Urgent Care RAP

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Urgent Care RAP show. Earn CME on your commute while getting the latest practice-changing urgent care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/UCRAPPOD When someone comes in with prostate related symptoms and infection, it’s hard to know if we’re working with prostatitis vs prostate abscess. How can we improve our prostate game? Tarlan Hedayati, MD schools Matthieu DeClerck, MD, and Neda Frayha, MD with her prostate pro-tips.   Pearls: Think about acute bacterial prostatitis when someone presents with symptoms of acute prostatitis AND has the following characteristics: immunocompromised, symptoms > 36 hours, progressive urinary retention, recent antibiotics for prostatitis. Avoid prostate exams in people with neutropenia given theoretical risk of seeding bacteria.   Distinguishing between acute bacterial prostatitis and prostate abscess can be difficult because patients will look sick (fever, tachycardia, abdominal pain) in both cases Suprapubic pain Abdominal pain Urinary retention History of having had prostatitis in the past Pain with defecation or with prolonged sitting Immunocompromised patient Protracted symptoms > 36 hours Progressive urinary retention Patients who have received antibiotics for prostatitis but are getting worse Overlap symptom: Physical exam and CT scan ultimately will help rule out deadly abscess or other Things to make you think more about abscess: Pearl: do not send a PSA during acute prostatitis. Leads to unnecessary worry and future monitoring of PSA levels. Prostate exam tips: Start with palpation of the anal-rectal junction to get a sense if discomfort is coming from the exam itself versus the prostate and examine if there a rectal abscess Palpate the prostate last to feel for bogginess, tenderness Prostate massage is supposed to increase the sensitivity of urine culture by squeezing bacteria out of the prostate into the urethra. However given the discomfort, probably not needed in the emergency or even primary care setting → it should be a quick exam Pearl: avoid prostate exam in people with neutropenia given theoretical risk of seeding bacteria Categories of prostatitis: A urinalysis, gram stain and culture should not have any bacteria Patients have been dealing with for a longer time and are non-toxic appearing Chronically have WBC’s in the urine with no symptoms Diagnosed by biopsy Acute bacterial prostatitis  Chronic bacterial prostatitis Chronic prostatitis or chronic pelvic pain (90% of prostatitis) Asymptomatic inflammatory prostatitis Treatment: E-coli is the bacteria you’re treating against → check your local antibiogram for resistance patterns Prostate abscess  5th or 6th decade of life Immunosuppression End stage renal disease Indwelling catheter Any recent instrumentation of the prostate Potential complication of inflammatory prostatitis At most 2.5% of patients Risk factors:   REFERENCE: Carroll DE, Marr I, Huang GKL, Holt DC, Tong SYC, Boutlis CS. Staphylococcus aureus Prostatic abscess: a clinical case report and a review of the literature. BMC Infect Dis. 2017 Jul 21;17(1):509. Datillo WR, Shiber J. Prostatitis or prostatic abscess. J of Emerg Med. 2013; 44(1):e121-e122 Hsieh MJ, Yen ZS. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 1: Is there a role for serum prostate-specific antigen level in the diagnosis of acute prostatitis? Emerg Med J. 2008 Aug;25(8):522-3. Khan FU, Ihsan AU, Khan HU, Jana R, Wazir J, Khongorzul P, Waqar M, Zhou X. Comprehensive overview of prostatitis. Biomed Pharmacother. 2017 Oct;94:1064-1076.

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Urgent Care RAP show. Earn CME on your commute while getting the latest practice-changing urgent care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/UCRAPPOD Matthieu DeClerck, MD, Mike Weinstock, MD, and Cameron Berg, MD sit down to discuss the diagnostic criteria for acute pancreatitis. They discuss workup: the role of imaging to rule out gallstone pancreatitis. They go into risk stratification of acute pancreatitis as well as Initial management: pain control, IV fluids, nutrition. And ultimate disposition – when to go home? When to admit to a higher level of care?   Pearls: Confirmatory CT scanning is rarely needed to confirm pancreatitis Amylase level is neither as sensitive or specific as lipase. Early feeding, has been shown to improve outcomes in patients with pancreatitis. DIAGNOSING PANCREATITIS Must meet 2 of the following 3 criteria: Clinical presentation that is consistent with pancreatitis - epigastric or upper abdominal pain, frequently radiating to the back often with associated with nausea and vomiting, A lipase level that is three times the upper lab limit of normal for a given assay. Do not order an amylase as it not as sensitive or specific for pancreatitis as lipase. The initial lipase level cannot predict outcomes of patients with pancreatitis and there's no utility in trending lipase levels A CT scan demonstrating pancreatic inflammation consistent with pancreatitis. Note: A CT is rarely needed to confirm pancreatitis but it is the gold standard when there is diagnostic uncertainty. Perform a RUQ ultrasound to rule out gallstone pancreatitis as the most common cause of pancreatitis in the United States is biliary. Patients with biliary tract obstruction will need an ERCP or MRCP urgently that many facilities cannot get 24/7. Obtain a triglyceride level as hypertriglyceridemia is the third most common cause of pancreatitis after alcohol and gallstones. MANAGEMENT Not all patients with acute pancreatitis require hospital stay. Consider the following factors before deciding on admission: Patient vital signs Clinical appearance Ability to perform ADLs Presences or absence of markers of end organ stability Patients with pancreatitis who are admitted should receive adequate fluid resuscitation in the form of 2-3L  of IV crystalloid. Feed the patient orally as soon as possible as early enteral nutrition, rather than bowel rest, has been shown to greatly increase recovery. Patients with gallstone pancreatitis and pancreatitis secondary to hypertriglyceridemia require a higher level of care and should be referred appropriately. REFERENCES: Uhl, W. et al. 2003. IAP Guidelines for the surgical management of acute pancreatitis. Pancreatology. Tenner, S. 2013. American College of Gastroenterology Guidelines: Management of Pancreatitis. The American Journal of Gastroenterology.

