1 00:00:00,000 --> 00:00:02,310 Tracey: You know, one of the standing jokes when I was a resident is if you 2 00:00:02,310 --> 00:00:05,580 take five chest x-rays and you give it to five different radiologists, you're 3 00:00:05,580 --> 00:00:06,990 gonna get five different readings. 4 00:00:14,657 --> 00:00:18,107 Joe: Welcome to the Evidence-Based Urgentology podcast from EB Medicine, 5 00:00:18,107 --> 00:00:20,387 where urgent care meets evidence. 6 00:00:20,497 --> 00:00:23,737 I'm Joe Toscano, senior research editor for Emergency Medicine Practice, 7 00:00:23,797 --> 00:00:26,527 and a member of the evidence-based Urgent Care editorial board. 8 00:00:27,832 --> 00:00:29,332 Tracey: Hi there, and I'm Tracy Davidoff. 9 00:00:29,332 --> 00:00:32,602 I'm editor in chief of Evidence-Based Urgent Care, and we're practicing 10 00:00:32,602 --> 00:00:35,482 urgent care physicians with years of experience, probably too many years 11 00:00:35,482 --> 00:00:37,222 of experience, on the front lines. 12 00:00:37,282 --> 00:00:41,152 And for us, diagnosis is detective work and the clues are in the history, 13 00:00:41,152 --> 00:00:42,862 the exam, and of course the evidence. 14 00:00:43,102 --> 00:00:45,262 That thrill of solving the patient's puzzle is really 15 00:00:45,262 --> 00:00:46,402 what keeps us coming back. 16 00:00:47,037 --> 00:00:51,477 Joe: Each month we unpack the latest issue of evidence-based urgent care tackling 17 00:00:51,477 --> 00:00:53,277 common chief complaints from presentation. 18 00:00:53,277 --> 00:00:57,147 Through diagnosis to disposition, we highlight the best evidence, the key 19 00:00:57,147 --> 00:00:58,377 takeaways, and the clinical pearls. 20 00:00:59,247 --> 00:01:02,367 Tracey: And by the end of every episode, you'll have sharper skills, deeper 21 00:01:02,367 --> 00:01:06,087 knowledge, and more sound strategies that you can use on your very next shift. 22 00:01:06,477 --> 00:01:07,437 So let's dive in. 23 00:01:07,437 --> 00:01:08,577 The evidence starts now. 24 00:01:08,727 --> 00:01:14,007 And remember, you can always find more at www.ebmedicine.net. 25 00:01:14,506 --> 00:01:15,286 Joe: Hi everyone. 26 00:01:15,449 --> 00:01:19,699 Before we get started today, I want to direct everybody to eb medicine.net. 27 00:01:19,729 --> 00:01:22,456 Please go and check out, the special of the day. 28 00:01:22,456 --> 00:01:25,646 You know, we kind of have a habit of announcing the promos, but people 29 00:01:25,646 --> 00:01:29,006 listen to these sometimes a month or two or three later or anytime after. 30 00:01:29,396 --> 00:01:32,426 So the best thing to do, if you're interested in getting a good deal 31 00:01:32,546 --> 00:01:36,636 or getting the usual deal, which is still a good deal go to eb 32 00:01:36,636 --> 00:01:38,796 medicine.net and check out what's there. 33 00:01:38,826 --> 00:01:42,146 They have the issues of evidence-based urgent care as well as emergency medicine, 34 00:01:42,596 --> 00:01:46,376 pediatric emergency medicine, a lot of other information, and that is where you 35 00:01:46,376 --> 00:01:51,556 will find the foamed site F-O-A-M-E-D which is where you can find our podcast 36 00:01:51,586 --> 00:01:52,786 and a lot of other good stuff too. 37 00:01:53,486 --> 00:01:53,996 Tracey: All right. 38 00:01:54,056 --> 00:01:55,976 Well, I'd like to welcome everybody today. 39 00:01:56,102 --> 00:01:59,372 today's issue is going to be evidence-based urgent care 40 00:01:59,422 --> 00:02:02,312 evaluation management of motor vehicle collisions an evidence-based 41 00:02:02,312 --> 00:02:05,272 approach and back by popular demand. 42 00:02:05,272 --> 00:02:08,482 We have one of the authors with us because that seems to be going over. 43 00:02:08,627 --> 00:02:12,844 So well first author, which isn't here is Dr. Frank DeFazio, who's a clinical 44 00:02:12,844 --> 00:02:15,694 orthopedist that works for doctors care in Columbia, South Carolina. 45 00:02:16,054 --> 00:02:19,864 And the author that is here with us is my friend Shelley Janssen, who's the Chief 46 00:02:19,864 --> 00:02:24,514 Medical Officer of Novant health Urgent Care also in Columbia, South Carolina. 47 00:02:24,859 --> 00:02:28,009 Our peer reviewers were Lisa Campanella and Kyla Howrish. 48 00:02:28,489 --> 00:02:29,149 Hi Shelly. 49 00:02:29,849 --> 00:02:30,569 shelley-janssen--she-her-_1_12-17-2025_203838: Hi Tracy. 50 00:02:30,569 --> 00:02:31,379 Thanks for having me. 51 00:02:31,384 --> 00:02:32,344 Tracey: Oh, we love to have you. 52 00:02:32,344 --> 00:02:33,784 We love talking to the authors. 53 00:02:33,784 --> 00:02:36,424 It just, it just gives it, you know, like a really more 54 00:02:36,424 --> 00:02:41,194 well-rounded approach and to hear the perspective of the author as well. 55 00:02:41,554 --> 00:02:44,854 And people, you know, I, I guess they don't wanna hear us talk all the time, 56 00:02:44,854 --> 00:02:46,564 although actually I guess they kind of do. 57 00:02:46,754 --> 00:02:47,549 But it's nice to add some. 58 00:02:47,709 --> 00:02:48,059 shelley-janssen--she-her-_1_12-17-2025_203838: they do. 59 00:02:48,109 --> 00:02:49,129 Tracey: Yeah, I guess they do. 60 00:02:49,429 --> 00:02:49,729 Yeah. 61 00:02:49,729 --> 00:02:52,579 But it's kind of nice to have some special guests, and we're actually gonna try to 62 00:02:52,579 --> 00:02:53,989 start doing this a little more frequently. 63 00:02:54,049 --> 00:02:55,436 so stay tuned to this. 64 00:02:56,096 --> 00:02:58,699 So Shelly, could you tell us what prompted you to write this 65 00:02:58,699 --> 00:03:00,409 issue on motor vehicle accidents? 66 00:03:00,409 --> 00:03:03,499 Did you see the need or was it something that you're passionate about? 67 00:03:03,599 --> 00:03:06,299 Did you see a lot of these patients being handled incorrectly? 68 00:03:06,389 --> 00:03:07,289 Why'd you wanna do it? 69 00:03:07,989 --> 00:03:08,589 shelley-janssen--she-her-_1_12-17-2025_203838: Sure. 70 00:03:08,899 --> 00:03:12,109 Well, the inspiration for this article came from a clear clinical 71 00:03:12,109 --> 00:03:16,159 need as the chief medical Officer of a large urgent care group. 72 00:03:16,489 --> 00:03:21,649 I've seen firsthand how emergency department overcrowding and rising 73 00:03:21,649 --> 00:03:25,759 healthcare costs are driving more and more motor vehicle collision 74 00:03:25,759 --> 00:03:27,559 patients into urgent care centers. 75 00:03:28,259 --> 00:03:32,539 To support urgent care clinicians, I collaborated with Dr. Frank DiFazio. 76 00:03:32,939 --> 00:03:36,119 He's an experienced orthopedic surgeon and AI innovator. 77 00:03:36,119 --> 00:03:40,239 We realized that many urgent care clinicians haven't received 78 00:03:40,239 --> 00:03:44,342 formal training, specific to the complexities of motor vehicle injuries. 79 00:03:45,042 --> 00:03:49,632 So with the goal of improving patient outcomes, we wrote this EB Medicine 80 00:03:49,632 --> 00:03:54,112 issue to bridge the educational gap, giving giving clinicians the confidence 81 00:03:54,112 --> 00:03:59,032 to make safe triage decisions and the tools to provide evidence-based care. 82 00:03:59,732 --> 00:04:02,072 Tracey: Yeah, I think that's definitely so needed. 