1 00:00:00,100 --> 00:00:02,113 Joe: What's the feeling about x-rays? 2 00:00:02,163 --> 00:00:03,303 Tracey: X-rays don't do it. 3 00:00:03,753 --> 00:00:06,307 Um, in the majority of patients don't do it. 4 00:00:13,715 --> 00:00:17,165 Joe: Welcome to the Evidence-Based Urgentology podcast from EB Medicine, 5 00:00:17,165 --> 00:00:19,445 where urgent care meets evidence. 6 00:00:19,555 --> 00:00:22,795 I'm Joe Toscano, senior research editor for Emergency Medicine Practice, 7 00:00:22,855 --> 00:00:25,585 and a member of the evidence-based Urgent Care editorial board. 8 00:00:26,890 --> 00:00:28,390 Tracey: Hi there, and I'm Tracy Davidoff. 9 00:00:28,390 --> 00:00:31,660 I'm editor in chief of Evidence-Based Urgent Care, and we're practicing 10 00:00:31,660 --> 00:00:34,540 urgent care physicians with years of experience, probably too many years 11 00:00:34,540 --> 00:00:36,280 of experience, on the front lines. 12 00:00:36,340 --> 00:00:40,210 And for us, diagnosis is detective work and the clues are in the history, 13 00:00:40,210 --> 00:00:41,920 the exam, and of course the evidence. 14 00:00:42,160 --> 00:00:44,320 That thrill of solving the patient's puzzle is really 15 00:00:44,320 --> 00:00:45,460 what keeps us coming back. 16 00:00:46,095 --> 00:00:50,535 Joe: Each month we unpack the latest issue of evidence-based urgent care tackling 17 00:00:50,535 --> 00:00:52,335 common chief complaints from presentation. 18 00:00:52,335 --> 00:00:56,205 Through diagnosis to disposition, we highlight the best evidence, the key 19 00:00:56,205 --> 00:00:57,435 takeaways, and the clinical pearls. 20 00:00:58,305 --> 00:01:01,425 Tracey: And by the end of every episode, you'll have sharper skills, deeper 21 00:01:01,425 --> 00:01:05,145 knowledge, and more sound strategies that you can use on your very next shift. 22 00:01:05,535 --> 00:01:06,495 So let's dive in. 23 00:01:06,495 --> 00:01:07,635 The evidence starts now. 24 00:01:07,785 --> 00:01:13,065 And remember, you can always find more at www.ebmedicine.net. 25 00:01:13,857 --> 00:01:14,967 Joe: Hey, welcome everybody. 26 00:01:15,387 --> 00:01:15,567 Tracey: Yeah. 27 00:01:15,572 --> 00:01:15,692 Welcome. 28 00:01:16,467 --> 00:01:20,097 Joe: Hey, this month we'll be discussing the urgent care management 29 00:01:20,097 --> 00:01:24,327 of Acute Low back Pain, authored by my co-host Dr. Tracy Davidoff. 30 00:01:24,582 --> 00:01:24,882 Tracey: Thank you. 31 00:01:24,882 --> 00:01:25,242 Thank you. 32 00:01:25,960 --> 00:01:27,370 Joe: I didn't know you were a professor. 33 00:01:27,805 --> 00:01:28,375 Tracey: I am. 34 00:01:28,510 --> 00:01:28,930 Joe: awesome. 35 00:01:29,785 --> 00:01:30,295 Cool. 36 00:01:30,775 --> 00:01:33,925 Hey, peer reviewers for this issue were Martha Williams, who works with us at 37 00:01:33,925 --> 00:01:38,635 UCA and works clinically in Virginia, and then also Roger Wu, who is National 38 00:01:38,635 --> 00:01:39,865 Medical Director for Carbon Health. 39 00:01:40,495 --> 00:01:42,865 Before we jump in though, let's announce some promos. 40 00:01:43,615 --> 00:01:48,075 The back to school sale starts September 12th, 2025 and will run through the 41 00:01:48,075 --> 00:01:49,405 end of the month, September 30th. 42 00:01:50,025 --> 00:01:54,285 This sale is a bit different as there will be an offer for two free months for 43 00:01:54,285 --> 00:01:58,875 subscriptions and or 20% off courses, you can take your pick and that also 44 00:01:58,875 --> 00:02:01,245 includes LLSAs or any other product. 45 00:02:01,695 --> 00:02:05,195 The coupon codes are www.ebmedicine.net. 46 00:02:05,886 --> 00:02:09,486 Tracey: And also on September 17th at 11:00 AM if you're listening before 47 00:02:09,486 --> 00:02:13,636 that EB Medicine will be hosting a webinar on steroid stewardship, how 48 00:02:13,636 --> 00:02:16,696 to protect your patients and your practice from the harms of overuse. 49 00:02:17,096 --> 00:02:20,956 Very, very hot topic right now and something we need to do better at. 50 00:02:20,956 --> 00:02:22,606 So get some good information. 51 00:02:22,936 --> 00:02:26,236 You can find more information on the EB Medicine website, again for 52 00:02:26,236 --> 00:02:29,836 the third time, www.ebmedicine.net. 53 00:02:29,866 --> 00:02:31,486 And there's lots of other good things there too. 54 00:02:31,486 --> 00:02:32,716 So go check it out. 55 00:02:33,141 --> 00:02:34,341 Joe: Tons of good stuff. 56 00:02:34,611 --> 00:02:36,381 We're gonna talk a little bit about steroids today too. 57 00:02:37,031 --> 00:02:37,161 Tracey: Yes. 58 00:02:37,161 --> 00:02:38,311 Joe: Well, Tracey, let me start off. 59 00:02:38,421 --> 00:02:40,071 Compliments on the issue. 60 00:02:40,121 --> 00:02:44,511 It was super interesting you kind of research it from scratch and really 61 00:02:44,511 --> 00:02:48,791 geared it toward urgent care and the thing that I found astounding was that 62 00:02:48,791 --> 00:02:51,624 you talked about all the things that we typically do and think about when we 63 00:02:51,624 --> 00:02:55,584 deal with patients with back pain, how we approach them, the questions that 64 00:02:55,584 --> 00:03:00,114 we ask, the tests that we might do, the treatments that we might prescribe, and 65 00:03:00,114 --> 00:03:03,654 all of that I think is based on tradition because you dug into the evidence and 66 00:03:03,654 --> 00:03:06,354 found that most of what we do in terms of testing and treatment, or most of 67 00:03:06,354 --> 00:03:10,764 what we think we should do or might do, there's really no evidence behind it. 68 00:03:11,234 --> 00:03:14,174 The evidence that we do have shows that there's no benefit or even 69 00:03:14,174 --> 00:03:15,424 maybe some harm to those things. 70 00:03:16,084 --> 00:03:18,404 What do you think is just your overall take on that? 71 00:03:18,494 --> 00:03:20,924 Basically, how have we been managing back pain through the 72 00:03:20,924 --> 00:03:22,471 years and how could we do it better? 73 00:03:23,139 --> 00:03:26,096 Tracey: Oh, before I get to that one, this is topic that's near and dear to my heart. 74 00:03:26,096 --> 00:03:28,676 Anybody that knows me, I've had lots of back issues over the years. 75 00:03:29,076 --> 00:03:31,536 So something that I try to actually see the patient. 76 00:03:31,536 --> 00:03:34,416 I know a lot of people cringe when they see back pain on their tracking board. 77 00:03:34,696 --> 00:03:37,366 But I think, because I've done the research and I've experienced it 78 00:03:37,366 --> 00:03:39,761 myself, I can kind of do it pretty good. 79 00:03:40,101 --> 00:03:43,311 So I will, choose these patients off the tracking board on purpose. 80 00:03:43,701 --> 00:03:46,304 And the issue, you know, originally it was supposed to be a redo from an 81 00:03:46,304 --> 00:03:49,484 emergency medicine practice, but I found there was so much on there that 82 00:03:49,484 --> 00:03:53,991 was talking about IM meds and getting MRIs and CTs and really all that stuff 83 00:03:53,991 --> 00:03:55,966 is stuff we don't do in urgent care. 84 00:03:55,966 --> 00:03:58,816 So I, I broke it down to the nitty gritty and re researched 85 00:03:58,816 --> 00:03:59,776 it and kind of rewrote it. 86 00:03:59,836 --> 00:04:03,886 And yeah, I suspected a lot of this stuff was true, but when you look at the 87 00:04:03,886 --> 00:04:08,956 evidence, a lot of it was super staggering that one, we do back pain really poorly. 