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Urgent Care RAP show. Earn CME on your commute while getting the latest practice-changing urgent care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/UCRAPPOD Arun Sayal, MD runs through a thoughtful approach to the knee exam with Neda Frayha, MD, Matthieu DeClerck, MD. One that includes the Mnemonic “SLR-CDEF” as a reminder of what diagnosis we should think about with every knee injury. The mnemonic stands for Septic knee, Locked knee, Referred pain, Compartment syndrome, Dislocation (spontaneously reduced), Extensor mechanism disruption (Over 40, look over the patella – i.e., a quadriceps tear. Under 40 look under the patella  – i.e., a patellar tendon rupture), Fracture (radiographically occult … Pearls: History of injury and patient age often will narrow the differential for post-traumatic knee pain to a short list of possible diagnoses.  Knee dislocations can occur in obese patients with very minor trauma and often spontaneously reduce resulting in ‘normal’ x-rays. Adding oblique x-ray views improves the sensitivity in the diagnosis of tibial plateau fracture. Radiologists ability to read films in a helpful way is highly influenced by the completeness of the history and the differential diagnoses of concern provided to them.     History will often reveal the source of knee pain after trauma, as a full and careful exam is not generally possible due to pain, swelling, and spasm.  For example, patients with an ACL tear will describe four classic historical features:  Deceleration mechanism Swelling within 1 hour Sensation of a “pop” or shift at the knee joint Inability to return to play Patients with a meniscal tear will describe a twisting mechanism. The force of twisting required to tear the meniscus decreases with age.   Elderly patients can simply tear their meniscus by standing up. Valgus (ie: knee bending inward) stress tends to cause different injuries depending on the age of the patient. Salter-Harris Femur and/or Proximal fibula in adolescents MCL injury in younger patients (ie: 20-30 years old) Lateral tibial plateau fractures in older patients (ie: >50 years) Examining patients before reviewing their x-rays will help to determine what to suspect clinically and look for radiographically.  Other advantages of performing a history and physical prior to ordering x-rays include recognizing that additional views may be helpful and providing a more complete history for the radiologist interpreting the films.  A mnemonic for x-ray ‘negative’ injuries of the knee that can prove useful is SLR-CDEF. S - Septic joint L - Locked knee (ie: when the knee cannot be fully extended) from meniscal injury R - Referred pain (e.g. hip pathology) due to Obturator nerve irritation Knee pain which is not reproduced when ranging the knee is suggestive of a referred source of pain.   C - Compartment syndrome  This can easily excluded by palpating the compartments and, when in doubt, comparing the firmness to the contralateral, uninjured side. D - Dislocation (ie: at least 3 of 4 collateral ligaments have been disrupted) Instability is the key finding indicating that a knee dislocation has likely occurred. Knee dislocations commonly will spontaneously reduce, however, even if reduced, patients are at high risk of popliteal artery injury and subsequent ischemia/amputation.  In very obese patients, knee dislocation can occur with minimal force (e.g. stepping off a curb). E - Extensor Disruption (e.g. Patellar fracture, Patellar tendon rupture, and/or Quadriceps tendon rupture) Patient will be unable to extend their knee/lower leg fully against gravity. Patellar tendon rupture generally occurs in younger patients with high mechanism injury. Quadriceps tendon rupture is more often spontaneous or low mechanism in older patients.  F - Fracture (occult)  The most common occult fracture of the knee is a lateral tibial plateau fracture. Oblique knee films can allow for better examination for tibial plateau fractures. Segond fractures involve the tibial spine.  Osteochondral fragments from the patella can be seen radiographically after certain injuries in adolescent athletes, commonly gymnasts, and should be suspected if when there’s significant knee swelling. Osteochondritis desicans is caused by a twisting mechanism (similar to medial meniscal injury) in adolescents.

