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How do you tell if an accident is urgent care time or emergency room time?


JenneinCA
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How do you decide if something is emergency room worthy or urgent care worthy?

My boys, aged 17 and 14, decided to go to lunch this afternoon.  They were riding their bikes, both wearing helmets!, on a bike path to the local strip mall that happens to contain an In-n-Out when my younger child lost control of his bike and crashed.  Absolutely no cars involved, just asphalt bike trail.  He scraped his face, his arms, and his knees.  Older son sends me a text message that explains the situation and the fact they are beginning to walk back home.  At this point I did not know how bad the situation was.

Then I get a message from older son that younger one is asking the same questions over and over and is apparently seeing strange colors.  He asks if he should call 911.  I tell him to call me.  We talk briefly.  I talk to younger son.  He doesn’t ask the same questions to me.  We decide that I will walk to where they are and make a decision when I get there.

Ten minutes later I meet up with them.  Younger son is bloody from his forehead to his chin.  His glasses are scratched.  The bike’s front tire does not spin.  He is talking to older child and me but definitely needs to see a medical pro.  Today.

After a little more time, my husband and the car arrive and we head to the freeway.  I make the executive decision to go to the er instead of urgent care.  I am worried that he has truly bonked his head and the urgent care would send him to the er anyway.  The folks at the er are super nice.  He triages very quickly.  All that blood and his somewhat confused state move him right along.  He gets a ct scan that rules out a concussion and a broken nose.  The braces are really hard on the inside of his mouth but the teeth are all wear they need to be.  Woot!

Ultimately he is bandaged up, told to rest, and we are given a list of things to be concerned if they happen.  He is doing much better now.  He got a nap and some food and both helped. He is taking a shower and then going to bed again.  I will check on him again in the morning.

I am confident I made the right decision this time, but what is the line?  How do you tell when a situation is er time or urgent care time or worse 911 time?   

 

 

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I probably would have gone to urgent care.... I wouldn't have pushed for a CT scan.  CT scans, IMO, should be limited to cases where there has been a loss of consciousness, deteriorating symptoms, aphasia, vision changes or other things that make me think brain bleed instead of brain bruise.  I believe CTs are overused, and given the amount of radiation exposure given relative to a MRI, I err on the side of caution. Have I had them? Yes, but it was when there was no other way around it. There are some scary studies out there re: CT scans and increased risk of leukemia and brain tumors.  

ER: hemorrhage, open fractures, difficulty breathing (of the needing nebulizer treatment/oxygen/epinephrine variety), internal bleeding, deep tissue stuff, wounds gaping more than 1/2", cardiac stuff, temperature over 104F in an older child or adult, etc.

Urgent care: minor wounds that can be glued or stern-stripped, sprains, infections of the can't wait until morning variety (strep and pink eye, imo)....

My doctor's office can actually X-ray for fractures.  During the day, we would head there as my kid could get stitched up for a reasonable copay.  It's the same at urgent care. An ER is a $300 copay + deductible or some serious co-insurance. We avoid it unless life or limb is threatened.

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I would have made the same decision — there would have been no question about going straight to the ER and I absolutely would have insisted on the CT scan. 

I’m so glad to hear that your 14yo is okay, and I’m sure you are very proud of your older son because it sounds like he handled the situation perfectly and did everything he could to take care of his brother. 

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Our urgent care  does x-ray so most injuries go there.

Head Injuries

Spinal Injuries

Allergies

Hand Injuries (friends son had a deep slice they sent us away to ER for a specialist because their is just too many ligaments and tendons)

Orthopedic stuff where a true tear and imaging seems likely.

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Depends on who it is.

If it had been me I would probably be assessing the situation differently (if I am still coherent, of course :) ) as I know what feels right and what does not and can accurately describe symptoms.

Depending on age of child and how accurate I judge his/her assessments of symptoms to be would decide for me if CT scans or MRIs are necessary. I don't even know if local Urgent Care does imaging. Fortunately, I have not had to find out. I used to err on the side of caution with kiddos. If it's me, I tend to take the "wait and see" approach.

