Intro: It's Your Health Radio, a special podcast series presented by Henry Mayo Newhall Hospital. Here's Melanie Cole.

Melanie Cole, MS (Host): You're not feeling well, and you think you need to seek care. But when is it appropriate to go to urgent care, and when should you really just go to the ER? We're talking about that here on It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. And it's so exciting today we have a panel with two of my favorite guests. We have Dr. Anirudh Rai, he's a primary care physician at Henry Mayo Newhall Primary Care, and Dr. Oliver Sahagun, he's an Emergency Medicine physician at Henry Mayo Newhall Hospital. Doctors, thank you so much for joining us today. Dr. Sahagun, I'd like to start with you. What's the difference between walk-in clinics, urgent care, and the emergency room?

Dr. Oliver Sahagun: Thanks for having me on you guys. Every medical illness, in my opinion, exists on a spectrum, where it could be something benign, trivial, non-life-threatening. But it could progress to something that's potentially life-threatening, some are more concerning than others. And so, when I see patients in the emergency room, the way I approach things is I take a history, do a physical examination, take a good look at the patient, and try to figure out what it is that I'm dealing with. Sometimes I know immediately, sometimes I have to do diagnostic testing. But the reality is that the vast majority of times when I have seen the patient or come up with the diagnosis before any diagnostic testing, I have a fairly good idea whether this was emergent or non-emergent, at least at the time that I'm seeing the patient.

Melanie Cole, MS: Dr. Rai, I'd like you to jump in here as we're speaking about these differences. What is urgent care? Really, what is that? What kinds of testing? As Dr. Sahagun was just saying, he looks to diagnostics. He can usually tell whether it should be emergent or not. What about urgent care? What is that? What kinds of testing and scans can they do?

Dr. Anirudh Rai: So from my perspective, when we go do the difference between urgent care and emergency room, it's a pretty broad big difference, but there's tons of overlap though. From my perspective, I look at a physical exam finding. I take a detailed history to kind of see, you know, is there something here that we should look out for?

Generally speaking, from my perspective, I always try to do what we can at the urgent care setting, just because it's more cost-effective. It tends to decrease the burden on the emergency room. But when it comes to any kind of caution or any pre-test probability that I have for my patients saying, "Hey, something to kind of watch out for and run," I would definitely send the emergency room because they could get the tests done faster. They can do the scans faster versus an emergency room where you have a limited capacity. We could do things like x-rays and ultrasounds. But if you need a more detailed view, or if you want to rule out things that are in your differential, then I would send them to emergency room.

But at the same time, keeping this in mind that there's a cost to it. There is time associated with it as well. And keeping that in mind, you would often inform the patient that these are the things that we're thinking about, definitely go to the emergency room, because there's an awful lot of resistance in patients going to the emergency room period. We had plenty of cases where a patient shouldn't even come to the urgent care, but they just didn't want to go to the emergency room just because of the many variables, honestly.

Melanie Cole, MS: Well, I can understand that too, because going to the emergency room seems a bit scarier, larger, as you say, more expensive. I mean, it's a busy place. It feels like it's just a scarier place to go. And Dr. Sahagun, there are certain times when it's just absolutely necessary to go to the emergency room. So, I would like you to speak about the ones that we know are emergent: stroke, heart attack, severe burns, chest pain, that sort of thing. Tell us what you want us to know about these things. And when you say, "Okay, I need you to call 911," or depending on what the situation is, you can drive yourself. But some, we do not drive ourselves.

Dr. Oliver Sahagun: I really appreciate the partnership that we have with all our primary care physicians, our urgent care doctors, including Dr. Rai. We have a very well established relationship with him and his patients. I will say that there's a difference between complaint and diagnosis, right? The diagnosis usually doesn't come until you see a physician, although sometimes it's so obvious that you don't need a medical provider to make that diagnosis for you. But there are certain complaints that we always have to take very seriously because ultimately if they end up benign, that's great. But what we're making sure is to make sure it's not anything that's life-threatening, especially at the moment.

