Joe: What's the feeling about x-rays?
Tracey: X-rays don't do it.
Um, in the majority of patients don't do it.
Joe: Welcome to the Evidence-Based Urgentology podcast from EB Medicine,
where urgent care meets evidence.
I'm Joe Toscano, senior research editor for Emergency Medicine Practice,
and a member of the evidence-based Urgent Care editorial board.
Tracey: Hi there, and I'm Tracy Davidoff.
I'm editor in chief of Evidence-Based Urgent Care, and we're practicing
urgent care physicians with years of experience, probably too many years
of experience, on the front lines.
And for us, diagnosis is detective work and the clues are in the history,
the exam, and of course the evidence.
That thrill of solving the patient's puzzle is really
what keeps us coming back.
Joe: Each month we unpack the latest issue of evidence-based urgent care tackling
common chief complaints from presentation.
Through diagnosis to disposition, we highlight the best evidence, the key
takeaways, and the clinical pearls.
Tracey: And by the end of every episode, you'll have sharper skills, deeper
knowledge, and more sound strategies that you can use on your very next shift.
So let's dive in.
The evidence starts now.
And remember, you can always find more at www.ebmedicine.net.
Joe: Hey, welcome everybody.
Tracey: Yeah.
Welcome.
Joe: Hey, this month we'll be discussing the urgent care management
of Acute Low back Pain, authored by my co-host Dr. Tracy Davidoff.
Tracey: Thank you.
Thank you.
Joe: I didn't know you were a professor.
Tracey: I am.
Joe: awesome.
Cool.
Hey, peer reviewers for this issue were Martha Williams, who works with us at
UCA and works clinically in Virginia, and then also Roger Wu, who is National
Medical Director for Carbon Health.
Before we jump in though, let's announce some promos.
The back to school sale starts September 12th, 2025 and will run through the
end of the month, September 30th.
This sale is a bit different as there will be an offer for two free months for
subscriptions and or 20% off courses, you can take your pick and that also
includes LLSAs or any other product.
The coupon codes are www.ebmedicine.net.
Tracey: And also on September 17th at 11:00 AM if you're listening before
that EB Medicine will be hosting a webinar on steroid stewardship, how
to protect your patients and your practice from the harms of overuse.
Very, very hot topic right now and something we need to do better at.
So get some good information.
You can find more information on the EB Medicine website, again for
the third time, www.ebmedicine.net.
And there's lots of other good things there too.
So go check it out.
Joe: Tons of good stuff.
We're gonna talk a little bit about steroids today too.
Tracey: Yes.
Joe: Well, Tracey, let me start off.
Compliments on the issue.
It was super interesting you kind of research it from scratch and really
geared it toward urgent care and the thing that I found astounding was that
you talked about all the things that we typically do and think about when we
deal with patients with back pain, how we approach them, the questions that
we ask, the tests that we might do, the treatments that we might prescribe, and
all of that I think is based on tradition because you dug into the evidence and
found that most of what we do in terms of testing and treatment, or most of
what we think we should do or might do, there's really no evidence behind it.
The evidence that we do have shows that there's no benefit or even
maybe some harm to those things.
What do you think is just your overall take on that?
Basically, how have we been managing back pain through the
years and how could we do it better?
Tracey: Oh, before I get to that one, this is topic that's near and dear to my heart.
Anybody that knows me, I've had lots of back issues over the years.
So something that I try to actually see the patient.
I know a lot of people cringe when they see back pain on their tracking board.
But I think, because I've done the research and I've experienced it
myself, I can kind of do it pretty good.
So I will, choose these patients off the tracking board on purpose.
And the issue, you know, originally it was supposed to be a redo from an
emergency medicine practice, but I found there was so much on there that
was talking about IM meds and getting MRIs and CTs and really all that stuff
is stuff we don't do in urgent care.
So I, I broke it down to the nitty gritty and re researched
it and kind of rewrote it.