88 00:04:09,296 --> 00:04:11,553 We order a lot of things that are not evidence-based. 89 00:04:11,893 --> 00:04:14,803 And we throw the kitchen sink at people hoping will make them better, 90 00:04:15,023 --> 00:04:17,723 but the truth of the matter is, a lot of it is smoke and mirrors. 91 00:04:17,723 --> 00:04:20,683 It's giving people something to make them think they're gonna get better. 92 00:04:20,993 --> 00:04:23,543 But the truth of the matter is most back pain, it just gets better on 93 00:04:23,543 --> 00:04:24,923 its own no matter what we do to it. 94 00:04:25,283 --> 00:04:26,813 Especially what we see in urgent care. 95 00:04:26,863 --> 00:04:28,933 Obviously you gotta rule out the red flags and stuff, which 96 00:04:28,933 --> 00:04:29,713 we'll talk about in a minute. 97 00:04:29,713 --> 00:04:31,629 But this is one of our bread and butter things. 98 00:04:31,629 --> 00:04:34,379 It's very common for us to see back pain in the urgent care. 99 00:04:34,814 --> 00:04:38,114 The research is so limited and so unsupportive of everything that we 100 00:04:38,114 --> 00:04:40,244 do, and we've been doing it for years. 101 00:04:40,431 --> 00:04:43,691 And then just think about, you know, if you're old enough to remember or see old 102 00:04:43,691 --> 00:04:46,511 movies on TV, you had back pain, they'd put you in the hospital and put you on 103 00:04:46,511 --> 00:04:51,001 traction, and you'd be in bed with weights on your ankles for weeks at a time. 104 00:04:51,391 --> 00:04:54,631 And that's just not not the right thing to do anymore. 105 00:04:54,846 --> 00:04:56,826 squadcaster-3b88_2_08-27-2025_205432: Yeah, so traction definitely a no-no, 106 00:04:56,876 --> 00:04:58,526 obviously, and bedrest a no-no. 107 00:04:58,746 --> 00:05:02,019 Narcotics and benzos, if you remember in the ED in the nineties, man, 108 00:05:02,019 --> 00:05:05,367 everybody got a shot of Valium and a shot of Demerol and that's a no-no. 109 00:05:05,737 --> 00:05:09,325 Surgery, anybody had a herniated disc, they went to surgery, and now that's 110 00:05:09,325 --> 00:05:11,185 definitely something that's to be avoided. 111 00:05:11,585 --> 00:05:14,435 And now we're still using a whole lot of steroids, which the 112 00:05:14,435 --> 00:05:16,145 evidence just doesn't support that. 113 00:05:16,770 --> 00:05:19,280 Many, many of these things, the evidence doesn't pan out that this 114 00:05:19,280 --> 00:05:23,280 was the right treatment and as a, I don't wanna say as an industry, but 115 00:05:23,310 --> 00:05:26,610 you know, medicine in general, the research just kind of sucks at back pain. 116 00:05:26,610 --> 00:05:29,204 It's something that's a lot of it out there and there's not a lot of 117 00:05:29,204 --> 00:05:30,954 evidence to support anything that we do. 118 00:05:30,954 --> 00:05:32,357 So, more of that needs to be done. 119 00:05:32,975 --> 00:05:33,155 Joe: Yeah. 120 00:05:33,155 --> 00:05:34,535 I feel the same way you do. 121 00:05:34,580 --> 00:05:36,150 I like it, but I don't like it. 122 00:05:36,630 --> 00:05:41,470 And at the end I see the visit pop up and then I go and I'm worried about 123 00:05:41,470 --> 00:05:42,700 all the things that could be wrong. 124 00:05:42,950 --> 00:05:47,900 It's so common and it's so hard to make people feel better quickly. 125 00:05:48,230 --> 00:05:49,910 They don't think of it like an injury. 126 00:05:49,910 --> 00:05:53,180 I think in the article you talked about explaining like an ankle sprain. 127 00:05:53,340 --> 00:05:53,430 Tracey: Mm-hmm. 128 00:05:53,430 --> 00:05:55,130 Joe: I think people think about it like a headache. 129 00:05:55,475 --> 00:05:58,075 You're gonna take something and it's gonna go away. 130 00:05:58,815 --> 00:06:00,875 And I tell people, no, this is more like an injury. 131 00:06:00,945 --> 00:06:05,235 And sometimes it goes away, but it's more like a, not like a transient pain, but 132 00:06:05,235 --> 00:06:06,585 you have to think of it like an injury. 133 00:06:07,035 --> 00:06:10,645 And then, I think bits and pieces through the years, I knew all of this 134 00:06:10,645 --> 00:06:13,945 stuff and it boiled down to not that much works, but it was great how you 135 00:06:13,945 --> 00:06:17,162 put it all together to say that, yeah, you know what, there's only a few 136 00:06:17,162 --> 00:06:18,842 things that we really should focus on. 137 00:06:19,262 --> 00:06:20,252 So I thought that was great. 138 00:06:21,002 --> 00:06:21,842 Tracey: Thanks. 139 00:06:21,942 --> 00:06:22,672 Joe: And thinking about that, yeah. 140 00:06:22,832 --> 00:06:25,772 Kind of boiling it down to what adds value and what we should 141 00:06:25,772 --> 00:06:29,785 be doing, the helpful tests and treatments are few and far between. 142 00:06:30,045 --> 00:06:30,885 What do we have left? 143 00:06:30,885 --> 00:06:31,845 Good old h and p. 144 00:06:32,760 --> 00:06:34,440 Tracey: Yeah, that's always the place to start, right? 145 00:06:34,720 --> 00:06:37,667 So first you really wanna rule out your red flags and really 146 00:06:37,667 --> 00:06:39,727 tease out the things that are bad. 147 00:06:39,917 --> 00:06:42,497 Most of what we're gonna see in urgent care is gonna be garden 148 00:06:42,497 --> 00:06:45,527 variety, non-specific, low back pain, or maybe some sciatica. 149 00:06:45,897 --> 00:06:49,917 But there are some really significant pathologies that we need to rule out. 150 00:06:50,207 --> 00:06:51,707 And really there's just a few of them. 151 00:06:51,737 --> 00:06:55,517 One is obviously the non back pain, non back etiologies, like your 152 00:06:55,547 --> 00:06:58,967 abdominal aortic aneurysm or your kidney stone or those sorts of things. 153 00:06:59,317 --> 00:07:02,507 Which, you can pretty much tease out by history and physical exam findings. 154 00:07:02,847 --> 00:07:06,527 But then things like epidural abscess and epidural hematomas 155 00:07:06,807 --> 00:07:08,187 and cauda equina syndromes. 156 00:07:08,187 --> 00:07:10,887 Those are very, very important to rule out. 157 00:07:10,887 --> 00:07:14,967 And there's all sorts of research about which red flags, you know, new onset 158 00:07:14,967 --> 00:07:20,447 fever, worsening of chronic pain, numbness and tingling in the genital area, or 159 00:07:20,447 --> 00:07:23,477 now all of a sudden you're having a motor deficit or something like that. 160 00:07:24,197 --> 00:07:27,437 But taken by themselves, all of those red flags are really not helpful. 161 00:07:27,437 --> 00:07:29,657 You kind of gotta look at the big picture of these things. 162 00:07:30,037 --> 00:07:33,717 Your red flags multiple of them increase your risk of there being 163 00:07:33,717 --> 00:07:36,747 something bad and increase your level of helpfulness on the red flags. 164 00:07:37,027 --> 00:07:40,577 Definitely go through that list of red flags that you can see in the 165 00:07:40,577 --> 00:07:43,697 issue, or if you just honestly Google it, you'll find those red flags. 166 00:07:43,997 --> 00:07:47,158 More is better diagnostically in dealing with the red flags. 167 00:07:47,158 --> 00:07:50,401 So the more you have, the more your risk is, the more you need to rule out those 168 00:07:50,401 --> 00:07:54,251 bad things like the infections and the hematoma and the cauda equina syndrome. 169 00:07:54,946 --> 00:07:55,306 Joe: I agree. 170 00:07:55,306 --> 00:07:59,236 You have to ask them to every patient because you're used to the no answers. 171 00:07:59,236 --> 00:08:01,396 They're uncommon things that you're asking about. 