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Urgent Care RAP show. Earn CME on your commute while getting the latest practice-changing urgent care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/UCRAPPOD Ilene Claudius, MD, Matthieu DeClerck, MD, Lisa Patel, MD, and Mizuho Morrison, DO walk us through the classification of burns in pediatric patients and how this affects management. Criteria and referral to a burn center is discussed as well as the treatment of burns for outpatient vs. inpatient management. Pearls: When calculating the total body surface area burned, only include areas of partial or full thickness injury.  A good burn area estimation tool is that a child’s hand is ~1% of their total BSA.  Any partial and/or full thickness burn involving >15% of the total BSA requires immediate burn center referral. Topical antibiotic ointment is now preferred over silver sulfadiazine for superficial partial thickness burns. All full thickness burns and partial thickness burns to the hands, face, genitals, or over joints should be seen within several days by a pediatric burn specialist.  When considering burns in children, it is useful to classify them into 3 categories: life threatening, common, and negligible burns. Superficial burns (ie: those with erythema only) are of no clinical consequence.  When using a burn formula to calculate the total body surface area (BSA) involved, only the areas of partial and full thickness areas of burn count (ie: with blistering and/or loss of skin).  Partial thickness burns involve the papillary (superficial partial) or reticular (deep partial) layers of the dermis. These are generally very painful. Full thickness burns involve any tissue below the dermis (e.g. fat, muscle, bone etc). These are commonly less painful because the nerves have been destroyed. Overestimation of burned surface area is common, especially in children. Most pediatric burns have a small area of partial thickness surrounded by extensive superficial burn.   A common pitfall is to count the entire area of injury in the estimate of the percent of total BSA burned.  When estimating the percent of total BSA affected in children, the “rule of 9’s” (commonly used in adults) does not work because the proportional anatomy of children is different. The Lund Browder Chart (see references) is useful for estimating total BSA burned in children.  1% of a child’s BSA is also roughly the size of the palm and fingers on one of their hands.  Serious burns may require immediate burn center referral or outpatient follow-up depending on anatomic areas affected and the percent of total BSA burned. Burns involving >15% of the total BSA require immediate burn center referral because of the risk of significant fluid losses.  Lactated Ringer’s is preferred over Normal Saline because of the risk of acidosis. In an ED/ICU setting, fluid management is guided by monitoring urine output.  If possible, it is reasonable to begin IV fluids from UC while arranging an emergent burn center referral.  Heat loss and risk of hypothermia can be significant for children with large burns and covering children with a warm, dry sheet can help mitigate this while arranging transfer. Burns are very painful, so the liberal use of topical and oral analgesia for severe burns is critical. Smaller areas partial thickness burns involving the hands, face, genitals, or extending over a joint or complete circumference of an extremity can cause serious cosmetic and functional impairment and are best managed with close burn center follow-up.  All full thickness burns will require non-urgent burn center follow-up (ie: within several days) because skin grafting will usually be required to allow for healing. Recommended topical wound/burn care depends on the depth of the burn. Superficial burns require no wound care but aloe products or Vaseline™ can soothe discomfort.  Superficial partial thickness burns with intact blisters seem to become infected less often and heal faster if the blister is drained and debrided, but this remains controversial. It is appropriate to NOT debride blisters that are thick walled or

Almost all athletes should undergo a pre-participation physical. While there is significant variability in terms of what may occur during this exam, the ultimate goal is to identify high risk historical or physical exam findings that could increase the risk that the athlete has a bad outcome. Join Matt Baird, MD, and our very own Matthew DeLaney, MD in conversation on this important topic. Like what you hear? Subscribe today to listen to part 2 To view the references and show notes CLICK HERE.

In this Hippo Education bonus conversation, Drs. Jay-Sheree Allen and Neda Frayha sit down with noted health disparities researcher Dr. Utibe Essien, an Assistant Professor of Medicine at the University of Pittsburgh School of Medicine and Core Investigator for the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System. They explore reasons for disparities in the health care outcomes of our patients, disparities in the diversity of our medical profession, and the crucial bridge that connects these two. They close with three concrete steps we all can take to improve our clinical practice and reduce health disparities in our patient communities. CLICK HERE to view the references and join our thriving online community of clinicians

Viral warts are common in children and most resolve spontaneously without treatment. Salicylic acid with regular paring and occlusion is the preferred treatment for cutaneous viral warts. Cryotherapy in combination with salicylic acid is recommended as a second-line treatment. Join Mizuho Morrison, DO, Brittney DeClerck, MD, and Matthieu DeClerck, MD in this free chapter.  Click here for show notes and references  