And yeah, I suspected a lot of this stuff was true, but when you look at the
evidence, a lot of it was super staggering that one, we do back pain really poorly.
We order a lot of things that are not evidence-based.
And we throw the kitchen sink at people hoping will make them better,
but the truth of the matter is, a lot of it is smoke and mirrors.
It's giving people something to make them think they're gonna get better.
But the truth of the matter is most back pain, it just gets better on
its own no matter what we do to it.
Especially what we see in urgent care.
Obviously you gotta rule out the red flags and stuff, which
we'll talk about in a minute.
But this is one of our bread and butter things.
It's very common for us to see back pain in the urgent care.
The research is so limited and so unsupportive of everything that we
do, and we've been doing it for years.
And then just think about, you know, if you're old enough to remember or see old
movies on TV, you had back pain, they'd put you in the hospital and put you on
traction, and you'd be in bed with weights on your ankles for weeks at a time.
And that's just not not the right thing to do anymore.
squadcaster-3b88_2_08-27-2025_205432: Yeah, so traction definitely a no-no,
obviously, and bedrest a no-no.
Narcotics and benzos, if you remember in the ED in the nineties, man,
everybody got a shot of Valium and a shot of Demerol and that's a no-no.
Surgery, anybody had a herniated disc, they went to surgery, and now that's
definitely something that's to be avoided.
And now we're still using a whole lot of steroids, which the
evidence just doesn't support that.
Many, many of these things, the evidence doesn't pan out that this
was the right treatment and as a, I don't wanna say as an industry, but
you know, medicine in general, the research just kind of sucks at back pain.
It's something that's a lot of it out there and there's not a lot of
evidence to support anything that we do.
So, more of that needs to be done.
Joe: Yeah.
I feel the same way you do.
I like it, but I don't like it.
And at the end I see the visit pop up and then I go and I'm worried about
all the things that could be wrong.
It's so common and it's so hard to make people feel better quickly.
They don't think of it like an injury.
I think in the article you talked about explaining like an ankle sprain.
Tracey: Mm-hmm.
Joe: I think people think about it like a headache.
You're gonna take something and it's gonna go away.
And I tell people, no, this is more like an injury.
And sometimes it goes away, but it's more like a, not like a transient pain, but
you have to think of it like an injury.
And then, I think bits and pieces through the years, I knew all of this
stuff and it boiled down to not that much works, but it was great how you
put it all together to say that, yeah, you know what, there's only a few
things that we really should focus on.
So I thought that was great.
Tracey: Thanks.
Joe: And thinking about that, yeah.
Kind of boiling it down to what adds value and what we should
be doing, the helpful tests and treatments are few and far between.
What do we have left?
Good old h and p.
Tracey: Yeah, that's always the place to start, right?
So first you really wanna rule out your red flags and really
tease out the things that are bad.
Most of what we're gonna see in urgent care is gonna be garden
variety, non-specific, low back pain, or maybe some sciatica.
But there are some really significant pathologies that we need to rule out.
And really there's just a few of them.
One is obviously the non back pain, non back etiologies, like your
abdominal aortic aneurysm or your kidney stone or those sorts of things.
Which, you can pretty much tease out by history and physical exam findings.
But then things like epidural abscess and epidural hematomas
and cauda equina syndromes.
Those are very, very important to rule out.
And there's all sorts of research about which red flags, you know, new onset
fever, worsening of chronic pain, numbness and tingling in the genital area, or
now all of a sudden you're having a motor deficit or something like that.
But taken by themselves, all of those red flags are really not helpful.
You kind of gotta look at the big picture of these things.
Your red flags multiple of them increase your risk of there being
something bad and increase your level of helpfulness on the red flags.
Definitely go through that list of red flags that you can see in the
issue, or if you just honestly Google it, you'll find those red flags.
More is better diagnostically in dealing with the red flags.
