Urgent Care Telehealth Protocol for Telehealth-Telemedicine Providers

Urgent Care Telehealth Protocol for Beginners: High Quality Documentation: No Representation Without Documentation

Do’s: Verify, don’t TRUST

  • Always document allergies
  • Check HT/WT, if BMI greater than 26, refer to Obesity Medicine, Nutrition and Integrative/Functional Medicine
  • Prescribe Augmentin 875 mg BID for 7 days, Zithromax 500 mg QD for 3 or 5 days, and Nitrofurantoin 100 mg BID for 7 days for Sx UTI. Hydrate with 2,000 ml distilled water/Pedialyte for 10 days or daily.
  • Tamiflu protocol: up to 4 days of symptoms 75 mg BID for 5 days, by 5 days of symptoms Rx patient with Abx (aforementioned)
  • Always inform patient that they must go to ER/urgent care center if Sx persist/worsen/wax-wane in 24-48 hours.
  • UTI protocol: check for CVA tenderness and pink/red urine in toilet/gross hematuria
  • For ICD 10, always additionally code for SIRS/Sepsis when appropriate
  • Sinusitis/Pharyngitis/Otitis Media protocol: Check for anterior/posterior cervical adenopathy/muscle tenderness/pain. Place chin on chest to evaluate for nuchal rigidity/neck suppleness, if positive increased risk for meningitis.
  • Bronchitis/Pneumonia protocol: make sure to check for productive cough and pleuritic chest pain
  • Have a low threshold to send patient to ER/urgent care center

Don’ts: must send to urgent care center/ER

  • Rx chest pain, send for cardiac enzymes/PA-lateral CXR
  • Rx failure of Abx Rx
  • Rx tooth abscess, send to dentist or above, need X-ray
  • Rx arrhythmia, evaluated by wearable or if blood pressure cuff says it can’t read the rhythm
  • Rx abdominal pain, only if absolutely sure that it is gastroenteritis and inform about visiting ER/urgent care center in 24-48 hours
  • Rx possible Fx, send for X-rays
  • Rx digit/hand or foot/toe infection that cover several joints with inability to flex or extend. Again, if need X-ray sent to urgent care/ER.
  • Refills only give 15-30 days supply, insist they see PCP/PMD
  • Don’t Rx chronic Dz, send to PMD/PCP and appropriate specialist (neurology, endocrinology, cardiology, pulmonology, allergy-immunology, gyn-urology, endometriosis specialist-reproductive endocrinology, and rheumatology), document clearly in chart

Endometriosis: The Great Chameleon

Endometriosis is an inflammatory autoimmune disease that affects 1 in 10 women globally and affects women mainly during their reproductive years. Secondary to the ability of these inflamed tissues or inflammatory mediators possibly spreading to anywhere in the body, endometriosis is woefully underdiagnosed and misdiagnosed. Unfortunately, it can take an average of up to 15 years before a woman is diagnosed with endometriosis. Those intervening years of non-treatment, and constantly being exposed to the cognitive bias of psych-out bias, most women suffer excruciating pain, devastating disabilities, as well as, untreated fertility issues.

Alas, endometriosis can cause migraines with subsequent seizures. Many women with lung and heart issues are not asked about the occurrence of these symptoms with their menses, which should be a routine part of the history of reproductive-age women. Additionally, lung lesions are normally only realized when the patient’s lung collapses, and the patient undergoes emergency surgery.

Another issue with the prolonged misdiagnoses of endometriosis is the lack of understanding that Stage 0 endometriosis has no macroscopic or critical mass findings. Thus, endometriosis is a clinical diagnosis and not a pathological diagnosis. Unfortunately, there may not be enough tissue specimens to even send to pathology. A patient who has to go to the emergency room almost every month when having her menses due to excruciating pain, has endometriosis, even if there is no evidence of pathological disease upon diagnostic laparoscopy. However, if an endometrioma is found during laparoscopy, it is now recommended to ultimately perform an oophorectomy emergently for increased risk of ovarian cancer over time. In the face of pulmonary endometriosis, removal of the endometrioma normally results in the lung symptoms being resolved.

