​blood ​clot. ​Okay, ​that's ​fine. ​• ​But ​then ​ordered ​a ​CT ​of ​the ​chest, ​but ​there ​was ​not ​what's ​called ​a ​CT ​angiogram, ​which ​is ​how ​you ​check ​for ​a ​blood ​clot. ​• ​But, ​like, ​why ​would ​you ​order ​the ​CT ​chest? ​Unless, ​like, ​if ​the ​d ​dimer ​was ​positive ​and ​you ​needed ​to ​rule ​out ​a ​blood ​clot, ​then, ​yes, ​you ​would ​order ​the ​CT ​angiogram. ​But ​they ​ordered ​the ​wrong ​CT, ​• ​• ​and ​then ​the ​d ​dimer ​ended ​up ​coming ​back, ​quote ​unquote ​positive. ​So ​they ​sent ​the ​patient ​to ​the ​emergency ​department ​anyways. ​And ​lo ​and ​behold, ​if ​you ​do ​what's ​called ​an ​age ​adjusted ​d ​dimer, ​it ​was ​actually ​negative. ​So ​this ​patient ​basically ​got ​sent ​to ​the ​ER ​for ​no ​reason ​at ​all. ​So ​this ​stuff ​happens ​all ​the ​time,because ​people ​order ​tests, ​they ​don't ​know ​what ​the ​hell ​to ​do ​with ​them, ​and ​it's ​really ​unfortunate. ​So ​again, ​I ​would ​be ​very ​careful ​going ​to ​an ​urgicare ​with ​anything ​• ​• ​substantial, ​and ​we'll ​kind ​of ​talk ​about ​that ​later.


The emergency room, obviously run by board certified emergency medicine physicians


Now, ​the ​emergency ​room, ​obviously ​run ​by, ​for ​the ​most ​part, ​board ​certified ​emergency ​medicine ​physicians ​and ​then ​NP's ​and ​pas ​that ​we ​work ​side ​by ​side ​with ​now ​in ​this ​type ​of ​environment ​for ​the ​most ​part. ​And ​what ​I ​see, ​you ​know, ​a ​lot ​of ​these ​MP's ​and ​pas ​are ​being ​supervised ​by ​the ​physician ​on ​some ​level. ​Maybe ​not ​like ​100% ​like, ​you ​know, ​helicoptering ​over ​their ​shoulder, ​but ​they ​are ​involved. ​For ​example, ​when ​I ​work,I ​do ​look ​at ​every ​single ​thing ​that's ​being ​done ​as ​far ​as ​medications ​being ​ordered. ​I ​do ​look ​at,every ​single ​x ​ray ​that's ​taken ​in ​the ​department, ​even ​if ​the ​patient ​is ​not, ​you ​know, ​quote ​unquote ​mine. ​If ​it's ​somebody ​that's ​really ​sick ​or, ​you ​know, ​needs ​intervened ​upon ​or ​is ​really, ​really ​having ​trouble, ​then ​I'm ​going ​to ​be ​there. ​I'm ​going ​to ​be ​there ​side ​by ​side ​with ​the ​MP, ​with ​the ​PA, ​• ​• ​working ​with ​that ​patient. ​So ​I ​think ​in ​the ​emergency ​room, ​there ​is ​an ​opportunity ​to ​sort ​of ​supervise ​a ​little ​bit ​better, ​as ​opposed ​to ​potentially ​like ​an ​office ​setting ​or ​something ​along ​those ​lines. ​Now, ​the ​other ​thing ​I'll ​tell ​you ​about ​the ​emergency ​department, ​however, ​is ​that ​there ​just ​simply ​aren't ​enough ​board ​certified ​ER ​physicians ​to ​staff ​every ​ER ​in ​America. ​So ​you ​will ​go ​to ​an ​ER ​at ​some ​point ​in ​your ​life ​where ​you ​may ​not ​be ​seen ​by ​a ​board ​certified ​ER ​physician. ​There ​are ​some ​ers ​that, ​you ​know, ​have, ​you ​know, ​critical ​access ​or ​things ​like ​that, ​where, ​you ​know, ​they ​just ​have ​to ​have ​a ​family ​physician ​that ​happens ​to ​have ​had ​worked ​in ​the ​department ​for ​like ​20 ​years ​or ​something ​along ​those ​lines. ​The ​entire ​country ​is ​moving ​towards ​having, ​you ​know, ​ers ​being ​run ​by ​board ​certified ​ER ​physicians ​because ​they ​value ​their ​training. ​They ​understand ​it. ​Now, ​30 ​years ​ago, ​people ​were ​like, ​oh, ​you ​guys ​are ​just, ​you ​know, ​glorified ​triage ​nurses, ​you ​know, ​which ​is ​always ​the ​running ​joke ​that ​we ​love ​so ​much ​to ​hear. ​So, ​you ​know, ​I ​think ​that ​there ​are ​some ​limitations ​there. ​But ​understand, ​for ​the ​most ​part, ​you're ​going ​to ​be ​seen ​by ​a ​board ​certified ​ER ​physician, ​which ​is, ​you ​know, ​that's ​kind ​of ​what ​we ​do. ​Again,I ​can't ​restate ​this ​enough. ​If ​you ​feel ​the ​need ​to ​take ​your ​child ​to ​the ​ER, ​then ​please ​do ​so.


