How to Handle the Urgent Need Patient: Telephone Triage/Preparation
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1 How to Handle the Urgent Need Patient: Telephone Triage/Preparation Pamela A. Lowe, O.D., F.A.A.O. Diplomate, American Board of Optometry Professional Eye Care Center, Inc. Chicago/Niles, Illinois Disclosures 1
2 Disclosures Speaker s Bureau/Consulting for: -Alcon -Diopsys -Heidelberg -Maculogix -Optos -Visionix -Zeavision Know Your Lecturer -Loyola University of Chicago, Illinois College of Optometry, Associate optometrist private practice Solo practitioner after purchase of Chicago practice Professional Eye Care Center, Inc. is a full-scope, primary care setting-moved location in 2007 from 1900 sq. foot space to 5400 sq. foot facility, currently employ one full-time associate doctor, one parttime doctor, eight full-time employees, and three part-time staff (tech, marketing and optical lab) 2
3 Lecture Objectives Understand medical urgency vs. perceived urgency Obtain an understanding of urgent care conditions Determine what care a patient needs based on urgency of condition Challenge: How does one best manage true ocular urgencies? What is Urgent Need? By Definition: ur gent ˈərjənt/ adjective: urgent (of a state or situation) requiring immediate action or attention. (of action or an event) done or arranged in response to a pressing or critical situation. "she needs urgent treatment" 3
4 What is Urgent Need? Optometrically: A need that is sight, or (in some cases) life threatening What is NOT Urgent Need? Patient perception of urgent: A need that they want immediate attention with; timely but not urgent!!! NOT sight or life threatening!!! 4
5 What is NOT Urgent Need? Vision blurry in new glasses Minor irritation-waxes/wanes* Last pair of contact lenses Red eye with no other Sx s Longstanding blurred vision Longstanding irritation Lack of wanting to wear specs Redness with good vision, no pain or discharge *may require timely but not urgent care Urgent Need-sight or life threatening Pain Vision blurred Vision loss Redness Irritation Discharge Swelling 5
6 What is Urgent Need? Altercations Burns (Chemical & Thermal) Foreign Object (organic/inorganic) Sports related (ball, fingers) Altercations/blunt trauma Sight-threatening complications Induced glaucoma/high eye pressure Cataracts Retinal Tear/Detachment Papillaedema (if forceful enough to cause increased intracranial pressure) 6
7 Altercations/blunt trauma Life-threatening complications (associated head trauma) Concussion-mild traumatic brain injury (MTBI) Intracranial Hematoma (blood pooling in the brain) Chemical Burn (sight-threatening) Common household/workplace events Acid (not as harmful) ph closer to human tears Alkaline/Base (more harmful) Most common Toxicity increases scarring Key is immediate irrigation/ rinsing Have pt. hang up and return their call not any earlier than 15 minutes 7
8 Chemical (sight-threatening) Key is immediate irrigation/ rinsing Have pt. hang up and return their call not any earlier than 15 minutes Sterile, buffered saline is best for irrigation/rinsing but tap water will do! Have patient bring in the source of the chemical (if possible) Thermal Burn (sight-threatening) Curling iron (most common) Cigarette (kids most commonly) Usually more lid involvement Poor vision but surprisingly good prognosis Calming patient down is paramount 8
9 Foreign Object (organic) sight threatening Organic substances are living cells, i.e, fingernail, plants, branches Increased risk of recurrent corneal erosion (RCE) greater Months later can recur with no apparent insult!! Infection more prevalent Fingernail beds Plant flora/chemicals Foreign Object (inorganic) sight threatening Inorganic substances are not living cells, i.e. plastic, paper, metal Less risk of recurrence (RCE) Metallic substances can rust so should be removed Most injuries involve smaller objects 9