Race and health are inextricably linked to each other. Pediatricians Nathan Chomilo and Michael Cosimini break down the AAP Policy Statement on the health effects of racism on children. To view the reference for this segment Click Here

In recent weeks, many of our medical organizations have released official statements declaring racism to be a public health crisis. In this introduction to Hippo Education’s new Race and Medicine audio series, Dr. Jay-Sheree Allen sits down with Primary Care RAP host Dr. Neda Frayha for a candid conversation exploring the definition and types of racism, the historical and present-day manifestations of racism in medicine, and potential strategies we all can incorporate into our daily practices to go beyond the hashtag and become true allies.  To view the references for this segment: Click Here  

How do you decide if you should go after a retained foreign body in the urgent care setting?  Dr. Matthieu DeClerk and UC/EM physician assistant Vicky Pittman discuss an approach to cutaneous foreign bodies, including removal tips and post-removal care. To read the show notes and references to this pearl packed segment  Click Here

Drs. Brian Lin and Mike Weinstock discuss alterations to our usual practice patterns of laceration repair in the setting of the COVID pandemic, which include increasing patient throughput through faster closure techniques, reducing total points of contact with the healthcare system by using techniques to obviate the need for a return visit, and habit changes during closure to minimize exposure risk during face-to-face contact.   To view the references and show notes from this podcast Click here

How are you coping with all of the death around us these days? In this Hippo Education update, Primary Care RAP host Dr. Neda Frayha interviews Dr. BJ Miller, a hospice and palliative care specialist at the University of California, San Francisco whose TED talk on what really matters at the end of life has been viewed over 10 million times. Along with Shoshana Berger, Dr. Miller is the co-author of the book, A Beginner’s Guide to the End: Practical Advice for Living Life and Facing Death and founder of the Center for Dying and Living. In this conversation, he helps us come to terms with our own mortality and provide better support to our patients at the end of life.    To view the references and show notes from this podcast Click here

Dr. Mizuho Morrison & Dr.Jenny Beck Esmay both having had covid themselves, briefly discuss the clinical course and what presence of IgM vs. IgG signifies. They discuss what we currently know about antibody testing (national availability, reliability, sensitivity) as well as convalescent plasma transfusion (CPT) and criteria for donation vs. recipient.   To view the references and show notes from this podcast Click here

*Editor's note: As of June 4, 2020, The Lancet article by Mehra MR et al has been retracted. (https://www.thelancet.com/lancet/article/s0140673620313246) In this Hippo Education short, Dr.Salim Rezaie from REBEL EM and Lit Matters critically appraises two papers published on Friday May 22nd, 2020.  He discusses what the evidence shows for both remdesivir & hydroxychloroquine/chloroquine as effective treatment or prophylaxis for COVID-19.   To view the references and show notes from this podcast Click here

COVID-19 causes STEMI’s, arrhythmias and myocarditis?!? Emergency medicine and cardiology guru Amal Mattu, MD chats with Mizuho Morrison, DO on the cardiovascular effects of COVID-19. They discuss: the known pathophysiology of how viral infections affect the heart; Review the new consensus statement from the Society of Cardiovascular Angiography and interventions (SCAI), American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP) on how to manage STEMIs; and lastly discuss how cardiac arrest management differs in this COVID era.    To view the references and show notes from this podcast Click here

Children seem to be less affected than adults by the direct effects of COVID-19 infection, but the pandemic has brought forth other health risks to the pediatric population. Sol Behar interviews Oakland, CA based primary care pediatricians Celine Sparrow and Katie D’Harlingue about the indirect  impact of COVID-19 on children. Topics covered include home school and academic achievement, mental health issues, and nutrition/food insecurity.    To view the references and show notes from this podcast Click here

Shooters abscesses tend to be larger and can lead to a more complicated incision and drainage than typical abscesses that present in the urgent care setting. Jessica Osterman, MD, and Matthieu DeClerck, MD discuss common presentations, complications, and management of these infections. View the show notes and references by CLICKING HERE

In this Hippo Education update, Primary Care RAP host Dr. Neda Frayha interviews regular guest and Infectious Diseases expert Dr. Devang Patel for a discussion of where the IDSA stands on all the potential treatments for COVID-19, a review of the remdesivir paper that is all the rage lately, and a look back on whether or not their very first conversations on the novel coronavirus have stood the test of time.  To view the references and show notes from this podcast Click here

Sol Behar, MD interviews New York City pediatric emergency physician Dr. Ee Tay, highlighting the features of pediatric COVID disease, including an emerging illness that is being compared to Kawasaki Shock Syndrome called “pediatric inflammatory multisystem disease” (PIMS). To view the references and show notes from this podcast Click here

Dr. Matthieu DeClerck talks to Dr. Manie Beheshti on how the healthcare system should approach the “re-opening” of society as we plan the lifting of social restrictions. What safety implementations need to be in place in order to protect our most vulnerable patients. What changes can we anticipate in the healthcare system moving forward?   To view the references and show notes from this podcast Click here

NSAIDs, corticosteroids, and colchicine can all be used to treat acute gout. While these agents have similar efficacy, they have vastly different side effect profiles.  Mizuho Morrison, DO and Matthew DeLaney, MD are your guides on the path to gout knowledge.  To read show notes and references Click Here  Subscribe today for more educational awesomeness. 