When do you take your child to the ER versus the pediatrician's office


Let's ​talk ​about ​some ​complaint ​specific ​guidance ​here. ​So, ​fever, ​you ​know, ​that's ​probably ​one ​of ​the ​most ​common ​reasons ​on ​earth ​why ​a ​child ​or ​a ​parent ​will ​seek ​out ​medical ​evaluation. ​• ​• ​So ​when ​do ​you ​take ​your ​child ​to ​the ​ER ​versus ​the ​urgent ​care ​versus ​the ​pediatrician's ​office ​for ​a ​fever? ​Well, ​clearly, ​if ​it's ​been ​there ​for ​at ​least ​an ​hour, ​you ​call ​911 ​and ​go ​to ​the ​ER. ​Yes, ​that ​has ​happened. ​We ​see ​this ​all ​the ​time. ​We ​see ​patients ​that ​have ​had ​a ​fever ​for ​an ​hour ​that ​come ​to ​the ​ER, ​and ​it ​makes ​us ​homicidal. ​All ​right, ​not ​really ​homicidal. ​That ​would ​be ​weird. ​But ​it ​does ​drive ​us ​crazy. ​Like ​an ​hour, ​like, ​that's ​the ​benchmark. ​Sometimes ​I ​wish ​I ​could ​speak ​my ​mind ​and ​say, ​why ​did ​you ​wait ​so ​long? ​Spent ​a ​whole ​hour? ​Did ​you ​take ​a ​Tylenol? ​So, ​you ​know, ​this ​obviously ​becomes ​an ​area. ​Fever ​is ​very ​sort ​of ​a. ​It ​is ​objective ​100.4 or ​higher, ​but ​it's ​more ​subjective ​in ​severity. ​Right. ​Like, ​is ​this ​something ​that ​needs ​to ​be ​seen ​in ​the ​emergency ​room, ​or ​is ​this ​something ​that ​can ​go ​to ​the ​pediatrician's ​office? ​And ​this ​is ​where ​this ​gets ​into ​a ​very ​gray ​area ​here. ​Very ​hard ​to ​put ​parameters ​on ​this ​because ​people ​aren't, ​like, ​checking ​vital ​signs ​at ​home. ​Like, ​yes, ​if ​your ​child ​is ​hypoxic, ​you ​know, ​you ​definitely ​want ​to ​come ​to ​the ​ER. ​Well, ​most ​people ​don't ​have ​pulse ​ox ​at ​home. ​You ​know, ​if ​your ​child ​is ​tachycardic ​and ​their ​heart ​is ​racing, ​you ​should ​go ​to ​the ​ER. ​Well, ​fever ​does ​make ​your ​heart ​race. ​So ​by ​definition, ​every ​single ​kid ​on ​earth ​with ​influenza ​needs ​to ​go ​to ​the ​ER. ​By ​the ​way, ​spoiler ​alert, ​they ​don't. ​So, ​you ​know, ​there ​are ​very, ​it's ​very ​difficult ​to ​put ​parameters ​on ​where. ​Where ​you ​go. ​So ​I ​think ​my ​message ​for ​fever ​would ​be, ​if ​your ​child ​looks ​toxic ​and ​look, ​every. ​Every ​parent ​that's ​out ​there ​will ​look ​at ​their ​child ​with ​a ​fever ​and ​be ​like, ​oh, ​he's ​just ​not ​himself. ​He ​just. ​He's ​lethargic ​and ​all ​these ​things. ​Understand ​that ​that's ​different ​than ​what ​we ​look ​at ​in ​healthcare. ​As, ​you ​know, ​board ​certified ​docs, ​when ​we ​say ​a ​child ​looks ​sick, ​that ​means ​something ​different ​than ​when ​a ​parent ​says, ​my ​child ​looks ​sick. ​Of ​course ​your ​child ​looks ​sick. ​He's ​pale. ​He ​or ​she ​is ​pale, ​you ​know, ​not ​eating ​or ​drinking ​as ​much. ​Probably ​curled ​up, on ​the ​couch ​like ​a ​ball, ​not ​really ​eating ​or ​drinking ​as ​much. ​You ​know, ​not ​no ​longer ​interested ​in ​playing ​video ​games, ​you ​know, ​things ​like ​that. ​That's ​obviously ​alarming ​to ​parents. ​But ​as ​a ​physician, ​that's ​not ​alarming. ​That's. ​That's ​completely ​normal. ​That's,completely ​normal ​to ​feel ​that ​way ​with ​fevers. ​When ​physicians ​use ​the ​word ​lethargic, ​it ​means ​something ​completely ​different. ​It ​means ​someone ​that ​has, ​like, ​hypotonia, ​like, ​less ​muscle ​tension ​and ​tone, ​and ​they ​can't ​hold ​their ​head ​up, ​and ​they ​can't ​really ​open ​their ​eyes ​and ​things ​like ​that. ​So ​there's ​different ​variables ​here ​where ​it's ​very ​difficult ​to ​say ​• ​• ​who ​looks ​sick ​• ​• ​that ​needs ​to ​come ​to ​an ​ER ​versus ​someone ​who's ​got ​a ​runny ​nose, ​and ​they're ​still ​playing ​video ​games, ​and ​they ​look ​fine, ​and ​then ​they ​can ​go ​to ​their ​pediatrician. ​• ​• ​You ​know, ​this ​sort ​of ​has ​to ​be ​that ​gut ​feeling ​for ​the ​parents. ​And ​if ​you're ​ever ​really ​not ​sure, ​you ​know, ​I ​would ​just ​say ​err ​on ​the ​side ​of ​either ​a ​calling ​the ​pediatrician ​and ​kind ​of ​getting ​their ​advice ​on ​where ​to ​go ​from ​here. ​If ​they ​can't ​see ​you, ​obviously, ​then ​come ​to ​the ​emergency ​department. ​I ​don't ​know ​that ​I ​would ​go ​to ​an ​urgent ​care ​with ​a ​fever ​unless ​it ​was ​something ​simple ​like, ​hey, ​I ​need ​a ​strep ​test. ​You ​know, ​my ​child's ​got ​a ​sore ​throat. ​Like, ​that's ​kind ​of ​hard ​to ​screw ​up. ​Like, ​I ​mean, ​you ​do ​the ​strep ​swabs. ​You ​know, ​there ​are ​some. ​There ​are ​some ​pitfalls. ​Don't ​get ​me ​wrong. ​You ​could ​have ​peritonsular ​abscess, ​which ​someone ​has ​to ​be ​able ​to ​identify, ​because ​that ​needs ​to ​be ​seen ​by ​an ​Ent ​physician. ​We ​see ​that ​all ​the ​time ​in ​the ​ER. ​There's ​other ​things, ​too. ​Like, ​you ​know, ​if ​the ​patient's ​had ​sore ​throat ​for ​a ​week, ​and ​they ​say, ​oh, ​you ​got ​strep ​throat, ​and ​they ​put ​you ​on ​antibiotics. ​But ​really, ​it's ​mono. ​You ​know, ​you ​could ​develop ​a ​rash. ​It's ​not ​life ​threatening, ​but ​still, ​it's ​a ​pain ​in ​the ​butt. ​So ​there ​are ​some ​pitfalls ​with ​even ​something ​as ​simple ​as ​sore ​throat. ​But ​for ​the ​most ​part, ​I ​think ​the ​urge ​of ​care ​is ​like, ​hey, ​I ​just. ​I ​really ​want ​to ​get ​a ​strep ​test, ​because ​if ​it's ​positive, ​my ​child ​needs ​antibiotics ​and ​to ​be ​off ​of ​school ​today. ​If ​it's ​negative, ​we ​don't ​need ​antibiotics, ​and ​it's ​likely ​viral ​and ​my ​child ​can ​go ​to ​school ​today ​or ​the ​following ​day. ​So ​I ​think, ​you ​know, ​fever ​is ​very ​difficult ​to ​put ​parameters ​on, ​but ​I ​think ​that's ​where ​I ​would ​start. ​Now, ​part ​and ​parcel ​with ​fevers, ​you ​know, ​most ​common ​thing ​that ​we ​see ​in, the ​emergency ​department ​regarding ​fevers ​would ​be ​respiratory ​complaints, ​especially ​in ​the ​middle ​of ​winter. ​So ​upper ​respiratory ​infections, ​you ​know, ​bronchitis, ​pneumoniae, ​we ​do ​see ​the ​sore ​throat, ​like ​I ​talked ​about ​before, ​and ​then ​ear ​infections, ​both ​inner ​ear, ​and ​then ​occasionally ​the ​outer ​ear, ​especially ​in ​summertime. ​We ​do ​see ​the ​swimmers ​here. ​So ​the ​respiratory ​stuff, sort ​of ​the ​infections, ​upper ​respiratory. ​This ​is ​going ​to ​be ​more ​age ​dependent. ​So, ​you ​know, ​a ​fever ​in ​a ​three ​week ​old ​is ​a ​much ​bigger ​deal ​than ​a ​fever ​in ​a ​three ​year ​old. ​Right. ​I ​mean, ​that's, ​that's ​the, ​you ​know, ​we ​start ​to ​look ​at ​categorizing ​these ​children. ​So ​newborn, ​basically ​up ​until ​weeks ​of ​age, ​you ​know, ​fever ​is ​pretty ​huge ​deal. ​Up ​until ​three ​months ​of ​age, ​you ​should ​still, ​you ​know, ​go ​to ​the, ​at ​least ​the ​pediatrician, ​if ​not ​the ​emergency ​room. ​And ​then ​after ​three ​months ​of ​age, ​that ​three ​to ​six ​months, ​your ​immune ​system ​is ​more ​fully ​developed. ​At ​this ​point, ​this, becomes ​less ​dangerous. ​You ​still ​seek ​out ​evaluation, ​but ​this ​is ​when ​you ​start ​to ​get ​into ​teething, ​especially ​if ​the ​child's ​in ​daycare. ​You ​can ​get ​the, ​you ​know, ​all ​the ​viruses ​that ​do ​occur. ​So ​it ​is ​a ​sort ​of ​age ​dependent. ​And ​then ​after ​six ​months, ​nobody ​cares ​about ​you. ​I'm ​just ​joking, ​obviously ​less. ​That's ​dangerous ​at ​that ​point.