172 00:08:01,876 --> 00:08:04,456 But when you start to get yes answers to those things, you need 173 00:08:04,456 --> 00:08:05,776 to dig in a little bit more deeply. 174 00:08:05,776 --> 00:08:06,376 For sure. 175 00:08:06,796 --> 00:08:08,086 So history and exam. 176 00:08:08,236 --> 00:08:08,506 Yeah. 177 00:08:08,686 --> 00:08:10,186 Super important as a starting point. 178 00:08:10,751 --> 00:08:10,951 Tracey: Yeah. 179 00:08:11,011 --> 00:08:13,071 And do that whole exam, I should have mentioned that, 180 00:08:13,144 --> 00:08:14,314 you gotta do that whole exam. 181 00:08:14,314 --> 00:08:16,684 You can't just look at them and poke on their back a little bit. 182 00:08:16,994 --> 00:08:19,574 Look at the skin, make sure there's no zoster under there. 183 00:08:19,794 --> 00:08:21,894 Have 'em stand up and maybe walk a little bit. 184 00:08:21,894 --> 00:08:24,354 Make sure they're not shuffling or tripping over their big toe. 185 00:08:24,664 --> 00:08:26,374 Do that straight leg raise test. 186 00:08:26,454 --> 00:08:29,761 To make sure that there's no pain radiating down the leg when you do that. 187 00:08:30,151 --> 00:08:31,051 Palpate that belly. 188 00:08:31,051 --> 00:08:35,311 If you have any thought of any sort of risk factor for abdominal aortic aneurysm, 189 00:08:35,311 --> 00:08:36,571 make sure you palpate that belly. 190 00:08:36,911 --> 00:08:40,351 So do definitely make sure you do that whole physical and, my 191 00:08:40,351 --> 00:08:41,941 other pet peeve, document it. 192 00:08:42,281 --> 00:08:43,691 Make sure you write down what you did. 193 00:08:43,691 --> 00:08:46,151 So many times I'll see people that have seen other providers or been 194 00:08:46,151 --> 00:08:48,291 to the ED and it says no tenderness. 195 00:08:48,291 --> 00:08:49,821 I'm like, where's the rest of your exam? 196 00:08:50,201 --> 00:08:53,221 If that patient did have a cauda equina or something like that, 197 00:08:53,221 --> 00:08:54,901 you have not protected yourself. 198 00:08:55,016 --> 00:08:57,326 So do make sure that you document that exam. 199 00:08:58,491 --> 00:09:00,921 Joe: And if there's no tenderness, it's even harder to explain, I think. 200 00:09:00,921 --> 00:09:01,311 Gosh. 201 00:09:01,971 --> 00:09:04,251 Hey, so let's talk specifics about imaging. 202 00:09:04,281 --> 00:09:07,521 So we all have x-ray, or most of the time we have x-ray, if we have an x-ray tech 203 00:09:07,561 --> 00:09:07,751 Tracey: Yep. 204 00:09:07,751 --> 00:09:10,596 Joe: And we have these at our disposal, why don't we get some pictures, right? 205 00:09:10,696 --> 00:09:12,736 What's the feeling about x-rays? 206 00:09:12,736 --> 00:09:15,886 And then when should we be referring patients for something more than that? 207 00:09:16,501 --> 00:09:17,641 Tracey: X-rays don't do it. 208 00:09:18,134 --> 00:09:20,384 In the majority of patients don't do it. 209 00:09:20,784 --> 00:09:24,894 If you think that you have a compression fracture, or you're concerned about the 210 00:09:24,894 --> 00:09:29,879 potential of a malignant neoplasm, maybe metastatic from somewhere, maybe that's 211 00:09:29,879 --> 00:09:31,409 gonna help you doing a plain x-ray. 212 00:09:31,619 --> 00:09:35,849 But the one thing that I find that people do all the time is they don't realize that 213 00:09:35,849 --> 00:09:38,279 the sensitivity on that is extremely low. 214 00:09:38,579 --> 00:09:43,049 By getting an X-ray and seeing it normal and not finding anything on there, that 215 00:09:43,049 --> 00:09:44,239 doesn't mean that you've ruled it out. 216 00:09:45,084 --> 00:09:48,774 You can still have that infection, you can still have that metastatic disease. 217 00:09:48,774 --> 00:09:50,634 You can still have that compression fracture. 218 00:09:50,904 --> 00:09:53,514 There's a really good picture in the article where it shows a plain 219 00:09:53,514 --> 00:09:57,544 film and the lumbar, I think it's L2, looks completely normal, but 220 00:09:57,544 --> 00:09:59,814 when they CTed it, there was a huge compression fracture in it. 221 00:10:00,064 --> 00:10:03,154 You are not ruling out anything with a plain x-ray. 222 00:10:03,434 --> 00:10:07,359 It may be useful if someone has some of those red flags for metastatic 223 00:10:07,359 --> 00:10:10,329 disease or a potential compression fracture, but it's not gonna rule it 224 00:10:10,329 --> 00:10:14,424 out and both of those things, really not that emergent, you don't have 225 00:10:14,424 --> 00:10:16,614 to get that plain x-ray on day one. 226 00:10:16,924 --> 00:10:19,354 You can wait and see if they're getting a little worse, or if you want to 227 00:10:19,444 --> 00:10:22,324 have them follow up with their primary care or if you're sending 'em to the 228 00:10:22,324 --> 00:10:25,494 ED, don't x-ray them, because the ED will do advanced imaging that's 229 00:10:25,494 --> 00:10:30,194 gonna be a little more sensitive and specific for anything serious there. 230 00:10:30,644 --> 00:10:33,944 Yeah and then trauma, if you're having trauma, acute trauma, it's a 231 00:10:33,944 --> 00:10:38,024 motor vehicle accident or something like that, again, plain x-ray is 232 00:10:38,024 --> 00:10:39,404 not ruling out much of anything. 233 00:10:39,654 --> 00:10:42,534 That person really is gonna need a CT, so they're really gonna need 234 00:10:42,534 --> 00:10:44,214 to go to the emergency department. 235 00:10:44,714 --> 00:10:46,794 Just a word about positive findings on x-rays. 236 00:10:46,794 --> 00:10:52,346 You know, if you x-ray everybody over the age of 55, probably 40 if we're being 237 00:10:52,346 --> 00:10:56,516 realistic here, everybody's gonna have some degree of arthritis and degenerative 238 00:10:56,516 --> 00:10:59,156 disease in their spine, and that doesn't mean that's the cause of their pain. 239 00:10:59,606 --> 00:11:01,286 That just means that's there. 240 00:11:01,626 --> 00:11:05,356 So don't really think you're helping yourself too much by getting an x-ray 241 00:11:05,356 --> 00:11:09,456 because it's really not helping you unless you have a risk of trauma or 242 00:11:09,456 --> 00:11:12,981 you've got some risk for metastatic disease, or you've got a compression 243 00:11:12,981 --> 00:11:15,781 fracture that you're worried about maybe think about doing it. 244 00:11:16,091 --> 00:11:18,881 But again, for the third time, because it's so important, don't 245 00:11:18,881 --> 00:11:21,101 think you're ruling out anything by getting a negative x-ray. 246 00:11:21,568 --> 00:11:22,918 Joe: So I was gonna say just about x-rays. 247 00:11:22,968 --> 00:11:26,488 I think people sometimes are used to getting x-rays when something hurts or 248 00:11:26,568 --> 00:11:31,608 more specifically if there's trauma, and the way I sometimes will talk a person 249 00:11:31,608 --> 00:11:36,118 out of it is, most of the time back pain comes from things that are not the bones, 250 00:11:36,118 --> 00:11:39,669 muscles and even if it is your disc or a pinched nerve, let's say, which a lot of 251 00:11:39,669 --> 00:11:43,299 people think that they have, you just tell 'em that's not gonna show up on x-ray. 252 00:11:43,509 --> 00:11:47,164 And even if it is something in the bone, trauma or if you're concerned 253 00:11:47,164 --> 00:11:49,924 about cancer, the sensitivity is a lot lower than other tests. 