83 00:04:02,172 --> 00:04:06,132 although in the beginning most urgent care providers were emergency medicine trained 84 00:04:06,132 --> 00:04:09,432 now a lot of them are family medicine trained and that may not be something that 85 00:04:09,432 --> 00:04:12,816 they've really had a whole lot of exposure to while they were doing their training 86 00:04:12,866 --> 00:04:15,806 and now they're plopped into urgent care and have to deal with some of these things 87 00:04:15,806 --> 00:04:17,186 that they may be less comfortable with. 88 00:04:17,556 --> 00:04:20,826 We also see a lot of the, people a few days afterwards, you know, and, 89 00:04:21,016 --> 00:04:24,076 maybe not somebody that would think, you know, why am I still in pain? 90 00:04:24,076 --> 00:04:26,686 Or that sort of thing, and not something that really needs to go to the ED, but 91 00:04:26,686 --> 00:04:28,396 somebody that's gonna present to us. 92 00:04:28,456 --> 00:04:30,136 So, yes, and I totally agree. 93 00:04:30,136 --> 00:04:33,701 There's a lot of, people that are uncomfortable or have trouble with this. 94 00:04:33,701 --> 00:04:38,074 So I think this was a great issue for us to bring to the forefront to educate 95 00:04:38,074 --> 00:04:40,144 our readers and urgent care clinicians. 96 00:04:40,844 --> 00:04:43,424 Joe: Yeah, I thought it was great how you brought so much information together. 97 00:04:43,874 --> 00:04:46,667 You know, when you think about sometimes reading something like this, you could 98 00:04:46,667 --> 00:04:51,437 actually do a whole paper just on neck pain or chest trauma, and you've actually 99 00:04:51,437 --> 00:04:54,347 covered a lot of different body areas. 100 00:04:54,347 --> 00:04:55,817 It could be injured really well. 101 00:04:55,817 --> 00:04:58,187 Went over the evidence and talked about, you know, what the same 102 00:04:58,187 --> 00:05:00,047 way of evaluating these patients. 103 00:05:00,047 --> 00:05:03,951 One of the most important take home points, I thought was kind of the 104 00:05:03,951 --> 00:05:05,481 importance of the primary survey. 105 00:05:05,871 --> 00:05:09,091 You know, vitals pop up there for us, hopefully or if we're seeing somebody 106 00:05:09,091 --> 00:05:12,301 right away, maybe they're getting taken as we're seeing the patient. 107 00:05:12,721 --> 00:05:16,391 GCS age and then beginning to ask those questions where the answers 108 00:05:16,391 --> 00:05:18,881 might characterize the patient at being high risk, you know, 109 00:05:18,881 --> 00:05:20,291 what was the mechanism of injury? 110 00:05:20,561 --> 00:05:22,001 Are they on any blood thinning medications? 111 00:05:22,001 --> 00:05:22,841 Those sorts of things. 112 00:05:23,201 --> 00:05:28,027 And to have in our mind ahead of time, what sort of patient we're gonna refer 113 00:05:28,027 --> 00:05:32,317 to the ED call 9 1 1 and refer to the ED without doing any further testing. 114 00:05:32,687 --> 00:05:34,757 Can you flesh that out a little bit better for us? 115 00:05:35,457 --> 00:05:36,237 shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, sure Joe. 116 00:05:36,341 --> 00:05:40,156 You know, as a clinician, you should never assume an ambulatory motor 117 00:05:40,156 --> 00:05:42,286 vehicle collision patient is stable. 118 00:05:42,616 --> 00:05:47,516 All All victims, regardless of age or timing, require an evaluation 119 00:05:47,786 --> 00:05:51,986 in accordance with advanced trauma life support A TLS guidelines. 120 00:05:52,686 --> 00:05:55,746 Triage decision should be driven by the primary survey. 121 00:05:55,966 --> 00:05:59,716 And as such, you know, clinicians should contact EMS immediately. 122 00:05:59,896 --> 00:06:03,706 For instance, if a patient has a Glasgow Coma score less than 14, 123 00:06:04,036 --> 00:06:08,600 low oxygen saturation, low systolic blood pressure, or tachycardia. 124 00:06:08,830 --> 00:06:12,390 And another point I'd like to make is because the mechanism of injury 125 00:06:12,630 --> 00:06:16,710 determines how physical forces affect the body at the time of impact. 126 00:06:17,100 --> 00:06:21,220 It is really the foundation of trauma triage in addition to the vital 127 00:06:21,220 --> 00:06:22,570 signs that we just talked about. 128 00:06:23,025 --> 00:06:26,985 So in urgent care, the mechanism of injury and associated injury patterns 129 00:06:27,315 --> 00:06:31,725 often will provide a more reliable insight into the potential serious or 130 00:06:31,725 --> 00:06:36,672 life-threatening injuries more than the patient's clinical appearance especially 131 00:06:36,672 --> 00:06:38,652 in those cases of delayed presentation. 132 00:06:38,857 --> 00:06:41,747 Tracey: Yeah, that's good advice for anything, not just MVAs. 133 00:06:41,767 --> 00:06:45,787 I mean, it took me a long time to realize that with a mechanism of injury, you know, 134 00:06:45,787 --> 00:06:49,207 you can really predict what the injury is gonna be before you even get that 135 00:06:49,207 --> 00:06:51,547 x-ray or, do those further evaluations. 136 00:06:51,547 --> 00:06:55,672 So, so important to really flush that out when you're taking your history. 137 00:06:56,372 --> 00:06:58,982 So one of the biggest things that I see in practice, and I know a lot 138 00:06:58,982 --> 00:07:01,682 of my colleagues see in practice is clinicians ordering a lot of plain 139 00:07:01,682 --> 00:07:04,172 films on cervical and lumbar spines. 140 00:07:04,422 --> 00:07:08,162 And in my opinion, you're not ruling out anything with that especially in a trauma 141 00:07:08,162 --> 00:07:12,632 patient with a high pretest probability of a possible neck or a lumbar spine injury. 142 00:07:12,962 --> 00:07:17,372 Can we talk about some of the pitfalls of, thinking that you're, doing anybody 143 00:07:17,372 --> 00:07:22,052 any good by ordering plain films and when should we escalate that to a higher level? 144 00:07:22,925 --> 00:07:23,975 shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, that, that's a common 145 00:07:23,975 --> 00:07:27,275 problem we see in urgent care just because plain films are available. 146 00:07:27,275 --> 00:07:32,735 But you know, for post NVC imaging, non-contrast, CT is the gold standard 147 00:07:32,825 --> 00:07:35,345 for head, face and spine injuries. 148 00:07:36,045 --> 00:07:40,575 Clinicians should be aware that plain x-rays miss approximately 50% of 149 00:07:40,575 --> 00:07:42,195 significant cervical spine fractures. 150 00:07:42,895 --> 00:07:43,773 Tracey: 50%. 151 00:07:43,823 --> 00:07:44,843 shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, exactly. 152 00:07:45,173 --> 00:07:49,583 So, therefore, they should not be used to clear a patient's c-spine. 153 00:07:50,283 --> 00:07:54,043 Use of well-established clinical decision tools such as the Canadian 154 00:07:54,043 --> 00:07:58,333 C-Spine rule can help guide clinicians in determining which of those patients 155 00:07:58,333 --> 00:08:00,418 require advanced cervical spine imaging. 156 00:08:01,118 --> 00:08:03,628 And you also mentioned thoraco lumbar injuries. 157 00:08:03,938 --> 00:08:07,598 You know, CT is the definitive tool for those injuries as well. 158 00:08:08,228 --> 00:08:14,078 While CT has a 99% sensitivity rate, plain films miss roughly one in four unstable 159 00:08:14,078 --> 00:08:16,608 fractures, and then thoraco lumbar spine. 160 00:08:16,668 --> 00:08:16,998 Yeah. 161 00:08:17,028 --> 00:08:19,578 So, when you think about those statistics, it's pretty scary. 162 00:08:20,128 --> 00:08:23,158 This is particularly critical in the case of burst fractures, which are 163 00:08:23,158 --> 00:08:27,088 frequently misidentified as stable compression fractures on plain films. 