Most minor respiratory problems can be seen without going to the emergency room


And ​then ​the ​other ​thing ​you ​have ​to ​consider ​is ​seasonally ​dependence. ​You ​know, ​we ​do ​have ​rsv ​season, ​there's ​flu ​season, ​there ​used ​to ​be ​all ​these ​Covid ​seasons. ​Now ​I ​don't ​really ​know ​what's ​happening ​with ​COVID ​It's ​really ​not ​an ​issue. ​And ​if ​it ​is, ​it's ​very, ​very ​minor, ​so ​nothing ​really ​to ​worry ​about ​it. ​It ​really ​never ​impacted ​kids ​in ​a ​negative ​way ​anyway. ​So, ​you ​know, ​these ​things ​are ​sort ​of ​age ​dependent, ​seasonally ​dependent ​on ​where ​to ​go. ​But ​understand, ​most ​• ​minor ​respiratory ​and, ​you ​know, ​earaches ​and ​sore ​throats ​and ​that ​kind ​of ​stuff ​can ​kind ​of ​be ​seen ​by ​all ​three, ​can ​be ​seen ​by ​your ​pediatrician, ​can ​go ​to ​the ​emergency ​room, ​especially ​if ​it's ​a ​weekend ​or ​there's ​no ​other ​place ​to ​go. ​And ​yes, ​if ​it's ​something ​simple, ​you ​know, ​can ​probably ​be ​seen ​at ​the ​dreaded ​urge ​of ​care.