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I go to urgent care if it is something I would have gone to my PCP for (but can't get in due to urgency etc) 

Things we have gone to urgent care for: Strep throat, ear ache, infected insect bite, extreme swelling around mosquito bite that needs steroids (dd gets softball size lumps), cellulitis (I am prone to it so it is easy to self diagnosis, but need the script for meds), cut finger that needed stitches, abdominal cramping in my son, Shingles, broken toe (Swelling made it look bent, needed xray), very itchy rash.

Er. Head wound that needed stiches, high fever in baby (tried uc first but they were closed), asthma attack that wasn't stopping,  appendicitis.

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Generally, I go with gut feeling.  It also depends on which UC is open/convenient.  After a lot of experience, I'm more likely to use a UC for illness, ER for injury.

 My closest UC does x-rays on site, but sends them to the ER to be read.  I waited OVER 24 HOURS to find out if my foot was broken again.  It wasn't. A friend waited even longer to see if their kid's arm was broken. It was. But a UC farther out has given us results in 20 minutes.  When ds clearly needed stitches, I called the UC to see if dh should take him there, or drive past to the ER. UC said to bring him in.  They got there and were told they couldn't do it and should go to the ER.

The UC with the great x-ray turn around is also fabulous with sick kids. If only it were the one that's actually closest to us. @@ 

 

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At my old house, it was almost always ER, simply because it was the closest...like within walking distance.  

Around here it’s almost always ER because the urgent care has odd hours (well I consider them odd, for UC anyway), always have long waits, and the couple of times we have been, they aren’t the nicest people.  Plus, there is only one UC in the area, and they are only 3 blocks from the hospital anyway.  

When DD7 broke her are, I called the UC to see how long the wait was.   They said over 3 hours.  So we went to the ER.  They had her back right away, XRay, wrapped up and we were back home with an appointment at the ortho for the next day, within 3 hrs.

 

 

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I don't always know either.  When my son's lip was split open by a dog, we went to UC.  We were told they couldn't treat/stitch up, so we had to go to the ER anyway.  We ended up spending almost 6 hours with wait times and transportation times.  UGH.  

I would have gone to the ER in your case for sure.

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I would have gone to the ER. I would call 911 for something that could be deadly within minutes. I go to the UC if it needs attention today but probably doesn’t matter if it takes a few hours to address. 

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5 hours ago, prairiewindmomma said:

I probably would have gone to urgent care.... I wouldn't have pushed for a CT scan.  CT scans, IMO, should be limited to cases where there has been a loss of consciousness, deteriorating symptoms, aphasia, vision changes or other things that make me think brain bleed instead of brain bruise.  I believe CTs are overused, and given the amount of radiation exposure given relative to a MRI, I err on the side of caution. Have I had them? Yes, but it was when there was no other way around it. There are some scary studies out there re: CT scans and increased risk of leukemia and brain tumors.  

 

I completely agree.  My son, then 13, had an obvious concussion at a baseball game (diving catch, collided with another kid's knee)--he was disoriented, asked the same questions over and over, cried for no reason, flat affect, all of the classic symptoms.  We went straight to the children's ER.  The doctor there gave us a choice:  CT now or just sit there and watch him for a few hours to see if he started to come out of it.  He gave us a time, like 3:00, and suggested we revisit the issue then.  Sure enough, pretty close to 3:00, we saw his symptoms getting better.  The doctor explained that a head CT is not without risk and, since we were sitting in the ER of a facility that could react promptly to any deterioration, we elected the more conservative path.  A CT scan was going to show that he had a concussion; we KNEW he had a concussion.  Heck, the concession stand worker at the park could tell he had a concussion.  Seeing it on a CT scan wasn't going to change his treatment at all, but any time I can opt not to radiate a growing brain, I'll take it.  If I hadn't been in an ER that could have reacted immediately, of course, the answer might have been different, but I very much appreciated the doctor's giving us the choice in this situation.

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I've had multiple concussions, and only lost consciousness with one of them. Head injuries with any other symptom of concussion call for a CT.  The radiation concern is nothing when you think about how many people refuse them and then die of slow brain bleeds later.

Nursing background, Arctic Mama's list is pretty similar to mine. I'd also go to the ER for injuries in the area of the liver, for bleeding lasting longer than 15 minutes (even minor bleeding like nosebleeds), for severe headaches that last longer than 3 days for those with migraines.

