Tracey: You know, one of the standing jokes when I was a resident is if you
take five chest x-rays and you give it to five different radiologists, you're
gonna get five different readings.
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: Hi everyone.
Before we get started today, I want to direct everybody to eb medicine.net.
Please go and check out, the special of the day.
You know, we kind of have a habit of announcing the promos, but people
listen to these sometimes a month or two or three later or anytime after.
So the best thing to do, if you're interested in getting a good deal
or getting the usual deal, which is still a good deal go to eb
medicine.net and check out what's there.
They have the issues of evidence-based urgent care as well as emergency medicine,
pediatric emergency medicine, a lot of other information, and that is where you
will find the foamed site F-O-A-M-E-D which is where you can find our podcast
and a lot of other good stuff too.
Tracey: All right.
Well, I'd like to welcome everybody today.
today's issue is going to be evidence-based urgent care
evaluation management of motor vehicle collisions an evidence-based
approach and back by popular demand.
We have one of the authors with us because that seems to be going over.
So well first author, which isn't here is Dr. Frank DeFazio, who's a clinical
orthopedist that works for doctors care in Columbia, South Carolina.
And the author that is here with us is my friend Shelley Janssen, who's the Chief
Medical Officer of Novant health Urgent Care also in Columbia, South Carolina.
Our peer reviewers were Lisa Campanella and Kyla Howrish.
Hi Shelly.
shelley-janssen--she-her-_1_12-17-2025_203838: Hi Tracy.
Thanks for having me.
Tracey: Oh, we love to have you.
We love talking to the authors.
It just, it just gives it, you know, like a really more
well-rounded approach and to hear the perspective of the author as well.
And people, you know, I, I guess they don't wanna hear us talk all the time,
although actually I guess they kind of do.
But it's nice to add some.
shelley-janssen--she-her-_1_12-17-2025_203838: they do.
Tracey: Yeah, I guess they do.
Yeah.
But it's kind of nice to have some special guests, and we're actually gonna try to
start doing this a little more frequently.
so stay tuned to this.
So Shelly, could you tell us what prompted you to write this
issue on motor vehicle accidents?
Did you see the need or was it something that you're passionate about?
Did you see a lot of these patients being handled incorrectly?
Why'd you wanna do it?
shelley-janssen--she-her-_1_12-17-2025_203838: Sure.
Well, the inspiration for this article came from a clear clinical
need as the chief medical Officer of a large urgent care group.
I've seen firsthand how emergency department overcrowding and rising
healthcare costs are driving more and more motor vehicle collision
patients into urgent care centers.
To support urgent care clinicians, I collaborated with Dr. Frank DiFazio.
He's an experienced orthopedic surgeon and AI innovator.
We realized that many urgent care clinicians haven't received
formal training, specific to the complexities of motor vehicle injuries.
So with the goal of improving patient outcomes, we wrote this EB Medicine
issue to bridge the educational gap, giving giving clinicians the confidence
to make safe triage decisions and the tools to provide evidence-based care.
Tracey: Yeah, I think that's definitely so needed.
although in the beginning most urgent care providers were emergency medicine trained
now a lot of them are family medicine trained and that may not be something that
they've really had a whole lot of exposure to while they were doing their training
and now they're plopped into urgent care and have to deal with some of these things
that they may be less comfortable with.
We also see a lot of the, people a few days afterwards, you know, and,
maybe not somebody that would think, you know, why am I still in pain?
Or that sort of thing, and not something that really needs to go to the ED, but
somebody that's gonna present to us.
So, yes, and I totally agree.
There's a lot of, people that are uncomfortable or have trouble with this.
So I think this was a great issue for us to bring to the forefront to educate
our readers and urgent care clinicians.
Joe: Yeah, I thought it was great how you brought so much information together.
You know, when you think about sometimes reading something like this, you could
actually do a whole paper just on neck pain or chest trauma, and you've actually
covered a lot of different body areas.
It could be injured really well.
Went over the evidence and talked about, you know, what the same
way of evaluating these patients.
One of the most important take home points, I thought was kind of the
importance of the primary survey.
You know, vitals pop up there for us, hopefully or if we're seeing somebody
right away, maybe they're getting taken as we're seeing the patient.
GCS age and then beginning to ask those questions where the answers
might characterize the patient at being high risk, you know,
what was the mechanism of injury?
Are they on any blood thinning medications?
Those sorts of things.