If you truly think your child has a broken bone, just go straight to ER


All ​right, ​how ​about ​injuries? ​Injuries? ​Well, ​obviously, ​depending ​on ​the ​severity ​of ​the ​injury, ​if ​someone's ​arm's ​falling ​off. ​You ​need ​to ​go ​to ​the ​ER. ​If ​you ​think ​you ​have ​an ​ankle ​sprain, ​then ​you ​may ​be ​able ​to ​go ​to ​your ​pediatrician's, ​office. ​Or ​the ​urgency ​now ​disclaimer. ​You ​need ​to ​make ​sure ​that, ​you ​know, ​both ​of ​those ​places ​have ​the ​ability ​to ​do ​an ​x ​ray. ​Iif ​you're ​going ​there ​for ​an ​injury, ​or ​for ​like, ​a ​laceration, ​you ​may ​need ​to ​call ​ahead ​and ​see ​if ​they ​do ​stitches. ​Again, ​I'm ​not ​being ​a ​jerk ​when ​I ​say ​this, ​but ​the ​vast ​majority ​of ​nurse ​practitioner ​training ​• ​does ​not ​involve ​procedures, ​which ​is ​crazy, ​but ​they're ​the ​ones ​staffing ​them, ​urgent ​care. ​So ​now ​there ​are ​some ​training ​programs ​available, ​like ​outside ​of ​MP ​school, ​where ​you ​can ​try ​to ​get ​more ​practice ​and ​get ​better ​at, laceration ​repairs, ​things ​like ​that. ​So ​you ​may ​need ​to ​call ​ahead ​and ​say, ​hey, ​do ​you ​guys, ​do, ​you ​know, ​stitch ​repair ​and ​that ​kind ​of, ​you ​know, ​suture ​repair? ​And ​same ​thing ​with ​pediatrician's ​office. ​Sometimes ​they'll ​just ​send ​you ​straight ​to ​the ​ER, ​and ​that's ​fine. ​You ​know, ​we. ​We ​do ​this ​all ​day ​long. ​So ​if ​you ​need ​to ​come ​in ​and ​get ​that ​done, ​then ​that's ​fine. ​So ​if ​you ​think ​it's ​something ​that's ​like ​a ​minor ​orthopedic ​injury, ​like ​an ​ankle ​sprain, ​wrist ​sprain, ​Ithink ​it's ​okay ​to ​start ​off ​in ​the ​office ​of ​your ​pediatrician ​or ​even ​the ​urgent ​care, ​so ​long ​as ​they ​have ​the ​ability ​to ​do ​the ​x ​rays. ​However, ​understand ​• ​• ​• ​that ​we ​get ​this ​all ​the ​time, ​where, ​like, ​let's ​say ​they ​think, ​oh, ​it's ​just ​an ​ankle ​spray, ​and ​I'll ​just, ​I'll ​just ​get ​the ​x ​ray, ​or ​it's ​a ​wrist ​spray, ​and ​I'll ​get ​the ​x ​ray. ​What ​happens ​is, ​if ​it's ​positive, ​meaning ​there's ​a ​fracture ​there, ​they ​have ​no ​idea ​what ​to ​do ​with ​it. ​So ​they ​ended ​up ​sending ​them ​to ​the ​ER ​anyways, ​in ​which ​case ​we ​have ​to ​put ​a ​splint ​on. ​And ​then ​for ​us, ​it's ​actually ​a ​pretty ​easy ​visit ​because ​we ​just ​look ​at ​the ​x ​ray. ​Oh, ​yeah, ​okay. ​You ​got ​a ​colleagues ​fracture, ​put ​you ​in ​a, ​you ​know, ​splints, ​put ​you ​in ​a ​volar ​splint, ​send ​you ​on ​your ​way ​to ​go ​see ​ortho. ​And ​it's ​a ​very ​quick ​appointment ​usually. ​But ​understand ​from ​a, ​you ​know, ​patient ​standpoint, ​it's ​not ​very ​efficient ​use ​of ​time ​to ​go ​all ​the ​way ​to ​the ​office ​of ​the ​pediatrician, ​schedule ​an ​appointment, ​you ​wait ​for ​several ​hours, ​and ​then ​you ​get ​the ​x ​ray, ​and ​then ​several ​hours ​later, ​they'll ​call ​you ​and ​say, ​hey, ​it's, ​you ​know, ​it's ​broken. ​Now ​you ​need ​to ​go ​to ​the ​ER ​because ​you ​got ​to ​get ​splinted, ​etcetera. ​So ​I ​think ​if ​you ​truly ​think ​your ​child ​has ​a ​broken ​bone, ​just ​go ​straight ​to ​the ​ER. ​I ​don't ​think ​it's ​worth ​going ​to ​the ​office ​of ​the ​pediatrician. ​If ​you're ​like, ​ah, ​it's ​probably ​just ​a ​sprain, ​rub ​some ​dirt ​on ​it. ​Yeah, ​I ​think ​that's ​probably ​a ​good ​place ​to ​start ​in ​the ​office ​of ​the ​pediatrician ​or ​the ​urge ​of ​care, ​if ​they ​have ​the ​ability ​to ​do ​that.


