Know when to go: ER vs. primary care

When you or a loved one needs medical attention, you want to make the right decision and fast. Do you need to go to the emergency room? Will an urgent care clinic be able to help? Or can you wait and make an appointment with your primary care provider? It’s important to understand all of your options before it’s an urgent situation, so you don’t waste time during a medical emergency.

20% of Americans visit the ER at least once a year. With those odds, you need a plan. Click To Tweet

I recently spoke with Dr. Miles Varn, Chief Medical Officer of PinnacleCare, the world’s leading private health advisory firm. Dr. Varn is also a board certified emergency physician who spent 15 years at Inova Fairfax Hospital, a level 1 trauma center in Northern Virginia to get his advice on how to decide which treatment path to take.

There can be cost and time implications to going to the emergency room, which has a higher out-of-pocket deductible than a doctor visit. But in a life-threatening emergency, an emergency room (either hospital-based or freestanding) is your best option. Emergency rooms are always open, and have access to specialized care not available elsewhere. So when is it really worth it to head to the ER?

Don’t Wait

If someone is choking, has stopped breathing or is severely burned, call 9-1-1 and take an ambulance to the ER. The same is true for someone suffering from a head, neck or spine injury, or electric shock.

You should also head to the emergency room for severe chest pain or pressure, which could indicate a heart attack. Stroke symptoms – sudden numbness or weakness, confusion, blurred vision, dizziness, loss of balance or coordination – necessitate an emergency room visit. Seizures, deep wounds, severe allergic reactions, or poisoning are also best treated in the ER. 

 

Schedule An Appointment

If you think you have a common illness like the flu or an ear infection, or a minor injury, there is no need to go to the ER. In addition to the higher out-of-pocket cost, you’re likely to spend a long time waiting. Emergency rooms prioritize patients based on the seriousness of their situation. Those patients described above will need immediate attention. You and your ear infection will be forced to wait.

If you have an established relationship with a primary care provider, you can always call your doctor if you’re unsure about what to do. Even after hours, you should be able to speak with a doctor on call.

 

While we can all hope to never need to make that call to 9-1-1, the truth is that roughly 20% of Americans have at least one emergency room visit in any given year. With those odds, it’s a good idea to think ahead and have a plan in place.

To find the nearest Emergency Room, click here. To schedule an appointment with a primary care physician, click here.

Why the work done at MITIE matters

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MITIE provides training to not only doctors, but law enforcement and emergency medical service providers, too.

elcome to part two of a three part series on MITIE – the Houston Methodist Institute for Technology, Innovation and Education. To recap, MITIE is one of the largest and most comprehensive surgical education and research facilities in the world. The first blog was a photo tour of MITIE, and the next blog will feature a Q&A with Dr. Brian Dunkin, the medical director of MITIE.

If you don’t work in health care, you might be wondering why you should care about MITIE and the work we do here. Well, I’ll tell you! There are two main reasons:

  • MITIE is a medical education facility. MITIE provides surgeons and surgical nurses with an opportunity to learn, practice and perfect new surgical techniques.
  • MITIE isn’t just for health care providers. MITIE also partners with other organizations to provide classes with curriculum tailored to their needs. Think law enforcement, emergency medical service providers, etc.
You want surgeons to know the latest techniques and perform them safely. That's the role of MITIE. Click To Tweet

After nursing school or residency, there are few educational facilities surgeons and nurses can go to learn new techniques. Cue MITIE. New surgical techniques are being developed all the time that make surgeries safer and more successful while decreasing the amount of time needed for recovery. You want your surgeons to know these latest and greatest techniques, but to perform them safely and successfully, the doctors need to practice them.

The alternative to practicing in MITIE is practicing on you – any volunteers? I didn’t think so. One example is laparoscopic colon surgery. Laparoscopic surgery, also known as minimally invasive surgery, uses several small incisions instead of one large incision. A laparoscope, or camera, is inserted through one incision and special laparoscopic surgical instruments are inserted through the other incisions. Laparoscopic colon surgery has been practiced in the United States since the 1990s and has been proven to be less painful with less scaring and allows patients to get back to their normal lives faster.