So the more you have, the more your risk is, the more you need to rule out those
bad things like the infections and the hematoma and the cauda equina syndrome.
Joe: I agree.
You have to ask them to every patient because you're used to the no answers.
They're uncommon things that you're asking about.
But when you start to get yes answers to those things, you need
to dig in a little bit more deeply.
For sure.
So history and exam.
Yeah.
Super important as a starting point.
Tracey: Yeah.
And do that whole exam, I should have mentioned that,
you gotta do that whole exam.
You can't just look at them and poke on their back a little bit.
Look at the skin, make sure there's no zoster under there.
Have 'em stand up and maybe walk a little bit.
Make sure they're not shuffling or tripping over their big toe.
Do that straight leg raise test.
To make sure that there's no pain radiating down the leg when you do that.
Palpate that belly.
If you have any thought of any sort of risk factor for abdominal aortic aneurysm,
make sure you palpate that belly.
So do definitely make sure you do that whole physical and, my
other pet peeve, document it.
Make sure you write down what you did.
So many times I'll see people that have seen other providers or been
to the ED and it says no tenderness.
I'm like, where's the rest of your exam?
If that patient did have a cauda equina or something like that,
you have not protected yourself.
So do make sure that you document that exam.
Joe: And if there's no tenderness, it's even harder to explain, I think.
Gosh.
Hey, so let's talk specifics about imaging.
So we all have x-ray, or most of the time we have x-ray, if we have an x-ray tech
Tracey: Yep.
Joe: And we have these at our disposal, why don't we get some pictures, right?
What's the feeling about x-rays?
And then when should we be referring patients for something more than that?
Tracey: X-rays don't do it.
In the majority of patients don't do it.
If you think that you have a compression fracture, or you're concerned about the
potential of a malignant neoplasm, maybe metastatic from somewhere, maybe that's
gonna help you doing a plain x-ray.
But the one thing that I find that people do all the time is they don't realize that
the sensitivity on that is extremely low.
By getting an X-ray and seeing it normal and not finding anything on there, that
doesn't mean that you've ruled it out.
You can still have that infection, you can still have that metastatic disease.
You can still have that compression fracture.
There's a really good picture in the article where it shows a plain
film and the lumbar, I think it's L2, looks completely normal, but
when they CTed it, there was a huge compression fracture in it.
You are not ruling out anything with a plain x-ray.
It may be useful if someone has some of those red flags for metastatic
disease or a potential compression fracture, but it's not gonna rule it
out and both of those things, really not that emergent, you don't have
to get that plain x-ray on day one.
You can wait and see if they're getting a little worse, or if you want to
have them follow up with their primary care or if you're sending 'em to the
ED, don't x-ray them, because the ED will do advanced imaging that's
gonna be a little more sensitive and specific for anything serious there.
Yeah and then trauma, if you're having trauma, acute trauma, it's a
motor vehicle accident or something like that, again, plain x-ray is
not ruling out much of anything.
That person really is gonna need a CT, so they're really gonna need
to go to the emergency department.
Just a word about positive findings on x-rays.
You know, if you x-ray everybody over the age of 55, probably 40 if we're being
realistic here, everybody's gonna have some degree of arthritis and degenerative
disease in their spine, and that doesn't mean that's the cause of their pain.
That just means that's there.
So don't really think you're helping yourself too much by getting an x-ray
because it's really not helping you unless you have a risk of trauma or
you've got some risk for metastatic disease, or you've got a compression
fracture that you're worried about maybe think about doing it.
But again, for the third time, because it's so important, don't
think you're ruling out anything by getting a negative x-ray.
Joe: So I was gonna say just about x-rays.
I think people sometimes are used to getting x-rays when something hurts or
more specifically if there's trauma, and the way I sometimes will talk a person
out of it is, most of the time back pain comes from things that are not the bones,
muscles and even if it is your disc or a pinched nerve, let's say, which a lot of
people think that they have, you just tell 'em that's not gonna show up on x-ray.