The most common diagnosis for abdominal pain in children is constipation


All ​right, ​how ​about ​abdominal ​pain? ​Abdominal ​pain ​is ​more ​challenging. ​You ​know, ​you ​have ​to ​understand, ​the ​most ​common ​two ​diagnoses for ​abdominal ​pain ​in ​the ​emergency ​room ​for ​children ​are ​going ​to ​be ​constipation ​number ​one. ​And ​number ​two ​is Uti. ​And ​it's ​funny ​to ​me, ​I ​have ​this ​conversation ​with ​parents ​literally ​every ​shift ​of ​my ​life. ​Well, ​they ​can't. ​It ​can't ​be ​constipated. ​He ​just ​had ​a ​ball ​movement ​today ​or ​yesterday. ​Can't ​be ​constipated. ​Yeah, ​that's ​not ​how ​that ​works. ​So, ​you ​know, ​you ​think ​about ​what ​kids ​eat. ​Kids ​eat ​what? ​Pizza, ​chicken ​nuggets. ​Right? ​Butter ​noodles, ​cheese. ​All ​these ​things ​that ​are ​just ​going ​to ​constipate ​you. ​They're ​not ​getting ​five ​servings ​of ​fruits ​and ​vegetables ​a ​day. ​Right. ​So, ​you ​know, ​it ​is ​absolutely ​the ​most ​common ​cause. ​It ​can ​be ​easily ​seen ​on ​an ​x ​ray. ​Sometimes ​we ​do ​an ​x ​ray ​just ​to ​kind ​of ​make ​everyone ​feel ​better ​and, ​you ​know, ​sort ​of ​identify ​the ​fact ​that ​there's, ​like, ​this ​huge ​stool ​burden, ​which ​just ​means ​you're ​full ​of ​poop. ​So ​those ​are ​going ​to ​be ​the ​most ​common ​two ​causes. ​Now, ​we ​do ​worry ​about ​things, ​you ​know, ​appendicitis, ​UTI, ​especially ​in ​young ​girls. ​Those ​things ​we ​don't ​want ​to ​necessarily ​miss, ​obviously. ​So ​that's ​where ​it ​gets ​into, ​you ​know, ​the ​ER ​has ​the ​ability ​to ​do ​more ​testing. ​So, ​like, ​look, ​if ​you. ​If ​your ​child ​has ​very ​severe ​abdominal ​pain ​and, ​you ​know, ​they're ​running ​fevers, ​you ​know, ​fever ​plus ​abdominal ​pain, ​you ​know, ​I ​think ​that's ​where ​you ​definitely ​should ​go ​to ​the ​emergency ​room. ​Now, ​if ​your ​child ​is ​chronically ​constipated ​and ​they've ​been ​dealing ​with ​this ​and ​they ​have ​this ​sort ​of ​colicky, ​you ​know, ​intermittent ​episodic ​abdominal ​pain, ​and ​it's ​been ​going ​on ​for ​weeks ​or ​months ​or ​years, ​that's ​where ​you ​go ​to ​your ​pediatrician ​that's ​not ​the ​time ​to ​go ​to ​the ​emergency ​room ​and ​certainly ​not ​the ​time ​to ​go ​to ​the ​urgicare ​either. ​So ​I ​think ​that's ​where, ​you ​know, ​you ​have ​to ​look ​kind ​of ​the ​chronicity. ​Is ​this ​acute ​or ​is ​this ​chronic? ​If ​it's ​an ​acute ​abdominal ​pain, ​I ​mean, ​yes, ​you ​can ​start ​in ​the ​office ​of ​your ​pediatrician, ​but ​a ​lot ​of ​times ​you're ​going ​to ​end ​up ​in ​the ​ER ​because ​we ​can ​do ​blood ​work, ​ultrasounds, ​CAT ​scans, ​things ​like ​that ​that ​you ​may ​need. ​So ​I ​think, ​you ​know, ​a ​little ​bit ​of ​your ​gut ​feeling. ​• ​• ​• ​• ​Yeah, ​I ​cracked ​myself ​up. ​A ​little ​bit ​of ​a ​gut ​feeling ​there. ​With ​your ​abdominal ​pain, ​whether ​you ​want ​to ​go ​to ​the ​office ​of ​your ​pediatrician ​versus ​the ​emergency ​room. ​So ​I ​think ​that's ​kind ​of ​a ​good ​place ​to ​start. ​And ​then ​jumping ​off ​of ​that, ​vomiting, ​diarrhea. ​Look, ​if ​it's ​minor, ​it ​just ​started ​today. ​Then, ​yeah, ​you ​can ​start ​off ​in ​an ​urgent ​care ​or ​a ​pediatrician ​office. ​But ​if ​this ​is, ​like, ​dangerous, ​this ​child ​has ​vomited ​375 ​times. ​Can't ​keep ​anything ​down. ​You're ​really ​concerned ​that ​they ​may ​need ​an ​iv ​or, ​God ​forbid, ​they're ​type ​one ​diabetic, ​then, ​yes, ​just ​go ​to ​the ​emergency ​room. ​Spoiler ​alert. ​However, ​everyone ​thinks ​that ​something ​magical ​happens ​when ​we ​give ​iv ​fluids. ​The ​American ​Academy ​of ​Pediatrics ​does ​recommend ​that ​we ​actually ​give ​po ​meaning, ​oral ​fluids ​first, ​because ​it ​is ​absorbed ​faster ​and ​much ​more ​efficiently, ​rather ​than ​the ​iv. ​Everyone ​thinks ​the ​iv ​is ​like ​the ​cure ​all. ​So ​understand ​that ​the ​first ​thing ​that ​we're ​probably ​going ​to ​do ​if ​it's ​something ​that's ​minor ​is ​we're ​going ​to ​give ​you ​some ​zofran ​or ​something ​similar ​to ​that ​to ​control ​your ​nausea. ​And ​then ​we're ​going ​to ​see ​if ​we ​can ​do ​what's ​called ​a ​po ​challenge, ​meaning ​we're ​going ​to ​see ​if ​we ​can ​get ​you ​to ​keep ​something ​down, ​because ​the ​vast ​majority ​of ​vomiting, ​diarrhea ​is ​going ​to ​be ​viral. ​Now, ​there ​are ​plenty ​of ​things ​that ​cause ​vomiting ​and ​diarrhea ​beyond ​the ​scope ​of ​this ​show. ​We're ​not ​going ​to ​get ​into ​it, ​but ​for ​the ​most ​part, ​part, ​they ​are ​viral ​causes. ​All ​right, ​chest ​pain, ​shortness ​of ​breath. ​Look, ​cardiac ​events ​are ​very ​rare ​in ​kids. ​Chest ​pain ​in ​children's ​usually ​going ​to ​be ​something ​else. ​It's ​going ​to ​be ​pulmonary, ​like ​asthma ​or ​pleurisy ​or ​pneumonia, ​or ​it's ​going ​to ​be ​from ​the ​GI ​tract, ​some ​indigestion, ​dyspepsia, ​gastritis, ​you ​know, ​those ​kinds ​of ​things. ​You ​know, ​occasionally, ​maybe ​a ​stomach ​ulcer, ​but ​that's ​going ​to ​be ​someone ​that's ​usually ​a ​little ​bit ​older ​or ​has ​some ​other ​underlying ​condition. ​And ​then ​the ​other ​thing ​is ​musculoskeletal, ​you ​know, ​chest ​wall ​pain, ​something ​we ​call ​costochondritis. ​Everyone ​says ​the ​words ​chest ​pain ​and ​freaks ​out. ​We ​get ​this ​sometimes, ​like, ​in ​schools ​and ​things ​like ​that. ​Oh, ​my ​God, ​the ​child's ​having ​chest ​pain. ​Call ​911. ​I've ​yet ​to ​see ​the ​child ​come ​in ​with ​chest ​pain, ​from ​school ​that ​is ​having ​a ​heart ​attack. ​You ​know, ​we ​do ​see ​some ​dangerous ​things ​once ​in ​a ​while. ​We ​do ​see ​like, ​a ​collapsed ​lung ​or ​something ​like ​that. ​But, ​you ​know, ​for ​the ​most ​part, ​• ​very ​rarely ​when ​we ​see ​chest ​pain, ​shortness ​of ​breath, ​does ​it. ​Is ​it ​really ​something ​that's ​dangerous ​in ​the ​emergency ​room?