And so, the things that we're always concerned about are those specific things. And so, we're talking about specifically about complaints and somebody has a complaint of chest pain and they have certain risk factors, they're older, they're diabetic, high blood pressure, high cholesterol, then we have to take that very seriously. That's something that I would say you immediately come to the emergency room. Although if you went and saw your primary care doctor, hopefully you can just walk right in, which is difficult to do, or you went to an urgent care, more times than not, they would either immediately send you to the emergency room, call 911, or do the basic diagnostic study, which would be an EKG, to assess whether or not that chest pain was a specific type of heart attack. But there are other things. And so, you worry about other things, specifically stroke. We all know what stroke is or have a fairly good idea what that is. That's "I can't move the left side of my body or I'm immediately disoriented or confused" or "I have a horrible headache" or "I have difficulty with language and speaking," that's a very serious thing. As far as injuries, you know, there are certain injuries that you probably wouldn't go to your primary care doctor or an urgent care if you were involved in a motor vehicle accident and you have significant injuries, orthopedic injuries, or you had really bad abdominal pain, or you had a broken bone that protruded through the skin. Those are all very, very concerning.

But as Dr. Rai was mentioning earlier today is that there's always overlap. And so, my advice to patients or just people that I see in the community, is that if there's any concern, you come to the emergency room. Now, certainly, I know there's always trepidation with coming to the emergency room for a lot of reasons. It's just like you guys mentioned, it's a scarier place, but then there's also cost and time involved. Some people have certain insurances that are going to pay a lot of money if they come to the emergency room. And I understand that. And so, my advice to the people that are listening to this podcast is that if there's any question as to whether or not their specific complaint could be life-threatening is to come to the emergency room because we have a triage system set in place that will see you immediately. And then, we could reassure you. But if you think, "Well, I don't think it's that bad and I'm concerned about time and cost," then you can go see your primary care doctor or an urgent care physician in the community.

Dr. Anirudh Rai: To jump on that a little bit more, ideally, from our perspective, we always try to tell our patients Any doubt that does occur, definitely go to the emergency room. I think it's fair to be reassured that nothing terrible is happening. And then, we could kind of reconvene on that account. So, I would say in that sort of scenarios where there is a little bit of doubt about what may be going on, my, at least, personal philosophy is let's send to the emergency room, let's make sure everything is ruled out completely before we have any doubts about anything.

Melanie Cole, MS: That's great information. And now, gentlemen, I am going to do a lightning round with you, and we're going to have a little fun here, go back and forth, and I'm going to mention some conditions. And you're going to tell us about that condition, whether that is emergent or urgent. So Dr. Rai, I'm starting with you for parents. One of the most difficult decisions is that emergency room. We call our lovely, wonderful pediatricians at two in the morning, fevers, vomiting, there's all kinds of things that go on with kids. Gosh, I remember all of that. But febrile seizures are pretty scary. We don't know as parents what that is. So, what happens if our child is listless, fever, not moving, urgent care, emergency?

Dr. Anirudh Rai: That is a clear-cut emergency room. Definitely with pediatric population, you want to kind of address things sooner, because they tend to go downhill much more quicker than our adult counterparts.

Melanie Cole, MS: Dr. Sahagun, appendicitis, what would we feel? People here, "Oh, on the right upper quadrant" or whatever it is, tell us what we would feel. What symptom? And is that emergency or urgent?

Dr. Oliver Sahagun: Right. So, this is one of those situations where the complaint comes before the diagnosis. And so, the complaint usually is abdominal pain. Early on, it might be just sort of vague, nonspecific, lower abdominal pain. And that's usually associated with nausea, plus or minus vomiting, usually your bowel movements are normal. Usually, there's a fever, there's a lack of appetite. But then, as it progresses, usually within hours, up to about a day or two, then the pain starts to localize in your right lower quadrant. And so, my answer to that would be is if you have lower abdominal discomfort without any injury and you feel a little nauseous, even if it turned out to be appendicitis, is not necessarily an emergency at that time. Now, if you waited a couple of days and your pain is severe and you're vomiting and you can't hold anything down, then that is an emergency. But early on, I would say it's okay to go to urgent care.