And even if it is something in the bone, trauma or if you're concerned
about cancer, the sensitivity is a lot lower than other tests.
So, you might get it occasionally in those situations where you're
looking for something that's bony.
And I just have a really funny story.
What's that aphorism?
Uh, eventually a blind squirrel finds a nut.
I did have a colleague who got some spine films on a patient who was
having some back pain and saw a huge calcified abdominal aortic aneurysm
and was relieved that he found it and eventually referred the patient
on and got an appropriate diagnosis.
But it's not a test for abdominal aortic aneurysm either, so
Tracey: Nope.
Joe: Just got lucky on that one.
Tracey: Absolutely.
Absolutely.
Yeah.
And then, advanced imaging, right?
So if you think the patient has any significant trauma, they need to go
to emergency for advanced imaging.
If you think that they have an epidural abscess or an epidural hematoma,
they're on some blood thinners and they have sudden acute pain.
Or they have any neurologic deficits and or anything that makes you think
they've got some quada equina going on.
Those people need emergent imaging and your plain films aren't gonna help you.
They need either a CT or an MR. That person is gonna have to be referred to
the emergency department, emergently, duh.
So, you know, make sure that that happens.
As far as anybody who needs an urgent outpatient MRI or CT?
Yeah, probably not something we're gonna really need to do in urgent care.
I guess if you had somebody who showed up and they'd been having pain for six
weeks and you were concerned about it and you have that capability to send
a patient for an outpatient test in a couple of days you could do that.
But generally, 80% of people with back pain, probably even higher, non-specific
back pain without red flags, are gonna get better usually in one week to four weeks.
So if they're presenting after four weeks and they're not getting better
or they're getting worse, those patients might need some advanced
imaging in the form of an MRI.
But again, not something that really needs to be done emergently.
You can refer that either to the spine specialist or to the primary care doctor.
But if you're in a location where that's something that you do and you're
willing to follow up those results then that's something that you can do.
I run into trouble with Occupational Medicine and Workman's compensation,
because most of the insurance adjusters and the employers want
you to get x-rays for the injuries.
So sometimes I find myself doing unnecessary x-rays for that.
But even the occupational medicine guidelines, if you look at the ones
that are published by that organization, agree with what we're saying here that
plain x-rays are really not required.
But I guess the employers and the insurance adjusters just
haven't caught up on that one.
So you might get stuck doing 'em on those.
Joe: Cool.
So you got your patient, no red flags to make you want to do any imaging or tests,
and you did a good history and physical, so you feel confident about that.
And that's gonna be most of our urgent care patients.
You gotta go through and do all of that stuff, but in the end, most of 'em are
gonna have uncomplicated back pain.
What does the evidence tell us about the best way to treat them?
Tracey: NSAIDs, and I'm gonna say this about three times.
The only thing that's ever been proven to do anything for pain and anything for
improving functional status is NSAIDs.
And they don't decrease the amount of time you're gonna have back pain for.
They make your pain more manageable so that you can deal with it and have a
little bit less pain and be a little more functional for a short period of time.
And the only thing that's really been studied is ibuprofen and naproxen.
But I think we can probably extrapolate that to some of the other NSAIDs as well.
I know most of us have our favorites of ones that we like to prescribe
for people if they're finding the ibuprofen isn't working.
But those are really the only things that have been supported by the
literature and been studied enough to say that, yes, this is gonna help you.
And it's minimal, so if you wanna give that patient who's having severe
pain, maybe a dose of ketorolac in the urgent care or if you want to
prescribe it for them, that's fine.
You can do those things, but that's really what you're gonna do.
If it's someone who can't take NSAIDs, you are stuck because nothing else
has really been proven to work.
Acetaminophen.
Not good, worthless, doesn't do anything.
Narcotics, doesn't really do anything.
Muscle relaxants, they will improve pain slightly, temporarily.