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Urgent care for things like UTI, flu test, strep, etc. 

ER or walk in orthopedist for anything else. Urgent care doctors are NOT specialist in reading X-rays, so anything that needs imaging we go to a place with an orthopedist to read them or a radiologist. I've seen so many fractures missed at urgent care centers that I've lost count. 

As someone else said, if i"d go to the regular primary care doctor or pediatrician, urgent care. Broken bone/sprain, we go to the walk in orthopedist clinic (like an urgent care but just orthopedics). Head/back/neck injury we go to ER. 

Oh, and any cut on the face or a deep cut on the hand would be ER, as I want a plastic surgeon to stitch up the face and a hand specialist to do anything major on a hand (so many nerves/etc). 

 

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7 hours ago, JenneinCA said:

How do you decide if something is emergency room worthy or urgent care worthy?

My boys, aged 17 and 14, decided to go to lunch this afternoon.  They were riding their bikes, both wearing helmets!, on a bike path to the local strip mall that happens to contain an In-n-Out when my younger child lost control of his bike and crashed.  Absolutely no cars involved, just asphalt bike trail.  He scraped his face, his arms, and his knees.  Older son sends me a text message that explains the situation and the fact they are beginning to walk back home.  At this point I did not know how bad the situation was.

Then I get a message from older son that younger one is asking the same questions over and over and is apparently seeing strange colors.  He asks if he should call 911.  I tell him to call me.  We talk briefly.  I talk to younger son.  He doesn’t ask the same questions to me.  We decide that I will walk to where they are and make a decision when I get there.

Ten minutes later I meet up with them.  Younger son is bloody from his forehead to his chin.  His glasses are scratched.  The bike’s front tire does not spin.  He is talking to older child and me but definitely needs to see a medical pro.  Today.

After a little more time, my husband and the car arrive and we head to the freeway.  I make the executive decision to go to the er instead of urgent care.  I am worried that he has truly bonked his head and the urgent care would send him to the er anyway.  The folks at the er are super nice.  He triages very quickly.  All that blood and his somewhat confused state move him right along.  He gets a ct scan that rules out a concussion and a broken nose.  The braces are really hard on the inside of his mouth but the teeth are all wear they need to be.  Woot!

Ultimately he is bandaged up, told to rest, and we are given a list of things to be concerned if they happen.  He is doing much better now.  He got a nap and some food and both helped. He is taking a shower and then going to bed again.  I will check on him again in the morning.

I am confident I made the right decision this time, but what is the line?  How do you tell when a situation is er time or urgent care time or worse 911 time?   

 

 

 

For us, the question is usually, "is this going to need more than an X-ray to diagnose and treat in the short-term?" if the answer is "probably not" we go to urgent care. I would take possible concussion to the ER as well. Our last emergency trip, DH had fallen and tore up his shoulder in the process. We went to urgent care, since we were pretty sure there were no breaks. Sure enough, they did X-rays, announced he'd torn muscles and nothing broken, gave him a sling and pain meds, and told him to follow up with his PCP.

 

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1 hour ago, Katy said:

I've had multiple concussions, and only lost consciousness with one of them. Head injuries with any other symptom of concussion call for a CT.  The radiation concern is nothing when you think about how many people refuse them and then die of slow brain bleeds later.

Nursing background, Arctic Mama's list is pretty similar to mine. I'd also go to the ER for injuries in the area of the liver, for bleeding lasting longer than 15 minutes (even minor bleeding like nosebleeds), for severe headaches that last longer than 3 days for those with migraines.

The most updated research does not support a CT scan for a run-of-the-mill concussion.  This is a good summary, and it notes:

"No wonder, then, that the American Academy of Neurology guidelines state in no uncertain terms that "CT imaging should not be used to diagnose [sport-related concussion]."  [2] 

In addition to being ineffective (and expensive), there is another reason for fewer CTs: A 2012 study reported in the British medical journal, The Lancet  [6] found that children and young adults scanned multiple times by CT have a small increased risk of leukemia and brain tumors in the decade following their first scan. A 2013 study [7] suggests that reducing the highest 25% of radiation doses could prevent 43% of those cancers.