164 00:08:27,788 --> 00:08:31,508 Although no validated clinical decision criteria exists for imaging 165 00:08:31,508 --> 00:08:36,038 blunt trauma, thoraco lumbar spine injuries, urgent care clinicians 166 00:08:36,038 --> 00:08:40,028 should follow evidence-based guidelines for identifying patients at risk. 167 00:08:40,728 --> 00:08:42,618 Those include patients over the age of 65. 168 00:08:43,318 --> 00:08:47,338 Patients involved in motor vehicle collisions that have a high risk 169 00:08:47,338 --> 00:08:52,438 mechanism of injury, those with back pain, thoracolumbar spine tenderness 170 00:08:52,438 --> 00:08:56,908 on examination neuro deficits or distracting injuries, which may 171 00:08:56,908 --> 00:09:02,358 make it difficult to identify a significant thoracolumbar spine injury. 172 00:09:03,058 --> 00:09:09,208 Joe: You know, taking a step back from CT being the best test for those areas and 173 00:09:09,208 --> 00:09:13,378 deciding who we're gonna get the tests on, or in most cases, who we're gonna 174 00:09:13,378 --> 00:09:17,765 refer to the ED to do that because we don't have access to CT in urgent care. 175 00:09:17,945 --> 00:09:21,515 I thought it was really interesting, the statistic that you all cited, 176 00:09:21,515 --> 00:09:25,545 that nearly a quarter of patients 65 and older with cervical spine 177 00:09:25,595 --> 00:09:27,625 fractures are entirely asymptomatic. 178 00:09:27,995 --> 00:09:32,135 And we know from the Canadian C-spine rule itself that generally 179 00:09:32,135 --> 00:09:35,975 if you're 65 or older, you can't use the rule to rule people out. 180 00:09:35,975 --> 00:09:38,465 So if there's some suspicion you're gonna go ahead and get the imaging, 181 00:09:38,705 --> 00:09:44,435 NEXUS doesn't really have, age as, part of the decision making criteria, but we 182 00:09:44,435 --> 00:09:45,875 do know that that does not work well. 183 00:09:45,875 --> 00:09:49,955 And it's been proven that that doesn't work well in patients 65 or older, 184 00:09:49,955 --> 00:09:52,355 that that sensitivity is at like 60%. 185 00:09:52,355 --> 00:09:53,525 So almost a coin toss. 186 00:09:53,895 --> 00:09:59,915 But should we really send every MVA patient 65 or older to the ED for CT? 187 00:10:00,395 --> 00:10:04,850 You know, the rule tells us who we don't need it on doesn't necessarily 188 00:10:04,850 --> 00:10:06,440 tell us that we need to do that. 189 00:10:06,810 --> 00:10:10,640 How do you manage that and for CT or even the head injury rules, should we 190 00:10:10,640 --> 00:10:12,260 just kneejerk and send everybody there? 191 00:10:12,260 --> 00:10:15,657 Is there room for some clinical judgment or shared decision making, 192 00:10:15,687 --> 00:10:17,097 that sort of thing with these patients? 193 00:10:17,097 --> 00:10:17,457 What do you think? 194 00:10:18,157 --> 00:10:18,757 shelley-janssen--she-her-_1_12-17-2025_203838: Yeah. 195 00:10:18,807 --> 00:10:24,037 When Dr. D made this recommendation, we realized and it was gonna be the most 196 00:10:24,037 --> 00:10:26,277 controversial stance of this issue. 197 00:10:26,377 --> 00:10:30,987 So we did it with great, great care you know, with the rigorous literature review. 198 00:10:31,307 --> 00:10:36,087 Supporting the stance age related anatomical changes in comorbidities 199 00:10:36,087 --> 00:10:42,347 significantly increase the risk of occult and high level fractures in the elderly. 200 00:10:42,697 --> 00:10:47,597 while younger patients have peak mobility and thus more injuries in the C four 201 00:10:47,597 --> 00:10:53,013 to C seven cervical segment the aging spine undergoes degenerative changes 202 00:10:53,013 --> 00:10:54,333 that stiffen these lower vertebrae. 203 00:10:55,033 --> 00:10:59,423 So this shifts the point of max mobility and the shifts the risk of 204 00:10:59,423 --> 00:11:02,453 injury to the C one and C two segment. 205 00:11:02,863 --> 00:11:07,180 Consequently C two fractures are the most common cervical injury in geriatric 206 00:11:07,180 --> 00:11:09,070 patients, followed by C one fractures. 207 00:11:09,770 --> 00:11:13,370 Furthermore, comorbidities such as ankylosing spondylitis, rheumatoid 208 00:11:13,370 --> 00:11:17,480 arthritis, spinal stenosis, and decreased bone density further 209 00:11:17,480 --> 00:11:21,320 predispose this population to significant cervical spine injury. 210 00:11:22,020 --> 00:11:24,930 Essentially the available literature suggests that some clinically 211 00:11:24,930 --> 00:11:28,740 significant asymptomatic injuries may be missed when imaging is not 212 00:11:28,740 --> 00:11:31,120 performed in patients age 65 and older. 213 00:11:31,800 --> 00:11:34,980 When you consider the potential harm of a missed cervical spine injury, 214 00:11:35,220 --> 00:11:39,630 particularly in the C one and C two region we recommend cervical ct for 215 00:11:39,630 --> 00:11:44,160 geriatric patients suffering any level of motor vehicle collision injury. 216 00:11:44,860 --> 00:11:46,300 So yes, the answer is yes. 217 00:11:46,300 --> 00:11:47,440 We recommend they all go. 218 00:11:48,600 --> 00:11:52,170 Joe: Yeah, I would tell You from ED practice that, uh, if that patient shows 219 00:11:52,170 --> 00:11:53,550 up in the ED, they're gonna get a CT. 220 00:11:53,950 --> 00:11:57,510 For myself when I'm working there and my colleagues, it's, you know, automatic. 221 00:11:57,560 --> 00:12:00,170 So So the idea is if you send 'em there, they're gonna get it. 222 00:12:00,360 --> 00:12:02,670 But it sounds like we should be sending 'em, because if they presented 223 00:12:02,670 --> 00:12:03,720 there, they would get it anyway. 224 00:12:04,065 --> 00:12:05,145 Tracey: Yeah, exactly. 225 00:12:05,235 --> 00:12:06,315 shelley-janssen--she-her-_1_12-17-2025_203838: It's the standard of care. 226 00:12:06,375 --> 00:12:09,505 So, you know, we wanna make sure they get the same standard in urgent care 227 00:12:09,570 --> 00:12:09,990 Tracey: Yeah. 228 00:12:10,420 --> 00:12:14,440 I find that some people will do plain films, you know, not necessarily because 229 00:12:14,440 --> 00:12:18,400 they think they're required, or I guess sometimes they do think they're required. 230 00:12:18,820 --> 00:12:21,700 Actually, I do have some nurse practitioners that in my practice 231 00:12:21,700 --> 00:12:24,455 that mVA I'm gonna x-ray the C spines. 232 00:12:24,915 --> 00:12:28,035 But sometimes also, they do them because the patient asks for 233 00:12:28,035 --> 00:12:31,815 them or they do them because the patient's lawyer asks for them. 234 00:12:32,155 --> 00:12:35,335 Should we be doing plain films in that case or should we, use some judgment 235 00:12:35,335 --> 00:12:37,135 here and not do them or CT them? 236 00:12:37,135 --> 00:12:38,595 What's your take on that sort of thing? 237 00:12:39,200 --> 00:12:40,940 shelley-janssen--she-her-_1_12-17-2025_203838: Clinicians should resist the pressure 238 00:12:40,940 --> 00:12:45,780 to order what we call reassurance x-rays for motor vehicle collision victims. 239 00:12:46,300 --> 00:12:47,420 The danger is twofold. 240 00:12:47,770 --> 00:12:51,590 First, plain films can overlook major pathology, giving the 241 00:12:51,590 --> 00:12:53,270 patient a false sense of safety. 242 00:12:53,970 --> 00:12:57,780 second, this mixed diagnosis creates a significant liability 243 00:12:57,780 --> 00:12:58,645 trap for the provider. 244 00:12:59,345 --> 00:13:02,705 Instead, clinicians should adhere strictly to evidence-based guidelines, 245 00:13:02,945 --> 00:13:07,385 such as the Nexus criteria or Canadian C-spine rule to determine 246 00:13:07,385 --> 00:13:09,875 if imaging is actually necessary. 