254 00:11:49,924 --> 00:11:53,321 So, you might get it occasionally in those situations where you're 255 00:11:53,321 --> 00:11:54,671 looking for something that's bony. 256 00:11:54,981 --> 00:11:56,661 And I just have a really funny story. 257 00:11:57,081 --> 00:11:58,011 What's that aphorism? 258 00:11:58,011 --> 00:12:00,321 Uh, eventually a blind squirrel finds a nut. 259 00:12:00,601 --> 00:12:04,204 I did have a colleague who got some spine films on a patient who was 260 00:12:04,204 --> 00:12:07,954 having some back pain and saw a huge calcified abdominal aortic aneurysm 261 00:12:08,524 --> 00:12:11,644 and was relieved that he found it and eventually referred the patient 262 00:12:11,644 --> 00:12:13,324 on and got an appropriate diagnosis. 263 00:12:13,324 --> 00:12:16,744 But it's not a test for abdominal aortic aneurysm either, so 264 00:12:16,804 --> 00:12:16,894 Tracey: Nope. 265 00:12:16,894 --> 00:12:17,894 Joe: Just got lucky on that one. 266 00:12:18,339 --> 00:12:19,059 Tracey: Absolutely. 267 00:12:19,479 --> 00:12:20,169 Absolutely. 268 00:12:20,699 --> 00:12:20,999 Yeah. 269 00:12:20,999 --> 00:12:23,039 And then, advanced imaging, right? 270 00:12:23,069 --> 00:12:27,299 So if you think the patient has any significant trauma, they need to go 271 00:12:27,299 --> 00:12:28,949 to emergency for advanced imaging. 272 00:12:29,249 --> 00:12:33,449 If you think that they have an epidural abscess or an epidural hematoma, 273 00:12:33,449 --> 00:12:35,964 they're on some blood thinners and they have sudden acute pain. 274 00:12:36,804 --> 00:12:40,114 Or they have any neurologic deficits and or anything that makes you think 275 00:12:40,114 --> 00:12:41,564 they've got some quada equina going on. 276 00:12:41,904 --> 00:12:45,364 Those people need emergent imaging and your plain films aren't gonna help you. 277 00:12:45,424 --> 00:12:49,244 They need either a CT or an MR. That person is gonna have to be referred to 278 00:12:49,244 --> 00:12:51,510 the emergency department, emergently, duh. 279 00:12:51,900 --> 00:12:53,730 So, you know, make sure that that happens. 280 00:12:54,080 --> 00:12:58,810 As far as anybody who needs an urgent outpatient MRI or CT? 281 00:12:58,900 --> 00:13:02,647 Yeah, probably not something we're gonna really need to do in urgent care. 282 00:13:02,887 --> 00:13:05,617 I guess if you had somebody who showed up and they'd been having pain for six 283 00:13:05,617 --> 00:13:09,427 weeks and you were concerned about it and you have that capability to send 284 00:13:09,427 --> 00:13:13,467 a patient for an outpatient test in a couple of days you could do that. 285 00:13:13,657 --> 00:13:18,007 But generally, 80% of people with back pain, probably even higher, non-specific 286 00:13:18,007 --> 00:13:22,967 back pain without red flags, are gonna get better usually in one week to four weeks. 287 00:13:23,177 --> 00:13:27,077 So if they're presenting after four weeks and they're not getting better 288 00:13:27,077 --> 00:13:29,987 or they're getting worse, those patients might need some advanced 289 00:13:29,987 --> 00:13:31,397 imaging in the form of an MRI. 290 00:13:31,737 --> 00:13:34,407 But again, not something that really needs to be done emergently. 291 00:13:34,407 --> 00:13:38,127 You can refer that either to the spine specialist or to the primary care doctor. 292 00:13:38,447 --> 00:13:41,027 But if you're in a location where that's something that you do and you're 293 00:13:41,027 --> 00:13:43,987 willing to follow up those results then that's something that you can do. 294 00:13:44,597 --> 00:13:47,694 I run into trouble with Occupational Medicine and Workman's compensation, 295 00:13:47,729 --> 00:13:50,789 because most of the insurance adjusters and the employers want 296 00:13:50,789 --> 00:13:52,682 you to get x-rays for the injuries. 297 00:13:52,867 --> 00:13:56,650 So sometimes I find myself doing unnecessary x-rays for that. 298 00:13:56,680 --> 00:13:59,680 But even the occupational medicine guidelines, if you look at the ones 299 00:13:59,680 --> 00:14:04,750 that are published by that organization, agree with what we're saying here that 300 00:14:04,750 --> 00:14:06,670 plain x-rays are really not required. 301 00:14:07,000 --> 00:14:09,690 But I guess the employers and the insurance adjusters just 302 00:14:09,690 --> 00:14:10,800 haven't caught up on that one. 303 00:14:10,800 --> 00:14:12,810 So you might get stuck doing 'em on those. 304 00:14:13,375 --> 00:14:13,645 Joe: Cool. 305 00:14:13,645 --> 00:14:18,202 So you got your patient, no red flags to make you want to do any imaging or tests, 306 00:14:18,202 --> 00:14:21,082 and you did a good history and physical, so you feel confident about that. 307 00:14:21,512 --> 00:14:23,372 And that's gonna be most of our urgent care patients. 308 00:14:23,432 --> 00:14:26,342 You gotta go through and do all of that stuff, but in the end, most of 'em are 309 00:14:26,342 --> 00:14:27,762 gonna have uncomplicated back pain. 310 00:14:28,342 --> 00:14:30,127 What does the evidence tell us about the best way to treat them? 311 00:14:31,617 --> 00:14:33,897 Tracey: NSAIDs, and I'm gonna say this about three times. 312 00:14:34,197 --> 00:14:38,847 The only thing that's ever been proven to do anything for pain and anything for 313 00:14:38,847 --> 00:14:41,607 improving functional status is NSAIDs. 314 00:14:41,847 --> 00:14:44,847 And they don't decrease the amount of time you're gonna have back pain for. 315 00:14:45,087 --> 00:14:49,397 They make your pain more manageable so that you can deal with it and have a 316 00:14:49,397 --> 00:14:52,907 little bit less pain and be a little more functional for a short period of time. 317 00:14:53,537 --> 00:14:57,437 And the only thing that's really been studied is ibuprofen and naproxen. 318 00:14:57,697 --> 00:15:01,437 But I think we can probably extrapolate that to some of the other NSAIDs as well. 319 00:15:01,437 --> 00:15:04,687 I know most of us have our favorites of ones that we like to prescribe 320 00:15:04,687 --> 00:15:07,147 for people if they're finding the ibuprofen isn't working. 321 00:15:07,537 --> 00:15:10,777 But those are really the only things that have been supported by the 322 00:15:10,777 --> 00:15:14,662 literature and been studied enough to say that, yes, this is gonna help you. 323 00:15:14,692 --> 00:15:18,662 And it's minimal, so if you wanna give that patient who's having severe 324 00:15:18,662 --> 00:15:22,125 pain, maybe a dose of ketorolac in the urgent care or if you want to 325 00:15:22,125 --> 00:15:24,055 prescribe it for them, that's fine. 326 00:15:24,055 --> 00:15:28,045 You can do those things, but that's really what you're gonna do. 327 00:15:28,555 --> 00:15:32,955 If it's someone who can't take NSAIDs, you are stuck because nothing else 328 00:15:32,955 --> 00:15:34,095 has really been proven to work. 329 00:15:34,185 --> 00:15:34,965 Acetaminophen. 330 00:15:35,370 --> 00:15:37,140 Not good, worthless, doesn't do anything. 331 00:15:37,570 --> 00:15:39,820 Narcotics, doesn't really do anything. 332 00:15:40,150 --> 00:15:44,560 Muscle relaxants, they will improve pain slightly, temporarily. 333 00:15:44,630 --> 00:15:46,280 They don't improve functional status at all. 334 00:15:46,280 --> 00:15:47,900 They don't decrease the amount of time. 335 00:15:48,240 --> 00:15:51,885 But, in most cases, their side effects outweigh their benefit. 