And to have in our mind ahead of time, what sort of patient we're gonna refer
to the ED call 9 1 1 and refer to the ED without doing any further testing.
Can you flesh that out a little bit better for us?
shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, sure Joe.
You know, as a clinician, you should never assume an ambulatory motor
vehicle collision patient is stable.
All All victims, regardless of age or timing, require an evaluation
in accordance with advanced trauma life support A TLS guidelines.
Triage decision should be driven by the primary survey.
And as such, you know, clinicians should contact EMS immediately.
For instance, if a patient has a Glasgow Coma score less than 14,
low oxygen saturation, low systolic blood pressure, or tachycardia.
And another point I'd like to make is because the mechanism of injury
determines how physical forces affect the body at the time of impact.
It is really the foundation of trauma triage in addition to the vital
signs that we just talked about.
So in urgent care, the mechanism of injury and associated injury patterns
often will provide a more reliable insight into the potential serious or
life-threatening injuries more than the patient's clinical appearance especially
in those cases of delayed presentation.
Tracey: Yeah, that's good advice for anything, not just MVAs.
I mean, it took me a long time to realize that with a mechanism of injury, you know,
you can really predict what the injury is gonna be before you even get that
x-ray or, do those further evaluations.
So, so important to really flush that out when you're taking your history.
So one of the biggest things that I see in practice, and I know a lot
of my colleagues see in practice is clinicians ordering a lot of plain
films on cervical and lumbar spines.
And in my opinion, you're not ruling out anything with that especially in a trauma
patient with a high pretest probability of a possible neck or a lumbar spine injury.
Can we talk about some of the pitfalls of, thinking that you're, doing anybody
any good by ordering plain films and when should we escalate that to a higher level?
shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, that, that's a common
problem we see in urgent care just because plain films are available.
But you know, for post NVC imaging, non-contrast, CT is the gold standard
for head, face and spine injuries.
Clinicians should be aware that plain x-rays miss approximately 50% of
significant cervical spine fractures.
Tracey: 50%.
shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, exactly.
So, therefore, they should not be used to clear a patient's c-spine.
Use of well-established clinical decision tools such as the Canadian
C-Spine rule can help guide clinicians in determining which of those patients
require advanced cervical spine imaging.
And you also mentioned thoraco lumbar injuries.
You know, CT is the definitive tool for those injuries as well.
While CT has a 99% sensitivity rate, plain films miss roughly one in four unstable
fractures, and then thoraco lumbar spine.
Yeah.
So, when you think about those statistics, it's pretty scary.
This is particularly critical in the case of burst fractures, which are
frequently misidentified as stable compression fractures on plain films.
Although no validated clinical decision criteria exists for imaging
blunt trauma, thoraco lumbar spine injuries, urgent care clinicians
should follow evidence-based guidelines for identifying patients at risk.
Those include patients over the age of 65.
Patients involved in motor vehicle collisions that have a high risk
mechanism of injury, those with back pain, thoracolumbar spine tenderness
on examination neuro deficits or distracting injuries, which may
make it difficult to identify a significant thoracolumbar spine injury.
Joe: You know, taking a step back from CT being the best test for those areas and
deciding who we're gonna get the tests on, or in most cases, who we're gonna
refer to the ED to do that because we don't have access to CT in urgent care.
I thought it was really interesting, the statistic that you all cited,
that nearly a quarter of patients 65 and older with cervical spine
fractures are entirely asymptomatic.
And we know from the Canadian C-spine rule itself that generally
if you're 65 or older, you can't use the rule to rule people out.
So if there's some suspicion you're gonna go ahead and get the imaging,
NEXUS doesn't really have, age as, part of the decision making criteria, but we
do know that that does not work well.
And it's been proven that that doesn't work well in patients 65 or older,
that that sensitivity is at like 60%.
So almost a coin toss.
But should we really send every MVA patient 65 or older to the ED for CT?
You know, the rule tells us who we don't need it on doesn't necessarily
tell us that we need to do that.
How do you manage that and for CT or even the head injury rules, should we
just kneejerk and send everybody there?
Is there room for some clinical judgment or shared decision making,
that sort of thing with these patients?
What do you think?
shelley-janssen--she-her-_1_12-17-2025_203838: Yeah.
When Dr. D made this recommendation, we realized and it was gonna be the most
controversial stance of this issue.
So we did it with great, great care you know, with the rigorous literature review.