It depends if this is like an acute diagnosis or a chronic headache

All ​right, ​so ​what ​about ​headaches? ​Headaches, ​migraine ​headache ​is ​somewhat. ​That's ​a ​little ​bit ​different. ​It ​depends ​if ​this ​is ​like ​an ​acute ​diagnosis. ​Is ​this ​chronic? ​My ​child ​has ​migraines, ​and ​this ​has ​been ​an ​ongoing ​issue. ​We've ​seen ​the ​neurologist, ​you ​know, ​that ​kind ​of ​stuff. ​If ​you ​need ​to ​come ​to ​the ​emergency ​room ​and ​just ​get ​relief, ​that's ​fine. ​I ​mean, ​that's. ​If ​you've ​ever ​had ​a ​migraine ​headache, ​that ​can ​be ​very ​debilitating. ​It's ​very ​painful. ​You ​can't ​focus. ​You ​really ​can't ​function ​on ​anything, ​you ​know? ​So ​I ​think ​that's, ​you ​know, ​the ​ER ​is ​probably ​the ​best ​place ​to ​treat ​an ​acute ​migraine, ​but ​if ​it's ​like ​a ​chronic ​thing ​and, ​you ​know, ​well, ​Junior's ​been ​dealing ​with ​this ​headache ​for ​several ​weeks ​now, ​and, ​you ​know, ​we've ​seen ​the ​neurologist ​and, ​you ​know, ​we ​really ​just ​don't ​know ​what ​to ​do. ​And, ​you ​know, ​coming ​to ​the ​ER ​is ​really ​not ​a ​great ​place ​unless ​the ​pain ​is ​real ​severe. ​You're ​just ​trying ​to ​break ​the ​pain. ​You ​have ​to ​understand ​that ​there's ​diagnostic ​limitations ​in ​the ​Er ​like ​we ​talked ​about ​before, ​you ​know, ​for ​example, ​there's ​a ​million ​things ​that ​can ​cause ​headaches. ​You ​know, ​what ​are ​the ​odds ​that ​we're ​going ​to ​find ​that ​in ​the ​emergency ​room? ​You ​know, ​blood ​tests ​are ​almost ​worthless, when ​it ​comes ​to ​headaches, ​with ​the ​exception ​of, ​you ​know, ​maybe ​like ​a ​really ​low ​sodium. ​But ​that's ​going ​to ​be, ​you ​know, ​some, ​that's ​not ​going ​to ​be ​a ​child. ​That's ​going ​to ​be ​an ​80 ​year ​old ​on ​diuretics ​or ​whatever. ​And ​then, ​you ​know, ​yeah, ​we ​do ​find ​things, ​you ​know, ​once ​in ​a ​while ​that ​are ​pretty ​awful. ​You ​know, ​brain ​tumors ​and ​aneurysms ​and ​things ​like ​that. ​But ​that's, ​that's, ​that's ​rare. ​That's ​very ​rare ​when ​it ​comes ​to ​your ​average ​person, ​your ​average ​human ​being ​that, ​that ​has ​a ​headache. ​So ​we ​had, ​like, ​for ​example, ​we ​had ​a ​case ​several ​months ​ago ​that ​I ​can't ​really ​talk ​about ​too ​specifically, ​but ​this, ​this ​patient ​ended ​up ​coming ​to ​the ​ER, ​had ​a ​headache, ​had ​completely ​normal ​vital ​signs, ​you ​know, ​so ​they ​treated ​him, ​sent ​him ​home, ​then ​he ​came ​back ​a ​couple ​days ​later. ​So ​I ​still ​have ​the ​headaches. ​And ​now ​at ​this ​point, ​they ​appropriately ​expanded ​the ​workup. ​So ​they ​did ​blood ​work ​that ​was ​completely, ​completely ​normal, ​the ​vital ​signs, ​completely ​normal, ​no ​fever. ​And ​they ​even ​did ​a ​cat ​scan ​completely ​normal. ​And ​then ​they ​sent ​the ​guy ​home ​and ​then ​like ​three ​weeks ​later, ​he ​bounces ​into ​another ​ER ​because, ​you ​know, ​the ​other ​ER ​has, ​you ​know, ​they're ​better. ​And ​so ​they ​do ​all ​the ​tests. ​And ​at ​this ​point, ​there ​were ​some ​changes ​to ​the ​blood ​work ​and ​there ​was ​like ​an ​elevated ​white ​count. ​Now, ​at ​this ​point, ​he ​was ​running ​a ​fever, ​and ​so ​they ​ended ​up ​doing ​like ​a ​lumbar ​puncture ​at ​that ​time. ​And ​they ​ended ​up ​finding ​this, ​like, ​extremely ​rare, ​you ​know, ​infectious ​disease ​cause ​of ​headaches ​that ​I ​can't ​really ​get ​into ​because ​I ​don't ​want ​to ​violate ​any ​patient ​privacy ​laws. ​But ​at ​the ​end ​of ​the ​day, ​• ​this ​took ​like ​a ​month ​to ​sort ​of ​sort ​out. ​And, ​you ​know, ​of ​course ​there's ​a ​complaint. ​And, ​oh, ​the ​ER ​that ​saw ​me ​the ​first ​and ​the ​second ​time, ​they ​should, ​they're. ​They're ​dumb ​and ​they ​don't ​know ​what ​they're ​doing ​and. ​Well, ​no, ​• ​first ​of ​all, ​it ​took ​a ​month ​to ​get ​to ​that ​point, ​number ​one. ​Number ​two, ​we ​can't ​just ​do ​lumbar ​punctures ​and ​cts ​on ​every ​single ​human ​that ​walks ​in ​with ​a ​headache. ​Are ​you ​kidding ​me? ​Do ​you ​have ​any ​idea ​how ​many ​people ​would ​be ​harmed ​by ​that ​instead ​of ​helped ​by ​that? ​Radiation, ​needles ​in ​the ​back, ​etcetera. ​Like, ​people ​have ​to ​understand ​that ​the ​disease ​progression ​is ​something ​that ​takes ​time ​and ​no ​one ​wants ​that. ​I ​wish ​we ​had ​a ​magic ​wand ​that ​we ​could ​just ​wave ​as ​soon ​as ​everybody ​walks ​through ​the ​door. ​I ​can't ​tell ​you, ​last ​time ​I ​did ​a ​lumbar ​puncture ​for ​a ​headache, ​like, ​that's ​pretty ​rare ​and ​that's ​a ​really ​tough ​case. ​And ​the ​fact ​that ​they ​got ​to ​a ​diagnosis, ​that's ​great. ​And ​by ​the ​way, ​had ​we ​done ​the ​lumbar ​puncture ​four ​weeks ​sooner, ​probably ​wouldn't ​have ​seen ​anything ​anyways ​because ​it ​takes ​time ​for ​that ​to ​sort ​of ​manifest ​and ​be ​able ​to ​show ​up ​on ​testing. ​So ​understand ​that ​there ​are ​limitations ​in ​healthcare, ​specifically ​when ​discussing ​headache, ​I ​think ​when ​it ​comes ​to ​where ​to ​go, ​I ​think, ​you ​know, ​if ​it's ​something ​that's ​you ​need ​acute ​relief ​of ​pain, ​or ​this ​is ​an ​acute ​headache ​and ​you're ​very ​concerned ​about ​it, ​then ​come ​to ​the ​ER. ​Absolutely. ​Just ​understand ​there ​are ​limitations ​to ​what ​we're ​going ​to ​be ​able ​to ​diagnose ​there. ​Rashes. ​Rashes ​are ​a ​little ​bit ​difficult. ​Again, ​90% ​or ​higher ​of ​rashes ​are ​completely ​benign. ​They're ​usually ​due ​to ​viruses ​or ​something ​silly, ​you ​know, ​poison ​ivy, ​things ​like ​that. ​Nothing ​that's ​really ​dangerous. ​Less ​than ​10% ​of ​rashes ​are ​going ​to ​be ​what ​we ​considered ​dangerous ​in ​the ​emergency ​room. ​We ​just ​have ​to ​be ​able ​to ​recognize ​that, ​that. ​So ​again, ​I ​think ​if ​you ​have ​something ​simple, ​you're ​like, ​oh, ​I ​know ​what ​this ​is. ​This ​is ​poison ​ivy ​or ​whatever. ​Viral ​exanthum. ​Yes, ​you ​could ​potentially ​go ​to ​the ​urgent ​care, ​but ​even ​then ​I ​would ​caution ​against ​it ​because ​we ​get ​this ​all ​the ​time. ​These ​patients ​go ​into ​the ​urgent ​care ​with ​poison ​ivy ​and ​they ​get ​put ​on ​steroids ​and ​they ​get ​put ​on ​the ​wrong ​dose. ​You ​know, ​in ​order ​to ​treat ​• ​• ​poison, ​ivy, ​you ​have ​to ​be ​treated ​for ​like ​two ​weeks. ​You ​can ​have ​what's ​called ​a ​rebound ​phenomenon. ​Like ​if ​they, ​if ​they ​give ​you ​a ​five ​day ​or ​a ​seven ​day ​course, ​or ​God ​forbid, ​a ​medrol ​dose ​pack, ​you ​know, ​you ​could ​have ​something ​called ​a ​rebound ​phenomenon ​where ​you ​actually ​get ​the ​symptoms ​kind ​of ​get ​better, ​and ​then ​they ​get ​a ​thousand ​times ​worse. ​And ​I've ​seen ​this ​in ​the ​ER. ​When ​patients ​come ​back ​in, ​they're ​like, ​well, ​I ​was ​treated ​at ​this ​urge ​of ​care, ​so ​again, ​I ​would ​be ​really ​cautious ​about ​going ​to ​the ​urgent ​care ​for ​that ​type ​of ​a ​rash. ​I ​think ​your ​best ​bet ​is ​going ​to ​be ​the ​pediatrician, ​especially ​because ​they're ​used ​to ​seeing ​these ​viral ​rashes ​all ​the ​time. ​or ​the ​emergency.