However, the US adoption rate of this procedure hovers around 40 percent because performing a colon surgery laparoscopically is a difficult procedure that is tedious to learn. In October 2014, MITIE hosted a laparoscopic colon surgery course for seven surgeons and their operating room staff. After spending four days training at MITIE, these surgeons returned to their hospital and were mentored by an expert surgeon during their first laparoscopic colon surgery. Several of the learning surgeons noted that the hands-on class at MITIE coupled with mentoring during their first surgeries at home helped increase their comfort level with the procedure and has benefitted their patients with safer surgeries and faster recovery times.

MITIE also partners with other organizations to provide classes with curriculum tailored to their needs. MITIE recently collaborated with the Harris County Sheriff’s Office (HCSO) Tactical Medicine Program to create the HCSO’s first tactical medicine school. Tactical medicine is the delivery of emergency medical care in a law enforcement special operations scenario. 

“Most people don’t know that the Sheriff’s Office is staffed with deputies who are physicians and paramedics who respond to emergencies to provide care to their fellow officers and citizens until EMS can arrive,” explained Dr. Aashish Shah, a HCSO deputy and administrator over the HCSO’s Tactical Medicine Program. 

During the first tactical medicine school, the HCSO Academy hosted the tactical trainings, such as gun safety, medical extraction, building clearing and distraction devices. At MITIE, the students covered a variety of tactical medical tactics, such as triage, airway management, hemorrhaging and burns.

After a week of lectures and practice, the students put it all together with a live High-Risk Operations Unit (HROU) exercise at MITIE. We simulated an active shooter in a hospital scenario to test the participants’ new understanding of tactical medicine. The learners were assigned to teams of SWAT officers. Each team entered the building and took the stairs to the 5th floor where MITIE is located, just like they would do in a real situation.

MITIE doesn't just educate doctors. The institute also trains law enforcement in tactical medicine. Click To Tweet

When they arrived on the 5th floor, they were greeted with a variety of scenarios, including blaring music, a sound track of dogs barking, rooms that were dimly lit or completely dark and random MITIE staff who would act like innocent people caught on the floor or the suspect the team was looking for. Their mission was to locate an injured Oscar or Mayer (you remember the SimMan patient simulators from part 1, right?), provide care to help stabilize the patient then continue to look for the suspect. At the end of the exercise, the students were credentialed by the HCSO to provide tactical medicine support. 

While you may never take a class at MITIE, the work done here affects you. Next week, we’ll sit down with Dr. Brian Dunkin, the medical director of MITIE, for a Q&A about his work and why he’s so passionate about the MITIE.

Common injuries at RODEOHOUSTON

Rodeo has returned to Houston! Last week, we shared what a typical day was like for the RodeoHouston® sports medicine team. To recap, Houston Methodist serves as the official health care provider for RodeoHouston. The sports medicine team consists of medical volunteers from across the city, who take care of the rodeo athletes and their families before, during and after the competitions.

Just like any other elite athlete, @rodeohouston competitors deal with injuries. Click To Tweet

Just like any other elite athlete, rodeo competitors deal with injuries. But did you know the types of injuries vary by competition? I talked to Dr. Timothy Sitter, the lead orthopedic surgeon on the RodeoHouston sports medicine team, about the rodeo injuries he’s seen in his nearly 20 years working with RodeoHouston.

Tie-Down Roping and Steer Wrestling: The most common injuries in these rodeo athletes occur in the knee. “If you’ve ever wondered why the dirt on the stadium or arena floor is being tilled up between events, it’s to keep it soft for events like tie-down roping and steer wrestling,” Dr. Sitter said. “These cowboys are coming down off their horses fast, so they keep the dirt around one foot-thick and soft because hitting a hard surface, like packed dirt, can cause a lot of damage to the knee.”

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Team Roping: As part of this event, the cowboy or cowgirl must wrap the rope around their saddle horn a few times after they’ve roped the steer. Because the steer will pull on and tighten the rope, the competitor’s must wrap the rope around the saddle horn quickly and be sure to get their hands out of the way. Many riders have gotten their fingers caught in the rope while wrapping it around the saddle horn causing damage to or even losing a finger.