Psychiatrist Dr. Melissa Shepard sits down with Primary Care RAP host Dr. Neda Frayha for some real talk on the mental health challenges facing health care workers in the COVID-19 pandemic, and some concrete, tangible tools to help us get through this period. Spoiler alert: it’s more than yoga.  To view the references and show notes from this podcast Click here    

Dr. Matthew DeLaney and Dr. Michael Weinstock sit down to discuss the threat of lawsuits in the midst of the COVID pandemic. The last thing anyone wants to think about is the risk of a lawsuit. Unfortunately, despite the extra challenges posed by our current pandemic, the threat of medicolegal consequences remains. In this segment, we evaluate the unique medicolegal risks that can occur during disaster situations and look at potential sources of medicolegal protection. To view the references and show notes from this podcast Click here  

Drs. Mike Weinstock and Josh Russell, from Urgent Care RAP, just published a landmark COVID study: CXRs obtained from confirmed and symptomatic COVID-19 patients presenting to the UC were normal in 58.3% of cases, and normal or only mildly abnormal in 89% of patients. Matthew DeLaney, MD joins in on the conversation in this important podcast. To view the references and show notes from this podcast Click here

Hospitals are calling clinicians in to help with COVID inpatient care. Part 4 of 4 in this critical care crash course with Dr. Scott Weingart and Dr. Mizuho Morrison on the latest "What if I get called in?" podcast. Just-in-time critical care pearls and pitfalls from the frontlines. Highlights IVF: Keep patients dry but not too dry; check the IVC; Scott prefers LR Furosemide: Only if iatrogenically fluid-overloaded Vasopressor: Norepinephrine sooner rather than later in a hypotensive COVID patient Corticosteroids: Scott's team is doing Dexamethasone 10mg qdaily to any admitted patient with respiratory failure; Methylprednisolone 60mg q6hr for those with rising inflammatory markers (CRP, D-dimer); Methylprednisolone 125mg q6hr if critically ill Anticoagulation: Scott's team is giving prophylactic enoxaparin to all hospitalized patients; if D-dimer is rising, full treatment dose of enoxaparin To view the references and show notes from this podcast Click Here 

Hospitals are calling clinicians in to help with COVID inpatient care. Part 3 of 4 in this critical care crash course with Dr. Scott Weingart and Dr. Mizuho Morrison on the latest "What if I get called in?" podcast. Just-in-time critical care pearls and pitfalls from the frontlines. Highlights Initial COVID ventilator settings: Volume AC mode, Tidal volume of 8 mL/kg of ideal body weight, Respiratory rate of 16 to 18 breaths per minute, FiO2 of 100%, and PEEP of 8 cmH2O Ventilator alarming? Think “DOPE” (displaced tube, obstruction, pneumothorax, equipment failure) To view the references and show notes from this podcast Click Here

Hospitals are calling clinicians in to help with COVID inpatient care. Part 2 of 4 in this critical care crash course with Dr. Scott Weingart and Dr. Mizuho Morrison on the latest "What if I get called in?" podcast. Just-in-time critical care pearls and pitfalls from the frontlines.   Highlights Preoxygenate using CPAP with a viral filter Induce and paralyze while the patient is sitting up Avoid post-intubation auscultation and confirm with ETCO2 Avoid using the BVM until after the patient is intubated To view the references and show notes from this podcast Click Here

Hospitals are calling clinicians in to help with COVID inpatient care. Part 1 of 4 in this critical care crash course with Dr. Scott Weingart and Dr. Mizuho Morrison on the latest "What if I get called in?" podcast. Just-in-time critical care pearls and pitfalls from the frontlines. Highlights COVID “happy hypoxemics” may require intubation if they have:  Any increased work of breathing (tachypnea is common but they should be a “happy tachypneic”) Altered mental status Rising CO2 on serial VBGs Oxygen saturation consistently below 80-85% To view the references and show notes from this podcast Click Here 

Patients with COVID-19 present in a variety of ways and clinicians need to have a low index of suspicion for diagnosis. Management involves emergency referrals for patients with low oxygen saturation. Every patient should be treated as if they could have COVID-19. Mike Weinstock, MD, and Matthieu DeClerck, MD are joined by Frank Illuzzi, MD in this very important segment.  To view the references and show notes from this podcast Click Here