There is no cure for endometriosis at the moment, even if one removes both ovaries and uterus during surgery. The adrenal glands and the patient’s adipocytes, especially if overweight or obese will produce estrogen analogs/imitators, and can cause symptoms wherever there are endometriosis lesions or inflammatory mediators in the body.

The severity of the systemic endometriosis symptoms should be decreasing as one approaches menopause. However, there is postmenopausal endometriosis, although it is rare. With the advent of Telemedicine, psych-out bias and posterior probability bias should be greatly diminished relative to improved continuity of care. Thus, endometriosis with more education, awareness, and academic studies should be easier to diagnose over time. There is a blood test developed in England, but the sensitivity is only 90%, meaning the test can miss 10% of positive cases.

Treatment for Low Sexual Desire in Women

Hyposexual desire disorder (HSDD) or low sexual desire in women affects about 1 in 10 women globally. The causes of low sexual desire in women are varied and many. The main causes I have seen in my practice are due to oral contraceptives, intrauterine devices, implantable hormonal devices, occupational/life stress, anxiety/depression, and psychiatric medications.

Unfortunately, obesity also plays a huge role in low sexual desire in women. Obesity is a chronic inflammatory state and can cause hypertensionheart disease, kidney damage, and diabetes. One of the main side effects of medications used to treat the aforementioned diseases is low sexual desire. So it is absolutely important to maintain a body mass index of 25, and a waist circumference of 35 inches in women. Additionally, obesity can be responsible for polycystic ovary disease (PCOS) and infertility.

The most important systems to be optimized are endocrine such as thyroid/parathyroid levels, a circulatory system such as hemoglobin level, and vitamin B/D levels. Optimization means that levels should be above the 50th percentile, sometimes even closer to the 100th percentile. The level should be titrated to how the patient feels relative to the improvement in symptoms.

The main treatment for low sexual desire is dietary/lifestyle change. The diet that is normally recommended for low sexual desire in women is the Mediterranean diet. It is important to make sure that this diet has organic components since regular food has a lot of hormones/steroids, antibiotics, and fertilizers/dioxins.

Medications that are available to treat low sexual desire in women are few. The drug that works really well after any underlying medical conditions are stabilized or resolved, and the aforementioned optimization of systems achieved is Addyi. Addyi can take up to 8 to 12 weeks to start working, the shortest time frame I have seen in my practice is 2 to 3 weeks, and I advised the patient to discontinue her oral contraceptive prior to starting Addyi. Once underlying medical conditions are stabilized, Addyi can be effective 70 percent to 90 percent of the time, otherwise, it is only 10-20 percent effective.

Telemedicine/Telehealth is a methodology for facilitating the delivery of women’s health and should be utilized frequently to improve the care of women globally. Low sexual desire in women is easily eradicated with Telehealth/Telemedicine as a modality for the delivery of women’s healthcare.

COVID-19: An endovascular systemic disease

Even though COVID-19 disease is caused by the SARS-COV 2 virus entering the human body mainly through the respiratory system, it is not a respiratory disease. The virus also proliferates in the sinuses, and thus enters our neurological system, causing a lot of damage. Any system in the body with a rich capillary network for blood supply is heavily prone to clotting, and thus ischemia, and ultimately the death of tissues/cells in that ischemic penumbra/area.

Systems in the body that are detrimentally damaged by this microvascular clotting are mainly; the neurological/psychological system resulting in central nervous system injury with subsequent peripheral nerve damage, the respiratory system with extensive lung scarring, the cardiac system with resultant arrhythmias, the renal system with chronic renal failure and the gastrointestinal system. These systemic sequela thus can morph into chronic or long haul COVID-19, which can effect 50-75% of COVID-19 disease survivors.

Long haul/chronic COVID-19 disease

Chronic COVID-19 disease is very debilitating and is normally multi-systemic. The bone crushing fatigue alone leads to such functional impairment, that there will a population of seriously disabled patients applying for disability and early retirement in the next 6-12 months. Treatment for chronic COVID-19 disease is currently supportive. I recommend optimization of thyroid/parathyroid function, meaning levels above the 50th percentile, which includes hemoglobin level, and Vitamin D/B12 levels. I also recommend high doses of Vitamin C with rose hips/bioflavonoids, dose of 2,000-3,000 mg daily, as well as, Magnesium Citrate 800 mg to 1,200 mg daily. All doses should be adjusted if renal failure is present.