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Bareback and Saddle Bronc Riding: “Elbow and shoulder injuries are common in this event,” Dr. Sitter said. “The cowboys are holding on to the rope to stay on the horse, so their shoulder and elbow are under a lot of stress. These athletes deal with a lot of sprains, strains and ligament tears.” Dr. Sitter added that most of these cowboys also wear neck collars to help prevent whiplash.

Barrel Racing: The key to barrel racing is to make tight turns around the barrels. Dr. Sitter said many of the cowgirls will hit their knees on the barrels, which can cause ligament tears and even fractures.

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Bull Riding: One might think that the most common injury in bull riders is caused by whiplash or getting their hand caught in the rope, but the most common injury in these athletes is to the groin and hip. “The cowboys are holding on to the bull with their knees,” Dr. Sitter said. “The groin and hip muscles are straining because the knees are clinching on to the bull. Many bull riders work on increasing the flexibility in their hips to help prevent groin and hip muscle strains.”

No matter the event or injuries, the cowboys and cowgirls at RodeoHouston have a multi-disciplinary team at the ready to take care of them and get them back in the saddle.

Behind the scenes at RODEOHOUSTON

f you live in or near Houston, March is the month you pull out your western gear and become a cowboy or cowgirl to celebrate the return of the Houston Livestock Show and Rodeo™. RodeoHouston® has it all – a BBQ cook-off, mutton bustin’ for the kiddos, bull riders, barrel racers and hit music stars.

While Houstonians enjoy the festivities for the entire month of March, the rodeo contestants come to town to compete for three days before moving on to the next rodeo. Sprains, strains, fractures, concussions – these are just a few of the injuries contestants risk when they enter the competition. To continue their sport, contestants need a team of health care professionals to back them up. That’s why Houston Methodist is proud to serve as the official health care provider for RodeoHouston.

In a typical night, the @RodeoHouston sports medicine team averages 60-70 treatments for the contestants. Click To Tweet

Houston Methodist coordinates the RodeoHouston sports medicine team with medical volunteers from across the city to ensure a multi-disciplinary team is available to care for contestants and their families. For the sports medicine team, the show starts long before you find your seat in NRG Stadium. A typical day in the RodeoHouston training room looks like this:

  • 9 a.m. – 12 p.m. – A physical therapist treats athletes and Rodeo staff (think Rodeo clowns and other support staff) for injuries sustained the night before or pre-existing injuries
  • 12:00 – 1:00 p.m. – Lunch break (eat while you can!)
  • 1:00 – 2:00 p.m. – Restock supplies (we go through a lot of tape and ice)
  • 2:00 – 4:00 p.m. – Prepare for the pre-event madness
  • 4:00 – 6:00 p.m. – The competitions usually start around 6 p.m., so between 4 and 6 p.m. is the madness.

In a typical night, we’ll average 60 to 70 treatments for the rodeo contestants. The cowboys and cowgirls come in to ice sore muscles, get therapy for aches and pains, tape their ankles, ask the primary care physician about a lingering health issue like a cold or get the surgeon’s opinion on a recurring shoulder problem. Our team also performs and reads x-rays on-site. 

At the same time, we’re treating the rodeo athletes’ family members. Many contestants travel with their spouses and children, so they need medical care while on the road, too. It may be the husband of a barrel racer with back pain or the son of a bull rider with an ear infection – the team can take care of them all. 

When the competition starts, the contestants know the same team of medical experts taking care of them in the training room will be standing by in case a ride doesn’t go their way. In the arena, two athletic trainers, two emergency medicine/trauma physicians, a team of paramedics and an orthopedic surgeon are ready to provide care if a rider is injured. In case of a concussion, we have neuropsychologist on call to provide an evaluation and treatment recommendations.

When the rodeo is over and the fans are waiting for the concert to begin, the training room is once again packed with athletes coming in to see the medical staff. While not all injuries that occur on the arena floor are serious, they can cause problems if left untreated before the next rodeo in the next town. 

The next day, the cycle repeats. Although the medical staff may change from day to day, we all have the same mission and provide the same level of care for each of the athletes and their family members.

After three days, the contestants move on to the next rodeo, and at the end of March, the medical staff will go back to their normal practices. So, if you’re heading to the rodeo, keep an eye out for the guys and gals in red vests. We’ll be there all night, every night, keeping the contestants at their best. Yeehaw!