247 00:13:10,575 --> 00:13:12,945 Effective patient communication is essential here. 248 00:13:12,975 --> 00:13:16,555 You know, taking the time to explain the limitations of x-ray can help 249 00:13:16,555 --> 00:13:21,115 resolve patient dissatisfaction over not getting the requested study. 250 00:13:21,320 --> 00:13:24,180 Tracey: Yeah, I find , some issue with the whole lawyer thing. 251 00:13:24,180 --> 00:13:27,840 You know, my lawyer sent me here for x-rays and sometimes I have to bite my 252 00:13:27,840 --> 00:13:31,050 tongue and resist the urge to say, well, then your lawyer can order the x-rays. 253 00:13:31,277 --> 00:13:35,828 but yeah, usually we'll try to, provide some patient education in that, point. 254 00:13:36,068 --> 00:13:39,078 We actually have the benefit of having what we call an MVA follow-up 255 00:13:39,078 --> 00:13:43,312 clinic where there's a group not too far from us that has a lot of 256 00:13:43,312 --> 00:13:46,882 referral base to chiropractors, physical therapy that sort of thing. 257 00:13:46,882 --> 00:13:49,712 And a lot of lawyers will send people there for that sort of thing. 258 00:13:49,712 --> 00:13:53,765 And they can do it there if they need it, but I don't want that liability on me. 259 00:13:54,186 --> 00:13:55,786 you're exactly right on that one. 260 00:13:56,286 --> 00:13:56,616 Joe: Yeah. 261 00:13:57,168 --> 00:13:59,728 That's such an interesting request too, because, when you think 262 00:13:59,728 --> 00:14:02,326 about the lack of sensitivity, they're probably gonna be fine. 263 00:14:02,596 --> 00:14:06,556 And if you saw anything on there, they needed a CT in the first place. 264 00:14:06,556 --> 00:14:10,499 So it's such a weird request . But anyway, they're lawyers, 265 00:14:10,949 --> 00:14:12,269 Tracey: Who knows why they do what they do. 266 00:14:12,344 --> 00:14:13,724 shelley-janssen--she-her-_1_12-17-2025_203838: Not, not doctors. 267 00:14:15,331 --> 00:14:19,641 Joe: Hey, moving uh, superiorly in the body from the neck to the head, 268 00:14:19,641 --> 00:14:22,791 and we have Nexus and Canadian rules for the head too, and head injuries. 269 00:14:23,131 --> 00:14:27,292 Maybe let's take your point of view overseeing uh, a lot of clinics and 270 00:14:27,292 --> 00:14:31,180 having an idea of what's going on, do you think, that there's appropriate 271 00:14:31,180 --> 00:14:32,890 referral for those patients. 272 00:14:32,890 --> 00:14:36,670 Are they sending too many, do people use those clinical decision rules in 273 00:14:36,670 --> 00:14:38,560 practice to help them make the decision? 274 00:14:38,910 --> 00:14:40,950 What do you see and what do you think people should be doing? 275 00:14:41,650 --> 00:14:43,444 shelley-janssen--she-her-_1_12-17-2025_203838: Well to avoid over referring minor 276 00:14:43,444 --> 00:14:47,519 head trauma to the emergency department for further diagnostic studies. 277 00:14:47,579 --> 00:14:50,909 Urgent care clinicians should use validated decision tools like you 278 00:14:50,909 --> 00:14:53,969 do in the emergency department, the Canadian head CT rule. 279 00:14:54,179 --> 00:14:55,319 You mentioned the Nexus, 280 00:14:55,366 --> 00:14:57,646 rules or even the New Orleans criteria. 281 00:14:58,346 --> 00:15:03,306 For patients with a Glasgow Coma score of 15 both the Canadian CT head 282 00:15:03,306 --> 00:15:07,416 rule and the New Orleans criteria are highly effective at catching 283 00:15:07,466 --> 00:15:09,526 clinically significant brain injuries. 284 00:15:09,949 --> 00:15:14,146 However, the Canadian CT head rule is the tool endorsed by the 285 00:15:14,146 --> 00:15:17,596 American College of Emergency Physicians, and it's the one that we 286 00:15:17,596 --> 00:15:19,483 mentioned in the EB Medicine issue. 287 00:15:19,743 --> 00:15:21,693 Because of its higher specificity. 288 00:15:21,973 --> 00:15:24,463 And it, so thus it helps prevent over referral. 289 00:15:24,703 --> 00:15:27,176 And that's the trend we tend to see in the ambulatory, setting. 290 00:15:27,176 --> 00:15:30,741 Too many patients are referred to the emergency department for head injuries. 291 00:15:30,981 --> 00:15:36,608 So by applying the Canadian CT head rule, clinicians can maintain, you know, high 292 00:15:36,608 --> 00:15:42,098 safety standards while reducing the burden of unnecessary CT scans on patients and 293 00:15:42,155 --> 00:15:44,015 the overburdened emergency departments. 294 00:15:44,400 --> 00:15:46,880 Tracey: Yeah, I guess it's kind of a balance, you know, we want people to 295 00:15:46,880 --> 00:15:50,780 err on the side of caution if there's any concern, but, we don't want them 296 00:15:50,780 --> 00:15:54,220 to just knee jerk every head injury to go to the emergency department. 297 00:15:54,220 --> 00:15:58,171 So using those rules are very helpful for trying to weed those patients out. 298 00:15:58,871 --> 00:16:00,888 shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, so, they're not sending enough neck 299 00:16:00,888 --> 00:16:04,518 injuries to the emergency department And they're sending too many head injuries. 300 00:16:04,713 --> 00:16:05,133 Tracey: Yeah. 301 00:16:05,283 --> 00:16:06,653 It's all the matter of balance, right? 302 00:16:06,906 --> 00:16:09,993 So let's go even further south and talk about chest injuries. 303 00:16:10,273 --> 00:16:12,793 So you mentioned in the article that you know, you should really have a 304 00:16:12,793 --> 00:16:14,503 low threshold for chest injuries. 305 00:16:14,843 --> 00:16:16,823 Is plain x-ray ever enough? 306 00:16:16,853 --> 00:16:21,138 Or should we be going for CT even if you have somebody whose vitals are stable? 307 00:16:21,570 --> 00:16:22,740 shelley-janssen--she-her-_1_12-17-2025_203838: well, it kind of depends. 308 00:16:22,840 --> 00:16:26,260 Motor vehicle collisions are the leading cause of significant 309 00:16:26,350 --> 00:16:28,630 blunt thoracic trauma in adults. 310 00:16:28,960 --> 00:16:32,740 And while urgent care providers most frequently encounter just chest 311 00:16:32,740 --> 00:16:37,184 contusions, rib fractures, and maybe pneumothoraces, they must remain 312 00:16:37,184 --> 00:16:41,070 highly vigilant for more severe cardiovascular or pulmonary injuries. 313 00:16:41,770 --> 00:16:46,070 According to the American College of Radiology a standard chest x-ray 314 00:16:46,070 --> 00:16:49,490 is the essential initial study to screen for life-threatening 315 00:16:49,490 --> 00:16:54,230 complications such as pneumothorax, hemothorax, or pulmonary contusions. 316 00:16:54,930 --> 00:16:59,100 And while chest x-rays miss roughly 50% of rib fractures, this is 317 00:16:59,100 --> 00:17:03,580 rarely clinically significant as it seldom changes patient management. 318 00:17:04,060 --> 00:17:07,480 However, for patients with persistent pain or dyspnea, advanced 319 00:17:07,510 --> 00:17:10,580 imaging like CT may be necessary. 320 00:17:11,280 --> 00:17:14,340 Although the majority of urgent care patients with blunt chest wall trauma 321 00:17:14,340 --> 00:17:19,380 do not require a chest CT, immediate EMS transport to the emergency department is 322 00:17:19,380 --> 00:17:24,710 required for those patients who've had a high energy mechanism of injury or are 323 00:17:24,730 --> 00:17:31,360 65 or older have abnormal x-ray findings or concerning symptoms such as hypoxia, 324 00:17:31,360 --> 00:17:36,758 tachypnea, or altered mental status . So, you know, another point I'd like to 325 00:17:36,758 --> 00:17:42,010 make is rib series , are not indicated for evaluation of thoracic trauma. 