They don't improve functional status at all.
They don't decrease the amount of time.
But, in most cases, their side effects outweigh their benefit.
If somebody's sleepy, goofy, and it drives me crazy when I see some 80-year-old lady
coming in because her back pain isn't getting better, and I saw somebody gave
her cyclobenzaprine and I'm thinking, were you asking that patient to fall down?
So you really need to be very careful with that, maybe case by case basis.
Think about whether or not you wanna give that patient a muscle relaxant,
knowing the amount of benefit that you're gonna get is gonna be pretty small.
Opioids, like I said, same thing.
Risk, way worse than benefit.
Really minimal, minimal benefit from opioids.
Topicals, there's some research on the topicals.
Diclofenac is better than nothing but it's not as good as ibuprofen orally.
So might be an option in someone who has, say a gastric bypass.
You could tell them to get some diclofenac gel and use that.
The menthol topicals also, some minimal benefit as far as pain is concerned.
Probably not enough to be really statistically significant, but in
my opinion, better than nothing.
Topical lidocaine, worthless for acute back pain, doesn't work at all.
Maybe might be a little bit benefit from chronic, but nothing for acute.
Gabapentin, for a while there I was throwing gabapentin at people,
especially with sciatica thinking that maybe that would be helpful for
nerve pain to kind of improve that.
No studies have proven that that's been beneficial for
back pain, even with sciatica.
And benzodiazepines, again, they do help a little bit but their side
effects and risks of addiction and all that stuff outweigh the benefits.
A couple of the studies for those were really done in a hospital based
study and an emergency based study.
And it actually delayed the time to discharge by giving them a
narcotic or a benzodiazepine.
So they were taking up more time and having more side effects in the
emergency room than they would've if they hadn't been given those
medications with really no benefit.
So yeah.
And since that's it, I'm gonna say it again.
The only thing proven to do anything for short term pain and improving punction,
and again, it's minimal, is NSAIDs.
So if you've got someone that can't take NSAIDs for whatever reason, kidney
disease, gastric bypass status, that sort of thing, you're kind of stuck.
You can do the topicals, you can do the acetaminophen.
You can maybe do a short course of muscle relaxants, not a whole lot is helping.
Joe: Yeah, NSAIDs are so crucial to this.
It's important to know what the contraindications are so you can
kind of weigh the risks and benefits and avoid them when you need to.
And the interesting thing that came out that I, gosh, it was years
ago, I remember thinking, why are there so many different NSAIDs.
And I don't think this has been studied in back pain or much else, but in treating
patients with arthritis, that sometimes you can switch from one to another.
And you said that.
If the ibuprofen's not working then switch to a different one.
And although there are equal potent anti-inflammatory effects, it's
probably maybe not the anti-inflammatory effect that's causing the analgesia.
And so changing to another one's very reasonable rather than having
people continuing to take the one.
And there's so many options that you can switch.
Tracey: Right.
Joe: And I think the topicals are great as an option when somebody can't take an oral
NSAID or maybe you don't wanna give them a injectable NSAID because they do have
those contraindications, then the topical NSAIDs are kinda like your next best
thing, it seems based on the evidence and maybe a little bit better than the menthol
topically . But yeah it's surprising how much we do for back pain and it
just, there's no evidence that it works.
Tracey: No.
Nope.
Joe: In all of that, you didn't mention steroids.
But I do see a lot of that among my colleagues.
I kind of took on a steroid stewardship mantle myself probably a few years ago
when a couple papers came out that showed the side effects that we just don't see.
We don't see the patients two weeks, four weeks, six weeks later, having
fractures and GI bleeds and infection that they wouldn't have gotten otherwise.
Tracey: Yeah.
Joe: And so we don't have the sense of it, but when I was confronted with that,
I was like, dang, what are these good for?
And let me kind of contract my practice down to that.
What does the literature tell us about that?