Melanie Cole, MS: Dr. Rai, nausea, vomiting, diarrhea. When is that considered an emergent situation? I mean, I am somebody who had C. diff, and I didn't know it for like days until it got so bad. When is something like that-- and I'm glad I didn't go to the emergency room at the time because I would have been quarantined. But, you know, when do we know that nausea, vomiting, diarrhea is something we can either go to urgent care or emergent?

Dr. Anirudh Rai: Absolutely. I think in this circumstances, the general rule is if you can't drink water without vomiting or essentially losing it, I would say go to the emergency room because you aren't replenishing your fluids fast enough to kind of compensate for that. And usually, as time progresses and you're losing more fluids, you tend to have imbalances as well. And then, depending on the time course of how often this is happening, I would send them to the emergency room. But more often than not, actually, that's usually in the end of the spectrum. Usually, they come to urgent care with these symptoms as well, they're gone for a couple days.

And in urgent care, we could actually replete their fluids. We could give them at least their body some nourishment or some sort of fluid reinforcement to kind of get them through it. Because more often than not, these are viral illnesses that are the most common cause, but my general rule is if you can't drink water and if you've been vomiting for a greater amount of time, then your body could kind of tolerate, we would see it on physical exam findings, then that point I would send them to the emergency room. But more often than not, I'd say majority of the time, we often see them in the urgent care.

Dr. Oliver Sahagun: I agree with that, Dr. Rai. But if I can just add to that is, you know, nausea, vomiting and diarrhea, once again, are signs and symptoms that are related to some underlying cause. The vast majority of times, as Dr. Rai said, it is a viral illness. Usually, it's transient, it's short-lived, it's going to go away. But the patient typically doesn't know that. I would say that, just like Dr. Rai said, if you're unable to hold food down, orally, then that would be a sign to come to the emergency room.

Another reason is if your pain is severe or intractable, if your diarrhea is copious and nonstop and that results in severe dehydration where you experience symptoms like severe weakness, lightheadedness, dizziness, there's loss of consciousness, if there's a very high fever or there's blood in your stool or you know of a significant other sick contacts who have gotten just as sick and have gone to the emergency room, typically that would be an indication that something more significant is happening like a bad bacterial infection.

Melanie Cole, MS: Dr. Sahagun, minor cuts and burns while we're cooking.

Dr. Oliver Sahagun: So, minor cuts and burns, I would say more times than not can go to an urgent care. It really depends, you know, we think of burns. And as far as the thickness of involvement to the skin, we break them down into degrees. First degree is a minor burn that involves just a superficial aspect of the skin, but they can go deeper. Second degree would form a blister. Third degree would kill the nerve endings and affect the blood vessels so they would blanch. But more times than not, if it's a minor burn, thermal burn from hot liquid that does not involve the face, does not involve a large portion of your hands where there's a lot of dexterity and it doesn't involve the genitalia, then I would say it's okay to start off in an urgent care. But if it's a large burn, that involves a large area of your body, it is thicker where your skin blanches or it involves your face, your airway, or the genitalia, then I would recommend that you come to the emergency room.

Dr. Anirudh Rai: Yeah, absolutely. Typically, in these scenarios when it's household injuries, we see that quite often in urgent care and it's something that we definitely watch out for. The other thing to consider is also the surface area, depending on how big the area of injury is would also determine whether urgent care or emergency. Typically, a larger surface area would warrant more of an emergency setting, but that doesn't happen too often, but it is something that we do consider whenever a patient does show up.

Melanie Cole, MS: Dr. Rai, along those lines, same-day STI testing and treatment. If we notice something going on down there, is that an emergency or is that urgent care?

Dr. Anirudh Rai: Definitely for same-day, we definitely can treat that in the urgent care. We see that quite often as well. And it is something we handle quite frequently. When it comes to chronic setting, that can be a bit questionable, whether other symptoms arise. Nonetheless, we do handle all this in urgent care without too much of a problem.