7 questions for an ER nurse

hen minutes count, it’s best to be prepared. Sharon Tatum, a nurse in the Emergency Department, answers seven questions about knowing when to go to the emergency room and how to get the most out of your visit.  

Q: When should I come to the Emergency Department as opposed to an urgent care?

A: There are some conditions that require time-sensitive treatment to improve your recovery (example – stroke and heart attack). In situations that are serious or life-threatening, it is best to go to the ED.

In situations that are serious or life-threatening, it is best to go to the ED Click To Tweet

Q: What can I do to speed up the process?

A: When you arrive, have your identification ready as this allows us to link you with the correct medical record and start a record for your care. It is important to know your history, including allergies, past medical conditions and surgeries because the more we know, the quicker we intervene.

Q: What can I expect when I arrive?

A: You will be greeted by a nurse who will ask you if you are seeking medical attention. This nurse will determine your level of care based on your medical complaint.

Q: Why am I getting tests/treatment done before I see a doctor?

A: The Medical Director has designed protocols to help speed up the care when the ED is busy. Protocols are tests/treatment that can be completed before you are placed in the room. Examples include X-rays, CT scans, intravenous fluid and medication for nausea.

Q: What should I bring with me?

A: It is important to have a list of the medications that you are taking (including herbal supplements) with the name, dose, how often you take the medication and the last time you took the medication. 

Q: I got here first, why did they take someone before me?

A: Patients are brought back to a treatment room based on the medical complaint, test results, type of treatment needed and the type of room available. Please note that a patient may be taken back for X-rays and blood work then return back to the waiting area until a room becomes available.

Q: What is the busiest time? Least busy?

A: Historically the middle of the week tends to be busier and after 11 a.m. Waiting can be difficult, and wait times are dependent on how many patients are in the department and how many diagnostic tests are required for your care. Please know that we are working hard to expedite your care and apologize for any inconvenience it may cause. We are dedicated to keeping you informed of your plan of care.

Recovering from a sports injury

 have been playing football since I was 10 years old. Like most football players, I’ve had sprains and scrapes, but had never experienced an injury that kept me from the game I love. But during a game in 2013, I felt the fear and panic that comes with a season-ending sports injury. 

I’m the starting center for Rice University. Rice and the University of Houston have been sports rivals for years, and the teams have played an annual football game since 1971. On Sept. 21, 2013, we were playing against UH at NRG Stadium. We lined up to kick an extra point when my right arm was caught between our long snapper and a UH player. I felt the weight crushing down on my arm and saw the doctors rushing toward me, but it took me a moment to feel the pain and realize that my right arm was broken in several places. Intense pain was all I could feel, and all I could think was that I’d just experienced my final play of college football.

I was taken off the field and had X-rays taken at the stadium before being transported via ambulance to Houston Methodist Hospital. Dr. Shari Liberman was on call that night. By the time I met her, I was panicking about everything – using my arm again, finishing college, playing football, getting a job, having a normal life. Dr. Liberman calmed me down and explained the extent of my injury and exactly how she was going to fix it. She didn’t sugarcoat anything and told me recovery would be hard, but that regaining normal use of my arm was possible.

I've played football since I was 10. In 2013 I experienced the panic that comes from a sports injury Click To Tweet

I needed surgery as soon as possible, but we had to wait four days for the swelling to go down. Dr. Liberman planned to put my arm back together using titanium plates and screws. However, during surgery she found that the titanium wasn’t going to work because the thread on the screws was too fine for the extent of my injury. She removed the titanium plates and screws and replaced them with stainless steel. Eight hours later, the surgery was done. I stayed in the hospital five more days for observation and treatment.  

For the next two months, my arm was in a locked brace to give the bone time to heal properly, but the brace made even simple tasks difficult. I had amazing family and friends supporting me, but I could not wait to get that brace off. As soon as the brace came off, I started rehabbing with Ricardo Young, a certified hand therapist at Houston Methodist. When Ricardo first started working with me, I was barely able to move my arm because I’d lost so much muscle strength. I had therapy nearly every day for several months and slowly regained my strength and mobility.