Covid-19 is a rapidly spreading pandemic that has already had world wide ramifications. As Emergency Rooms and Hospitals quickly get overwhelmed by ill patients, the Urgent Care and Primary Care setting play critical roles in appropriately triaging patients that can go home vs those that need to be transferred to the Emergency Department for further evaluation and treatment. The ability to act as levies to the large number of patients during this pandemic will help preserve the ED and Hospital “resources” for those critically ill patients that need it most.  In order to help UC and PC providers make these decisions the College of Urgent Care Medicine (CUCM) and the American College of Emergency Physicians (ACEP) have published a set of criteria that break suspected Covid-19 patients into 2 categories. Category 1, who can go home; and Category 2, who should be transferred to the ED. To view the references and show notes from this podcast Click Here

There are so many active threads, subthreads, and sub-sub-threads of conversation in the medical community surrounding the COVID-19 pandemic. In this Hippo Education Short, Tom Robertson, MD and Steve Biederman, MD of Primary Care RAP’s Paper Chase take 4 hot topics in COVID-19 and examine the literature behind them. They look into the epidemiology of the outbreak in the U.S. and lessons learned, the sensitivity and specificity of SARS-CoV-2 testing, the rates of co-infection with other respiratory viruses, and convalescent plasma as a potential therapy. To view the references and show notes from this podcast Click Here

Mizuho Morrison, DO sits down with emergency medicine pharmacist/toxicologist Bryan Hayes, PharmD to answer some pertinent questions and myth-bust clarifications about pharmaceutical options in COIVD-19 treatment. To view the references and show notes from this podcast click here

Dog bites are common injuries in the US. The dogma that all bites require delayed primary closure and prophylactic antibiotics due to their high risk of infection may not hold true. High risk bites (such as those to the hand, those in immunocompromised patients, extensive deep crush wounds, or grossly contaminated) should be treated more conservatively with consideration for prophylactic antibiotics and delayed closure/healing by secondary intention. Those that are lower risk and likely derive no benefit from prophylactic antibiotics, such as wounds to cosmetic regions of the body (face), should be considered for primary closure and do not appear to have higher incidence of infection compared to those not primarily closed.

Sol Behar, MD interviews Children’s Hospital of Philadelphia NICU doc Joanna Parga-Belinkie, MD to discuss Covid-19 and some of the peripartum issues that come up during the novel coronavirus pandemic for both pregnant moms and their newborns. For the show notes and additional references please click here

Has your clinical practice shifted to telemedicine yet? In the era of COVID-19, clinicians everywhere are being thrown into telemedicine, often without any experience or background knowledge. To help us all get up to speed with this patient care technology, Hippo Education’s Dr. Neda Frayha sits down with Dr. Edward Kaftarian, the Vice Chair of Mental Health at the American Telemedicine Association and CEO of Orbit Health Telepsychiatry. Together they explore the benefits and potential pitfalls of telemedicine, the equipment required, billing and coding considerations, appropriate etiquette, and much more. For more information and to view all the detailed notes and get all the references for this segment please click here

As healthcare professionals, we all recognize the increased risks we face as we care for our patients during the COVID-19 pandemic, but we must also care for ourselves, especially when we come home to our families. It’s normal to be concerned and one of the first things we can do is to start having conversations and plan ahead.   Featuring Aaron Bright, MD and Salim Rezaie, MD

For healthcare professionals who do not often receive immediate laboratory results and diagnostic imaging reports, we’ll highlight unique diagnostic patterns and pitfalls with COVID-19 patients. Featuring Aaron Bright MD, and Salim Rezaie, MD

Most healthcare professionals are familiar with oxygen supplementation and nebulizers, maybe even CPAP/BiPAP. Most of us should have some Basic Life Support (BLS) training to use a bag-valve-mask (BVM) in case of emergency. But there are some of this changes with COVID-19. Featuring Aaron Bright, MD and Salim Rezaie, MD

For healthcare professionals who may get called in to help with COVID-19 patients, you will most likely be asked to help triage and manage ambulatory suspected COVID-19 patients. Here’s what you need to know. Featuring Aaron Bright, MD and Salim Rezaie, MD

Most healthcare professionals know what personal protective equipment (PPE) is, but the reality is that many of us don’t use this everyday and are wondering if we’re doing it correctly. Let’s highlight where people make mistakes and expose themselves to risk. Featuring Aaron Bright, MD and Salim Rezaie, MD

We know that there's a constant flood of information. So, we produced this podcast mini-series to help rapidly onboard healthcare professionals who don’t see COVID-19 patients regularly. We’re going to keep this simple and short, something you can listen to on your drive into work. We'll point out key clinical pearls and pitfalls that we've learned on the frontlines to help keep you and your patients safe. You can do this. Featuring Aaron Bright, MD and Salim Rezaie, MD