The psych system in this country is shattered. I mean, it's beyond shattered

The ​last ​thing ​I ​want ​to ​touch ​on, ​obviously, ​I ​can't ​cover ​every ​single ​complaint ​out ​there, ​but,psychiatry, ​you've ​heard ​me ​say ​this ​numerous ​times ​on ​this ​show ​before. ​The ​psych ​system ​in ​this ​country ​is ​shattered. ​I ​mean, ​it's ​beyond ​shattered. ​For ​every ​four ​patients ​out ​there ​who ​need ​a ​bed, ​to ​be ​hospitalized ​in ​the ​state ​of ​Ohio, ​there's ​like ​one ​available ​• ​• ​• ​that's ​not ​like ​a ​joke ​or ​anything ​else. ​Like, ​there ​just ​truly ​aren't ​enough ​beds ​that, ​you ​know, ​we ​don't ​have ​psych ​resources. ​• ​• ​• ​Very ​• ​few ​facilities ​have ​psychiatrists ​that ​actually ​come ​to ​the ​ER ​to, ​like, ​see ​the ​patients. ​So ​a ​lot ​of ​this ​is ​done ​via ​telehealth, ​through ​mental ​health ​professionals ​and ​counselors ​and, ​you ​know, ​just ​things ​like ​that. ​This ​is ​such ​a ​time ​consuming ​• ​• ​resource. ​Exhaustive ​visit ​to ​the ​emergency ​room. ​And ​that's ​not ​just ​for ​the ​healthcare ​professionals. ​I'm ​referring ​to ​the ​patients ​and ​the ​families ​as ​well. ​I ​used ​to ​work ​at ​a ​facility ​where ​a ​psych ​patient ​could ​be ​in ​the ​ER ​for ​seven ​days ​in ​the ​same ​room. ​Like, ​could ​you ​imagine ​if ​you ​weren't ​crazy ​before? ​You'd ​be ​crazy ​then, ​if ​you're ​still ​in ​the ​room ​for ​seven ​days. ​And, ​these ​are ​people ​that ​are, ​like, ​not ​getting ​showers. ​They're, ​they're ​in ​these ​dark ​rooms ​half ​the ​time, ​or ​if ​they're ​acutely ​psychotic ​or ​agitated, ​they're ​being ​put ​down ​with ​meds. ​Like, ​psych ​in ​the ​ER ​is ​very ​difficult. ​There's ​not, ​we're ​not ​psychiatrists ​where ​we ​are ​trained ​somewhat ​in, ​you ​know, ​obviously, ​the ​field ​of ​psychiatry, ​but ​not ​to ​the ​level ​that ​these ​patients ​need. ​So ​my ​message ​to ​you ​folks ​out ​there ​that ​do ​have, ​especially ​children ​that ​have ​psychiatric ​mental ​health ​issues ​and ​concerns, ​is ​learn ​the ​hospitals ​around ​you. ​That's ​the ​single ​biggest ​thing ​that ​you ​can ​do ​to ​help ​yourself ​and ​help ​your ​child. ​If ​you ​come ​to ​my ​emergency ​room, ​where ​we ​have ​zero ​psychiatric ​resources, ​• ​• ​that ​is ​going ​to ​be ​more ​difficult ​than ​if ​you ​present ​to ​life ​like ​rainbow ​babies ​and ​children's ​Hospital ​or ​Akron ​Children's ​Hospital, ​• ​places ​around ​you ​that ​have ​mental ​health ​resources. ​And, ​that's ​not ​to ​say ​that ​you ​always ​have ​to ​be ​admitted ​to ​the ​hospital, ​but ​there's ​just. ​There's ​not ​that ​much ​I ​can ​do ​in ​the ​emergency ​room ​from ​a ​mental ​health ​standpoint, ​specifically ​for ​children. ​And ​it ​drives ​me ​bonkers ​that ​these ​doctors, ​these ​nurse ​practitioners, ​urgent ​cares, ​et ​cetera, ​they're ​like, ​oh, ​well, ​just ​go ​to ​the ​ER. ​Go ​to ​the ​local ​community ​ER ​that ​has ​absolutely ​no ​psych ​resources ​whatsoever, ​and ​then ​these ​people ​stay ​there ​for ​hours ​and ​hours ​and ​hours. ​Like, ​you ​think ​your ​ER ​visit ​was ​long? ​Try ​coming ​in ​with ​a ​mental ​health ​issue. ​It ​is ​absolutely ​horrible, ​especially ​for ​children. ​Very ​difficult ​on ​us, ​and ​then ​obviously, ​very ​difficult ​for ​the ​patients ​and ​for ​their ​families.