Before I knew it, I was able to start training with the Rice athletic staff. A few weeks after that, I was able to work out with the football team again. In June 2014, less than a year after that fateful game and play, Dr. Liberman cleared me to play football again – just in time to start practicing for the 2014-15 season, which will be my last as a Rice college student. 

After such a severe injury, I thought I would never play again, but I’m a starter! It was a feeling of relief and excitement to be back on the field with my teammates. I don’t even worry about my elbow – I just play football. And, it’s all thanks to Dr. Liberman and Ricardo. Go Owls!

Concussion: movies vs. reality

Our hero sinks back into the shadows, waiting for the night watchman to make his regular rounds. He doesn’t have to wait long. He swings with the butt of his pistol and renders the guard unconscious with a blow to the head. “Sweet dreams,” he says. “You’re gonna wake up with a wicked headache.”

Stop the video. For decades, good guys and bad guys (and girls, too) have been knocked out with a bop on the head, a sock to the chin or a quick karate chop. The movies’ all time knockout champ has to be super spy James Bond, who usually comes into consciousness bound and gagged for the next cliffhanger. The hapless detective on The Rockford Files was knocked out pretty much every episode of the TV show’s six-season run.   

We asked Dr. Kenneth Podell, a neuropsychologist and co-director of the Houston Methodist Concussion Center: Is it really possible to smack someone in the head and render them unconscious?

The short answer is yes, it is indeed possible, but the complications come after. “If you hit somebody hard enough with an object to cause unconsciousness, you could also be hitting them hard enough to break the skull,” Podell says. “It depends on the weapon … one with a large surface area (like a frying pan) dissipates the shock over a larger area, while a smaller weapon focuses the force and can easily fracture a skull.”

It doesn't take a big blow to result in a concussion that carries many long-term health effects Click To Tweet

Podell has seen many cases of people suffering long-term effects from concussion after receiving a blow much less violent than those usually depicted in movies. A person coming out of an unconscious episode, waking up as if from a nap, does not happen most of the time. “There’s a kernel of truth there but a blow substantial enough to cause unconsciousness is also very, very dangerous,” he says.

Let’s speed up the video a bit and check out this part: two combatants grapple fiercely in hand-to-hand combat, and the battle is at a deadlock. Suddenly, one uses an explosive head butt to stun his opponent and gain the upper hand.

“Again, this has a bit of truth to it as well … the front, top part of the skull is the thickest part and can theoretically be used as a weapon,” Podell explains. “But remember that’s also the other guy’s thick skull, so the butt-er needs to select a weak point on the butt-ee, like the bridge of the nose or the side of the head.”

Podell cautions that any kind of head injury has the potential to be very serious and have long-term complications. Concussion can cause dizziness, shaky balance, confusion, headaches and memory loss that can linger for weeks or even months. If you suspect you or someone you know may have had a concussion, please immediately seek medical care. 

Like many other physicians, Podell regularly sees things in movies that don’t really line up with real life. He tries to check his expertise at the door, he says, and suspends disbelief to enjoy the fantasy on screen.

Medicine cabinet safety tips

When was the last time you went through your medicine cabinet? Did you know expired medical products can become weaker and less effective or risky due to a change in chemical composition or decrease in potency? Chances are a good portion of your medication is expired or no longer needed. What should you do with it?

The two safest, most effective ways to dispose of expired or unwanted medication are Take Back programs and your household trashcan. Take Back programs aim to provide a safe, convenient and responsible way to dispose of prescription drugs. Because these events are hosted by the Drug Enforcement Administration (DEA), they are able to accept prescriptions that contain controlled substances.

Expired medical products can become weaker and less effective or risky Click To Tweet

In addition, chain pharmacies like Walgreens or CVS offer a program where you can purchase a specially designed, postage-paid envelope for about five dollars. This envelope can be dropped into any U.S. Postal Service mailbox. The package is then sent to a medication incinerator facility. Unfortunately, due to current regulations, they are unable to take back controlled substances through this type of program.

Houston Methodist Pharmacy Services Director, Dan Metzen, explains that most locations will sponsor a program specifically for controlled substances a few times throughout the year when a representative from the DEA is present.

Take Back programs are the most efficient way to dispose of unwanted or expired drugs. They reduce the risk of prescription drugs entering the water or being consumed inappropriately. If there is not a Take Back program in your area, or you would like to dispose of them yourself, the steps are simple.  