326 00:17:42,010 --> 00:17:45,660 In fact, we have discontinued rib series in our urgent care centers. 327 00:17:45,760 --> 00:17:49,940 'Cause we really want clinicians to focus on getting that initial chest x-ray. 328 00:17:50,220 --> 00:17:53,556 And that's looking for the sequela of rib fractures that are more important. 329 00:17:54,256 --> 00:17:56,861 Joe: You know, there was a line in the manuscript that I thought 330 00:17:56,861 --> 00:17:59,341 was really important about the importance of physical exam. 331 00:17:59,341 --> 00:18:02,321 And you guys took the time to say, you know, x-rays should 332 00:18:02,321 --> 00:18:06,281 never replace a comprehensive physical exam in post MVC patients. 333 00:18:06,761 --> 00:18:10,541 I think we're under time constraints, obviously seeing a lot of patients, 334 00:18:10,541 --> 00:18:14,261 and we kind of maybe developed some bad habits during the pandemic of sort of 335 00:18:14,261 --> 00:18:17,881 keeping our distance and making decisions without necessarily touching patients. 336 00:18:18,251 --> 00:18:23,171 But how treacherous is it to kind of, you can see that the allure of 337 00:18:23,171 --> 00:18:26,021 saying, well, gosh, I'm gonna be looking inside the person's body. 338 00:18:26,381 --> 00:18:27,791 So what does the physical exam matter? 339 00:18:27,791 --> 00:18:31,344 But what is the risk of skipping the exam, let's say, because you're 340 00:18:31,344 --> 00:18:34,404 gonna get some imaging and have the imaging drive your decision making. 341 00:18:34,804 --> 00:18:36,664 shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, well, I was trained in the late 342 00:18:36,664 --> 00:18:38,173 20th century which is scary when you think 343 00:18:38,353 --> 00:18:38,823 Tracey: Join the club 344 00:18:38,988 --> 00:18:42,444 shelley-janssen--she-her-_1_12-17-2025_203838: about it, but I still believe that a 345 00:18:42,444 --> 00:18:46,404 meticulous history and physical exam are the hallmarks of a master clinician. 346 00:18:46,464 --> 00:18:51,489 This approach is based on Bayesian logic in which diagnostic tests 347 00:18:51,849 --> 00:18:56,079 provide the highest yield when the pretest probability is already high. 348 00:18:56,409 --> 00:19:00,819 So by using clinical clues to narrow the differential diagnosis first, we can 349 00:19:00,819 --> 00:19:02,409 use tools like x-ray more judiciously. 350 00:19:03,649 --> 00:19:08,459 In our section on plain radiography, in the issue we emphasize using physical 351 00:19:08,459 --> 00:19:14,519 exam to pinpoint maximal tenderness rather than adopting a wider is better approach. 352 00:19:14,939 --> 00:19:19,559 For example, a forearm x-ray is not a substitute for joint specific views When 353 00:19:19,709 --> 00:19:21,929 evaluating a wrist or a elbow injury. 354 00:19:22,329 --> 00:19:24,756 Imaging must be focused to be effective. 355 00:19:25,046 --> 00:19:30,759 You know, so we should be very focused in our use of diagnostics and 356 00:19:30,759 --> 00:19:35,849 use them to support what we already think is going on from the history 357 00:19:35,849 --> 00:19:39,930 and physical exam, rather than to replace the history and physical exam 358 00:19:40,788 --> 00:19:41,688 . Joe: Yeah, absolutely. 359 00:19:41,688 --> 00:19:45,018 It should drive your imaging decisions, and then sometimes 360 00:19:45,018 --> 00:19:47,713 it may make you question the fact that the film looks normal. 361 00:19:48,378 --> 00:19:51,408 You know, you guys talk about that in the issue where if your clinical 362 00:19:51,408 --> 00:19:55,878 suspicion is high and your films are normal, understanding the decreased 363 00:19:55,878 --> 00:19:58,968 sensitivity, you might still make that referral for advanced imaging 364 00:19:58,968 --> 00:20:03,138 and in some cases, and the way you're gonna make that decision is, gosh, 365 00:20:03,198 --> 00:20:04,728 it really hurt pushing on that area. 366 00:20:04,728 --> 00:20:05,958 I'm surprised it's not broken. 367 00:20:06,588 --> 00:20:08,978 But understanding that the film may not show it, you gotta take that 368 00:20:08,978 --> 00:20:10,298 extra step and the exam helps you 369 00:20:10,998 --> 00:20:12,463 shelley-janssen--she-her-_1_12-17-2025_203838: And knowing that mechanism of injury. 370 00:20:12,888 --> 00:20:13,398 Joe: exactly. 371 00:20:13,758 --> 00:20:16,848 Tracey: Yeah, you should know what you're gonna expect before you get your result. 372 00:20:16,848 --> 00:20:17,208 Joe: Tracy. 373 00:20:17,208 --> 00:20:17,928 That's your saying. 374 00:20:17,928 --> 00:20:18,288 I love it. 375 00:20:18,423 --> 00:20:18,843 Tracey: Yep. 376 00:20:18,993 --> 00:20:19,293 Yep. 377 00:20:19,413 --> 00:20:20,823 I can always predict ahead of time. 378 00:20:21,153 --> 00:20:24,166 Not always, but every once in a while you get a surprise, but, you know, no 379 00:20:24,166 --> 00:20:28,456 fishing expeditions allowed, you gotta be thoughtful with what you order and 380 00:20:28,576 --> 00:20:30,239 hopefully you won't get any surprises. 381 00:20:30,569 --> 00:20:33,319 And if you do get a surprise that it's negative, that's another thing 382 00:20:33,319 --> 00:20:36,699 I find a lot of younger clinicians struggle with is they think a lot of 383 00:20:36,699 --> 00:20:38,429 tests are positive or negative, and. 384 00:20:38,744 --> 00:20:41,954 It's really not, especially with x-rays, it requires interpretation. 385 00:20:42,344 --> 00:20:44,954 You know, one of the standing jokes when I was a resident is if you take 386 00:20:44,954 --> 00:20:47,924 five chest x-rays and you give it to five different radiologists, you're 387 00:20:47,924 --> 00:20:49,334 gonna get five different readings. 388 00:20:49,784 --> 00:20:53,464 So it's not just positive and negative if you don't get what you expect, dig 389 00:20:53,464 --> 00:20:56,734 a little deeper to convince yourself that x-ray is either truly negative 390 00:20:56,734 --> 00:20:58,724 or that, it's not a false negative. 391 00:20:59,274 --> 00:21:02,394 We see a fair number of delayed presentations for motor vehicle 392 00:21:02,394 --> 00:21:05,484 accidents or collisions, whichever you prefer to call it. 393 00:21:05,794 --> 00:21:08,824 Sometimes even one to two weeks later, they walk in later because, 394 00:21:08,824 --> 00:21:11,134 you know, I thought I'd get better in a few days and I didn't. 395 00:21:11,474 --> 00:21:15,714 Or I've now engaged a lawyer and they tell me I need to get checked out because 396 00:21:15,714 --> 00:21:18,263 the insurance has a, time limit on that. 397 00:21:18,633 --> 00:21:21,123 Or even the insurance company themselves advising the patient 398 00:21:21,123 --> 00:21:22,563 to get checks or family members. 399 00:21:22,936 --> 00:21:26,656 Do all of these rules still apply in the people that come in later? 400 00:21:26,656 --> 00:21:29,776 They're either just not getting better or they're not getting worse and they 401 00:21:29,776 --> 00:21:33,466 just wanna get checked, or can we sort of skew the rules a little bit? 402 00:21:33,526 --> 00:21:35,506 You know, when the presentation is later? 403 00:21:36,206 --> 00:21:36,626 shelley-janssen--she-her-_1_12-17-2025_203838: Hmm. 404 00:21:36,866 --> 00:21:37,646 good question. 