Prevention of microvascular clotting

If the patient is not on Lovenox subcutaneously after discharge from the hospital or was never hospitalized, then keep the blood thin with herbs such as Red Panax Ginseng and Gingko Biloba should be adequate. Avoid Vitamin K in vitamins/supplements, and foods rich in Vitamin K.

No cure for COVID-19

Currently there is no cure for COVID-19 disease. The cure is actually in the prevention of the disease or being an unavailable host, by wearing masks in public areas, physical distancing and excellent hand hygiene with 20 seconds hand washing. Remdesivir shows promise as a therapeutic agent and convalescent plasma is also helpful. Hydroxychloroquine treatment remains controversial, more robust academic studies need to be performed for the role of Hydroxychloroquine as a therapeutic agent.

Endometriosis: A systemic disease

Endometriosis is a progressive chronic autoimmune inflammatory disease that affect 1 in 10 women of reproductive age, which can sometimes start at 9-11 years old. It is an extremely debilitating disease which is often misdiagnosed and under diagnosed. There are two types invisible/microscopic disease (Stage 0) and macroscopic disease (endometriomas/pulmonary with catamenial pneumothorax). It mainly affects the reproductive system with severe menstrual cramps, however, most women have some aspect of systemic endometriosis since it also simultaneously affects the psychological system with PMS/PMDD, respiratory system with restrictive lung disease/pneumothorax, the neurological system with migraines, the musculoskeletal system with diffuse myalgia, endocrine system with severe fatigue, and gastrointestinal (GI) system with constipation/diarrhea and nausea/vomiting.

Rampant misdiagnosis

Since endometriosis is a systemic disease it is often misdiagnosed, for example as irritable bowel syndrome (IBS), chronic medication induced migraine, and fibromyalgia. I call the disease the great Chameleon. It is important to note that women understand that endometriosis is initially a clinical diagnosis, there may not be any macroscopic findings (Stage 0), and laparoscopy may be initially negative for macroscopic disease, this does not negate the fact that there are endometrial ectopic foci that are invisible.

Diagnosis and Treatment

As previously mentioned endometriosis is very difficult to diagnose especially for Stage 0/invisible systemic disease. There is a blood test that was developed, but it is only 90% sensitive. Thus, there is a 10% chance that the patient is positive for disease but the test says that the patient is negative. Otherwise, it is a clinical diagnosis until there is macroscopic disease seen on laparoscopy, which can take up to 20-25 years to manifest.

Treatment is mainly hormonal with utilization of birth control therapy, such as oral contraceptives, Mirena IUD, Climara Pro patch or combinations of the aforementioned hormonal therapy. GnRH agonist/antagonists such as Leupron or Orilissa are also used. The side effects of these therapies can be devastating, but Orilissa works really well if the side effects can be tolerated for at least 6 months. Surgical options include a hysterectomy or hysterectomy with ovary removal. The ovaries when removed prior to menopause can be very detrimental to women’s health even with hormone replacement therapy.

Traditional Chinese Medicine with locoregional treatment such as acupuncture with moxibustion, reflexology and cupping, is also extremely helpful. Energy medicine techniques such as Krieger-Kunz Therapeutic Touch and Tai Chi are also invaluable tools in the armamentarium for treatment of endometriosis. Herbs such as Pau D’ Arco, Astralagus, Red Panax Ginseng, Gingko Biloba, Nopal, Graviola and Reishi Mushroom are also critical to controlling systemic endometriosis. Memorial Sloan-Kettering’s complimentary medicine herbal website is an excellent source for informational education about these herbs relative to academic research.

Adjunctively, counseling is very highly recommended secondary to the debilitating effects of excruciating pain, symptoms being disregarded, and being told that symptoms are psychological, can be very damaging to a women’s global health and daily routine care.