The bottom line: parents should make sure a CT scan is really necessary in treatment of their child after head injury."

 

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I call the “811” health assessment and information phone number. I speak to a nurse. She tells me what level of care is needed.

She also alerts my destination to expect me/us and pre-starts the sign-in and assessment process using the information I have provided over the phone.

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6 minutes ago, plansrme said:

The most updated research does not support a CT scan for a run-of-the-mill concussion.  This is a good summary, and it notes:

"No wonder, then, that the American Academy of Neurology guidelines state in no uncertain terms that "CT imaging should not be used to diagnose [sport-related concussion]."  [2] 

In addition to being ineffective (and expensive), there is another reason for fewer CTs: A 2012 study reported in the British medical journal, The Lancet  [6] found that children and young adults scanned multiple times by CT have a small increased risk of leukemia and brain tumors in the decade following their first scan. A 2013 study [7] suggests that reducing the highest 25% of radiation doses could prevent 43% of those cancers.

The bottom line: parents should make sure a CT scan is really necessary in treatment of their child after head injury."

 

 

The point isn't to diagnose a concussion, which can be done purely from symptoms, it's to rule out a more serious slow brain bleed, which can cause permanent brain damage or death. Obviously there is no need for a CT with no symptoms of increased intracranial pressure, but ignoring those symptoms can lead to all kinds of issues.  Perhaps it's because we've taken medically fragile foster kids, but we've had two with damage to their vision due to slow brain bleeds.  I've known a child who died due to the same issue. We've all heard of celebrities who died from them.  3x the risk for leukemia in the next ten years is a minimal risk compared to the permanent brain damage or death in the next two weeks.  This is why a physician goes by symptoms when determining what tests to order.

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26 minutes ago, Katy said:

 

The point isn't to diagnose a concussion, which can be done purely from symptoms, it's to rule out a more serious slow brain bleed, which can cause permanent brain damage or death. Obviously there is no need for a CT with no symptoms of increased intracranial pressure, but ignoring those symptoms can lead to all kinds of issues.  Perhaps it's because we've taken medically fragile foster kids, but we've had two with damage to their vision due to slow brain bleeds.  I've known a child who died due to the same issue. We've all heard of celebrities who died from them.  3x the risk for leukemia in the next ten years is a minimal risk compared to the permanent brain damage or death in the next two weeks.  This is why a physician goes by symptoms when determining what tests to order.

But there are options other than throwing every head injury into a CT machine, e.g., to watch for deteriorating symptoms, significant loss of consciousness, etc.  A basic concussion to an otherwise health child from falling off of one's bike, or from diving into another kid's knee, is unlikely to result in a brain bleed.  So you sit in the ER and wait for 2 or 3 hours instead of throwing every head injury into a CT.  A medically fragile child is not what we're talking about here; well, it's not what I am talking about!  I just don't want everyone whose kid has a concussion to think the doctor is committing malpractice by not rushing him into a CT scan.  That is usually both an unnecessary risk and an unnecessary expense.

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Kudos to you 17 yo for a great reaction in this situation!  I struggle with the decision on these "border line" situations as well.  The problem is that every situation is different and every person is different and it's impossible to tell how an injured individual is going to respond. In addition, local medical clinics, dr's offices and ERs offer very different treatment, so it's good to know what you have available to you specifically.   I don't think there is a blanket statement of when to go and when not to go to ER.  

Sounds like you and your family assessed this situation well. 

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31 minutes ago, plansrme said:

But there are options other than throwing every head injury into a CT machine, e.g., to watch for deteriorating symptoms, significant loss of consciousness, etc.  A basic concussion to an otherwise health child from falling off of one's bike, or from diving into another kid's knee, is unlikely to result in a brain bleed.  So you sit in the ER and wait for 2 or 3 hours instead of throwing every head injury into a CT.  A medically fragile child is not what we're talking about here; well, it's not what I am talking about!  I just don't want everyone whose kid has a concussion to think the doctor is committing malpractice by not rushing him into a CT scan.  That is usually both an unnecessary risk and an unnecessary expense.