Our panel of podcast hosts from a variety of practice settings discuss the logistical and psychological impact of the COVID-19 pandemic on healthcare workers and discuss strategies to mitigate the stress associated with the pandemic. Featuring: Solomon Behar, MD, Neda Frayha, MD, Mike Weinstock, MD, and Matthieu DeClerck, MD References: Click Here

In this Hippo Education Short, Infectious Diseases specialist Dr. Devang Patel and our own Dr. Neda Frayha discuss the latest, clinician-focused updates on the COVID-19 coronavirus outbreak.  Subscribe to Urgent Care:RAP today to support this show and the important work being done to provide you with the most up-to-date medical knowledge from the world experts in the field.  http://www.hippoed.com   References: https://www.hippoed.com/urgentcare/rap/episode/bonusshortcovid/covid19update

Bryan Hayes, PharmD and Mike Weinstock, MD talk through different options to treat various conditions seen in urgent care while balancing the cost of the medication and the patients needs.  There is so much more to Urgent Care RAP each month? Click Here to hear more of what you need to be ready each day and stay in touch with your favorite hosts and contributors.   

Matthew DeLaney, MD  and Rick Pescatore, DO discuss the new IDSA updates regarding the diagnosis, disposition and treatment of patients with possible community acquired pneumonia. There is so much more to Urgent Care RAP each month? Click Here to hear more of what you need to be ready each day and we'll toss in 42 CME hours per year to boot. Pearls: When considering influenza, patients should be tested using NAAT rather than diagnosed clinically. Patients with test proven influenza and infiltrates on CXR should receive oseltamivir, regardless of duration of symptoms, in addition to appropriate antibiotics Patients should be risk stratified using a clinical decision tool, preferably PSI/PORT score,  to determine who is likely to benefit most from hospital admission. Procalcitonin is no longer recommended in the initial evaluation of patients with possible pneumonia.  At the end of 2019, the American Thoracic Society (ATS) and the Infectious Disease Society of America (IDSA) released the first update of the treatment guidelines for community acquired pneumonia (CAP) in >10 years.  IDSA now recommends more routine testing for influenza using nucleic acid amplification testing (NAAT) for influenza because of enhanced sensitivity of NAAT compared to older antigen based testing (>90% vs. ~50% sensitivity).  The IDSA now recommends that patients with test proven influenza and an infiltrate on CXR receive oseltamivir (regardless of duration of symptoms) in addition to appropriate antibiotics. 30% of deaths from influenza come from bacterial co-infection.  IDSA recommends risk stratifying patients with a Pneumonia Severity Index (PSI)/PORT score and recommends against relying heavily on a CURB-65 score to determine which patients will benefit from hospitalization.  Several questions on the PSI rely on lab testing which may not be available in UC, however, the parameters give guidance to factors associated with higher risk of adverse outcomes in patients with pneumonia. https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap Clinical gestalt and assessment are also critical. Patients who appear ill and/or show signs of respiratory distress should be referred immediately to an ED. The guidelines also discuss major and minor criteria suggesting need for ICU admission including need for intubation, hypotension, tachypnea, and multilobar infiltrates. Multilobar pneumonia is a concerning finding and an independent predictor of poor outcome.  All patients with multilobar pneumonia should be referred to an ED for further evaluation. These guidelines suggest that, based on the low quality of evidence supporting utility, procalcitonin is no longer recommended in the diagnosis or treatment of CAP. There may be some limited utility in specific patients (mostly hospital inpatients) however, so this test is probably not going away, but having access to PCT testing from UC shouldn’t be a priority.    References: Metlay JP, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST. PubMed PMID: 31573350 https://www.thennt.com/nnt/corticosteroids-treating-pneumonia/ Eliakim-Raz N, et al. Empiric antibiotic coverage of atypical pathogens for community-acquired pneumonia in hospitalized adults. Cochrane Database Syst Rev.  2012 Sep 12;(9):CD004418. doi: 10.1002/14651858.CD004418.pub4. Review.PubMed PMID: 22972070.