Supporting the stance age related anatomical changes in comorbidities
significantly increase the risk of occult and high level fractures in the elderly.
while younger patients have peak mobility and thus more injuries in the C four
to C seven cervical segment the aging spine undergoes degenerative changes
that stiffen these lower vertebrae.
So this shifts the point of max mobility and the shifts the risk of
injury to the C one and C two segment.
Consequently C two fractures are the most common cervical injury in geriatric
patients, followed by C one fractures.
Furthermore, comorbidities such as ankylosing spondylitis, rheumatoid
arthritis, spinal stenosis, and decreased bone density further
predispose this population to significant cervical spine injury.
Essentially the available literature suggests that some clinically
significant asymptomatic injuries may be missed when imaging is not
performed in patients age 65 and older.
When you consider the potential harm of a missed cervical spine injury,
particularly in the C one and C two region we recommend cervical ct for
geriatric patients suffering any level of motor vehicle collision injury.
So yes, the answer is yes.
We recommend they all go.
Joe: Yeah, I would tell You from ED practice that, uh, if that patient shows
up in the ED, they're gonna get a CT.
For myself when I'm working there and my colleagues, it's, you know, automatic.
So So the idea is if you send 'em there, they're gonna get it.
But it sounds like we should be sending 'em, because if they presented
there, they would get it anyway.
Tracey: Yeah, exactly.
shelley-janssen--she-her-_1_12-17-2025_203838: It's the standard of care.
So, you know, we wanna make sure they get the same standard in urgent care
Tracey: Yeah.
I find that some people will do plain films, you know, not necessarily because
they think they're required, or I guess sometimes they do think they're required.
Actually, I do have some nurse practitioners that in my practice
that mVA I'm gonna x-ray the C spines.
But sometimes also, they do them because the patient asks for
them or they do them because the patient's lawyer asks for them.
Should we be doing plain films in that case or should we, use some judgment
here and not do them or CT them?
What's your take on that sort of thing?
shelley-janssen--she-her-_1_12-17-2025_203838: Clinicians should resist the pressure
to order what we call reassurance x-rays for motor vehicle collision victims.
The danger is twofold.
First, plain films can overlook major pathology, giving the
patient a false sense of safety.
second, this mixed diagnosis creates a significant liability
trap for the provider.
Instead, clinicians should adhere strictly to evidence-based guidelines,
such as the Nexus criteria or Canadian C-spine rule to determine
if imaging is actually necessary.
Effective patient communication is essential here.
You know, taking the time to explain the limitations of x-ray can help
resolve patient dissatisfaction over not getting the requested study.
Tracey: Yeah, I find , some issue with the whole lawyer thing.
You know, my lawyer sent me here for x-rays and sometimes I have to bite my
tongue and resist the urge to say, well, then your lawyer can order the x-rays.
but yeah, usually we'll try to, provide some patient education in that, point.
We actually have the benefit of having what we call an MVA follow-up
clinic where there's a group not too far from us that has a lot of
referral base to chiropractors, physical therapy that sort of thing.
And a lot of lawyers will send people there for that sort of thing.
And they can do it there if they need it, but I don't want that liability on me.
you're exactly right on that one.
Joe: Yeah.
That's such an interesting request too, because, when you think
about the lack of sensitivity, they're probably gonna be fine.
And if you saw anything on there, they needed a CT in the first place.
So it's such a weird request . But anyway, they're lawyers,
Tracey: Who knows why they do what they do.
shelley-janssen--she-her-_1_12-17-2025_203838: Not, not doctors.
Joe: Hey, moving uh, superiorly in the body from the neck to the head,
and we have Nexus and Canadian rules for the head too, and head injuries.
Maybe let's take your point of view overseeing uh, a lot of clinics and
having an idea of what's going on, do you think, that there's appropriate
referral for those patients.
Are they sending too many, do people use those clinical decision rules in
practice to help them make the decision?
What do you see and what do you think people should be doing?
shelley-janssen--she-her-_1_12-17-2025_203838: Well to avoid over referring minor
head trauma to the emergency department for further diagnostic studies.
Urgent care clinicians should use validated decision tools like you
do in the emergency department, the Canadian head CT rule.
You mentioned the Nexus,
rules or even the New Orleans criteria.
For patients with a Glasgow Coma score of 15 both the Canadian CT head
rule and the New Orleans criteria are highly effective at catching
clinically significant brain injuries.
