The COVID-19 pandemic has affected every area of our lives. Nowhere is that more evident than in the way we look at healthcare. Today, seeking medical care is no longer seen as a straightforward path to pain relief and wellness. Rather, a hefty dose of anxiety clings to every decision.
- Should I risk going to the emergency room?
- Can I risk NOT going to the emergency room?
- Can I feel safe going to my doctor’s office?
- Is it better to go to urgent care or the ER?
To address these difficult questions, we assembled a panel of providers from Bucks County Orthopedic Specialists for a (socially distant) roundtable discussion. Specialists in pediatric orthopedics, sports medicine, and adult spine/pain management – Dr. Susan Griffith, Dr. Michelle Horn, and physician assistant Ashleigh Berge – offer their unique perspectives as healthcare professionals and mothers. Together, they talk about what to do in different scenarios, what symptoms you can’t ignore, and how to stay safe while getting the medical care you need.
What are some of the most common orthopedic emergencies that you regularly see?
Pediatric Orthopedic Specialist, Dr. Susan Griffith: The most common emergencies I see with children are displaced fractures and infections. A displaced fracture is one where the limb looks crooked or deformed due to the injury.
Sports Medicine and Concussion Specialist, Dr. Michelle Horn: In the office I usually see more “urgencies” than emergencies. These can still include displaced fractures that will need surgery to be properly fixed, and infections which need urgent treatment to prevent complications.
In the sports medicine world, if there is a head injury, symptoms such as “blacking out,” worsening headaches, or repetitive vomiting signal a trip to the Emergency Room, rather than the orthopedist office. While these symptoms can be seen in concussion, they sometimes indicate more severe conditions.
Orthopedic and Pain Management Specialist, Physician Assistant, Ashleigh Berge, PA-C: As a physician assistant specializing in spine and pain management in adults, I rarely see emergencies, however, I often do see “urgencies”.
I see a lot of patients with acute pain, including nerve pain that radiates into the arms/legs and disc injuries that cause spinal cord and/or nerve impingement. Other common urgencies include a foot drop (inability to pick up the foot at the ankle) and injury to the spinal cord, which could be related to a disc herniation, or as the result of trauma, such as a car accident.
For these common issues, how has COVID-19 impacted the way patients seek care and the way you provide it?
Berge: Unfortunately, pain did not stop when COVID arrived. Patients suffered during the lock downs. During quarantine, I held video visits to help patients control their pain in the best way possible. But, this was difficult without the ability to give the injections and epidurals that we normally use to help control pain.
Now that we are back in the office again with strict safety protocols in place, it has been so beneficial for my patients who struggle with chronic pain. I am proud of the way we have come together to make our office a safe place, where our patients can get the care and treatments they need, including injections and epidurals to manage pain.
Horn: In the COVID era, I have seen patients who delayed seeking care due to fear of exposure and ended up with a fracture that went beyond the timeframe when it could be properly aligned. Unfortunately, these patients will have long term issues that could have been prevented with prompt care and early diagnosis.
Our office has made a concerted effort to take precautions that minimize the risk of virus transmission. Our job requires close contact with patients to make an appropriate diagnosis, so we always wear masks, wash our hands, wear gloves when needed, and wipe down all surfaces between patients. I understand that people are scared about being in a doctor’s office right now, but the medical community is working hard to keep our patients safe and healthy.
Griffith: When dealing with a pediatric patient, there is fear and uncertainty for parents about potential exposure to the virus. But children still need appropriate medical evaluation and care for their orthopedic issues. As a physician, I know it is important reassure parents and children that they are safe, that we are here to help them, and that we are are taking every precaution to keep them healthy.
What are your recommendations for the most immediate first steps to take after an accident or injury?
Griffith: If there is deformity of the limb (the limb looks crooked), go to the nearest hospital’s ER, regardless of the time of day.
Horn: Adding on to that, if there is no deformity, treatment of Rest, Ice, and Elevation (RICE) is typically recommended. But, if pain and/or swelling are getting progressively worse, despite RICE and over the counter medicines like Ibuprofen or Acetaminophen, then the patient should come see us.
Now, if pain and/or swelling is happening more rapidly, the patient should seek more urgent care at the ER or an Urgent Care facility.
Berge: With a spine injury, if the patient has any emergent symptoms such as lower/upper extremity weakness or bowel/bladder incontinence, I direct patients to the ER, as these are symptoms of a more severe spinal cord injury.
If the situation is not an emergency, I also recommend rest and ice, but with the spine we do not elevate!
After a neck or low back injury, most of my patients come to the office with severe pain. My first step is often to get MRI imaging of the affected area. While they wait for the MRI results, I advise applying ice or heat to the affected area and taking NSAIDs (non-steroidal anti-inflammatory medicines such as Ibuprofen, Aleve) to help with acute inflammation. Once we have the MRI results, I can recommend the best next steps.
