MARCH 2015 ™ VOLUME 9, NUMBER 6 THE JOURNAL OF URGENT CARE MEDICINE® www.jucm.com The Official Publication of the UCAOA and UCCOP PUBLICATION BRAVEHEART A 5IFSJHIUGJUIBTB XBUDIGVMFZF *UhTBSFBMFZFPQFOFSXIFOZPVTFFBMMUIFQPTTJCJMJUJFTBSPVOEZPV.PSFGBDJMJUJFT BSFDPNCJOJOH6SHFOU$BSFBOE0DDVQBUJPOBM.FEJDJOFTFSWJDFT UXPTQFDJBMUJFT UIBUBSFQFSGFDUMZGJUUFEUPNBLFPOFSPCVTUCVTJOFTT5SJDLJT XIPhTLFFQJOH XBUDI "HJMJUZ4PGUXBSF UIBUhTIPP$IBSUBMMWJTJUUZQFTXJUIPOFQBUJFOUSFDPSE 1)*JTBMXBZTTFDVSFGSPN8PSLFST$PNQBOEFNQMPZFSEBUB.BOBHFQBZFSBOE FNQMPZFSCJMMJOHXJUIJOBTJOHMFTPMVUJPO'FFMMJLFTPNFPOFhTMPPLJOHPVUGPSZPV 4FFGPSZPVSTFMGBU#PPUIBUUIF6$"0"4QSJOH$POWFOUJPOPSOITJODDPN nhsinc.com The Art of the Right Fit™ ª/FU)FBMUI"MM3JHIUT3FTFSWFE LETTER FROM THE EDITOR-IN-CHIEF Evaluating Chest Pain in Urgent Care— “Catch 22 and the Three Bears”: Part 2 n my last column, I introduced a frame- The utility and meaning of point-of-care troponin testing are work for evaluating chest pain in urgent often misunderstood. Troponins are enzymes released by Icare. In this month’s column I discuss a injured heart muscle and therefore are evidence of myocardial risk and probability stratification that can injury, not of coronary artery disease. Why does this matter? A assist in disposition decision-making. The patient with unstable angina may have no myocardial injury, following discussion considers existing evi- and therefore findings for troponins will be negative. Yet unsta- dence, but there is no formal guideline for this process in the ble angina is an acute coronary syndrome, and patients with outpatient setting. Our goal is to make a risky scenario into it should be referred for cardiac evaluation. When symptoms something we can live with. This model is for risk-stratification of unstable angina are not classic, a decision tool like a throm- purposes only and recognizes that the ultimate treatment and bolysis in myocardial infarction (TIMI) score can help stratify disposition decisions grow out of the patient–physician rela- risk. A patient with a TIMI score of 0 or 1, normal ECG findings, tionship and shared decision-making. and negative findings for troponin has a low risk of morbidity Although the clinical evidence is certainly imperfect, there is and mortality. Thus, it is reasonable to refer these patients for some support for discharge for a select group of patients. Strong outpatient cardiology follow-up (within 24 to 48 hours). A cli- evidence suggests that patients should be referred to an emergency nician can further reduce risk in these patients through the department for additional evaluation and treatment if their judicious use of aspirin and ␤-blockers. In the evaluation of chest pain is exertional, radiating to one or both arms, similar to patients presenting with symptoms of a duration shorter than previous cardiac chest pain, or associated with nausea, vomit- 8 hours, a single troponin test should never be used to rule out ing, or diaphoresis. Yet there is also good evidence that patients myocardial infarction, because the enzyme will not be reliably with chest pain that is stabbing, pleuritic, positional, and repro- detectable until at least 6 hours after injury. The reliability of ducible with palpation are at very low risk for acute coronary the findings of a single test is controversial even when symp- syndrome and most likely have chest wall pain instead. toms have been present for 8 hours. However, when nega- Of course, other life-threatening causes of chest pain must tive troponin findings are considered only for those patients be considered, including pulmonary embolus and aortic dis- at lowest risk (TIMI 0 or 1) and with normal ECG findings at section. Established clinical decision tools for both can be least 8 hours after the onset of symptoms, it is reasonable to applied in the urgent care setting. The three most common use the test. A combination of a troponin test with close fol- noncardiac causes of chest pain are gastroesophageal reflux low-up, selective stress testing, and preventive pharmaceuti- disease, chest wall syndrome, and panic disorder. In the cals is an evidence-based approach in the outpatient setting. absence of ominous signs and symptoms and without abnor- Documentation of the patient’s understanding and acceptance malities on an electrocardiogram (ECG), patients with classic of the remaining risk further supports the approach. symptoms of these disorders can be reasonably evaluated as Remember, the realistic goal is to minimize—not eliminate— outpatients with close follow-up. I use the term reasonably here risk. A reasonable standard of care is the definitive defense because I cannot say without fail. If, despite “reasonable” care, against medical malpractice complaints. ■ a bad outcome ensues, there is no