However, the Canadian CT head rule is the tool endorsed by the
American College of Emergency Physicians, and it's the one that we
mentioned in the EB Medicine issue.
Because of its higher specificity.
And it, so thus it helps prevent over referral.
And that's the trend we tend to see in the ambulatory, setting.
Too many patients are referred to the emergency department for head injuries.
So by applying the Canadian CT head rule, clinicians can maintain, you know, high
safety standards while reducing the burden of unnecessary CT scans on patients and
the overburdened emergency departments.
Tracey: Yeah, I guess it's kind of a balance, you know, we want people to
err on the side of caution if there's any concern, but, we don't want them
to just knee jerk every head injury to go to the emergency department.
So using those rules are very helpful for trying to weed those patients out.
shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, so, they're not sending enough neck
injuries to the emergency department And they're sending too many head injuries.
Tracey: Yeah.
It's all the matter of balance, right?
So let's go even further south and talk about chest injuries.
So you mentioned in the article that you know, you should really have a
low threshold for chest injuries.
Is plain x-ray ever enough?
Or should we be going for CT even if you have somebody whose vitals are stable?
shelley-janssen--she-her-_1_12-17-2025_203838: well, it kind of depends.
Motor vehicle collisions are the leading cause of significant
blunt thoracic trauma in adults.
And while urgent care providers most frequently encounter just chest
contusions, rib fractures, and maybe pneumothoraces, they must remain
highly vigilant for more severe cardiovascular or pulmonary injuries.
According to the American College of Radiology a standard chest x-ray
is the essential initial study to screen for life-threatening
complications such as pneumothorax, hemothorax, or pulmonary contusions.
And while chest x-rays miss roughly 50% of rib fractures, this is
rarely clinically significant as it seldom changes patient management.
However, for patients with persistent pain or dyspnea, advanced
imaging like CT may be necessary.
Although the majority of urgent care patients with blunt chest wall trauma
do not require a chest CT, immediate EMS transport to the emergency department is
required for those patients who've had a high energy mechanism of injury or are
65 or older have abnormal x-ray findings or concerning symptoms such as hypoxia,
tachypnea, or altered mental status . So, you know, another point I'd like to
make is rib series , are not indicated for evaluation of thoracic trauma.
In fact, we have discontinued rib series in our urgent care centers.
'Cause we really want clinicians to focus on getting that initial chest x-ray.
And that's looking for the sequela of rib fractures that are more important.
Joe: You know, there was a line in the manuscript that I thought
was really important about the importance of physical exam.
And you guys took the time to say, you know, x-rays should
never replace a comprehensive physical exam in post MVC patients.
I think we're under time constraints, obviously seeing a lot of patients,
and we kind of maybe developed some bad habits during the pandemic of sort of
keeping our distance and making decisions without necessarily touching patients.
But how treacherous is it to kind of, you can see that the allure of
saying, well, gosh, I'm gonna be looking inside the person's body.
So what does the physical exam matter?
But what is the risk of skipping the exam, let's say, because you're
gonna get some imaging and have the imaging drive your decision making.
shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, well, I was trained in the late
20th century which is scary when you think
Tracey: Join the club
shelley-janssen--she-her-_1_12-17-2025_203838: about it, but I still believe that a
meticulous history and physical exam are the hallmarks of a master clinician.
This approach is based on Bayesian logic in which diagnostic tests
provide the highest yield when the pretest probability is already high.
So by using clinical clues to narrow the differential diagnosis first, we can
use tools like x-ray more judiciously.
In our section on plain radiography, in the issue we emphasize using physical
exam to pinpoint maximal tenderness rather than adopting a wider is better approach.
For example, a forearm x-ray is not a substitute for joint specific views When
evaluating a wrist or a elbow injury.
Imaging must be focused to be effective.
You know, so we should be very focused in our use of diagnostics and
use them to support what we already think is going on from the history
and physical exam, rather than to replace the history and physical exam
. Joe: Yeah, absolutely.
It should drive your imaging decisions, and then sometimes
it may make you question the fact that the film looks normal.
You know, you guys talk about that in the issue where if your clinical
suspicion is high and your films are normal, understanding the decreased
sensitivity, you might still make that referral for advanced imaging
and in some cases, and the way you're gonna make that decision is, gosh,
it really hurt pushing on that area.
I'm surprised it's not broken.
But understanding that the film may not show it, you gotta take that
extra step and the exam helps you
shelley-janssen--she-her-_1_12-17-2025_203838: And knowing that mechanism of injury.