Dr. Oliver Sahagun: I would agree with that. Most STIs in the acute setting do not cause any complications and can be more than readily handled in an urgent care or primary care setting. But if treatment is delayed, then the illness can result in what we call dissemination. It can get into the bloodstream and cause complications, any number of complications, in which case I'd recommend that you come to the emergency room.

Melanie Cole, MS: Only a few more, gentlemen. Just only a few more, Dr. Sahagun. A nosebleed.

Dr. Oliver Sahagun: Those are tricky. Once again, those exist on a spectrum. My advice would be most nosebleeds related to trauma in the young, otherwise healthy individual are short-lived and they're going to go away. And my advice would be it's okay to go to urgent care. But if it's a significant injury, with profuse long-term bleeding or if it's an elderly patient that is bleeding with or without trauma, especially if they're on blood thinning medication and the bleeding is so profuse that it's trickling to the back of their throat and they can't swallow fast enough that it's affecting their respirations, that is an emergency. When people have nosebleeds, more times than not, it involves what we call the venous plexus, which is the veins. Those are blood vessels that are going back to the heart and not under any sort of pressure. But sometimes the injury can be significant and involve the arteries where that's a pressure vessel. It's going to bleed out profusely. Typically, that happens with significant trauma or in cases of chronic disease like sinus disease where it can erode to those vessels. So, heavy, profuse bleeding, difficulty breathing, blood thinners, elderly population, I would say go to the emergency room. Otherwise, it's safe to go to an urgent care.

Dr. Anirudh Rai: Yeah, I agree. Typically, with nosebleeds, it is a spectrum. I 100% agree with that. The posterior nosebleeds tend to be a bit more trickier, but we definitely could take care of that in the urgent care as well. We do have the capabilities of that. But yeah, that is a tough one for a spectrum, I'll tell you.

Melanie Cole, MS: Similar to that, what about allergic reactions, Dr. Rai?

Dr. Anirudh Rai: That's also on the spectrum as well. Typically with allergies, the mildest being a rash, while the other end being something called anaphylaxis, where your whole body essentially starts reacting to a certain antigen or a component, that becomes life-threatening. At that point, we would send them to the emergency room. But typically, they would have some sort of history with it, more often than not. But If the rare occasions, or if it can happen more frequently, I would say two to a certain extent, you can have the introduction of the antigen and they get an anaphylactic reaction. and that would be an emergency room scenario, because what we worry about is airway compromise. As soon as all this inflammation, this reaction occurs in your body, your body essentially starts going into overdrive, starts dilating vessels, starts causing what we call edema, fluid buildup in places that shouldn't be. it's an uncontrolled inflammatory reaction leading to airway loss and it can lead to death. So in those scenarios, I would send the emergency room versus a mild reaction, whether it be to food, to certain antigens, to certain environmental factors, we could definitely handle that in the urgent care setting. And that would be taking care of just with topicals and sometimes even to anti-allergy pills.

Dr. Oliver Sahagun: Yeah. 10I 100%gree with you, Dr. Rai. Allergic reactions is a very common complaint we see in the emergency room and the first thing is, I just look at the patient. But the most common finding in a person who's having an allergic reaction is a skin manifestation. they get a rash and the rash is very itchy, But just like these other illnesses, they're going to get symptoms that exist on a spectrum where ultimately it can lead to other really bad, life-threatening things, including airway compromise where your lips swell, your tongue swells, the dangling structure in the back of your throat, the uvula swells. You can get spasms of your upper airway, your bronchi, and then it could lead to massive dilation of your blood vessels, where your blood pressure plummets, and that's called anaphylaxis. We would hope that most people would recognize those symptoms, but sometimes they don't, but the reality is that sometimes these symptoms exist on a spectrum. And, if your symptoms are mild, and you're not weak, you're not lightheaded, you're not having difficulty breathing, you're not having swelling of your lips or your tongue, it's okay to go to urgent care. And urgent care, they're going to check your vital signs, they're going to treat you if your blood pressure drops or there's any evidence for airway compromise. They're going to get you immediately transferred to the emergency room.