405 00:21:37,696 --> 00:21:42,466 The clinical significance of a mechanism of injury does not expire with time. 406 00:21:43,096 --> 00:21:43,516 Tracey: Okay. 407 00:21:43,696 --> 00:21:46,516 shelley-janssen--she-her-_1_12-17-2025_203838: just remember that if anything, clinicians 408 00:21:46,516 --> 00:21:50,606 should be more vigilant when evaluating motor vehicle collision patients who 409 00:21:50,606 --> 00:21:53,216 present days or even weeks after the event 410 00:21:53,346 --> 00:21:53,766 Joe: Mm-hmm. 411 00:21:53,846 --> 00:21:55,676 shelley-janssen--she-her-_1_12-17-2025_203838: because many life-threatening conditions 412 00:21:55,676 --> 00:22:00,656 have a delayed onset or present with non-specific symptoms, they're easily 413 00:22:00,656 --> 00:22:02,426 missed without a structured approach. 414 00:22:02,901 --> 00:22:06,951 So regardless of the patient's age, the time elapsed since the accident 415 00:22:07,191 --> 00:22:11,361 or the initial symptoms, every motor vehicle collision victim deserves a 416 00:22:11,361 --> 00:22:16,071 thorough history, a meticulous physical exam, and the rigorous application 417 00:22:16,071 --> 00:22:17,961 of clinical decision support tools. 418 00:22:18,356 --> 00:22:18,646 Tracey: Okay. 419 00:22:18,911 --> 00:22:19,741 shelley-janssen--she-her-_1_12-17-2025_203838: So don't let down your guard 420 00:22:19,766 --> 00:22:20,116 Tracey: Right, 421 00:22:20,161 --> 00:22:20,971 shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, just because they 422 00:22:20,971 --> 00:22:22,231 came in two weeks later. 423 00:22:22,281 --> 00:22:22,941 Tracey: right, right. 424 00:22:22,941 --> 00:22:23,781 Yeah, definitely. 425 00:22:23,781 --> 00:22:27,801 Uh, Make sure you do that full evaluation and don't miss the forest for the trees. 426 00:22:28,501 --> 00:22:28,921 Joe: Mm-hmm. 427 00:22:29,346 --> 00:22:34,266 One of the three example cases that you guys gave was somebody who presented, 428 00:22:34,506 --> 00:22:36,246 I think the dump truck rolled over. 429 00:22:36,556 --> 00:22:38,566 so how about that mechanism of injury? 430 00:22:38,806 --> 00:22:41,356 And the person had multi, you know, their head, their chest hurt, their 431 00:22:41,476 --> 00:22:44,536 back hurt, and they said, well, I got checked out that the trauma center, 432 00:22:44,536 --> 00:22:45,826 and they told me everything was fine. 433 00:22:46,186 --> 00:22:49,156 And then they showed up in urgent care, what, 11 days later. 434 00:22:49,366 --> 00:22:51,406 And you just have to start from square one. 435 00:22:51,406 --> 00:22:53,786 Consider that mechanism of injury. 436 00:22:53,996 --> 00:22:55,976 You can't assume that their workup was normal. 437 00:22:55,976 --> 00:22:58,916 And even if they did some tests that were normal, if the person's still 438 00:22:58,916 --> 00:23:02,046 having some symptoms, they might need that evaluation all over again. 439 00:23:02,046 --> 00:23:05,566 So yeah, I think the delayed presentation is a tricky one. 440 00:23:06,266 --> 00:23:10,866 Hey, for extremity injuries, you talked about training in the what, 20th century? 441 00:23:10,896 --> 00:23:12,546 Late late 20th century, right? 442 00:23:12,741 --> 00:23:13,071 shelley-janssen--she-her-_1_12-17-2025_203838: late 443 00:23:13,206 --> 00:23:14,226 Joe: Late 20th century. 444 00:23:14,571 --> 00:23:14,758 Um, 445 00:23:14,863 --> 00:23:15,163 shelley-janssen--she-her-_1_12-17-2025_203838: Late. 446 00:23:15,388 --> 00:23:15,958 Joe: that's right. 447 00:23:15,958 --> 00:23:19,348 And rice, rice had probably, you know, rest, ice compression elevation had 448 00:23:19,348 --> 00:23:21,978 probably been around for a hundred years maybe, or, something by then. 449 00:23:22,261 --> 00:23:24,454 But we now know a lot more about soft tissue injuries. 450 00:23:24,454 --> 00:23:26,614 Certainly fractures need to be immobilized. 451 00:23:26,894 --> 00:23:29,954 But all the range of soft tissue injuries that we see. 452 00:23:30,059 --> 00:23:32,699 You know, the importance of mobilization we're learning. 453 00:23:32,819 --> 00:23:36,933 And so now we have these new acronyms or initialisms, I guess they're 454 00:23:36,933 --> 00:23:38,523 acronyms because they look like words. 455 00:23:38,523 --> 00:23:41,855 But uh, M-E-A-T and P-O-L-I-C-E. 456 00:23:42,335 --> 00:23:43,685 Can we discuss that a bit? 457 00:23:44,075 --> 00:23:45,335 Are these better than rice? 458 00:23:46,035 --> 00:23:47,625 shelley-janssen--she-her-_1_12-17-2025_203838: Boy, that's a hard one to give up rice. 459 00:23:47,825 --> 00:23:48,240 Joe: I know. 460 00:23:48,295 --> 00:23:49,975 shelley-janssen--she-her-_1_12-17-2025_203838: Evidence is increasingly showing 461 00:23:49,975 --> 00:23:54,415 that the traditional protocols for musculoskeletal injuries specifically 462 00:23:54,415 --> 00:23:59,585 prolonged rest and prolonged icing may actually hinder long-term recovery. 463 00:24:00,308 --> 00:24:03,664 In place of the classic rice method we should use what you 464 00:24:03,664 --> 00:24:05,434 mentioned, police and meat. 465 00:24:05,624 --> 00:24:09,256 Modern sports medicine now favors these methods for treating 466 00:24:09,256 --> 00:24:10,696 musculoskeletal injuries. 467 00:24:10,816 --> 00:24:14,596 So meat stands for movement exercise analgesic. 468 00:24:15,296 --> 00:24:21,476 and police stands for protection, optimal loading, ice compression and elevation. 469 00:24:22,176 --> 00:24:28,206 The shift focuses on optimal loading and early mobilization because 470 00:24:28,296 --> 00:24:31,956 you know, bone tendon and muscle tissue require controlled stress 471 00:24:31,956 --> 00:24:33,576 to stimulate the healing process. 472 00:24:34,056 --> 00:24:37,866 Movement is now optimized or prioritized over total rest. 473 00:24:38,566 --> 00:24:42,316 furthermore, icing should be limited to the first 12 hours post-injury. 474 00:24:42,646 --> 00:24:47,256 Extended use can restrict blood flow and delay the mobilization, which we know 475 00:24:47,256 --> 00:24:52,928 is now necessary for tissue repair . So, ice you know, very limited and early 476 00:24:52,928 --> 00:24:55,438 mobilization., Protection of the joint. 477 00:24:55,628 --> 00:24:58,013 Load bearing is safely determined by pain. 478 00:24:58,133 --> 00:25:00,433 So, it's a little bit more complicated than rice. 479 00:25:00,692 --> 00:25:01,612 we've gotta get used to it 480 00:25:01,681 --> 00:25:02,101 . Joe: Mm-hmm. 481 00:25:02,436 --> 00:25:03,795 A little more judgment along the way. 482 00:25:03,795 --> 00:25:07,275 And I found that in My own injuries that you know, kind of getting 483 00:25:07,275 --> 00:25:10,495 moving sooner , I got better than when I babied it too much. 484 00:25:10,495 --> 00:25:13,705 So it's good to see that that's been validated for patients too, 485 00:25:14,405 --> 00:25:15,725 shelley-janssen--she-her-_1_12-17-2025_203838: If you can immediately walk on that 486 00:25:15,725 --> 00:25:16,805 ankle sprain, you're better off 487 00:25:16,855 --> 00:25:17,365 Joe: doing it. 488 00:25:17,365 --> 00:25:17,605 Mm-hmm. 489 00:25:17,750 --> 00:25:18,040 Tracey: Yeah. 490 00:25:18,275 --> 00:25:18,755 shelley-janssen--she-her-_1_12-17-2025_203838: yeah. 491 00:25:18,870 --> 00:25:19,160 Yeah. 492 00:25:19,190 --> 00:25:21,110 Joe: You remember the bulky Jones dressing 493 00:25:21,240 --> 00:25:21,460 Tracey: God. 494 00:25:21,717 --> 00:25:22,317 Joe: No more. 495 00:25:22,685 --> 00:25:22,975 shelley-janssen--she-her-_1_12-17-2025_203838: Good. 496 00:25:23,415 --> 00:25:24,945 Tracey: Yeah, definitely, definitely. 