AGING WELL IN EMERGENCY MEDICINE INTEREST GROUP
Telemedicine: Enhance Your Career and Wellness David Hoyer, MD FAAEM
T
elemedicine is a true game-changer in that many of the common diseases that afflict patients can be dealt with virtually. Of course that means physicians can now bypass the health care industrial complex (HIC), with its physician burnout and high costs for patients. The list of manageable telemedicine chief complaints includes (but is not limited to) UTI, sore throat, COVID, cough, sinusitis, vomiting and diarrhea, rash, hay fever, anxiety, depression, nontraumatic back pain, and pink eye. Starting with UTI, adult women with dysuria, urgency, and frequency without back pain or vaginal discharge have a 96% probability of uncomplicated UTI and can be treated empirically without any lab work.1 Many women have multiple UTIs per year and are very grateful when they can log on to their computer and within an hour have prescriptions sent electronically to their pharmacy instead of waiting to see their doctor.
“Telemedicine allows one to work as much or as little as wanted and still do what many of us love, which is taking care of patients based upon evidencebased medicine without HIC nuisances like PressGaney scores.”
For sore throat the Centor criteria can be used to decide between antibiotics or symptomatic treatment.2 Centor gives one point each for pharyngeal exudates, fever, absence of cough, tender cervical adenopathy, and patient age under 15 (-1 for age over 44). With a total of four to five points you can treat empirically with antibiotics. A score of two to three warrants referral to the PCP in two to three days. Centor, which has been widely used in the British National Health System for years, has the advantage over Rapid Strep in that it will allow antibiotic treatment of Fusobacterium Necrophorum and other non-strep bacterial causes of pharyngitis.
Telemedicine is especially valuable in treating COVID as the medications like Paxlovid generally need to be started ASAP and usually within five days of symptom onset. By the time patients have a positive COVID test it is often two to three days into the illness and by then, with the shortage of primary care doctors, it may not be possible to otherwise get the care they need without generating an expensive bill. Cough, sinusitis, vomiting and diarrhea, rash, hay fever, nontraumatic back pain, and pink eye usually do not need tests in the ER and so, can generally be managed virtually. For anxiety, the GAD7 is a useful tool to see if a patient warrants psych referral, with breathing exercises and perhaps a short prescription for a benzo in the interim.3 Depression can be screened for with the InSADCAGES mnemonic.4 Patients who screen positive and who are not suicidal can be started on an SSRI (like sertraline 50mg/day or citalopram 20mg/day) provided they can follow-up within a couple weeks.5 Obviously certain problems like chest pain, dyspnea of unknown etiology, abdominal pain, and ear pain are generally outside the scope of telemedicine. Ear pain may come off that list once the kiosks that allow photos of patients’ tympanic membranes become more widely available. Fortunately, EMTALA does not apply to telemedicine (outside of emergency departments), so you can decline any patient that makes you uncomfortable with a reason like “needs in person exam” or “needs to go to the ER.” Also, patients are generally good at self-triaging more serious illnesses away from telemedicine. I always document vital signs >>
COMMON SENSE SEPTEMBER/OCTOBER 2023
15