336 00:15:52,195 --> 00:15:55,735 If somebody's sleepy, goofy, and it drives me crazy when I see some 80-year-old lady 337 00:15:55,735 --> 00:15:58,435 coming in because her back pain isn't getting better, and I saw somebody gave 338 00:15:58,435 --> 00:16:02,455 her cyclobenzaprine and I'm thinking, were you asking that patient to fall down? 339 00:16:02,650 --> 00:16:06,130 So you really need to be very careful with that, maybe case by case basis. 340 00:16:06,130 --> 00:16:08,950 Think about whether or not you wanna give that patient a muscle relaxant, 341 00:16:09,340 --> 00:16:12,520 knowing the amount of benefit that you're gonna get is gonna be pretty small. 342 00:16:12,910 --> 00:16:14,920 Opioids, like I said, same thing. 343 00:16:15,245 --> 00:16:16,775 Risk, way worse than benefit. 344 00:16:16,775 --> 00:16:19,855 Really minimal, minimal benefit from opioids. 345 00:16:20,135 --> 00:16:22,895 Topicals, there's some research on the topicals. 346 00:16:22,935 --> 00:16:27,079 Diclofenac is better than nothing but it's not as good as ibuprofen orally. 347 00:16:27,422 --> 00:16:30,614 So might be an option in someone who has, say a gastric bypass. 348 00:16:30,614 --> 00:16:33,134 You could tell them to get some diclofenac gel and use that. 349 00:16:33,504 --> 00:16:38,629 The menthol topicals also, some minimal benefit as far as pain is concerned. 350 00:16:38,999 --> 00:16:42,749 Probably not enough to be really statistically significant, but in 351 00:16:42,749 --> 00:16:43,979 my opinion, better than nothing. 352 00:16:44,409 --> 00:16:48,329 Topical lidocaine, worthless for acute back pain, doesn't work at all. 353 00:16:48,359 --> 00:16:52,529 Maybe might be a little bit benefit from chronic, but nothing for acute. 354 00:16:53,019 --> 00:16:55,949 Gabapentin, for a while there I was throwing gabapentin at people, 355 00:16:55,949 --> 00:16:59,402 especially with sciatica thinking that maybe that would be helpful for 356 00:16:59,402 --> 00:17:01,442 nerve pain to kind of improve that. 357 00:17:02,007 --> 00:17:04,437 No studies have proven that that's been beneficial for 358 00:17:04,437 --> 00:17:06,147 back pain, even with sciatica. 359 00:17:06,537 --> 00:17:10,717 And benzodiazepines, again, they do help a little bit but their side 360 00:17:10,717 --> 00:17:14,267 effects and risks of addiction and all that stuff outweigh the benefits. 361 00:17:14,627 --> 00:17:17,747 A couple of the studies for those were really done in a hospital based 362 00:17:17,747 --> 00:17:19,171 study and an emergency based study. 363 00:17:19,171 --> 00:17:23,024 And it actually delayed the time to discharge by giving them a 364 00:17:23,024 --> 00:17:24,584 narcotic or a benzodiazepine. 365 00:17:24,584 --> 00:17:28,904 So they were taking up more time and having more side effects in the 366 00:17:28,904 --> 00:17:31,874 emergency room than they would've if they hadn't been given those 367 00:17:31,874 --> 00:17:33,734 medications with really no benefit. 368 00:17:34,114 --> 00:17:35,164 So yeah. 369 00:17:35,264 --> 00:17:37,244 And since that's it, I'm gonna say it again. 370 00:17:37,494 --> 00:17:41,074 The only thing proven to do anything for short term pain and improving punction, 371 00:17:41,094 --> 00:17:43,599 and again, it's minimal, is NSAIDs. 372 00:17:43,779 --> 00:17:47,019 So if you've got someone that can't take NSAIDs for whatever reason, kidney 373 00:17:47,019 --> 00:17:51,159 disease, gastric bypass status, that sort of thing, you're kind of stuck. 374 00:17:51,209 --> 00:17:53,859 You can do the topicals, you can do the acetaminophen. 375 00:17:54,099 --> 00:17:57,644 You can maybe do a short course of muscle relaxants, not a whole lot is helping. 376 00:17:58,499 --> 00:18:00,715 Joe: Yeah, NSAIDs are so crucial to this. 377 00:18:00,715 --> 00:18:03,535 It's important to know what the contraindications are so you can 378 00:18:03,535 --> 00:18:06,205 kind of weigh the risks and benefits and avoid them when you need to. 379 00:18:06,415 --> 00:18:09,215 And the interesting thing that came out that I, gosh, it was years 380 00:18:09,215 --> 00:18:12,955 ago, I remember thinking, why are there so many different NSAIDs. 381 00:18:13,230 --> 00:18:17,580 And I don't think this has been studied in back pain or much else, but in treating 382 00:18:17,580 --> 00:18:20,910 patients with arthritis, that sometimes you can switch from one to another. 383 00:18:20,910 --> 00:18:21,510 And you said that. 384 00:18:21,510 --> 00:18:23,880 If the ibuprofen's not working then switch to a different one. 385 00:18:24,240 --> 00:18:29,000 And although there are equal potent anti-inflammatory effects, it's 386 00:18:29,000 --> 00:18:32,030 probably maybe not the anti-inflammatory effect that's causing the analgesia. 387 00:18:32,120 --> 00:18:34,970 And so changing to another one's very reasonable rather than having 388 00:18:34,970 --> 00:18:36,290 people continuing to take the one. 389 00:18:36,290 --> 00:18:38,210 And there's so many options that you can switch. 390 00:18:38,625 --> 00:18:38,785 Tracey: Right. 391 00:18:38,785 --> 00:18:42,277 Joe: And I think the topicals are great as an option when somebody can't take an oral 392 00:18:42,517 --> 00:18:46,357 NSAID or maybe you don't wanna give them a injectable NSAID because they do have 393 00:18:46,357 --> 00:18:49,680 those contraindications, then the topical NSAIDs are kinda like your next best 394 00:18:49,680 --> 00:18:52,525 thing, it seems based on the evidence and maybe a little bit better than the menthol 395 00:18:52,525 --> 00:18:56,857 topically . But yeah it's surprising how much we do for back pain and it 396 00:18:56,857 --> 00:18:58,517 just, there's no evidence that it works. 397 00:18:58,587 --> 00:18:58,807 Tracey: No. 398 00:18:59,392 --> 00:18:59,752 Nope. 399 00:19:00,307 --> 00:19:02,257 Joe: In all of that, you didn't mention steroids. 400 00:19:02,257 --> 00:19:04,417 But I do see a lot of that among my colleagues. 401 00:19:04,467 --> 00:19:09,227 I kind of took on a steroid stewardship mantle myself probably a few years ago 402 00:19:09,227 --> 00:19:12,927 when a couple papers came out that showed the side effects that we just don't see. 403 00:19:12,927 --> 00:19:17,747 We don't see the patients two weeks, four weeks, six weeks later, having 404 00:19:17,747 --> 00:19:21,827 fractures and GI bleeds and infection that they wouldn't have gotten otherwise. 405 00:19:22,087 --> 00:19:22,297 Tracey: Yeah. 406 00:19:22,397 --> 00:19:26,067 Joe: And so we don't have the sense of it, but when I was confronted with that, 407 00:19:26,067 --> 00:19:28,217 I was like, dang, what are these good for? 408 00:19:28,217 --> 00:19:31,517 And let me kind of contract my practice down to that. 409 00:19:31,797 --> 00:19:33,627 What does the literature tell us about that? 410 00:19:33,627 --> 00:19:35,127 With back pain, steroids, and back pain? 411 00:19:35,302 --> 00:19:37,252 Tracey: Yeah, I mean, steroids really are the elephant in the room. 412 00:19:37,252 --> 00:19:39,112 I live in the south and steroids are rampant. 413 00:19:39,212 --> 00:19:41,492 Everybody writes steroids for everything. 414 00:19:41,772 --> 00:19:45,022 And I think in some cases, at least for respiratory infections and things 415 00:19:45,022 --> 00:19:48,512 like that, they write the steroids to try to avoid the antibiotics, saying 416 00:19:48,512 --> 00:19:49,802 that you'll feel better with this. 417 00:19:49,802 --> 00:19:51,962 I'm not gonna give you the antibiotic you want, but here's this. 418 00:19:52,302 --> 00:19:55,062 It's also rampant where people get injectable steroids for, 419 00:19:55,062 --> 00:19:56,202 you know, just to feel better. 