Melanie Cole, MS: I'd love to give you each a chance for a final thought here. I mean, I could go on with this list, right? There's so many things people don't know which one they should do. But Dr. Sahagun, I would like you to summarize what you want listeners to know about going to the emergency room. What should we take? When is it more important to call 911 than drive a loved one who we think may be having a stroke or a heart attack, but EMS can do a lot of things. I want you to just summarize the emergency room for us and maybe de-scarify it a little bit, because that's why people don't always want to go because it's scary. What do you want us to bring with and why is it not so scary? Because you guys are experts, you know what you're doing.

Dr. Oliver Sahagun: You know, I always tell my patients at the end of every single patient encounter that whatever concerns they have, they're always welcome to come back to the Emergency Department. If you're a lay person, more times than not, when you develop a symptom that you're concerned, it could be something bad, you don't know what truly it's going to be and what it's going to turn out to. And so, if there's any concern whatsoever, we're happy to assess you.

I understand the concern with being in a place like the emergency room. And there's a lot of factors that we take into consideration. But primarily, time and cost and those are huge concerns. But my advice is if you have any symptoms that you're in any way concerned could be life-threatening or dangerous, even if you're not manifesting those symptoms to either yourself or to your loved ones, come to the emergency room and we're happy to assess you. In the end, if it doesn't turn out to be anything bad, it's reassuring. But if it turns out to be something bad, then potentially we could have caught it in time.

Melanie Cole, MS: And you're not going to get mad at us if we show up at the emergency room and it wasn't something emergent.

Dr. Oliver Sahagun: No, we love all our patients and we're happy to take care of them regardless of their complaint.

Melanie Cole, MS: Thanks for saying that. And Dr. Rai, last word to you. What do you want people to know about urgent care walk-in clinics? They're showing up in many places. They're a godsend to so many people. So, tell us what you would like us to know about the urgent care and what we should bring with us. What do you want us to know?

Dr. Anirudh Rai: Yeah. So, the urgent care setting tends to be a bit more relaxed, thankfully, because it is not as intense as the emergency room, thankfully. So, it can be a better environment for patients who are worried about any sort of an anxious scenario, so to speak. But nonetheless, if there's any doubt, I agree with Dr. Sahagun, that any doubt, go to the emergency room, honestly, just because it's better to be reassured because your health is definitely worthwhile when it comes to your own well-being.

The urgent care and walk-in clinics are a huge sort of assay to get the burden off the emergency room. If there's any sort of question, definitely give us a call or come in. We can definitely direct you to the emergency room if you need to. There's no rush or no hassle to show up on the urgent care. It's quick. We see our patients fast as well and give them at least some reassurance saying, you know, it's not an emergent thing, but to be cautious and keep an eye on certain things.

On the other hand, if we do see something that requires more of an emergent setting, then we definitely don't slow down and send the emergency room right away. So, these are great sort of resources that we let our patients know. Definitely, go to the urgent care, go to primary care, walk-in clinics, because they're a great resource to decrease the burden on the emergency room so that the care can be received properly without overwhelming the patient as well.

So, it is a team effort. So, we work with our emergency colleagues as well, and they work with us. So, it is a give and take almost. And it is something that we always want to keep an eye out for because each and every person's health should be taken care of at a precise manner, but at the same time, without overburdening our colleagues and our professional friends.

Melanie Cole, MS: Very well said. Gentlemen, thank you so much for joining us today. That was a lot of fun, really informative. You're both so good and passionate at what you do. We can hear that and thank you for giving us such great information. And you can visit the Henry Mayo Newhall urgent care website at henrymayourgentcare.com. Henry Mayo Newhall Hospital's Emergency Department is open 24/7 and is located at 23845 McBean Parkway in Valencia, California. You can learn more about that at henrymayo.com. You can also always visit the free health information library at library.henrymayo.com.

That concludes this episode of It's Your Health Radio with Henry Mayo Newhall Hospital. Please always remember to subscribe, rate, and review It's Your Health Radio on Apple Podcasts, Spotify, iHeart, and Pandora. Until next time, I'm Melanie Cole.