Joe: exactly.
Tracey: Yeah, you should know what you're gonna expect before you get your result.
Joe: Tracy.
That's your saying.
I love it.
Tracey: Yep.
Yep.
I can always predict ahead of time.
Not always, but every once in a while you get a surprise, but, you know, no
fishing expeditions allowed, you gotta be thoughtful with what you order and
hopefully you won't get any surprises.
And if you do get a surprise that it's negative, that's another thing
I find a lot of younger clinicians struggle with is they think a lot of
tests are positive or negative, and.
It's really not, especially with x-rays, it requires interpretation.
You know, one of the standing jokes when I was a resident is if you take
five chest x-rays and you give it to five different radiologists, you're
gonna get five different readings.
So it's not just positive and negative if you don't get what you expect, dig
a little deeper to convince yourself that x-ray is either truly negative
or that, it's not a false negative.
We see a fair number of delayed presentations for motor vehicle
accidents or collisions, whichever you prefer to call it.
Sometimes even one to two weeks later, they walk in later because,
you know, I thought I'd get better in a few days and I didn't.
Or I've now engaged a lawyer and they tell me I need to get checked out because
the insurance has a, time limit on that.
Or even the insurance company themselves advising the patient
to get checks or family members.
Do all of these rules still apply in the people that come in later?
They're either just not getting better or they're not getting worse and they
just wanna get checked, or can we sort of skew the rules a little bit?
You know, when the presentation is later?
shelley-janssen--she-her-_1_12-17-2025_203838: Hmm.
good question.
The clinical significance of a mechanism of injury does not expire with time.
Tracey: Okay.
shelley-janssen--she-her-_1_12-17-2025_203838: just remember that if anything, clinicians
should be more vigilant when evaluating motor vehicle collision patients who
present days or even weeks after the event
Joe: Mm-hmm.
shelley-janssen--she-her-_1_12-17-2025_203838: because many life-threatening conditions
have a delayed onset or present with non-specific symptoms, they're easily
missed without a structured approach.
So regardless of the patient's age, the time elapsed since the accident
or the initial symptoms, every motor vehicle collision victim deserves a
thorough history, a meticulous physical exam, and the rigorous application
of clinical decision support tools.
Tracey: Okay.
shelley-janssen--she-her-_1_12-17-2025_203838: So don't let down your guard
Tracey: Right,
shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, just because they
came in two weeks later.
Tracey: right, right.
Yeah, definitely.
Uh, Make sure you do that full evaluation and don't miss the forest for the trees.
Joe: Mm-hmm.
One of the three example cases that you guys gave was somebody who presented,
I think the dump truck rolled over.
so how about that mechanism of injury?
And the person had multi, you know, their head, their chest hurt, their
back hurt, and they said, well, I got checked out that the trauma center,
and they told me everything was fine.
And then they showed up in urgent care, what, 11 days later.
And you just have to start from square one.
Consider that mechanism of injury.
You can't assume that their workup was normal.
And even if they did some tests that were normal, if the person's still
having some symptoms, they might need that evaluation all over again.
So yeah, I think the delayed presentation is a tricky one.
Hey, for extremity injuries, you talked about training in the what, 20th century?
Late late 20th century, right?
shelley-janssen--she-her-_1_12-17-2025_203838: late
Joe: Late 20th century.
Um,
shelley-janssen--she-her-_1_12-17-2025_203838: Late.
Joe: that's right.
And rice, rice had probably, you know, rest, ice compression elevation had
probably been around for a hundred years maybe, or, something by then.
But we now know a lot more about soft tissue injuries.
Certainly fractures need to be immobilized.
But all the range of soft tissue injuries that we see.
You know, the importance of mobilization we're learning.
And so now we have these new acronyms or initialisms, I guess they're
acronyms because they look like words.
But uh, M-E-A-T and P-O-L-I-C-E.
Can we discuss that a bit?
Are these better than rice?
shelley-janssen--she-her-_1_12-17-2025_203838: Boy, that's a hard one to give up rice.
Joe: I know.
shelley-janssen--she-her-_1_12-17-2025_203838: Evidence is increasingly showing
that the traditional protocols for musculoskeletal injuries specifically
prolonged rest and prolonged icing may actually hinder long-term recovery.
In place of the classic rice method we should use what you
mentioned, police and meat.
Modern sports medicine now favors these methods for treating
musculoskeletal injuries.