420 00:19:56,452 --> 00:20:02,337 And really the amount of badness from steroid use is just so extensive. 421 00:20:02,687 --> 00:20:06,317 You're immunosuppressed for three months after you get one little 422 00:20:06,317 --> 00:20:09,467 Medrol dose pack, you have some immunosuppression for three months. 423 00:20:09,717 --> 00:20:14,547 Your risk for GI bleed, your risk for DVT, glaucoma, increase risk for 424 00:20:14,547 --> 00:20:18,417 diabetes, even if you're not a diabetic, it increases your risk for diabetes. 425 00:20:18,797 --> 00:20:19,457 It's crazy. 426 00:20:19,457 --> 00:20:21,870 I've seen people in DKA from a steroid pack. 427 00:20:21,870 --> 00:20:24,600 We don't realize it because a lot of times, I guess we 428 00:20:24,600 --> 00:20:25,830 don't really see the follow up. 429 00:20:26,170 --> 00:20:29,465 Or we think that whatever side effect they're having is not 430 00:20:29,465 --> 00:20:31,925 really a side effect, but just their normal disease process. 431 00:20:32,205 --> 00:20:34,335 The one thing that a lot of people will say, oh, the 432 00:20:34,335 --> 00:20:35,595 exception to that is sciatica. 433 00:20:35,595 --> 00:20:38,565 I can give it for sciatica 'cause it's going to decrease the swelling of the 434 00:20:38,565 --> 00:20:40,235 sciatic nerve and make their pain better. 435 00:20:40,645 --> 00:20:43,665 No studies say, no, no, that doesn't work. 436 00:20:43,715 --> 00:20:45,848 And again, the risks outweigh the benefits. 437 00:20:46,098 --> 00:20:48,908 There are many, many articles and you can see all the references in 438 00:20:48,908 --> 00:20:52,635 the issue that steroids are not recommended for back pain, even 439 00:20:52,640 --> 00:20:54,315 if the patient's having sciatica. 440 00:20:54,535 --> 00:20:56,755 I know we're desperate to try and help these people. 441 00:20:57,080 --> 00:20:58,340 But this is not the answer. 442 00:20:58,340 --> 00:21:03,017 Giving them other side effects and other potential complications, just to think 443 00:21:03,017 --> 00:21:06,377 that we're maybe making them feel a little bit better, is not the answer. 444 00:21:06,437 --> 00:21:07,727 Just say no to those steroids. 445 00:21:08,357 --> 00:21:10,537 Joe: Yeah, no, they went out the window with true spinal 446 00:21:10,537 --> 00:21:12,237 cord injury a decade ago or so. 447 00:21:12,307 --> 00:21:12,667 Tracey: Yeah. 448 00:21:12,857 --> 00:21:14,867 Joe: I remember there was a lot of controversy about that, and maybe 449 00:21:14,867 --> 00:21:17,807 that's why they started to get used for back pain or radiculopathy. 450 00:21:17,807 --> 00:21:21,857 But I think the thing that impressed me about the side effects of 451 00:21:21,857 --> 00:21:23,447 steroids is that they're cumulative. 452 00:21:24,022 --> 00:21:24,262 Tracey: Yeah. 453 00:21:24,477 --> 00:21:28,197 Joe: Every successive course kind of increases your risk, almost 454 00:21:28,197 --> 00:21:29,727 like your radiation exposure. 455 00:21:30,132 --> 00:21:30,282 Tracey: Yep. 456 00:21:30,282 --> 00:21:33,597 Joe: And so it's not only do you have to think about, gosh, 457 00:21:33,597 --> 00:21:34,527 do they really need it now? 458 00:21:34,527 --> 00:21:35,907 It's like how many times have they had it? 459 00:21:36,563 --> 00:21:37,133 Okay, Tracy. 460 00:21:37,257 --> 00:21:41,097 How about stretching and exercise and PT? You hear a lot about that. 461 00:21:41,097 --> 00:21:45,627 I think there were some studies that said maybe PT doesn't help everybody, but maybe 462 00:21:45,627 --> 00:21:50,147 it's early PT. What's kind of the skinny on moving and stretching and exercise 463 00:21:50,147 --> 00:21:51,827 and maybe formal physical therapy? 464 00:21:52,112 --> 00:21:54,332 Tracey: Yeah, I mean, some of this is actually emerging research. 465 00:21:54,355 --> 00:21:58,415 There was a recent study that was done a year or two ago on actually doing PT 466 00:21:58,415 --> 00:22:01,995 evaluations and teaching people some exercises while the patient's still in 467 00:22:01,995 --> 00:22:06,262 the emergency department and it actually decreased their time to improvement, 468 00:22:06,262 --> 00:22:08,092 which was statistically significant. 469 00:22:08,462 --> 00:22:11,522 So I think that's getting some more research, so stay tuned on that one. 470 00:22:11,832 --> 00:22:14,172 But again, like I alluded to before when we were talking about 471 00:22:14,172 --> 00:22:17,182 the traction, we used to tell people bed rest, go home, relax. 472 00:22:17,182 --> 00:22:17,872 It's an injury. 473 00:22:17,872 --> 00:22:19,075 You have to rest the injury. 474 00:22:19,325 --> 00:22:20,945 But that's actually not true. 475 00:22:20,995 --> 00:22:22,075 You need to keep moving. 476 00:22:22,355 --> 00:22:25,925 I now tell patients, do as much as you can without doing too much. 477 00:22:26,235 --> 00:22:27,675 And you'll know when too much is. 478 00:22:27,850 --> 00:22:31,670 But the worst thing you can do is sit in a chair or lay in bed because think 479 00:22:31,670 --> 00:22:33,420 about it, you're not using those muscles. 480 00:22:33,420 --> 00:22:35,880 They get stiff and then you go and you get up and it makes your 481 00:22:35,880 --> 00:22:37,140 pain worse when you do get up. 482 00:22:37,480 --> 00:22:40,060 That's why you're always worse when you first wake up in the morning 'cause you've 483 00:22:40,060 --> 00:22:43,850 been laying in bed all night, so you've gotta, even if you just get up and walk 484 00:22:43,880 --> 00:22:45,620 around your house for a few minutes. 485 00:22:45,840 --> 00:22:49,260 Maybe try and do some gentle twisting and bending and stretching. 486 00:22:49,610 --> 00:22:53,190 Just a little tiny bit is better than doing nothing at all, because that's 487 00:22:53,190 --> 00:22:57,440 gonna prevent all that stiffness and actually improve your functional 488 00:22:57,440 --> 00:22:59,310 status by doing some of that. 489 00:22:59,530 --> 00:23:00,400 Exercises? 490 00:23:00,450 --> 00:23:03,150 I usually print out some exercises for people, even if they're, 491 00:23:03,180 --> 00:23:06,420 like I said, just minimal type exercises and physical therapy. 492 00:23:06,420 --> 00:23:08,670 That's another thing I think we do really bad at that I think we're 493 00:23:08,670 --> 00:23:12,160 starting to realize, maybe we should start doing more of this. 494 00:23:12,380 --> 00:23:15,470 It used to be for whatever injury it is, whether it's your back or your ankle 495 00:23:15,470 --> 00:23:18,510 or your elbow or whatever the heck it is, give the patient four to six weeks 496 00:23:18,510 --> 00:23:20,040 and then send them to physical therapy. 497 00:23:20,310 --> 00:23:22,850 But that's actually kind of wrong, and if you actually talk 498 00:23:22,850 --> 00:23:25,100 to the physical therapists, they're like, oh yes, thank you. 499 00:23:25,100 --> 00:23:26,780 Send them to us sooner rather than later. 500 00:23:27,030 --> 00:23:30,820 Because they can actually help with the acute episode of pain and then provide 501 00:23:30,820 --> 00:23:32,290 that patient with some exercises. 502 00:23:32,535 --> 00:23:36,575 And then as they improve their functional status and increase their level of 503 00:23:36,575 --> 00:23:41,968 exercising and give them some ideas to prevent future injuries like the Healthy 504 00:23:41,968 --> 00:23:43,675 Pack program and things like that. 505 00:23:43,725 --> 00:23:45,465 Again, some of that is emerging research. 