497 00:25:25,645 --> 00:25:28,485 All right, so let's just discuss discharge instructions. 498 00:25:28,485 --> 00:25:30,225 I'm the queen of discharge instructions. 499 00:25:30,225 --> 00:25:34,005 I write all these comprehensive things about how to treat yourself and what to 500 00:25:34,005 --> 00:25:37,635 look out for and when to seek further care and when it should be coming back to us 501 00:25:37,635 --> 00:25:38,955 and when it should be you go into the ED. 502 00:25:39,655 --> 00:25:40,465 What do you think, Shelly? 503 00:25:40,465 --> 00:25:42,685 What should we include in those discharge instructions? 504 00:25:43,532 --> 00:25:46,202 shelley-janssen--she-her-_1_12-17-2025_203838: I don't think this is anything new or 505 00:25:46,202 --> 00:25:49,862 earth shattering, but, you know, patient instructions should include the immediate 506 00:25:49,862 --> 00:25:53,982 red flags for going to the nearest emergency department, or calling 9 1 1. 507 00:25:53,982 --> 00:25:57,602 Of course managing the injury like we talked about, MEAT and police 508 00:25:58,052 --> 00:26:01,705 and you know, pain mitigation activity recommendations, as 509 00:26:01,705 --> 00:26:03,475 well as the follow up timeframe. 510 00:26:03,565 --> 00:26:06,300 So, your basic discharge instructions apply here as well. 511 00:26:06,720 --> 00:26:11,250 Tracey: So if you had say, you know, minor MVA, welcome to Florida, 512 00:26:11,250 --> 00:26:15,854 everybody's a rear end MVA, so you know, minor, you didn't send them to the ED. 513 00:26:15,884 --> 00:26:17,234 They've got some minor neck pains. 514 00:26:17,264 --> 00:26:21,284 Maybe some minor low back pain, two days out, no reason to really do 515 00:26:21,284 --> 00:26:23,204 any imaging or, send them forward. 516 00:26:23,204 --> 00:26:26,774 what sort of instructions would you, specific instructions would you give them? 517 00:26:27,474 --> 00:26:29,112 shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, certainly staying mobile. 518 00:26:29,362 --> 00:26:33,262 And I'm a big proponent of physical therapy, so, you know, they're, 519 00:26:33,262 --> 00:26:35,182 they're still hurting several days out. 520 00:26:35,282 --> 00:26:39,657 It'd be a good time to discuss physical therapy and fortunately here in South 521 00:26:39,657 --> 00:26:42,922 Carolina, we can get people into physical therapy pretty quickly and 522 00:26:42,952 --> 00:26:44,572 get them that treatment that they need. 523 00:26:44,572 --> 00:26:47,332 And, you know, physical therapy has such great pain modalities. 524 00:26:47,552 --> 00:26:51,842 You don't have to rely on you know, narcotics that it's really an optimal 525 00:26:51,842 --> 00:26:54,462 thing for these type of patients. 526 00:26:54,712 --> 00:26:57,572 And then certainly, give them an expectation of, when they should 527 00:26:57,572 --> 00:27:01,672 start to feel better and, when it's appropriate to, to seek further 528 00:27:01,672 --> 00:27:03,892 care or return for reevaluation. 529 00:27:04,592 --> 00:27:07,082 Tracey: What sort of medicines would you tell them to do, or what 530 00:27:07,082 --> 00:27:08,077 prescriptions would you write? 531 00:27:08,827 --> 00:27:11,977 shelley-janssen--she-her-_1_12-17-2025_203838: Acetaminophen and nonsteroidals are, 532 00:27:11,977 --> 00:27:17,037 the basis of what we use for, pain management for musculoskeletal injuries. 533 00:27:17,317 --> 00:27:20,897 We tend to avoid narcotics due to the side effects of those. 534 00:27:20,947 --> 00:27:24,777 Or if we do prescribe those in, in very limited short doses. 535 00:27:24,932 --> 00:27:25,352 Joe: Mm-hmm. 536 00:27:25,797 --> 00:27:26,925 shelley-janssen--she-her-_1_12-17-2025_203838: and muscle relaxants 537 00:27:26,925 --> 00:27:28,105 Really don't have a place. 538 00:27:28,425 --> 00:27:30,820 Lots of side effects , and no clinical benefit. 539 00:27:31,240 --> 00:27:33,420 So, generally we don't recommend prescribing those. 540 00:27:34,030 --> 00:27:34,470 Tracey: Right. 541 00:27:34,537 --> 00:27:34,897 Good. 542 00:27:35,587 --> 00:27:36,727 Joe, do you have anything to add? 543 00:27:37,077 --> 00:27:39,844 Joe: Yeah, well, I think so many People say return if worse. 544 00:27:40,101 --> 00:27:42,298 And it's as simple as that, you know, and then all the other 545 00:27:42,298 --> 00:27:45,858 pages that talk about whatever the diagnosis was, they rely on that. 546 00:27:46,218 --> 00:27:50,108 But I think it's important to describe the time. 547 00:27:50,523 --> 00:27:53,793 in addition to that and maybe even being more specific about what worsening 548 00:27:53,793 --> 00:27:56,703 is, you know, worsening headache, worsening pain, development of numbness 549 00:27:56,703 --> 00:28:00,533 or tingling change in color , it'd be somewhat, more descriptive of that, 550 00:28:00,683 --> 00:28:03,550 I think, to let people know when they should expect to feel better. 551 00:28:04,000 --> 00:28:07,150 And if they're not getting better in a particular period of time, that 552 00:28:07,150 --> 00:28:10,420 could indicate something like an undiagnosed fracture or they don't 553 00:28:10,420 --> 00:28:11,650 necessarily have to feel worse. 554 00:28:12,020 --> 00:28:14,600 But they should feel better in two or three days and then even better 555 00:28:14,600 --> 00:28:15,770 another two or three days later. 556 00:28:16,130 --> 00:28:17,706 So that's, I think that's an important part. 557 00:28:17,756 --> 00:28:18,114 They call it 558 00:28:18,114 --> 00:28:19,224 anticipatory guidance 559 00:28:19,298 --> 00:28:19,648 Tracey: right. 560 00:28:19,963 --> 00:28:23,959 Joe: So, that's as important as, return if worse maybe even more important. 561 00:28:24,469 --> 00:28:27,049 Tracey: Yeah, I usually start with, what you're experiencing after a 562 00:28:27,049 --> 00:28:28,849 motor vehicle accident is normal. 563 00:28:29,069 --> 00:28:30,959 Expect to be a little sore tomorrow. 564 00:28:31,319 --> 00:28:33,389 Feel free to take the medications we're providing. 565 00:28:33,389 --> 00:28:37,823 But if any of these things happen, and one of the verbiages that I generally use is, 566 00:28:37,823 --> 00:28:39,653 look, you should be gradually improving. 567 00:28:39,803 --> 00:28:42,743 If you're not gradually improving and you're worsening, then it's time. 568 00:28:42,833 --> 00:28:45,053 And it doesn't really matter what body part that is. 569 00:28:45,243 --> 00:28:47,553 Then it's time for you to be reevaluated again. 570 00:28:47,553 --> 00:28:51,193 So either, you know, come back, go to the ED you know, whatever works. 571 00:28:51,283 --> 00:28:51,583 So. 572 00:28:51,778 --> 00:28:52,198 Joe: Mm-hmm. 573 00:28:52,922 --> 00:28:56,602 You know, Shelly, every so often, Tracy and I will do an issue where we maybe 574 00:28:56,602 --> 00:29:00,022 bring up one thing that was completely new to us, that we read in the issue. 575 00:29:00,202 --> 00:29:03,542 And I'd have to say in this, the heads up concussion discharge 576 00:29:03,542 --> 00:29:06,632 protocol that the CDC has, I was like, well, I've never heard of that. 577 00:29:06,632 --> 00:29:07,262 I mean, I, I have. 578 00:29:07,672 --> 00:29:10,896 Basic understanding and, you know, my recommendations for patients. 579 00:29:11,086 --> 00:29:14,981 But that actually Drove me to the CDC website and there's some cool stuff there. 