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Since the holiday season was just upon us, I will take the opportunity to borrow heavily from the 1956 Cecil B. DeMille movie, The Ten Commandments. The movie portrays the life of Moses, from an infant floating down the Nile through his return to Egypt to lead the Hebrews across the Red Sea.
For the next few paragraphs, think of me as the Moses of Urgent CareWorld, as I attempt to lead you to the land of litigation-free tranquility!
- Know your alphabet.
Even in urgent care, the ABCs are crucial. Patients will occasionally present to the urgent care center in extremis, and it is imperative that the provider secure the ABCs while waiting for 911 to arrive to transport the patient to the closest appropriate emergency department.Many urgent care centers are not set up to handle life threatening events. Ensure that, at the very minimum, you have nasal and oral airways available. That the oxygen tank is filled and that a bag-valve mask is available in the appropriate sizes. Practice “codes” once a quarter so that every member of your staff knows where the equipment is located and what their roles are. It does not happen often, but when it does happen, seconds count. An empty oxygen tank, an unsecured airway, or the absence of a bag-valve mask can lead to poor patient outcomes and getting booted out of Egypt. - Assume every patient is trying to die.
Most providers are not trained to think like this. And, truth-be-told, it is not always the most “positive”way to approach life. “Hello, I’m Dr. Shufeldt, tell me how you are trying to die.”
Seriously, if you approach every patient with this perspective, you will often rule out, at least in your mind (and on the chart), the diseases which will kill them.For example, the patient with a runny nose, nasal congestion, low-grade temp and a “sinus pressure headache” switches from the guy with a sinus infection to “I have considered cavernous vein thrombosis in my differential diagnosis, however the patient does not have visual changes, is not exhibiting signs of increased intracranial pressure, and has a normal fundoscopic examination.” As rare as any of the plagues, yes. Fatal if not caught, yes. Need to rule it out, absolutely, yes! - Document informed-consent discussions.
Here’s what hap- pens: The 40-year-old presents with atypical chest pain, limited risk factors, and a normal EKG. You tell him that he has a normal EKG; however, the “story buys the admission,” at least to the ED, and you would like to send him over. He responds that he will follow up with his PCP in the next day and that he feels fine and does not want to go to the emergency department. You tell him that he re- ally needs to go and you go over the risk-benefit discussion with him. He understands, yet still declines. You document that “Patient will follow up with PCP in AM.” He does not follow up and drops dead three days later from his occluded left anterior descending coronary artery.All I can say is, “Get out your checkbook.” Thirty seconds of documentation would have saved you a potential seven-figure settlement and seven years of locusts. - Document pertinent negatives.Would you ever send someone home with fever, stiff neck and a headache? Of course not. However, if you don’t document the fact that the patient had no meningeal signs, someone looking at the chart with the retrospectoscope would assume you did if it was not documented.
The “crossing the Red Sea” point: if the course of action you are planning to follow ultimately turns out to be the wrong decision, resulting in serious morbidity or mortality, you must ensure that you have documented your reasoning, including the pertinent negatives which influenced your decision.
- Order a pregnancy test, EKG, troponin, etc.
In urgent care medicine, we often only have “one bite of the apple,” so we have to gather as much information as possible to make the appropriate decision.Make sure you are ordering tests which ultimately will support your eventual decision. Not ordering the test means you either did not think about it, or did not realize the importance of knowing the information, unless documented otherwise. Don’t find yourself “adrift down the Nile” without a basket. Order the test.
By the way, a woman post tubal ligation has a one in 200 chance of being pregnant. - They are called “vital signs” for a reason.One of the best answers I have heard in a deposition came from a plaintiff’s expert who was asked why he would not have sent the patient home with the abnormal vital signs. He replied, “They are called ‘vital’ for a reason.”
At least half of the cases I review on behalf of urgent care centers involve sending a patient home with unaddressed abnormal vital signs. When this occurs, and the patient has a bad outcome, you might as well give up your first born, because the outcome is not going to be good. - Trust no one.Patients lie. Staff members misrepresent the facts. Colleagues can be dismissive of patients. Obtain the information yourself, examine the patient yourself, and document on the chart yourself. As importantly, check old records and read your own x-rays, etc. Solely trusting others may lead to you getting bit in the asp!
- Learn from your and others’ mistakes.Mistakes abound; maybe the purpose of my life, like the burning bush, is simply to serve as a warning for others. I hope not. How- ever, if that is my lot in life so be it. If reading this column protects you and, more importantly, your patient from one of the plagues, then it is all worthwhile.
- Do unto others as you would your family.We all know how we want to be treated, and we all know what it means to provide great care and great customer service. So, knowing that, what is stopping you from providing that level of service? Patients (and staff) can be challenging at times; nevertheless, treating them with anything short of the utmost courtesy at the end of the “walk down the mountain” gets you nowhere, and chances are you will have to spend additional time repairing the
“damage to the tablets.” - Follow up on lab and x-ray results.
What is worse than not ordering an indicated x-ray or test? Ordering one and then not communicating the results to the patient.I know of many cases where a lab test or x-ray was ordered and showed a potential life-threatening condition and the patient was never contacted. Months go by, the patient’s symptoms become fulminant, and someone goes back to check the old records and sees the liver enzymes elevated or a mass on the chest x-ray.When that happens, you will be sued on the “loss of a chance” theory and, even worse, the patient will most likely have a bad outcome due to your lack of warning. All you would have had to do is make the call and by painting the proverbial blood on the door, spare the patient their fateful outcome.
After studying the aforementioned Ten Commandments of urgent care medicine, if you still find yourself in a court of law, defending your or your employee’s action, my advice to you is to quote Charlton Heston (Moses in The Ten Commandments) by screaming, “Let my people go!”
At this point, I am sure that at the very least you will have a good chance for an insanity plea.
Deconstructing the Ten Commandments of Urgent Care Medicine