506 00:23:45,488 --> 00:23:47,718 But the most important thing that you can give someone in 507 00:23:47,718 --> 00:23:50,208 their discharge instructions is to tell them to keep moving. 508 00:23:50,518 --> 00:23:52,948 Because to prevent that stiffness, don't lay around. 509 00:23:53,403 --> 00:23:57,043 Don't sit in bed, don't sit in the chair, because you are gonna get stiff. 510 00:23:57,043 --> 00:23:58,903 Keep yourself moving with some gentle stretching. 511 00:23:58,903 --> 00:23:59,593 Go for a walk. 512 00:23:59,593 --> 00:24:00,283 That sort of thing. 513 00:24:00,688 --> 00:24:01,628 Joe: I've found that helps. 514 00:24:01,708 --> 00:24:01,958 squadcaster-bbbc_2_08-27-2025_175432: I mean, 515 00:24:01,958 --> 00:24:04,558 Joe: I've had not anything major, times where your back 516 00:24:04,558 --> 00:24:05,518 hurts for a couple of weeks. 517 00:24:05,518 --> 00:24:08,188 You tweaked it and it results in you not being able to do 518 00:24:08,188 --> 00:24:09,418 everything that you can do. 519 00:24:09,688 --> 00:24:11,668 Like you said, you wake up first thing in the morning and you 520 00:24:11,668 --> 00:24:13,138 feel the worst you do all day. 521 00:24:13,138 --> 00:24:14,518 You move around a little bit, you feel better. 522 00:24:14,683 --> 00:24:17,283 And I'll tell patients, you can definitely overdo it and you'll know. 523 00:24:17,608 --> 00:24:21,473 But you can also underdo it and you are gonna reach your functional 524 00:24:21,473 --> 00:24:25,163 capacity and be feeling better if you try to do as much as you can 525 00:24:25,163 --> 00:24:27,023 comfortably while you're getting better. 526 00:24:27,023 --> 00:24:28,313 So I agree a hundred percent. 527 00:24:28,703 --> 00:24:31,133 Well, hey, we all love the new documentation guidelines, right? 528 00:24:31,133 --> 00:24:33,503 Or they're actually, they're not new anymore, but the most recent ones. 529 00:24:33,783 --> 00:24:36,943 Do you have any tips, and I know you're the documentation expert, on 530 00:24:36,943 --> 00:24:40,363 how we should document with all these treatments being out there to pick from, 531 00:24:40,363 --> 00:24:42,133 but only a few being really viable. 532 00:24:42,373 --> 00:24:45,613 And what about documenting whether somebody does not need 533 00:24:45,613 --> 00:24:47,773 imaging or steroids, for example. 534 00:24:47,823 --> 00:24:49,493 Should we be doing that and how do we do it? 535 00:24:49,963 --> 00:24:50,353 Tracey: Yep. 536 00:24:50,603 --> 00:24:53,063 Just a little shameless plug for my safeguarding charting course. 537 00:24:54,203 --> 00:24:56,523 Um, but there is a whole section on back pain there. 538 00:24:57,140 --> 00:24:57,920 Your worst case scenario. 539 00:24:57,920 --> 00:25:00,320 So always make sure that you're addressing your worst case scenario. 540 00:25:00,320 --> 00:25:05,203 When we were talking about infection, hematoma, fracture, cauda equina type 541 00:25:05,203 --> 00:25:08,753 things, in your history you want 'em to document no fever, no significant 542 00:25:08,753 --> 00:25:12,453 trauma, that they don't have a history of cancer, whether or not they have 543 00:25:12,453 --> 00:25:15,703 osteoporosis, whether or not they've had previous surgery, whether or not 544 00:25:15,703 --> 00:25:18,733 they've had previous experiences with back pain, because those are all useful 545 00:25:18,733 --> 00:25:21,495 things that will help you on down the road in your medical decision making. 546 00:25:21,805 --> 00:25:23,095 Same thing with the exam. 547 00:25:23,145 --> 00:25:26,835 If they're at risk for the abdominal aortic aneurysm, please put in 548 00:25:26,835 --> 00:25:29,795 an abdominal exam that says no pulsitile mass that's tender. 549 00:25:30,335 --> 00:25:33,695 Get that straight leg raise, get that neurologic exam to document 550 00:25:33,695 --> 00:25:35,465 that there's no neurologic deficits. 551 00:25:35,675 --> 00:25:38,765 Make sure you've documented that they're able to walk and get outta the chair. 552 00:25:38,975 --> 00:25:42,095 I always comment how they get outta the chair and onto the exam table. 553 00:25:42,242 --> 00:25:45,716 You know, I put something like, easily gets onto exam table, because right there 554 00:25:45,716 --> 00:25:49,619 I'm telling the reader that that patient doesn't have any neurologic deficits if 555 00:25:49,619 --> 00:25:53,099 they can get out of a chair and get into the exam table without much difficulty. 556 00:25:53,499 --> 00:25:54,699 Watch 'em walk down the hall. 557 00:25:54,699 --> 00:25:57,549 If they can walk and they're not limping and they're standing up straight, 558 00:25:57,579 --> 00:26:00,189 then they probably don't have any red flags that make you think they 559 00:26:00,189 --> 00:26:01,449 need to go to the emergency room. 560 00:26:01,857 --> 00:26:02,787 Be careful about that. 561 00:26:02,787 --> 00:26:05,817 And then when you get to your medical decision making, I always say something to 562 00:26:05,817 --> 00:26:11,684 the effect of, no evidence of red flags or concerns for sinister causes of back pain. 563 00:26:11,984 --> 00:26:16,024 Or I even write them out, you know, no evidence of infection or need for 564 00:26:16,024 --> 00:26:20,874 emergent imaging or emergent evaluation or ED evaluation at this time based 565 00:26:20,874 --> 00:26:22,314 on the history and physical findings. 566 00:26:22,314 --> 00:26:24,744 And if you documented all those history and physical findings, now 567 00:26:24,744 --> 00:26:25,944 you're reflecting back to that. 568 00:26:26,244 --> 00:26:29,784 So it shows the reader that, Hey, I've thought about these bad things and I've, 569 00:26:29,874 --> 00:26:32,874 even if I didn't do any advanced imaging, I've ruled them out with history and 570 00:26:32,874 --> 00:26:34,694 physical and I've thought about them. 571 00:26:34,944 --> 00:26:38,864 So that later on down the road if there is a bad outcome or something else 572 00:26:38,864 --> 00:26:43,484 happens that you can substantiate what your actions were and also substantiate 573 00:26:43,484 --> 00:26:44,624 why you didn't do the imaging. 574 00:26:44,674 --> 00:26:49,084 I've actually now started writing things like "based on current guidelines 575 00:26:49,084 --> 00:26:53,124 and recommendations of the American College of Radiology, no x-rays are 576 00:26:53,124 --> 00:26:56,664 indicated in this patient." That way if the other person who doesn't know 577 00:26:56,664 --> 00:26:59,874 about these guidelines reads my chart, they won't say, wow, she's an idiot. 578 00:26:59,874 --> 00:27:00,894 She didn't get any x-rays. 579 00:27:00,949 --> 00:27:01,369 Joe: Mm-hmm. 580 00:27:01,917 --> 00:27:04,741 Tracey: Yeah, so always in your medical decision making make sure 581 00:27:04,741 --> 00:27:07,501 that you document what you were thinking about and what you ruled out. 582 00:27:07,501 --> 00:27:10,021 And if you're dictating, that makes it so easier 'cause if you talk 583 00:27:10,021 --> 00:27:13,208 fast like me, you can very quickly put in your medical decision making 584 00:27:13,208 --> 00:27:14,648 there and have yourself covered. 585 00:27:15,266 --> 00:27:17,066 Joe: I was gonna say, I hope you had a macro for that, but if 586 00:27:17,066 --> 00:27:18,206 you can dictate it, it so it's 587 00:27:18,206 --> 00:27:18,776 Tracey: I actually do. 588 00:27:20,606 --> 00:27:22,556 MDM back pain, it's called. 