With back pain, steroids, and back pain?
Tracey: Yeah, I mean, steroids really are the elephant in the room.
I live in the south and steroids are rampant.
Everybody writes steroids for everything.
And I think in some cases, at least for respiratory infections and things
like that, they write the steroids to try to avoid the antibiotics, saying
that you'll feel better with this.
I'm not gonna give you the antibiotic you want, but here's this.
It's also rampant where people get injectable steroids for,
you know, just to feel better.
And really the amount of badness from steroid use is just so extensive.
You're immunosuppressed for three months after you get one little
Medrol dose pack, you have some immunosuppression for three months.
Your risk for GI bleed, your risk for DVT, glaucoma, increase risk for
diabetes, even if you're not a diabetic, it increases your risk for diabetes.
It's crazy.
I've seen people in DKA from a steroid pack.
We don't realize it because a lot of times, I guess we
don't really see the follow up.
Or we think that whatever side effect they're having is not
really a side effect, but just their normal disease process.
The one thing that a lot of people will say, oh, the
exception to that is sciatica.
I can give it for sciatica 'cause it's going to decrease the swelling of the
sciatic nerve and make their pain better.
No studies say, no, no, that doesn't work.
And again, the risks outweigh the benefits.
There are many, many articles and you can see all the references in
the issue that steroids are not recommended for back pain, even
if the patient's having sciatica.
I know we're desperate to try and help these people.
But this is not the answer.
Giving them other side effects and other potential complications, just to think
that we're maybe making them feel a little bit better, is not the answer.
Just say no to those steroids.
Joe: Yeah, no, they went out the window with true spinal
cord injury a decade ago or so.
Tracey: Yeah.
Joe: I remember there was a lot of controversy about that, and maybe
that's why they started to get used for back pain or radiculopathy.
But I think the thing that impressed me about the side effects of
steroids is that they're cumulative.
Tracey: Yeah.
Joe: Every successive course kind of increases your risk, almost
like your radiation exposure.
Tracey: Yep.
Joe: And so it's not only do you have to think about, gosh,
do they really need it now?
It's like how many times have they had it?
Okay, Tracy.
How about stretching and exercise and PT? You hear a lot about that.
I think there were some studies that said maybe PT doesn't help everybody, but maybe
it's early PT. What's kind of the skinny on moving and stretching and exercise
and maybe formal physical therapy?
Tracey: Yeah, I mean, some of this is actually emerging research.
There was a recent study that was done a year or two ago on actually doing PT
evaluations and teaching people some exercises while the patient's still in
the emergency department and it actually decreased their time to improvement,
which was statistically significant.
So I think that's getting some more research, so stay tuned on that one.
But again, like I alluded to before when we were talking about
the traction, we used to tell people bed rest, go home, relax.
It's an injury.
You have to rest the injury.
But that's actually not true.
You need to keep moving.
I now tell patients, do as much as you can without doing too much.
And you'll know when too much is.
But the worst thing you can do is sit in a chair or lay in bed because think
about it, you're not using those muscles.
They get stiff and then you go and you get up and it makes your
pain worse when you do get up.
That's why you're always worse when you first wake up in the morning 'cause you've
been laying in bed all night, so you've gotta, even if you just get up and walk
around your house for a few minutes.
Maybe try and do some gentle twisting and bending and stretching.
Just a little tiny bit is better than doing nothing at all, because that's
gonna prevent all that stiffness and actually improve your functional
status by doing some of that.
Exercises?
I usually print out some exercises for people, even if they're,
like I said, just minimal type exercises and physical therapy.
That's another thing I think we do really bad at that I think we're
starting to realize, maybe we should start doing more of this.
It used to be for whatever injury it is, whether it's your back or your ankle
or your elbow or whatever the heck it is, give the patient four to six weeks
and then send them to physical therapy.
But that's actually kind of wrong, and if you actually talk
to the physical therapists, they're like, oh yes, thank you.