ER versus Urgicare versus pediatrician: Where should you take sick child


All ​right, ​so ​to ​oversimplify, ​• ​kind ​of ​what ​we ​talked ​about ​today, ​we ​talked ​about ​pediatricians, ​routine ​healthcare, ​minor ​complaints, ​immunizations, ​follow ​ups, ​or ​things ​that ​have ​been ​going ​on ​for ​several ​weeks, ​for ​several ​months, ​or ​for ​several ​years. ​I ​think ​that's ​probably ​the ​way ​to ​sort ​of ​visualize ​pediatricians, ​Urgicare ​understand ​• ​• ​• ​the ​limitations ​of ​the ​urge ​of ​care. ​This ​is ​going ​to ​be ​something ​that's ​very ​simple. ​Minor ​complaints. ​You ​need ​a ​strep ​test. ​You ​need, ​do ​you ​have ​to ​have ​an ​x ​ray ​for ​an ​ankle ​sprain? ​So ​long ​as ​they ​can ​do ​that. ​Do ​you ​have ​a ​really ​small ​laceration ​check ​to ​see ​that ​they ​have ​that ​capability. ​Just ​understand ​what ​you ​are ​getting. ​You ​are ​getting ​a ​much ​cheaper ​visit, ​• ​• ​and ​you ​are ​likely, ​• ​not ​always, ​but ​you're ​likely ​saving ​some ​time, ​• ​but ​you're ​getting ​far ​lower ​quality ​of ​care ​or ​someone ​that ​has ​far ​lower ​training ​standards ​than ​the ​emergency ​room. ​Again, ​in ​the ​emergency ​room, ​if ​you ​truly ​believe ​your ​child ​needs ​an ​iv ​or ​a ​procedure ​like ​a ​splint ​fracture ​deformity, ​or ​if ​they ​need ​advanced ​workup, ​lab, ​ct, ​ultrasound, ​you ​know, ​imaging ​and ​things ​like ​that, ​or ​if ​they ​have ​something ​that's ​potentially ​dangerous, ​you ​know, ​someone'sanaphylactic ​to ​peanuts ​or ​penicillin ​or ​something ​like ​that, ​then ​yes, ​the ​ER ​is ​definitely ​the ​place. ​From ​you, ​I ​would ​never ​discourage ​you ​from ​coming ​in, ​especially ​with ​a ​child. ​• ​• ​Ultimately, ​if ​you're ​not ​sure, ​just ​call ​your ​pediatrician ​or ​just ​come ​to ​the ​emergency ​department. ​Especially ​if ​you ​call ​your ​pediatrician ​on ​a ​Friday ​afternoon, ​there's ​a ​100% ​chance ​they're ​going ​to ​send ​you ​to ​the ​ER ​anyways. ​I ​say ​that ​jokingly, ​but ​also ​serious. ​And ​what ​are ​they ​supposed ​to ​do? ​I ​mean, ​they're ​already, ​you ​know, ​packed ​for ​the ​week. ​There's ​no ​appointments ​left. ​Some ​occasionally ​haveoffice ​hours ​on ​Saturdays, ​but ​for ​the ​most ​part, ​on ​weekends, ​you're ​kind ​of ​on ​your ​own. ​Like ​I ​said, ​the ​healthcare ​system ​is ​broken. ​I ​want ​to ​thank ​you ​guys ​for ​joining ​me ​today ​for ​where ​should ​I ​take ​my ​sick ​child? ​Er ​versus ​urgicare ​versus ​pediatrician. ​I ​really ​appreciate ​you ​guys ​listening ​and ​all ​the ​reviews. ​The ​love ​on ​social ​media. ​Appreciate ​it ​when ​you ​guys ​comment ​on ​the ​posts ​or ​share ​them ​that ​I'm ​very ​thankful ​for ​that. ​Join ​me ​next ​time. ​I ​have ​a ​couple ​of ​shows ​in ​the ​pipeline. ​And ​also ​look ​for ​that ​show ​with ​doctor ​Dustin ​Porter. ​I ​think ​you'll ​find ​that ​very ​amusing ​as ​we ​talk ​about ​the ​very ​critical ​thing ​there ​with ​manscaping ​and ​how ​to ​do ​it ​the ​right ​way, ​or ​I ​guess, ​how ​not ​to ​do ​it ​the ​wrong ​way ​and ​end ​up ​in ​the ​emergency ​room. ​Anyways, ​hope ​you ​guys ​are ​enjoying ​your ​summer. ​As ​always, ​peace, ​love ​and ​happiness ​to ​everyone ​out ​there. ​Cheers, ​guys.

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