580 00:29:15,231 --> 00:29:18,801 You can click on the recovery from concussion and there's way more 581 00:29:18,801 --> 00:29:22,851 information than you could put on a discharge plan, or it talks about 582 00:29:22,851 --> 00:29:26,781 what to expect in the first 24 hours, 48 hours, you know, two days. 583 00:29:27,211 --> 00:29:29,251 It's actually very structured and very good. 584 00:29:29,671 --> 00:29:31,141 Can you explain a little bit more about that? 585 00:29:31,141 --> 00:29:33,721 I'm gonna go back and check it out more, but can you tell our 586 00:29:33,721 --> 00:29:37,408 listeners why it's one that you guys particularly recommended in the issue? 587 00:29:38,108 --> 00:29:39,908 shelley-janssen--she-her-_1_12-17-2025_203838: I think it's just a very conservative 588 00:29:40,058 --> 00:29:41,735 treatment plan for concussions. 589 00:29:41,735 --> 00:29:43,258 It, makes a lot of sense. 590 00:29:43,358 --> 00:29:47,448 It's easily followed by patients you know, endorsed by the CDC, 591 00:29:47,668 --> 00:29:49,228 easily accessed by clinicians. 592 00:29:49,378 --> 00:29:52,308 So that's why that one in particular is the one that we recommended. 593 00:29:53,008 --> 00:29:53,668 Joe: it made a lot of sense. 594 00:29:53,668 --> 00:29:54,358 It was very good. 595 00:29:54,808 --> 00:29:58,758 Informative, succinct, wasn't too much information and you could go 596 00:29:58,758 --> 00:30:02,428 to your particular phase of recovery where where it told you what to 597 00:30:02,428 --> 00:30:06,308 do, what to expect when you could expect to move on to the next phase. 598 00:30:06,648 --> 00:30:10,188 And it even went out to, several weeks if somebody were still persistently 599 00:30:10,368 --> 00:30:13,528 symptomatic, what to do two weeks, three weeks after your concussion 600 00:30:13,958 --> 00:30:14,813 which I thought was really helpful. 601 00:30:15,513 --> 00:30:16,803 Tracey: Yeah, you guys should check it out. 602 00:30:17,203 --> 00:30:18,463 So any other closing thoughts? 603 00:30:18,463 --> 00:30:20,443 Are there any other take home points or don't miss things 604 00:30:20,443 --> 00:30:21,043 that we didn't talk about today? 605 00:30:22,253 --> 00:30:23,543 shelley-janssen--she-her-_1_12-17-2025_203838: Yes, I'm glad you asked. 606 00:30:23,616 --> 00:30:28,585 Clinicians must maintain a high index of suspicion for three specific 607 00:30:28,585 --> 00:30:30,025 high risk groups, the elderly. 608 00:30:30,515 --> 00:30:33,635 Those over 65, and as I approach that, I don't think it's so 609 00:30:33,635 --> 00:30:34,985 elderly, but I guess they are. 610 00:30:35,685 --> 00:30:38,415 pregnant patients and patients who are taking blood 611 00:30:38,415 --> 00:30:40,735 thinners or Anti-platelet agents. 612 00:30:40,915 --> 00:30:45,685 These individuals require more exhaustive evaluation and should be referred to 613 00:30:45,685 --> 00:30:50,793 the emergency department more readily than the general population . If a 614 00:30:50,793 --> 00:30:54,873 patient in any of these categories is involved in a moderate to high energy 615 00:30:54,873 --> 00:30:59,223 motor vehicle collision, they cannot be safely cleared in urgent care and should 616 00:30:59,223 --> 00:31:03,213 be transferred for advanced imaging and monitoring to the emergency department. 617 00:31:03,913 --> 00:31:04,738 Tracey: It makes sense. 618 00:31:04,738 --> 00:31:04,978 Yeah. 619 00:31:04,978 --> 00:31:08,478 A lot of times I'll say to somebody who's on , Eliquis or whatever I'm 620 00:31:08,478 --> 00:31:11,268 sorry, but you know, I really think it's better for you to go to the hospital 621 00:31:11,268 --> 00:31:13,968 to make sure there's nothing going on here that we can't handle here. 622 00:31:14,418 --> 00:31:17,902 And they always give me a gimme grief and I'm like, look, that's the way it is. 623 00:31:17,902 --> 00:31:21,872 Blood thinners can be very dangerous and can have delayed presentations and you 624 00:31:21,872 --> 00:31:25,022 don't want me to miss something on you because it could be life threatening. 625 00:31:25,022 --> 00:31:26,912 So yeah, definitely. 626 00:31:27,612 --> 00:31:28,692 Joe: Definitely the right thing to do. 627 00:31:29,392 --> 00:31:31,052 shelley-janssen--she-her-_1_12-17-2025_203838: Oh, yes, I know how stubborn they can be. 628 00:31:31,392 --> 00:31:33,317 But yeah, you, you have to convince them to go. 629 00:31:33,492 --> 00:31:33,762 Tracey: Yep. 630 00:31:33,822 --> 00:31:34,512 Exactly. 631 00:31:34,662 --> 00:31:35,262 Exactly. 632 00:31:35,802 --> 00:31:36,102 All right. 633 00:31:36,102 --> 00:31:37,872 Well thank you so much, Shelly, for coming. 634 00:31:37,872 --> 00:31:40,462 We really appreciate chiming in and giving your 2 cents. 635 00:31:40,462 --> 00:31:41,782 It's so much better in person. 636 00:31:42,092 --> 00:31:44,775 Although, you know, like, Joe said, and I, I totally agree, this was 637 00:31:44,775 --> 00:31:47,755 one of our best written articles that we've ever had which actually 638 00:31:47,755 --> 00:31:49,315 required very little work on my part. 639 00:31:49,315 --> 00:31:50,485 So thank you very much on that. 640 00:31:52,370 --> 00:31:54,890 So we, we appreciate all your, your efforts for that. 641 00:31:54,890 --> 00:31:58,814 And we appreciate you, our listeners, for taking the time to read these articles 642 00:31:58,814 --> 00:32:00,404 and listen to our thoughts about them. 643 00:32:00,434 --> 00:32:01,034 And 644 00:32:01,114 --> 00:32:01,204 Joe: Mm-hmm. 645 00:32:01,459 --> 00:32:03,399 Tracey: we've got some stuff coming down the pike. 646 00:32:03,399 --> 00:32:06,039 I can't remember what they are because I worked all day and I'm tired. 647 00:32:06,229 --> 00:32:08,349 Um, But I know constipation's in there. 648 00:32:08,419 --> 00:32:10,099 Marine envenomations is in there. 649 00:32:10,459 --> 00:32:12,889 Yeah, that's gonna, that's gonna be a good one with lots of pictures of 650 00:32:12,889 --> 00:32:14,209 gross things that live in the ocean. 651 00:32:14,209 --> 00:32:15,169 I may never swim again. 652 00:32:15,479 --> 00:32:18,419 So we got a lot of good stuff coming down the pike, so look forward to that. 653 00:32:18,899 --> 00:32:21,315 And you may be listening to this after the holidays, but I'm gonna 654 00:32:21,315 --> 00:32:24,405 say happy holidays anyway to all our listeners because we're recording this 655 00:32:24,405 --> 00:32:26,095 in December, a week before Christmas. 656 00:32:26,095 --> 00:32:28,595 So, hope everybody has a happy and healthy new year. 657 00:32:29,295 --> 00:32:29,625 Joe: Yep. 658 00:32:30,315 --> 00:32:31,065 Same for me. 659 00:32:32,505 --> 00:32:33,060 care everyone. 660 00:32:33,180 --> 00:32:33,720 Tracey: Alrighty. 661 00:32:33,720 --> 00:32:34,260 Have a good one. 662 00:32:34,320 --> 00:32:34,680 Bye-bye. 663 00:32:35,380 --> 00:32:35,600 shelley-janssen--she-her-_1_12-17-2025_203838: Bye. 664 00:32:36,195 --> 00:32:39,315 Tracey: want to thank everybody to listening to this month's evidence based 665 00:32:39,315 --> 00:32:43,716 urgentology podcast . Just a reminder that subscribers can go to ebmedicine.net 666 00:32:43,906 --> 00:32:47,456 and read the full issue if you want more information, if you haven't already, 667 00:32:48,355 --> 00:32:50,245 Joe: And if you're not a subscriber head to the site. 668 00:32:50,415 --> 00:32:53,185 That's ebmedicine.net to check out what they have. 669 00:32:53,508 --> 00:32:57,118 If you subscribe you'll get access to the article as well as future articles 670 00:32:57,138 --> 00:32:59,738 and the whole archive of all past issues. 671 00:33:00,192 --> 00:33:01,342 Tracey: Look forward to seeing you there.