COVID 19 Rx Protocol relative to Hydroxychloroquine and Zithromax

First and foremost be very clear with your patients/clients that your goal is to slow down replication/reproduction of SARS-COV2 virus and not to cure or prevent COVID 19. Also, delineate the risk for QT prolongation with Hydroxychloroquine and Zithromax, since both drugs causes QT prolongation. Additionally, in the face of cardiac comorbidities, obesity, diabetes and hypertension, as well as, autoimmune disease, there will be an increase susceptibility for QT prolongation. The aforemnetioned chronic diseases also portend to electrolyte abnormalities that exacerbate QT prolongation such as hypocalcemia, hypomagnessemia and Vitamin D deficiency.

Prevention of QT prolongation

In medicine you are mainly restricted by the patient’s innate presenting comorbidities, innate immunity, genetic polymorphisms, epigenetic polymorphisms and pharmacogenetic polymorphisms. As a physician who includes Genomic Medicine in my practice, I am acutely aware of these determinants in the outcome of the patients COVID 19 disease course, and disease sequelae. Consequently, in my COVID 19 protocol I request that the patient consume Zinc, Vitamin D and Magnesium, 30 minutes to an hour before taking Hydroxychloroquine. I request that Zithromax be taken 2 hours after Hydroxychloroquine to minimize any drug-drug interaction relative to synergy or multiplicative QT prolongation side effects. I also address metabolic syndrome issues secondary to obesity, such as persistent chronic absorptivity issues, hypocalcemia, hypovitaminosis D and B12, as well as, the chronic inflammatory state due to obesity, which also affects myocardium and nerve/neural global conductivities.

The role of Telemedicine/Telehealth in the eradication of COVID 19

Telemedicine/Telehealth has the potential to eliminate health inequity and health disparities. In the COVID 19 era, I have seen where all the limitations and restrictions in the delivery, compensation/parity, and access to Telehealth/Telemedicine, basically evaporate or “gone with the wind”. I started practicing Telemedicine in 2016, and I thought it was the “Wild, Wild, Wild, Wild” West relative to the startup arm of the marketplace. I have even dappled in Telehealth consulting and was sometimes told I was too negative. Those companies of course eventually collapsed. We must understand in medicine that health care servants (MD, DO, PA, NP and DNP) are the Orcas in the food chain of the Trifecta that is medicine. The Trifecta is revenue cycle management, financial management and last but not least, medicine, the art and the science, which drives the whole space ship of reimbursement, the USS Enterprise.

Relative to Public Health, the validity and necessity for Telehealth/Telemedicine is indispensable in scope and reach, regarding the potential to eliminate health inequity, health disparity and underserved areas/population.

The Sacred Phoenix

Growing up in Jamaica, I was the village healer/doctor. I only had Chloraseptic, ice, soap/water and Mercurochrome. In my medical journey, I found that Traditional Chinese Medicine and Functional Medicine to be the best, and integrated methodology for modern Hippocratic medicine. The Hippocratic way focuses on all body systems, it doesn’t isolate and is not myopic. I was trained to believe that the patient is the textbook of medicine.

I practice energy medicine as a Krieger-Kunz Therapeutic Touch practitioner, and have been performing Tai Chi-Qigong for several years. I am passionate about Fashion designing and may switch in my later years. In the meantime, at the healer ranch, I will promulgate for the elimination of underserved areas/populations.

Demystifying Infertility

The causes of infertility are varied and multiple. However, on a pathophysiologic level infertility root cause is normally thyroid/parathyroid dysfunction, low/borderline progesterone, obesity and a pro-inflammatory diet. I normally recommend IVF as a last resort secondary to sometimes very toxic side effects. Fertility acupuncture and the Tao of Fertility book are excellent starting points on one’s fertility journey. Optimizing the aforementioned systems can easily be the cure for fertility issues.

The management of chronic pain syndrome

Chronic pain syndrome is mainly managed by first optimizing the body’s innate wound healing repair system and immunity system. To achieve this goal one has to mainly create a hemodynamically balanced system by focusing on function and not laboratory ranges. The balance is manifested by listening to the patient clearly delineate their symptoms and then try to figure out the source of the problem and eliminate it. The systems to focus on initially are thyroid/parathyroid, circulatory/hemoglobin, GI/microbiome-microbiota, micronutrient/Vit D-Vit B complex and the trace minerals such as zinc/copper/selenium.