How do you know when an injury requires immediate medical attention?
Horn: If things are changing rapidly, you seek immediate attention. Changes in consciousness or pain that is worsening despite home treatments warrant a more emergent response.
Berge: When it comes to the spine, I am most concerned when the injuries are from a trauma, such as a high impact auto accident or a hard fall in an elderly patient.
When should someone call 911 vs. drive to an emergency room?
Griffith: Call 911 if there is an open fracture (bone through skin), lack of circulation, or if the patient is unconscious.
Horn: I agree. Open fractures and issues with circulation need to be appropriately splinted and supported as soon as possible by emergency care and then quickly transported to the hospital. In situations where the person is unable to help themselves move, calling 911 is the best idea.
If you don’t want to go to the hospital, where else can you go? When is urgent care a better option, if someone is trying to avoid the hospital?
Horn: In the world of sports medicine, if a head injury is severe enough to warrant prompt medical attention, then it is generally best evaluated in an ER.
For other issues, urgent care is useful for getting initial care and studies. They usually have x-ray machines, equipment for splinting, and medical devices, such as boots and crutches. Going to urgent care also helps to keep the ER free for true emergencies that require more time and resources.
The job of the ER/Urgent Care is to stabilize an issue until a patient can be seen by a physician during regular hours. I emphasize this because sometimes people leave urgent care or the ER with a diagnosis that is changed at our office. As orthopedic specialists, we have the additional training to make a more detailed diagnosis and the advantage of observing an injury over time.
Berge: I do not suggest Urgent Care for back or neck pain. They unfortunately do not have the ability to do an MRI, which is the test of choice for the spine. They can sometimes order an x-ray to rule out a fracture and potentially show some degenerative disc disease. However, an MRI is usually needed for further assessment.
Griffith: I agree with Ashleigh, although for pediatrics, the study of choice for back pain is full length x-rays that can be ordered by BCOS to be performed at a hospital setting.
How do these recommendations change for “after hours” emergencies (nights and weekends)?
Griffith: Urgent care is appropriate in an “after hours” situation, if there is pain and mild swelling without deformity.
Berge: While some of my patients utilize urgent care to get temporary pain relief at night or on weekends, for severe symptoms related to the spine, the ER is the best place to go.
Are BCOS doctors available after hours?
Berge: Yes, we always have doctors and PA’s on-call who can provide emergent advice if necessary. Someone is always available by phone 24/7, nights, weekends, and even holidays. Depending on the situation, they may direct you to the emergency room.
Are there telemedicine appointments available for patients who want to avoid going out during COVID?
Berge: During the quarantine and shutdown, the BCOS office had telemedicine appointments only. Over the past few months, we have been slowly getting away from telemedicine appointments. That said, we can offer them if patients would prefer, especially for those who are elderly or immunocompromised in some way.
What information should you bring with you when seeking emergency care in order to ensure that you can get the very best care possible? (e.g., known allergies, current medications, etc.)
Griffith: Besides a list of medications and allergies and updated insurance information, it really helps to bring a calm demeanor and good listening ears to assure that you understand the diagnosis and treatment plan. And please remember that only one adult can accompany children while at the ER due to the COVID-19 pandemic.
What extra precautions should patients take when seeking medical care during COVID-19?
Griffith: Patients should all be wearing masks and limiting the number of people at the visit. For pediatric patients in our offices, we limit the people in the room to 1 parent accompanying patients under 18, and we only have the patient in the exam room if they are 18 and older.
As healthcare providers, we are wearing masks, doing proper hand-washing and sanitizing, and thoroughly cleaning exam and x-ray rooms between patients.
Berge: For senior citizens who need assistance, a caregiver may accompany them into the exam room. I believe that if all of our patients take appropriate precautions and we adhere to our strict protection and sanitizing practices, we will keep each other and our patients healthy.
All three of you are moms – have any of you run into particular challenges with your children’s health during COVID-19?
Griffith: My son has Type I diabetes and his endocrinologist provides outpatient care solely by telemedicine consultations. My son’s insulin pump broke while we were out of town and it’s been difficult to get his new pump accurately programmed with his appropriate settings.
It makes me appreciate that we are available for in-office evaluations of orthopedic issues at BCOS.
Berge: My family has continued to attend necessary routine and follow-up appointments during this time. We have not traveled and have continued to practice social distancing to ensure our safety and the safety of our friends and loved ones. The appointments we have attended with our kids have gone very well and we have felt very safe. They have worn masks and are getting very used to washing their hands frequently, especially after being in an office.
Horn: I have also been continuing to schedule routine health care appointments for my family. I have gone to several doctor’s offices and to the hospital for testing and have felt very safe in these environments.
My advice to other parents is – feel free to ask your healthcare providers what they are doing to protect patients and staff. Every office should have a plan and all employees should know the plan at this point. Don’t hesitate to ask questions to feel more secure about your healthcare decisions during this unprecedented time.