Metzen suggests adhering to the instructions given by the American Pharmacist Association (APhA). They recommend that consumers crush medications or dissolve them in water before mixing them with a palatable substance such as kitty litter or used coffee grounds. Make sure you place the substance in a sealed container before tossing it in the trash. To keep personal information confidential, remove or destroy all prescription labels before tossing out medication containers.

You should never flush unused medication unless the label or accompanying patient information specifically instructs you to do so. In cities and towns where residences are connected to wastewater treatment plants, medication that is flushed or poured down the sink can eventually end up in our lakes, rivers, and streams, polluting our waters and impacting aquatic species.

By choosing to dispose of your medication properly and following these medicine cabinet safety tips you are helping reduce the risk of intentional or accidental misuse and preventing them from ending up in our water.

Disaster response: Trading scrubs for military boots

The 2014 hurricane season started on June 1, and thousands across southeast Texas began preparing for what is supposed to be a quiet hurricane season. Across the country and right here at Houston Methodist, there is a unique group of people who are also prepared for hurricane season. But they don’t plan to “hunker down,” instead they run to the disaster.

When footage of a disaster starts rolling in, I’m always amazed by the people who are there within hours helping the homeless and injured. As a nurse practitioner at Houston Methodist, Paula Rupert cares for patients as they enter and leave the operating room for general surgery. As a member of the national Disaster Medical Assistance Team, or DMAT, Paula is one of those people you see rushing into a disaster area.

NDMS
Disaster Medical Assistance Teams (DMATs) are part of the National Disaster Medical System. They provide rapid-response medical care during a terrorist attack, natural disaster or other incident in the United States.

DMATs are groups of medical personnel, including physicians, nurses, and support staff, who are organized to provide rapid-response medical care during a terrorist attack, natural disaster or other incident in the United States. Deployed by the president of the United States, DMATs can mobilize within six hours of notification and can be on site within 24 hours. Deployments can last for up to two weeks, and team members work 14-hour shifts. While deployed, DMATs are set up like MASH units with tents, cots, etc. Team members also have to wear uniforms and boots at all times.

“I volunteered to be on the DMAT team almost ten years ago,” said Paula. “One of my favorite deployments was to the 2013 presidential inauguration to provide medical support in case of an emergency.  Having a real bed, hot showers and warm food during a deployment was a luxury for our team!”

Then, the conversation will turn to the numerous disasters where Paula has provided disaster response emergency medical care, and you can tell the difference in Paula as she recounts the masses of adults and children she has cared for in these extreme circumstances. Within in two weeks of volunteering for DMAT, she was deployed to Florida after Hurricane Charley. Her most recent deployment was to Oklahoma after a deadly tornado hit the small town of Moore and claimed 24 lives in May 2013.

Caring for others in need is not just a job for me,” Paula said. “It’s a way of life. From Florida to Oklahoma, I’ve been able to help people during one of the most devastating times of their lives. This is an experience I wouldn’t trade for anything.”

Caring for others in need is not just a job for me. It’s a way of life Click To Tweet

Usually, Paula and her team rotates being on-call with two other Texas-based teams. This hurricane season, Paula is a member of the strike force team, so she can be deployed at any time. We all hope Paula won’t have to trade in her scrubs for military boots, but just in case, here are some of her best tips for preparing to deal with a hurricane before and after it strikes the coast.

  1. Consider purchasing a battery-powered carbon monoxide monitor. If your carbon monoxide monitor is powered by electricity, it won’t work while the power is out, leaving you susceptible to the odorless, colorless gas that is fatal if inhaled.
  2. Stock up on food that does not need to be refrigerated and bottled water. Food that looks or smells bad or has touched floodwaters should be thrown away. By stocking up on canned and other preserved foods, you can ensure having enough food for you and your family while the power is out.
  1. Avoid standing flood water, especially without proper foot protection. Standing water can hide sharp objects and carry waterborne diseases.
  2. Watch out for wildlife. Standing water can also serve as a breeding ground for mosquitoes carrying diseases. The habitats of wasps, snakes and other creatures can be destroyed by flooding, so they might seek shelter at your house.