In this Hippo Education Short, Infectious Diseases specialist Dr. Devang Patel sits down with our own Dr. Neda Frayha to discuss what we know so far about the new 2019-n-CoV coronavirus outbreak and what front-line clinicians can do if we suspect a patient of ours might have this viral illness.  References: Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med, 24 Jan 2020. DOI: 10.1056/NEJMoa2001017.  Munster VJ, Koopmans M, van Doremalen M, et al. A novel coronavirus emerging in China - key questions for impact assessment. N Engl J Med, 24 Jan 2020. DOI: 10.1056/NEJMp2000929 Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet, 24 Jan 2020. https://doi.org/10.1016/ S0140-6736(20)30183-5    Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet, 24 Jan 2020. https://doi.org/10.1016/S0140-6736(20)30154-9 Phan LT, Nguyen TV, Luong QC, et al. Importation and human-to-human transmission of a novel coronavirus in Vietnam. N Engl J Med, 28 Jan 2020. DOI: 10.1056/NEJMc2001272 Wuhan Coronavirus - 2019-n-CoV. Infectious Diseases Society of America. https://www.idsociety.org/public-health/wuhan-coronavirus/. Accessed 29 Jan 2020 2019 Novel Coronavirus (2019-n-CoV), Wuhan, China. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/summary.html. Accessed 29 Jan 2020. Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-n-CoV) in Wuhan, China. Centers for Disease Control and Prevention. https://emergency.cdc.gov/han/han00426.asp. Accessed 29 Jan 2020.   Resource: Centers for Disease Control and Prevention 2019-n-CoV PUI Case Investigation Form: https://www.cdc.gov/coronavirus/2019-ncov/downloads/pui-form.pdfpdf icon

Urgent Care’s are well suited to provide care to patients presenting with work related injuries. The delivery of care for these patients does not differ in terms of diagnosis, examination, and treatment for such injuries. No specific accreditation is required to care for this patient population, but an understanding of how to properly chart the patient encounter for these patients is essential to improving the quality and work flow of the care provided for these patients. Join Andy Barnett, MD and Matthieu DeClerck, MD for a look into caring for patients with work related injuries.  

Patients who have cellulitis should have antibiotics selected based on potential for treatment of the cellulitis as well as risks of side effects of the antibiotic. Fluoroquinolone antibiotics have come under increasing scrutiny as we have become more aware of the growing list of possible adverse reactions. In this segment, Mike Weinstock, MD and Matt DeLaney, MD discuss a lawsuit that resulted from questionable use of a fluoroquinolone and offer several lessons surrounding prescription of these antibiotics.  There is so much more to Urgent Care RAP each month? Click Here to hear more of what you need to be ready each day and stay in touch with your favorite hosts and contributors.   

Regardless of your clinical setting, DVT’s are a common entity that we need to be very comfortable working up and treating. And though on the surface the workup and Tx is seemingly straightforward...the truth is there are some nuances and special cases that aren’t completely intuitive...Mizuho Morrison, DO chats with Salim Rezaie, MD  about this topic to reveal some practice changing pearls. There is so much more to Urgent Care RAP each month? Click Here to hear more of what you need to be ready each day and we'll toss in 42 CME hours per year to boot.

We all remember years ago when we took ACLS for the first time, once we got to the section on SVT, they would always say that we should “try vagal maneuvers” before moving to chemical conversion. Today we are going to review diagnosing SVT and re-examine all of the modalities available to those who see these patients present to the ED and Urgent Care. Supraventricular tachycardia (SVT) is a common tachydysrhythmia in young, otherwise healthy patients and can present in any acute care setting.  Drs. Little and Kalnow from the EM Over Easy Podcast (https://emovereasy.com/) sit down with Mizuho to discuss the diagnosis and management of SVT.    There is so much more to Urgent Care RAP each month? Click Here to hear more of what you need to be ready each day and we'll toss in 42 CME hours per year to boot.

Given the recent spike of VAPI (vaping associated pulmonary injury) cases, our HIPPO medical editorial team review the clinical presentation and latest management recommendations for this lung disease. Mizuho Morrison and Sol Behar discuss a recent case, and review the hot-off-the-press published CDC health alert. Take a listen! Pearls: There has been a recent explosion in vape associated pulmonary injury, with serious morbidity and mortality. VAPI has been more commonly associated with THC-containing products ,although a wide variety of nicotine containing products and devices have been reported. Symptoms:  Constitutional symptoms (100%) Respiratory distress and cough (98%) GI symptoms: nausea, vomiting, diarrhea (80%) Fever (30%) Diagnosis: Vaping in past 90 days, bilateral pulmonary infiltrates on imaging, Ground-glass appearance noted on CT chest. Absence of detectable bacterial/viral infection.  Treatment:  Respiratory support Steroids may be beneficial Antibiotics alone do not appear to help as this is not an infectious process, rather an inflammatory one. However given initial mixed presentation, it is not unreasonable to initiate antibiotics until pneumonia is ruled out and diagnosis is confirmed.    References:  Layden JE1,Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Preliminary Report. N Engl J Med. 2019 Sep 6.  https://www.cdc.gov/media/releases/2019/p0906-vaping-related-illness.html https://emcrit.org/ibcc/vaping-associated-pulmonary-injury/  https://health.ny.gov/press/releases/2019/2019-09-05_vaping.htm  How would you like to listen to 6 months of full episodes for free? For the month of September, when you refer a friend to sign up for Urgent Care RAP,  you'll get 6 free months of Urgent Care RAP for yourself--on top of the $25 Amazon gift card you get for every friend who signs up! Start sharing below! Refer a friend