So meat stands for movement exercise analgesic.
and police stands for protection, optimal loading, ice compression and elevation.
The shift focuses on optimal loading and early mobilization because
you know, bone tendon and muscle tissue require controlled stress
to stimulate the healing process.
Movement is now optimized or prioritized over total rest.
furthermore, icing should be limited to the first 12 hours post-injury.
Extended use can restrict blood flow and delay the mobilization, which we know
is now necessary for tissue repair . So, ice you know, very limited and early
mobilization., Protection of the joint.
Load bearing is safely determined by pain.
So, it's a little bit more complicated than rice.
we've gotta get used to it
. Joe: Mm-hmm.
A little more judgment along the way.
And I found that in My own injuries that you know, kind of getting
moving sooner , I got better than when I babied it too much.
So it's good to see that that's been validated for patients too,
shelley-janssen--she-her-_1_12-17-2025_203838: If you can immediately walk on that
ankle sprain, you're better off
Joe: doing it.
Mm-hmm.
Tracey: Yeah.
shelley-janssen--she-her-_1_12-17-2025_203838: yeah.
Yeah.
Joe: You remember the bulky Jones dressing
Tracey: God.
Joe: No more.
shelley-janssen--she-her-_1_12-17-2025_203838: Good.
Tracey: Yeah, definitely, definitely.
All right, so let's just discuss discharge instructions.
I'm the queen of discharge instructions.
I write all these comprehensive things about how to treat yourself and what to
look out for and when to seek further care and when it should be coming back to us
and when it should be you go into the ED.
What do you think, Shelly?
What should we include in those discharge instructions?
shelley-janssen--she-her-_1_12-17-2025_203838: I don't think this is anything new or
earth shattering, but, you know, patient instructions should include the immediate
red flags for going to the nearest emergency department, or calling 9 1 1.
Of course managing the injury like we talked about, MEAT and police
and you know, pain mitigation activity recommendations, as
well as the follow up timeframe.
So, your basic discharge instructions apply here as well.
Tracey: So if you had say, you know, minor MVA, welcome to Florida,
everybody's a rear end MVA, so you know, minor, you didn't send them to the ED.
They've got some minor neck pains.
Maybe some minor low back pain, two days out, no reason to really do
any imaging or, send them forward.
what sort of instructions would you, specific instructions would you give them?
shelley-janssen--she-her-_1_12-17-2025_203838: Yeah, certainly staying mobile.
And I'm a big proponent of physical therapy, so, you know, they're,
they're still hurting several days out.
It'd be a good time to discuss physical therapy and fortunately here in South
Carolina, we can get people into physical therapy pretty quickly and
get them that treatment that they need.
And, you know, physical therapy has such great pain modalities.
You don't have to rely on you know, narcotics that it's really an optimal
thing for these type of patients.
And then certainly, give them an expectation of, when they should
start to feel better and, when it's appropriate to, to seek further
care or return for reevaluation.
Tracey: What sort of medicines would you tell them to do, or what
prescriptions would you write?
shelley-janssen--she-her-_1_12-17-2025_203838: Acetaminophen and nonsteroidals are,
the basis of what we use for, pain management for musculoskeletal injuries.
We tend to avoid narcotics due to the side effects of those.
Or if we do prescribe those in, in very limited short doses.
Joe: Mm-hmm.
shelley-janssen--she-her-_1_12-17-2025_203838: and muscle relaxants
Really don't have a place.
Lots of side effects , and no clinical benefit.
So, generally we don't recommend prescribing those.
Tracey: Right.
Good.
Joe, do you have anything to add?
Joe: Yeah, well, I think so many People say return if worse.
And it's as simple as that, you know, and then all the other
pages that talk about whatever the diagnosis was, they rely on that.
But I think it's important to describe the time.
in addition to that and maybe even being more specific about what worsening
is, you know, worsening headache, worsening pain, development of numbness
or tingling change in color , it'd be somewhat, more descriptive of that,
I think, to let people know when they should expect to feel better.
And if they're not getting better in a particular period of time, that
could indicate something like an undiagnosed fracture or they don't
necessarily have to feel worse.
But they should feel better in two or three days and then even better
another two or three days later.
So that's, I think that's an important part.
They call it
anticipatory guidance
Tracey: right.
Joe: So, that's as important as, return if worse maybe even more important.
Tracey: Yeah, I usually start with, what you're experiencing after a
motor vehicle accident is normal.