Send them to us sooner rather than later.
Because they can actually help with the acute episode of pain and then provide
that patient with some exercises.
And then as they improve their functional status and increase their level of
exercising and give them some ideas to prevent future injuries like the Healthy
Pack program and things like that.
Again, some of that is emerging research.
But the most important thing that you can give someone in
their discharge instructions is to tell them to keep moving.
Because to prevent that stiffness, don't lay around.
Don't sit in bed, don't sit in the chair, because you are gonna get stiff.
Keep yourself moving with some gentle stretching.
Go for a walk.
That sort of thing.
Joe: I've found that helps.
squadcaster-bbbc_2_08-27-2025_175432: I mean,
Joe: I've had not anything major, times where your back
hurts for a couple of weeks.
You tweaked it and it results in you not being able to do
everything that you can do.
Like you said, you wake up first thing in the morning and you
feel the worst you do all day.
You move around a little bit, you feel better.
And I'll tell patients, you can definitely overdo it and you'll know.
But you can also underdo it and you are gonna reach your functional
capacity and be feeling better if you try to do as much as you can
comfortably while you're getting better.
So I agree a hundred percent.
Well, hey, we all love the new documentation guidelines, right?
Or they're actually, they're not new anymore, but the most recent ones.
Do you have any tips, and I know you're the documentation expert, on
how we should document with all these treatments being out there to pick from,
but only a few being really viable.
And what about documenting whether somebody does not need
imaging or steroids, for example.
Should we be doing that and how do we do it?
Tracey: Yep.
Just a little shameless plug for my safeguarding charting course.
Um, but there is a whole section on back pain there.
Your worst case scenario.
So always make sure that you're addressing your worst case scenario.
When we were talking about infection, hematoma, fracture, cauda equina type
things, in your history you want 'em to document no fever, no significant
trauma, that they don't have a history of cancer, whether or not they have
osteoporosis, whether or not they've had previous surgery, whether or not
they've had previous experiences with back pain, because those are all useful
things that will help you on down the road in your medical decision making.
Same thing with the exam.
If they're at risk for the abdominal aortic aneurysm, please put in
an abdominal exam that says no pulsitile mass that's tender.
Get that straight leg raise, get that neurologic exam to document
that there's no neurologic deficits.
Make sure you've documented that they're able to walk and get outta the chair.
I always comment how they get outta the chair and onto the exam table.
You know, I put something like, easily gets onto exam table, because right there
I'm telling the reader that that patient doesn't have any neurologic deficits if
they can get out of a chair and get into the exam table without much difficulty.
Watch 'em walk down the hall.
If they can walk and they're not limping and they're standing up straight,
then they probably don't have any red flags that make you think they
need to go to the emergency room.
Be careful about that.
And then when you get to your medical decision making, I always say something to
the effect of, no evidence of red flags or concerns for sinister causes of back pain.
Or I even write them out, you know, no evidence of infection or need for
emergent imaging or emergent evaluation or ED evaluation at this time based
on the history and physical findings.
And if you documented all those history and physical findings, now
you're reflecting back to that.
So it shows the reader that, Hey, I've thought about these bad things and I've,
even if I didn't do any advanced imaging, I've ruled them out with history and
physical and I've thought about them.
So that later on down the road if there is a bad outcome or something else
happens that you can substantiate what your actions were and also substantiate
why you didn't do the imaging.
I've actually now started writing things like "based on current guidelines
and recommendations of the American College of Radiology, no x-rays are
indicated in this patient." That way if the other person who doesn't know
about these guidelines reads my chart, they won't say, wow, she's an idiot.
She didn't get any x-rays.
Joe: Mm-hmm.
Tracey: Yeah, so always in your medical decision making make sure
that you document what you were thinking about and what you ruled out.
And if you're dictating, that makes it so easier 'cause if you talk
fast like me, you can very quickly put in your medical decision making
there and have yourself covered.