589 00:27:22,586 --> 00:27:22,766 Yeah. 590 00:27:23,436 --> 00:27:25,733 Joe: You know, the interesting thing about documentation is just 591 00:27:25,783 --> 00:27:28,063 it's sort of the thing you have to do for every visit, right? 592 00:27:28,063 --> 00:27:31,603 And if you love to practice medicine, you love the history and you love the exam, 593 00:27:31,603 --> 00:27:36,493 you love the thinking, but God, you just don't like the documentation, right? 594 00:27:36,643 --> 00:27:40,983 Except when you think about how it reflects the complexity of what you had 595 00:27:40,983 --> 00:27:43,768 to go through and every back pain patient you have to think about those things. 596 00:27:43,768 --> 00:27:45,328 So it's potentially complex. 597 00:27:45,398 --> 00:27:45,618 Tracey: Yep. 598 00:27:45,748 --> 00:27:48,058 Joe: You're going through those things in your mind and ruling them out. 599 00:27:48,058 --> 00:27:51,388 Yeah, most people don't have 'em, but those needles in a haystack that do 600 00:27:51,638 --> 00:27:53,018 it's our responsibility to find 'em. 601 00:27:53,018 --> 00:27:55,718 So we're ruling them out in everybody else, and that's a 602 00:27:55,718 --> 00:27:57,188 complicated decision making. 603 00:27:57,278 --> 00:28:02,078 And the fact that we don't do anything like imaging or prescribe opioids 604 00:28:02,528 --> 00:28:06,893 if it's based on the evidence rather than it being a simple problem. 605 00:28:06,893 --> 00:28:09,893 It's not a simple problem, it's just that, you know, there's nothing that's 606 00:28:09,893 --> 00:28:13,073 gonna help us at that point, except talking to the patient and urging them 607 00:28:13,073 --> 00:28:17,423 to be active, as active as they can be and prescribing those simple, basic 608 00:28:17,423 --> 00:28:19,103 treatments that we have some evidence for. 609 00:28:19,413 --> 00:28:21,333 It seems simple, but it's complicated. 610 00:28:21,333 --> 00:28:22,683 You have to go through that every time. 611 00:28:22,683 --> 00:28:26,578 So if the documentation reflects that you're protecting yourself risk-wise. 612 00:28:26,848 --> 00:28:27,148 Tracey: Yep. 613 00:28:27,278 --> 00:28:30,318 Joe: But you're also substantiating all the thought that went into it and 614 00:28:30,323 --> 00:28:32,048 getting the code that you deserve. 615 00:28:32,048 --> 00:28:32,311 Right? 616 00:28:32,361 --> 00:28:32,601 Tracey: Yeah. 617 00:28:32,661 --> 00:28:34,011 Oh, and yes, get paid for that. 618 00:28:34,101 --> 00:28:37,126 If you document a back pain properly, you will get yourself a level four 619 00:28:37,276 --> 00:28:40,366 easily, because it's either an exacerbation of a chronic problem 620 00:28:40,366 --> 00:28:44,456 that they already have or it's a new problem with an unknown prognosis 621 00:28:44,456 --> 00:28:46,316 or unknown how it's gonna work out. 622 00:28:46,316 --> 00:28:51,010 Plus your always talking about or considering some sort of 623 00:28:51,010 --> 00:28:52,060 a prescription medication. 624 00:28:52,300 --> 00:28:54,150 So right there, you're giving yourself the level four. 625 00:28:54,150 --> 00:28:58,105 If you add a few other things in there at least three complicated things 626 00:28:58,105 --> 00:29:01,235 that you've considered, you've totally substantiated yourself to a level four. 627 00:29:01,235 --> 00:29:02,585 So don't sell yourself short on that one. 628 00:29:03,025 --> 00:29:03,715 Joe: Perfect. 629 00:29:03,865 --> 00:29:04,315 I love it. 630 00:29:04,898 --> 00:29:05,598 Thank you Tracey. 631 00:29:05,618 --> 00:29:08,708 I really enjoyed reading the issue and it was really fun to talk about. 632 00:29:08,708 --> 00:29:10,978 And I can't wait for my next back pain patient, 633 00:29:11,368 --> 00:29:11,938 Tracey: Yeah, right? 634 00:29:11,988 --> 00:29:12,748 Joe: Although it will probably be a AAA. 635 00:29:13,248 --> 00:29:13,548 Tracey: Yep. 636 00:29:13,548 --> 00:29:14,838 Write them all for ibuprofen. 637 00:29:14,838 --> 00:29:17,118 Tell 'em all to keep moving and tell 'em all it's gonna take four 638 00:29:17,118 --> 00:29:20,118 to six weeks for them to get better, and they don't need an x-ray. 639 00:29:21,168 --> 00:29:23,058 So there's your bottom line, right? 640 00:29:23,508 --> 00:29:23,838 All right. 641 00:29:24,538 --> 00:29:27,628 Next month is, what do we got next month? 642 00:29:27,628 --> 00:29:30,528 We have returning traveler, I think is next month. 643 00:29:31,128 --> 00:29:32,258 Joe: I love that topic. 644 00:29:32,360 --> 00:29:34,510 Tracey: Yes, returning traveler is next month. 645 00:29:34,510 --> 00:29:37,840 And then November we've got some laboratory testing, which is really good. 646 00:29:38,065 --> 00:29:40,475 Yeah, and lots of good things coming down the pike in the future. 647 00:29:40,725 --> 00:29:43,575 So look forward to that in October with the returning travelers. 648 00:29:44,265 --> 00:29:44,925 Joe: That sounds great. 649 00:29:44,925 --> 00:29:45,555 I love that. 650 00:29:45,680 --> 00:29:49,190 I live and practice in an area where people are traveling a lot. 651 00:29:49,530 --> 00:29:52,050 A lot of businesses where people travel internationally, so having a 652 00:29:52,050 --> 00:29:55,720 good approach to that, symptom-based and then where do they travel to, 653 00:29:56,020 --> 00:29:57,400 can really help you pin it down. 654 00:29:57,400 --> 00:29:58,390 I'm looking forward to that. 655 00:29:58,560 --> 00:29:58,930 That'll be cool. 656 00:29:58,960 --> 00:30:00,670 Tracey: Yeah, I have the opposite problem. 657 00:30:00,720 --> 00:30:02,130 I'm the place where people travel to. 658 00:30:02,565 --> 00:30:03,165 Joe: To Disney. 659 00:30:03,570 --> 00:30:04,320 Tracey: Yeah, exactly. 660 00:30:04,320 --> 00:30:06,930 So I get people that come from all over the world, and I have to 661 00:30:06,930 --> 00:30:08,206 try and figure out what they have. 662 00:30:08,486 --> 00:30:12,256 I actually saw some influenza A a couple weeks ago from somebody from Australia. 663 00:30:12,406 --> 00:30:14,446 I'm like, oh, it's flu season there. 664 00:30:14,636 --> 00:30:15,736 Joe: Southern hemisphere. 665 00:30:16,021 --> 00:30:17,041 Tracey: Yep, exactly. 666 00:30:17,381 --> 00:30:17,581 Joe: Cool. 667 00:30:17,581 --> 00:30:18,923 Well take care everyone. 668 00:30:19,003 --> 00:30:21,911 Thank you for listening and we hope you learned something and 669 00:30:21,911 --> 00:30:22,991 we will talk to you next month. 670 00:30:23,306 --> 00:30:23,606 Tracey: Yep. 671 00:30:23,606 --> 00:30:24,056 You as well. 672 00:30:24,056 --> 00:30:24,351 Take care. 673 00:30:24,381 --> 00:30:24,871 Bye-bye. 674 00:30:25,061 --> 00:30:25,496 Joe: Alright, bye-bye. 675 00:30:26,296 --> 00:30:29,456 Tracey: I want to thank everybody to listening to this month's evidence based 676 00:30:29,456 --> 00:30:33,786 urgentology podcast . Just a reminder that subscribers can go to ebmedicine. 677 00:30:33,796 --> 00:30:37,596 net and read the full issue if you want more information, if you haven't already, 678 00:30:38,495 --> 00:30:40,385 Joe: And if you're not a subscriber head to the site. 679 00:30:40,555 --> 00:30:41,515 That's ebmedicine. 680 00:30:41,745 --> 00:30:43,325 net to check out what they have. 681 00:30:43,649 --> 00:30:47,259 If you subscribe you'll get access to the article as well as future articles 682 00:30:47,279 --> 00:30:49,879 and the whole archive of all past issues. 683 00:30:50,332 --> 00:30:51,482 Tracey: Look forward to seeing you there.