Expect to be a little sore tomorrow.
Feel free to take the medications we're providing.
But if any of these things happen, and one of the verbiages that I generally use is,
look, you should be gradually improving.
If you're not gradually improving and you're worsening, then it's time.
And it doesn't really matter what body part that is.
Then it's time for you to be reevaluated again.
So either, you know, come back, go to the ED you know, whatever works.
So.
Joe: Mm-hmm.
You know, Shelly, every so often, Tracy and I will do an issue where we maybe
bring up one thing that was completely new to us, that we read in the issue.
And I'd have to say in this, the heads up concussion discharge
protocol that the CDC has, I was like, well, I've never heard of that.
I mean, I, I have.
Basic understanding and, you know, my recommendations for patients.
But that actually Drove me to the CDC website and there's some cool stuff there.
You can click on the recovery from concussion and there's way more
information than you could put on a discharge plan, or it talks about
what to expect in the first 24 hours, 48 hours, you know, two days.
It's actually very structured and very good.
Can you explain a little bit more about that?
I'm gonna go back and check it out more, but can you tell our
listeners why it's one that you guys particularly recommended in the issue?
shelley-janssen--she-her-_1_12-17-2025_203838: I think it's just a very conservative
treatment plan for concussions.
It, makes a lot of sense.
It's easily followed by patients you know, endorsed by the CDC,
easily accessed by clinicians.
So that's why that one in particular is the one that we recommended.
Joe: it made a lot of sense.
It was very good.
Informative, succinct, wasn't too much information and you could go
to your particular phase of recovery where where it told you what to
do, what to expect when you could expect to move on to the next phase.
And it even went out to, several weeks if somebody were still persistently
symptomatic, what to do two weeks, three weeks after your concussion
which I thought was really helpful.
Tracey: Yeah, you guys should check it out.
So any other closing thoughts?
Are there any other take home points or don't miss things
that we didn't talk about today?
shelley-janssen--she-her-_1_12-17-2025_203838: Yes, I'm glad you asked.
Clinicians must maintain a high index of suspicion for three specific
high risk groups, the elderly.
Those over 65, and as I approach that, I don't think it's so
elderly, but I guess they are.
pregnant patients and patients who are taking blood
thinners or Anti-platelet agents.
These individuals require more exhaustive evaluation and should be referred to
the emergency department more readily than the general population . If a
patient in any of these categories is involved in a moderate to high energy
motor vehicle collision, they cannot be safely cleared in urgent care and should
be transferred for advanced imaging and monitoring to the emergency department.
Tracey: It makes sense.
Yeah.
A lot of times I'll say to somebody who's on , Eliquis or whatever I'm
sorry, but you know, I really think it's better for you to go to the hospital
to make sure there's nothing going on here that we can't handle here.
And they always give me a gimme grief and I'm like, look, that's the way it is.
Blood thinners can be very dangerous and can have delayed presentations and you
don't want me to miss something on you because it could be life threatening.
So yeah, definitely.
Joe: Definitely the right thing to do.
shelley-janssen--she-her-_1_12-17-2025_203838: Oh, yes, I know how stubborn they can be.
But yeah, you, you have to convince them to go.
Tracey: Yep.
Exactly.
All right.
Well thank you so much, Shelly, for coming.
We really appreciate chiming in and giving your 2 cents.
It's so much better in person.
Although, you know, like, Joe said, and I, I totally agree, this was
one of our best written articles that we've ever had which actually
required very little work on my part.
So thank you very much on that.
So we, we appreciate all your, your efforts for that.
And we appreciate you, our listeners, for taking the time to read these articles
and listen to our thoughts about them.
And
Joe: Mm-hmm.
Tracey: we've got some stuff coming down the pike.
I can't remember what they are because I worked all day and I'm tired.
Um, But I know constipation's in there.
Marine envenomations is in there.
Yeah, that's gonna, that's gonna be a good one with lots of pictures of
gross things that live in the ocean.
I may never swim again.
So we got a lot of good stuff coming down the pike, so look forward to that.
And you may be listening to this after the holidays, but I'm gonna
say happy holidays anyway to all our listeners because we're recording this
in December, a week before Christmas.
So, hope everybody has a happy and healthy new year.
Joe: Yep.
Same for me.
care everyone.
Tracey: Alrighty.
Have a good one.
Bye-bye.
shelley-janssen--she-her-_1_12-17-2025_203838: Bye.
Tracey: 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.