malpractice. If the clinician’s documentation supports the decision-making, then the stan- dard of care is met. The plaintiff’s attorneys are very unlikely to pursue a case that looks like the one I have presented here. They may subpoena the records and they may create a lot of anxiety, but their entire case hinges on standard of care, and Lee A. Resnick, MD, FAAFP this closely mirrors the “reasonable care” standard. Editor-in-Chief, JUCM, The Journal of Urgent Care Medicine www.jucm.com JUCM The Journal of Urgent Care Medicine | March 2015 1 Meet the family 9GoXGDGGPITQYKPI(WLKƂNOoU HCOKN[QHFKIKVCNZTC[UQNWVKQPUKU PQYNCTIGTVJCPGXGTOCMKPIOQTG EQUVGHHGEVKXGCPFVGEJPQNQIKECNN[ CFXCPEGFRTQFWEVUYGNNYKVJKP[QWT TGCEJCUCRTKXCVGRTCEVKEG 9JGVJGT[QWPGGFCVCDNGVQR %4QTYKTGNGUU&4RCPGNYKVJCNN VJGWRITCFGUVJGTGoUC(WLKƂNO CFXCPEGFKOCIKPIUQNWVKQPHQT [QWYKVJKP[QWTDWFIGV9KVJ [GCTUQHGZRGTKGPEGRTQXGP FGRGPFCDKNKV[CPFEWUVQOGT UWRRQTVYGYKNNCNYC[UDGVJGTG HQT[QW +PCFFKVKQPVQEQPUKUVGPVNQYFQUG QWTRTQFWEVUHGCVWTGGZENWUKXGUVJCV OCMGVJGOGXGPOQTGGZEGRVKQPCN 2CVGPVGF+TTCFKCVGF5KFG5CORNKPI +55 YJKEJKORTQXGUUKIPCN UVTGPIVJCPFFQUGGHƂEKGPE[CPF &[PCOKE8KUWCNK\CVKQP™YJKEJ KORTQXGUUJCTRPGUUEQPVTCUV CPFNCVKVWFGHQTGXGT[KOCIG 9JCVECPYGFQHQT[QWTRTCEVKEG! %CNNQTXKUKV YYYHWLKRTKXCVGRTCEVKEGEQO v>ViL°VÉvÕi`ÕÃ>««} twitter.com/FUJIMEDUSA ÞÕÌÕLi°VÉvÕwi`V> v>ViL°VÉvÕi`ÕÃ> ©2014 FUJIFILMi`V>-ÞÃÌiÃ1°-°č°]V° ™ The Official Publication of the UCAOA and UCCOP March 2015 VOLUME 9, NUMBER 6 CLINICAL 8 Urgent Care Evaluation of Fatigue Fatigue can be particularly difficult to diagnose because its causes can originate from every major body system and can range from benign to life-threatening. To obtain an accurate diagnosis, use a fatigue-plus approach. Michael B. Weinstock, MD, and Mizuho Spangler, DO PRACTICE MANAGEMENT IN THE NEXT ISSUE OF JUCM Gastritis is common, accounting for approximately 17 Image Check: Impact of 2 million visits annually to U.S. physicians’ offices. Employee Appearance on Patients age 60 years and older are more likely than younger patients to develop gastritis, but it affects the Patient Experience all age groups and both sexes. Peptic ulcer disease No matter how skilled your urgent care center’s affects about 500,000 Americans each year, most health-care providers and staff members are, of them between the ages of 25 and 64, resulting in patients will judge their professionalism in part health-care costs of more than $10 billion annually. on their clothing and grooming. Our cover story guides clinicians through the steps Alan A. Ayers, MBA, MAcc of assessment, testing, diagnosis, and treatment for these two gastrointestinal disorders. CASE REPORT DEPARTMENTS Fracture of the Penis 7 From the UCAOA CEO 25 29 Health Law with Urethral Rupture 31 Insights in Images Be alert for cases of penile trauma. 35 Abstracts in Urgent Care Undiagnosed fracture can have devastating 36 Coding Q&A consequences: stricture, fistula, and long-term voiding difficulty. 40 Developing Data Tayt Ellison, MS-3, Shailendra Saxena, MD, CLASSIFIEDS PhD, Laura Klug, PharmD, and Sanjeev Sharma, MD 38 Career Opportunities www.jucm.com JUCM The Journal of Urgent Care Medicine | March 2015 3 JUCM EDITOR-IN-CHIEF Joseph Toscano, MD Lee A. Resnick, MD, FAAFP San Ramon (CA) Regional Medical Center Chief Medical and Operating Officer Urgent Care Center, Palo Alto (CA) Medical WellStreet Urgent Care Foundation President, Institute of Urgent Care Janet Williams, MD, FACEP EDITOR-IN-CHIEF Medicine Rochester Immediate Care Lee A. Resnick, MD Assistant Clinical Professor, Case Western [email protected] Mark D. Wright, MD Reserve University MANAGING EDITOR Department of Family Medicine University of Arizona Medical Center Katharine O’Moore-Klopf, ELS [email protected] JUCM JUCM ADVISORY BOARD ASSOCIATE EDITOR, PRACTICE MANAGEMENT EDITORIAL BOARD Alan A. Ayers, MBA, MAcc Alan A. Ayers, MBA, MAcc Michelle H. Biros, MD, MS CONTRIBUTING EDITORS Concentra Urgent Care University of Minnesota Sean M. McNeeley, MD Tom Charland Kenneth V. Iserson, MD, MBA, FACEP, John Shufeldt, MD, JD, MBA, FACEP Merchant Medicine LLC FAAEM David Stern, MD, CPC The University of Arizona MANAGER, DIGITAL CONTENT Richard Colgan, MD Brandon Napolitano University of Maryland School of Medicine Gary M. Klein, MD, MPH, MBA, CHS-V, [email protected] Jeffrey P. Collins, MD, MA FAADM ART DIRECTOR Harvard Medical School mEDhealth advisors Tom DePrenda Massachusetts General Hospital Benson S. Munger, PhD [email protected] Tracey Quail Davidoff, MD The University of Arizona Accelcare Medical Urgent Care Emory Petrack, MD, FAAP Kent Erickson, MD, PhD, DABFM Petrack Consulting, Inc.; Unlimited Patient Care Center, PLLC Fairview Hospital 120 N. Central Avenue, Ste 1N Ramsey, NJ 07446 Thomas E. Gibbons, MD, MBA, FACEP Hillcrest