Joe: I was gonna say, I hope you had a macro for that, but if
you can dictate it, it so it's
Tracey: I actually do.
MDM back pain, it's called.
Yeah.
Joe: You know, the interesting thing about documentation is just
it's sort of the thing you have to do for every visit, right?
And if you love to practice medicine, you love the history and you love the exam,
you love the thinking, but God, you just don't like the documentation, right?
Except when you think about how it reflects the complexity of what you had
to go through and every back pain patient you have to think about those things.
So it's potentially complex.
Tracey: Yep.
Joe: You're going through those things in your mind and ruling them out.
Yeah, most people don't have 'em, but those needles in a haystack that do
it's our responsibility to find 'em.
So we're ruling them out in everybody else, and that's a
complicated decision making.
And the fact that we don't do anything like imaging or prescribe opioids
if it's based on the evidence rather than it being a simple problem.
It's not a simple problem, it's just that, you know, there's nothing that's
gonna help us at that point, except talking to the patient and urging them
to be active, as active as they can be and prescribing those simple, basic
treatments that we have some evidence for.
It seems simple, but it's complicated.
You have to go through that every time.
So if the documentation reflects that you're protecting yourself risk-wise.
Tracey: Yep.
Joe: But you're also substantiating all the thought that went into it and
getting the code that you deserve.
Right?
Tracey: Yeah.
Oh, and yes, get paid for that.
If you document a back pain properly, you will get yourself a level four
easily, because it's either an exacerbation of a chronic problem
that they already have or it's a new problem with an unknown prognosis
or unknown how it's gonna work out.
Plus your always talking about or considering some sort of
a prescription medication.
So right there, you're giving yourself the level four.
If you add a few other things in there at least three complicated things
that you've considered, you've totally substantiated yourself to a level four.
So don't sell yourself short on that one.
Joe: Perfect.
I love it.
Thank you Tracey.
I really enjoyed reading the issue and it was really fun to talk about.
And I can't wait for my next back pain patient,
Tracey: Yeah, right?
Joe: Although it will probably be a AAA.
Tracey: Yep.
Write them all for ibuprofen.
Tell 'em all to keep moving and tell 'em all it's gonna take four
to six weeks for them to get better, and they don't need an x-ray.
So there's your bottom line, right?
All right.
Next month is, what do we got next month?
We have returning traveler, I think is next month.
Joe: I love that topic.
Tracey: Yes, returning traveler is next month.
And then November we've got some laboratory testing, which is really good.
Yeah, and lots of good things coming down the pike in the future.
So look forward to that in October with the returning travelers.
Joe: That sounds great.
I love that.
I live and practice in an area where people are traveling a lot.
A lot of businesses where people travel internationally, so having a
good approach to that, symptom-based and then where do they travel to,
can really help you pin it down.
I'm looking forward to that.
That'll be cool.
Tracey: Yeah, I have the opposite problem.
I'm the place where people travel to.
Joe: To Disney.
Tracey: Yeah, exactly.
So I get people that come from all over the world, and I have to
try and figure out what they have.
I actually saw some influenza A a couple weeks ago from somebody from Australia.
I'm like, oh, it's flu season there.
Joe: Southern hemisphere.
Tracey: Yep, exactly.
Joe: Cool.
Well take care everyone.
Thank you for listening and we hope you learned something and
we will talk to you next month.
Tracey: Yep.
You as well.
Take care.
Bye-bye.
Joe: Alright, bye-bye.
Tracey: I want to thank everybody to listening to this month's evidence based
urgentology podcast . Just a reminder that subscribers can go to ebmedicine.
net and read the full issue if you want more information, if you haven't already,
Joe: And if you're not a subscriber head to the site.
That's ebmedicine.
net to check out what they have.
If you subscribe you'll get access to the article as well as future articles
and the whole archive of all past issues.
Tracey: Look forward to seeing you there.