10 Foreign Object (inorganic) larger Infrequently call practices; usually workplace injuries It is essential to instruct patients to NEVER pull offending object out Stabilize the eye with a shield and get to surgical care ASAP Sports related (ball, fingers) sight-threatening Subconjunctival hemorrhages are most common sign from finger pokes Corneal Abrasions (finger pokes) Hyphema (blood pooling in the anterior chamber) Retinal Tears/Detachment 10
11 Sports related (ball, fingers) sight-threatening Retinal Tears/Detachment Forceful, direct trauma (poke) High impact (balls, rackets, clubs) Sports-related life threatening Concussions, multiple events Intracranial Hematoma 11
12 Pain Acute (comes on quickly) Chronic (Hx of/wax & wanes) Severity Location Pain Acute Dryness Contact Allergy Styes (Clogged lid oil glands) Internal/External (hordeolum/chalazion) Sinus Pressure Contact Lens Complication Overwear Lens defect (tear, chip, warpage) Solution misuse 12
13 Pain Chronic Dryness (unresolved) Untreated Allergy Sinus Pressure Neurological/Optic Nerve Underlying conditions, Multiple Sclerosis Contact Lens Complication Overwear Lens defect (tear, chip, warpage) Solution misuse Pain Severity increases urgency! Mild Moderate Severe Disabling First Question is ALWAYS: Do you where contact lenses? R/O Microbial Keratitis 13
14 Pain Location One or both eyes (globe) Surrounding eye(s) Lids, brow, temples Sinus pressure projects pain to eyes Fever can be a serious marker of Preceptal Cellulitis Requires hospitalization Intravenous Antibiotics Vision Blurred Unilateral/Bilateral Unilateral- cause more localized Less severe/debilitating Bilateral Can have more severe cause Usually more debilitating Acute CL wearer increases urgency Chronic Usually less urgent, i.e. cataract Severity CL wearer increases urgency 14
15 Vision Blurred-Causes Sight Threatening -Cataracts -Infection/scarring -Diabetes -Glaucoma Life Threatening -Lesions- optic nerve/brain -Bleeds- intracranial -Stroke -AMD, age-related macular degeneration -Giant Cell Arteritis Vision Blurred-Benign Causes Not Sight Threatening -Ophthalmic Migraine -Mild/Moderate Dry Eye -Mild Allergies -Contact lens deposition Not Life Threatening Ophthalmic Migraine Mimics stroke Very scary Sx s Lasts under 1 hour 15
16 Vision Loss Unilateral/Bilateral Rare Acute Chronic Constant or Short Term Vision Loss-Sx s Sector Loss (partial loss of field) Total Loss (no light perception) Rare Curtain Short Term Acute Chronic Constant or Short Term 16
17 Vision Loss-Causes Cranial Nerve Disorders Diabetes Hypertension Vascular Disorders Diabetes Hypertension Cardiovascular Disease-Curtain Head Trauma-Occipital Lobe Helmuts are key Acute Chronic Constant or Short Term Vision Loss-Causes Sight Threatening -Cataracts -Infection/scarring -Diabetes -Glaucoma Life Threatening -Lesions- optic nerve/brain -Bleeds- intracranial -Stroke -AMD, age-related macular degeneration -Giant Cell Arteritis 17
18 Redness- The Pink Eye Unilateral (usual)/bilateral Acute (usual) Chronic (less common) Severity (surface hemorrhage) Redness-Causes Unilateral/Bilateral Infections Bacterial Viral Allergies Acute-most common Chronic Usually viral STD, Chlamydia 18
19 Redness-Causes Sight Threatening -Glaucoma- Acute Angle Closure Life Threatening -Not a presenting sign!!! Irritation Discharge -Mucous Thick/Crusty-Bacterial White Stringy-Allergy -Tearing Dryness-chronic Reflex-flushing Swelling -Allergic-most common -Styes-hordeolum -chalazion -/Insult 19
20 Key Learnings Determine medical urgency vs. perceived urgency Determine severity of urgent care condition Determine what care a patient needs based on urgency of condition Always ask: Are you a contact lens wearer? plowe@proeyecarecenter.com 20
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