 

Apparently you keep missing the part where I said THE PHYSICIAN DETERMINES THE NEED FOR FURTHER TESTING DEPENDING ON SYMPTOMS.  These are the same symptoms that they give you a list of to return to the ER after you're diagnosed with a concussion.  If you already have multiple of those symptoms after only a few hours in the ER they're going to order imaging right away. I NEVER said every single concussion needs a CT. 

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Our insurance will help decide. When my son broke his leg, they directed us to urgent care, and he received excellent care and a great referral to an orthopedic specialist because of a concern about possible growth plate involvement.

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9 hours ago, Arctic Mama said:

Head or deep hand injury is ER.  

Anything where I’d suspect internal bleeding is ER.  

Allergic reaction involving two or more body systems is ER.

Bone break/fracture is ER unless the urgent care does imaging.

Anything involving neurological symptoms is ER.  

Compromised respiration or circulation is ER.

I use the urgent care for minor wounds, sprains, infections, and the like.  Children who are having ear infection symptoms after hours for the pediatrician are also an urgent care for me, as is suspected strep or bronchitis.  

1

Beyond this list, sometimes you just need to know what your local options are like--from rural to urban, they differ drastically, and where we live, urgent care options vary wildly. Sometimes you can be sutured at our urgent care, and other times not, and it's not related only to the degree of injury--it's usually about who is on duty. Sometimes the age of the patient matters. Even if it's pretty clearcut an emergency department thing, an emergency department that sees a low volume of pediatric patients might send you on to a children's facility even if there really isn't any need to do so. They just don't want to deal with a pediatric patient. 

It's probably not a bad idea to ask local EMS providers if they have guidelines that would help in your area.

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We were recently forced to go to an ER cuz our urgent care was closed. I always have tried to go to Urgent Care cuz it's way cheaper   Thank God the urgent care was closed.  We thought our son had the stomach flu and was dehydrated after days of vomiting.  Long story short...he was admitted in critical condition with undiagnosed Tyoe 1 insulin dependent diabetes.  Had we taken him home and waited til the next day it could have been catastrophic.  Course now anytime he over sleeps I feel like I need to call an ambulance  ?

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Update:

He is doing okay this morning.  His face still looks awful and he now has a black eye in addition to all the scratches.  Other than being tired and feeling achy, he doing alright.  No pukey feeling, no dizziness, no balance issues, he just looks like he slid down the bike trail on his face.

He does not want to be seen by anyone or go outside.  I think I am going to let him.  I would hate the stares and looks too.

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It depends a lot on the Urgent Care. There are Urgent Cares here that are associated with the hospitals and are staffed by the same ER docs that are in those ERs. They have the ability to do Xrays, CTscans, etc. There are other Urgent Cares that are really just meant for things like an earache on a Sunday or something very simple. For younger kids, I usually recommend ERs  as they are more likely to have pediatric ER docs or at least docs that are more used to seeing kids. I find Urgent Cares often misdiagnose kids. If I think it’s anything that is fairly likely to need a specialist I send people to the ER or I would go there myself. Like abdominal pain, I would send them to the ER in case it’s an appendix. It’s easier than going to the Urgent Care and then having to be transferred. 

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DH is an emergency doc, so I call him :O)

This is a tough one though. Many people use good discernment with this question generally, but there are a lot who do not. And they contribute to a problem with door-to-doctor time. What seems to happen a lot (surprisingly) is someone has a chronic issue, such as “my back has been hurting me for 3 weeks,” and no significant change in the chronic issue but simply decide they can’t stand it a minute more.

On 6/6/2018 at 11:54 PM, Tap said:

I go to urgent care if it is something I would have gone to my PCP for (but can't get in due to urgency etc) 

Things we have gone to urgent care for: Strep throat, ear ache, infected insect bite, extreme swelling around mosquito bite that needs steroids (dd gets softball size lumps), cellulitis (I am prone to it so it is easy to self diagnosis, but need the script for meds), cut finger that needed stitches, abdominal cramping in my son, Shingles, broken toe (Swelling made it look bent, needed xray), very itchy rash.

Er. Head wound that needed stiches, high fever in baby (tried uc first but they were closed), asthma attack that wasn't stopping,  appendicitis.

I wish more people thought this way!!

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